Orthopedics
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| MESS Score > ____ needs trauma center | >7
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| Hemodynamically Unstable Fx imaging/look for: | AP lateral xray: Inspect inner/ outer main ring cortices; 2 small rings; SI joint spaces (equal); symphysis pubis should align, < 5mm joint space; acetabulum
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| Hemodynamically Unstable Fx: if fx identified or suspected: | CT (+/- MRI)
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| True Orthopedic Emergencies | Pelvis, Femoral neck; Extremity Arterial Injury; Compartment Syndrome; Mangled Extremity and Traumatic Amputations; Threatened Soft Tissues / Open Fx; Hip Dislocation ; Septic Joint / Osteomyelitis
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| Open fx Type I | <1 cm, clean; minimal mx contusion; simple transverse/oblique fx
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| Open fx Type II | Lac >1 cm; extensive tissue damage; min crushing
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| Open fx Type IIIA | extensive ST damage w/mx, skin, neurovasc
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| Open fx Type IIIB | ext ST damage with periosteal stripping & bone exposure
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| Open fx Type IIIC | High energy features with art damage
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| Septic joint/osteo: orgs: bone | Bone: GAS, S. aureus
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| Septic joint/osteo: orgs: joint | H. flu, GAS, E. coli, NG
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| Septic joint/osteo: sx | Fever, joint or bone pain, leukocytosis
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| Septic joint/osteo: Dx tests | Bone scans localize osteomyelitis; Joint aspiration to identify organism
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| MS trauma complications | Most common: Nerve compression, compartment syndrome, DVT, fx comps; Other = Rhabdomyolysis; Reflex Sympathetic Dystrophy; Myositis Ossificans
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| Fx complications | Delayed union; nonunion; infxn; N/V injury
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| MS Imaging | Plain films (at least 2 views); consider joints above/below injury; CT (bony); MRI (ST); nuc med (tumors); EMG/NCS
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| Trauma x-ray series | Lateral C-Spine; PA Chest; AP Pelvis
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| ____ are prone to avascular necrosis | Femoral neck fractures and hip dislocations
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| Injuries assoc w/arterial damage: | Knee dislocations, displaced tibial plateau fx, floating joint, GSW or knife wounds, mangled extremity
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| Compartment syndrome: compartment pressure of ____ warrants decompression with fasciotomy | > 30 mm Hg
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| Time from amputation to replantation | Warm ischemia: 6 hrs; Cold ischemia: 12 hrs; up to 30 hrs for digits
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| Septic joint/ Osteomyelitis Rx: | Parenteral Abx, I&D
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| MS injuries: plain films | At least 2 views; Check entire film; Consider joint above & below injury
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| Nuclear med studies to: | define tumors, etc
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| Dislocations | shoulder 95% ant; hip 90% posterior
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| Avulsion of the antero-inferior glenoid labrum = | Bankart lesion
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| Compression fx of posterior humeral head = | Hill-Sachs lesion
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| Shoulder dislocation: xray & reduction maneuvers (3): | Rowe (opposite ear over head), Stimson (prone), Hippocratic (traction)
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| Shoulder xrays | AP Grashey (30 deg), scap Y, axillary
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| Posterior fat pad is always: | pathologic
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| Hand lac: close within: | 8 hrs
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| Kanavel sx (fusiform swelling, tendon TTP, passive extension pain) = | septic tenosynovitis (staph, strep); I&D, Abx; tetanus/rabies prn
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| High pressure injection injury: paint vs grease | Paint: tissue necrosis; Grease causes fibrosis
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| Hip dislocation tx | Allis maneuver
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| Femur fx tx | usually ORIF; femoral fx = closed reduction & Nail; femoral neck fx: Garden III & IV need prosthetic
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| Bucket-handle or corner fracture on xray = | Metaphyseal Corner fx; less common, more specific for abuse than diaphyseal fx; represent planar fx through primary spongiosa
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| Vertebral fx & child abuse | spinous process avulsions > vertebral fractures; most are Asx; consequent neuro or kyphosis rare
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| Epiphyseal Separation | True physeal injuries unusual in the abused child; result of violent traction or rotation; MRI or arthrogram may be needed for dx
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| planar fx through primary spongiosa = | Metaphyseal Corner fx
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| Fracture: Region of bone: | diaphysis, metaphysis, epiphysis
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| Direction of fracture: | transverse, oblique, spiral
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| Fracture: Condition of bone: | comminuted, incomplete
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| Fracture: Condition of soft tissue: | closed, open, open joint
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| Fracture: Deformities of fracture: | displaced, angulated
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| Fracture: Peds: | greenstick, torus, Salter-Harris
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| Salter-Harris Growth Plate injury classification: I (S): | Straight. Affects growth plate only
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| Salter-Harris: II (A): | Above. Through growth plate and metaphysis
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| Salter-Harris: III (L): | Lower. Through growth plate and epiphysis
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| Salter-Harris: IV (T): | Through. Through growth plate, metaphysis, and epiphysis
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| Salter-Harris: V (R): | Ram. Crush/compression fx
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| Radial head fx (Mason) Class I: | undisplaced
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| Radial head fx (Mason) Class II: | displaced
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| Radial head fx (Mason) Class III: | comminuted
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| Radial head fx (Mason) Class IV: | dislocated
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| Fracture Description | Anatomic location; Region; Direction of fracture; Condition of bone
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| Fracture Healing: inflammation stage | Hematoma forms at fracture site; Osteoclasts remove necrotic bone; Hematopoietic cells in clot secrete growth factors
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| Fracture Healing: Repair stage | Soft callus stage: fibrous tissue unites fragments; Hard callus stage: callus converts to bone
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| Fat Embolism Syndrome results from: | Embolic marrow fat damaging pulmonary capillary beds leading to ARDS
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| Fat Embolism Syndrome: Pt presents with: | hypoxemia, dyspnea, altered mental status, tachycardia, and petechia
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| Rhabdomyolysis etiology | Blunt trauma, seizures, burns, strenuous exercise, electric shock, drugs (Lipitor), viruses
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| Rhabdomyolysis: Clinical sequelae | Hypovolemia, Hyperkalemia, Metabolic acidosis, Acute renal failure, DIC
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| Nerve Compression Syndromes | Carpal tunnel syn; Ulna n. palsy; peroneal n. palsy; sciatic n. neuropraxia
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| Reflex Sympathetic Dystrophy: S/S | Intense burning pain, edema, stiffness, skin discoloration and atrophy
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| Myositis Ossificans: Cause | Focal trauma to mx; calcification of hematoma in 3 months, ossification in 5 months
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| MESS Score > ____ needs trauma center | >7
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| True Orthopedic Emergencies | Pelvis, Femoral neck; Extremity Arterial Injury; Compartment Syndrome; Mangled Extremity and Traumatic Amputations; Threatened Soft Tissues / Open Fx; Hip Dislocation ; Septic Joint / Osteomyelitis
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| MS trauma complications | Most common: Nerve compression, compartment syndrome, DVT, fx comps; Other = Rhabdomyolysis; Reflex Sympathetic Dystrophy; Myositis Ossificans
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| Fx complications - Injuries assoc w/arterial damage: | Knee dislocations, displaced tibial plateau fx, floating joint, GSW or knife wounds, mangled extremity
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| Compartment syndrome: compartment pressure of ____ warrants decompression with fasciotomy | > 30 mm Hg
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| Dislocations: common types/sites | shoulder 95% ant; hip 90% posterior
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| Kanavel sx (fusiform swelling, tendon TTP, passive extension pain) = | septic tenosynovitis (staph, strep); I&D, Abx; tetanus/rabies prn
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| High pressure injection injury: paint vs grease | Paint: tissue necrosis; Grease causes fibrosis
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| Vertebral fx & child abuse | spinous process avulsions > vertebral fractures; most are Asx; consequent neuro or kyphosis rare
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| Epiphyseal Separation | True physeal injuries unusual in the abused child; result of violent traction or rotation; MRI or arthrogram may be needed for dx
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| planar fx through primary spongiosa = | Metaphyseal Corner fx
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| comorbid illness that predisposes to adhesive capsulitis | diabetes
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| Pain after tx of fracture w/ cast | Compartment syndrome
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| Sprain: | Stretched or torn ligament
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| Sprain: 1st degree | partial tear
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| Sprain: 2nd degree | partial/instability
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| Sprain: 3rd degree | complete tear
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| Strain: | Musculo-tendinous unit injury; first, second, third degree; Pulled muscle
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| Contusion: | Bruise; Hematoma ; Abrasions, lacerations
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| Tendonitis = | Overuse, mechanical irritation of tendon
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| Teenage female with long bone pain w/o trauma or injury; XR w/ lytic mass, multi-laminated periosteal reaction | Ewing sarcoma; periosteal “onion skin” reaction
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| AVN etiologies | Corticosteroids, EtOH, trauma
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| Rhabdomyolysis = | Breakdown of mx fibers with release of cellular contents into circulation
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| Rhabdomyolysis S/S | Muscle pain, dark urine
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| Neurapraxia etiology | Blunt injuries may produce nerve contusion
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| Neurapraxia: assoc with: | fracture; recovers in 6-12 weeks
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| Axonotmesis: | Crush injury; also seen in traction injuries; recovers at 1mm/day or 1 inch/month
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| Neurotmesis: | Sharp trauma results in a severed nerve; primary surgical repair indicated
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| Reflex Sympathetic Dystrophy = | Chronic Regional Pain Syndrome
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| Reflex Sympathetic Dystrophy = | Persistent pain & hyperesthesia after an injury
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| Myositis Ossificans = | Heterotrophic bone formation
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| Myositis Ossificans: must R/O: | R/O osteosarcoma
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| (Fx comp) Delayed union: | Slow callus formation
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| (Fx comp) Nonunion: | No clinical or radiographic signs of progression to bony union after 3 months
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| (Fx comp) Infection: esp. with: | open fractures
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| Osteomyelitis orgs: | S. aureus, Beta strep
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| (Fx comp) N/V injury | Evaluate circulation & sensation distal to injury site.
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| Tendonitis: Shoulder: site/mx | Supraspinatus
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| Tendonitis: Elbow AKA | Medial/lateral epicondylitis
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| Tendonitis: Wrist AKA | DeQuervain
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| Tendonitis: Hand AKA | Trigger finger
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| Tendonitis: Hip: site | ITB
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| Tendonitis: Knee: site | ITB, Patella, Quadriceps
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| Tendonitis: Ankle: sites | Peroneal tendon, Posterior tibial tendon, Achilles
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| Tendonitis: Foot AKA | Plantar Fasciitis
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| Plantar Fasciitis | pain worst 1st few steps in AM; tx = restrict prolonged standing; arch supports
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| Tumors: prevalence in ortho | Benign bone tumors common; malignant tumors rare
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| Metastases to bone are common in: | Pts > 40 yo
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| Benign tumors: | Osteoblastoma, Osteoid osteoma
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| Malignant tumors: | Ewing sarcoma, Osteosarcoma, Chondrosarcoma
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| Ratio benign soft tissue tumors to malignancy | 100:1
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| Benign soft tissue tumors | Ganglia, giant cell tumor, lipoma, hemangioma, angiomyoma
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| Malignant soft tissue tumors | Fibrosarcoma, liposarcoma, rhabdomyosarcoma
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| acute monoarticular sxs, consider: | trauma, infxn, crystalline dz (gout/ pseudogout)
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| Fat Embolism Syndrome: most common with: | femoral shaft fracture
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| Fat Embolism Syndrome occurs when? | Within several days of fracture
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| Peroneal nerve palsy: | with hip, fibular head, or ankle fracture/dislocation
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| Spinous Process fx: MOI: | sudden forceful ligamentous traction on spinous process, or a direct blow to the process
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| 50% of pts with solid tumors have: | mets to spine
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| Tumor: Highest prevalence: | BrCa, lung, prostate, colon, thyroid, kidney ca (hematogenous spread)
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| Tumor: Sx: | Night pain, n. root compression
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| 10% of spinal bone tumors are: | primary
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| Spinal bone tumors: in children, 20% are: | malignant
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| Spinal bone tumors: Primary malignant: | Osteosarcoma, Ewing Sarcoma, Chondrosarcoma
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| Spine Films/ Frontal: Vert body (owl head) for: | Missing eye (destrn); pedicle
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| Spine Films/ Frontal: Vert body: Crack in owls eye: in = | Chance fx (seat belt fx)
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| Spine Films/ Frontal: Vert body: Inc space btw owls eyes: in = | Burst fx
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| Chance fx: MOI | MVA: lap belt immobilizes pelvis & thorax is forcefully flexed forward
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| Chance fx: Seen on AP = | crack thru eyes (pedicles), or open beak (crack through spinous process)
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| Burst fx: Unstable = | Collapse of vert body
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| Burst fx: MOI: | fall from a ht, landing on feet or buttocks
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| Burst fx: Fragments: | may extend into spinal canal causing neuro S/S
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| Wedge fx: Stable = | Collapse of ant vert body w/ an intact posterior wall
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| Wedge fx: Stable: result of: | hyperflexion injury and / or osteoporosis
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| ____ are prone to avascular necrosis | Femoral neck fractures and hip dislocations
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| Greenstick fx = | Incomplete fx
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| Greenstick fx: MOA | thick periosteum in children prevents displacement; dorsal cortex intact
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| Septic Tenosynovitis: Etiology: | Staph, Strep, MRSA
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| Septic Tenosynovitis: Rx: | IV Abx, I&D if progressing; consider tetanus & rabies prophylaxis
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| Temporal bone fx: complications | hearing loss, facial paralysis, CSF leak, vertigo, TM perforation, nystagmus
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| Rhabdomyolysis: Labs | Myoglobinuria; CK elevated 5-10x normal (37-200)
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| Rhabdomyolysis: Rx | Fluids; Correct imbalances; tx underlying cause
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| Fat Embolism Syndrome: Rx: | Maintain perfusion with O2, inotropics, maintain hematocrit, correct metabolic acidosis; mechanical ventilation may be required.
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| Reflex Sympathetic Dystrophy: Rx | Early referral to a pain specialist; neuroleptic pain meds (Neurontin, Lyrica); Regional sympathetic nerve blocks; PT
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| Locations of sarcomas | Ewing: diaphysis of long bones, flat bones, ribs. Osteosarcoma: metaphysis of long bones. (ED / OM)
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