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USMLE2 Surgery 3

Ortho

QuestionAnswer
uneven gluteal folds, hips in a child that "clicks and snaps." what is it? How to dx it? How to tx it? Developmental dysplasia of the hip. Clicking is the posterior dislocation of the hip and the snap is it returning to normal position. Dx by US (not xray - since cartilage not seen well on xray). Tx is splinting and Pavlik harness in abduction.
Hip pathology generally presents with what? (2) either hip pain OR knee pain
child age 6, insidious development of limping, decreased hip ROM, antalgic gait. What is it? How to dx? And how to tx? Legg-Perthes (avascular necrosis of the capital femoral epiphysis). Dx with hip xrays. Tx with casting and crutches.
Chubby (or lanky) boy age 13, L groin or knee pain, limping. When sitting w legs dangling, sole of L foot points toward R foot. When hip is passively flexed, thigh goes into ext rot and can't be internally rotated. What is it? How to dx? And how to tx? Slipped capital femoral epiphysis (orthopedic emergency!! Because can lead to avascular necrosis). Dx with xray. Tx with surgical pinning of the femoral head in place
Toddler after a febrile illness refuses to move hip. Hold the leg with the hip flexed in abduction and external rotation. What is it? How to dx? And how to tx? Septic hip. Dx with aspiration of the hip under general anesthesia. Tx with open drainage if aspiration reveals pus.
Genu varum. What is it? What age is it normal? When would it not be normal? Bow legs. Normal from 0 to 3 yo. After 3, most likely Blount disease (disturbance of medial proximal tibial growth plate) - tx with surgery.
Genu valgus. What is it? What age is it normal? How to treat? Knock knees. Normal between 4 and 8. No tx.
How to tx Osgood Schlatter disease? Osteochondrosis of tibial tubercle. Tx with immobilization in extension or cylinder case for 4 to 6 weeks.
Club foot (talipes equinovarus). How to tx? Serial plaster casts. If not corrected after 6 to 8 months, surgical correction before age 2.
When would fractures in children be a bigger problem? Humerus fractures that are supracondylar --> can lead to Volkmann contracture (claw hand 2/2 vascular/nerve injuries); fractures that involve the growth plate (2/2 uneven growth if growth plates aren't set perfectly evenly)
When would you have to surgically correct fracture in a child that involved the growth plate? if growth plate is in >= 2 pieces. Need ORIF.
Sunburst pattern in bone in child 10 to 25 yo. Osteogenic sarcoma.
Onion skinning in child 5 to 15 yo Ewing sarcoma
Lytic bone tumor in a 50 yo woman. What should you check? For breast CA because breast CA mets are lytic lesions in bone.
Blastic bone lesion in older man. What should you check? PSA for prostate CA because that's how its mets present.
Punched out lytic bone lesions in old man with fatigue, anemia. consider multiple myeloma; tx with chemo (in child, can do BMT). If chemo fails, can use thalidomide
How to tx a clavicular fracture? figure of 8 immobilization device for 4 to 6 weeks
Most common shouler dislocation. How would the pt present? How to dx? anterior; pt holds arm close to body but rotated outward as if shaking hands; dx with xray
when would you get a posterior shoulder dislocation? epileptic seizure or electrical burn - massive uncorrdinated muscle contractions
old osteoporotic woman falls on outstretched hand. What bone is broken and how to tx? fracture of distal radius (Colles fracture), tx with closed reduction and long arm cast.
Pt was in altercation with police and arm was broken from hit by police nightstick as pt raised arm to protect his head. What is it and how to tx? Monteggia fracture - proximal ulna is broken with anterior dislocation of radial head. Tx with ORIF.
young adult falls on outstretched hand, has wrist pain, tenderness to palpation over snuff box. X-ray negative. What is the problem and how to tx? Fracture of the scaphoid bone. Tx with thumb spica cast. Xray will show fracture 3 weeks later.
young adult falls on outstretched hand, has wrist pain, tenderness to palpation over snuff box. X-ray shows displaced and angulated fracture of scaphoid. How to tx? ORIF
Why are scaphoid fractures particularly dangerous? high rate of non-union.
old person on a gurney with one leg shorter than the other and externally rotated hip fracture
fracture of the femoral head - how to tx? replacing femoral head with prosthesis - faster healing and earlier mobilization (this is because the femoral head has a very tenuous blood supply which causes slow healing)
how to tx intertrochanter fractures. What else should you treat for? ORIF with pins. High risk for DVT and PE so post-op should get anticoagulation.
how to tx a fracture of the femoral shaft intramedullary rod fixation. If it's an open fracture, it's an ortho emergency and needs to be cleaned and closed within 6 hrs.
person with BL fractures of the femoral shaft is at risk for what? can lose enough bloods to go into shock
2 tests for ACL injury. How to dx and treat? anterior drawer test (knee flexed 90) and Lachman test (knee flexed 20). Dx with MRI. Tx sedentary pt with immobilization and rehab. Tx athlete with arthroscopic reconstruction.
How to dx meniscal tear in knee? MRI
Knee catching and locking with movement meniscal injury
What is a future complication of complete removal of the meniscus in the knee? degenerative arthritis
Loud popping from ankle. What is it and how to tx? Rupture of Achilles tendon. Tx with casting in equinus position or surgery.
What is broken in fracture of the ankle? How to dx and tx? both malleoli. Dx with xray and Tx with ORIF if fragments are displaced.
Where does compartment syndrome occur most frequently? forearm or lower leg
How to tx an open fracture broken bone sticking out through wound. Must clean in OR and reduce within 6 hrs from the time of injury.
head on car collision and knees hit the dashboard - what injury to look for? How does this injury present? posterior dislocation of the hip - leg shorthened on the stretcher, adducted, internally rotated. This is an emergency and needs reduction to avoid avascular necrosis (blood supply to the femoral head is very tenuous)
Tx for gas gangrene IV PCN, surgical debridement, hyperbaric O2
Pt can't dorsiflex wrist, but regains function when fracture is reduced. What to do? What if function is not regained after reduction? Injury of radial nerve. If it gets better, no need for surgical exploration. However, if nerve paralysis doesn't get better after reduction --> entrapment of radial nerve and surgery is required.
Posterior dislocation of the knee. What should you worry about? Injury to popliteal artery. Check pulses, Doppler, and arteriogram.
Pt falls from tall height and land on feet. What injuries must you think about beyond the obvious foot/leg fractures? Lumbar or thoracic spine
What if the treatment for carpal tunnel syndrome? Splints and anti-inflammatory agents. If that doesn't work, then EMG --> surgery.
How to tx trigger finger? Finger flexed and can't extend it unless pull with it with the other hand. Tx with steroid injection. Surgery is last resort.
Old man of Norwegian descent has a contracture in the palm of his hand with nodules. What is it and what is the tx? Dupuytren contracture. Surgery is only effective tx -- done when hand can no longer be placed flat on the table.
What is a felon? How to tx? abscess in pulp of fingertip caused by neglecteing a penetration injury. Tx with surgical drainage or there will be tissue necrosis.
Gamekeeper thumb - how to tx? injry of UCL (ulnar collateral ligament) caused by hyperextension of thumb. Tx is by casting.
Pt injures finger playing soccer and gradding opponent's jersey as he is running by. How does pt present and how to tx? Jersey finger - injury when flexed finger is forcefully extended - injury of flexor tendon. Presents with not being able to flex the finger when the rest of the hand is in a fist. Tx with splinting.
What is the opposite of the Jersey finger? Mallet finger - injury from extended finger being forcefully flexed (i.e. in volleyball) - rupture of extensor tendon. Tx with splinting.
Pt bends over and feels an electrical shock that shoots down the leg and exits on in the big toe. What is the tx? Lumbar disc herniation. Tx is bed rest for 3 weeks, pain control. Surgery if neuro deficits are progressing.
Cauda equina syndrome spinal cord injury that causes distended bladder, flaccind rectal sphincter, and perineal saddle anesthesia -- surgical emergency!
HLA B-27 associated with what? Ankylosing spondylitis, uveitis, IBD.
ulcer at pressure point (heel, metatarsal heads, tips of toes) diabetic ulcers
ulcer at the tip of toes, pale base, no granulation tissue arterial insufficiency ulcer
ulcer in a leg that chronically edematous, indurated, and hyperpicmented, above the malleolus, painless, has granulation tissue venous stasis ulcer
What should you evaluate a pt for when they have chronic foot ulcers? DM and atherosclerosis
Older overweight pt who has disabling sharp heel pain every time foot strikes the ground, worse in AM, xray shows a bony spur matching location of pain, TTP over the spur. What is it and how to tx? Plantar fasciitis. Tx with analgesic and rest. Will spontaneously resolve in 12 to 18 months. Surgical resection of the bony spur is NOT indicated.
nodule is palpated between the third and fourth toes in a woman who wears pointed high heel shoes every day. What is it and how to tx? Morton neuroma - inflammation of the common digital nerve. Tx with analgesics and better shoes. Surgical excision can be done if still sxmatic.
Created by: christinapham