Download MBBS (Bachelor of Medicine, Bachelor of Surgery) Orthopedics 1st Year Handwritten Notes, 2nd Year Handwritten Notes, 3rd Year Handwritten Notes & Final Year Handwritten Notes (Lecture Notes)
? Test questions are part of the "trauma"
section
? Remember, an orthopod can do this
? It is not ALL fractures
? Ligamentous injuries, tendon problems, joint
dislocations and associated injuries seem to
be disproportionately important
? Part of day in / day out EM
? Focused review should suffice for the exam
2
Fracture Complications
? Compartment syndrome
? Fat emboli (long bones)
? Nonunion, malunion
? Arthritis
? Avascular necrosis
? Osteomyelitis
3
Anatomy of a Growing Bone
4
Salter Fractures (1)
? SALTER Mnemonic
1 (S) = Slip through growth plate
2 (A) = Above the level of the growth plate
Assumes shaft of bone is proximal to
epiphysis (e.g., knee joint and
femur)
3 (L) = Lower than growth plate
4 (T) = Through the growth plate
5 (R) = Ram the growth plate
5
Salter Fractures (2)
S=
A =
L =
T =
eR =
Slipped
Above
BeLow
Through
Ram
6
Salter Fractures (3)
? Epiphyseal growth plate is weaker than supporting
ligaments
? Long bones in children
? All involve growth plate or joint surface
? May result in growth complications
? Growth complications increase from I-V
? X-ray may be negative for types I and V
? Salter II most common
Complication of S-IV, S-V: future growth impairment
Crush injury (Salter V) has worst prognosis
(no further bone growth)
7
Salter-Harris Type I Fracture
8
Salter-Harris Type II Fracture
Med-Chal enger ? EM
9
Salter-Harris Type III Fracture
10
Med-Chal enger ? EM
Salter-Harris Type IV Fracture
11
Salter Fracture Facts (1)
? Core concept: Physis (growth plate) is composed
of cartilage cel s ? not visualized on X-ray) weaker
than supporting ligaments
? Blood supply to the growth plate comes through
the epiphysis. The worse the injury to the
epiphysis, the greater the likelihood of growth
disturbances
? Type I least likely to be associated with growth
disturbances, type V most likely
? Most common ages: 10 to 16 (80%)
? Mostly males (due to delayed skeletal maturation
compared to females and more physical activity)
12
Salter Fracture Facts (2)
? Type I, 6%, mostly infants and toddlers
? Type II, 75%, growth problems uncommon
? Type III, 10%, growth problems related to
? Extent of epiphyseal injury
? Size of the fracture fragment
? Amount of fragmentation
? Type IV, 10%, same as above, most commonly
distal humerus
? Type V, 1%, usual y due to crush / compression
associated with severe abduction or adduction /
knee & ankle most commonly
13
14
Distribution of the Sensory Nerves of the Hand
M
M
U
R
U
R
15
The Nerves of the Hand
Sensory
Motor
Radial Nerve
Dorsal web space Extension of
between thumb
fingers and wrist
and index finger
Median Nerve
Thumb, index,
Thumb opposition
long and ? of ring and flexion of
finger
index and middle
fingers
Ulnar Nerve
? of ring and little Finger adduction
finger
and abduction;
flexion of ring and
little fingers
16
The Million Dollar Nerve
? The recurrent median nerve
? Purely motor to the thenar muscles
? Motor exam of the thumb is complex with
opposition and abduction
? Exam is difficult especial y with volar 1st web
space injuries
A Pure Sensory Nerve Too
? Dorsal branch of the radial nerve is a purely
sensory nerve
17
Recurrent Branch
of the Median Nerve
Draws 1st metatarsal lateral y to
APB - abducts thumb
oppose thumb toward the center of
and helps oppose it
the palm and rotates it medial y
18
FPB ? flexes thumb
Amputation Care (1)
? In a plastic bag in ice water (not directly in water)
? Thumb has better outcome proximal to IP joint
? Distal third of fingertip doesn't need graft in smal
children
? General indications for replantation
?Multiple digits
?Thumb
?Single digit between PIP & DIP (distal to the
superficialis insertion)
?Metacarpal (palm)
?Wrist, forearm
?Almost any part in child
19
Amputation Care (2)
Clean and Sharp is Best
Amputated Part Storage
20
Boutonniere Deformity
? Central slip extensor hood disruption near PIP
joint
? Forced flexion at PIP joint
? Lateral bands of extensor hood split and become
PIP flexors
? +/- avulsion fracture
? Deformity (PIP flexion and DIP extension)
? Treatment: splint PIP in extension
21
Boutonni
ere Deformity
Disruption of the central extensor
mechanism allows the PIP joint to
protrude through the extensor
hood
Displaced intact lateral components
of the extensor mechanism hold the
DIP joint in extension while flexing
the PIP joint.
22
Med-Chal enger ? EM
Felon (1)
? Staph. aureus
? Pulp space infection
? Distal fingertip
? Treatment: I&D, antibiotics
23
Felon (2)
Pus
The fibrous septa tend
to loculate the infection.
The optimal incision site is where
the infection points, or over the area
Med-Chal enger ? EM
of greatest fluctuance.
24
Felon (3)
25
Paronychia (1)
? Nailbed infection
? Acute infection
usual y Staph
? Chronic infection:
? C. albicans, other fungi
? Moist hands (dishwashers, bartenders)
? Treatment: I&D, soaks, ABX not indicated
? Consider osteo if not improving
? DO NOT I&D herpetic whitlow
as this wil often result in
herpetic myositis
26
Paronychia (2)
27
Paronychia (3)
Med-Chal enger ? EM
Paronychia Drainage: Simple Paronychia
28
Collar Button Abscess
? Palmar aponeurosis prevents extension volarly
? Pus spreads between MC bones and erupts dorsal y
creating a hand abscess
? A volar and dorsal abscess
connected by a tract
? Look for splinter/FB on the palm!
Sporotrichosis
? Rose gardener
? Fungal infection with
skip lesions
? SSKI or itraconazole treatment
29
Gamekeeper's (Skier's) Thumb
? Ulnar col ateral ligament (UCL)
of thumb MCP joint
? UCL critical for pincher
and grasp function
? Forced radial abduction
MCP joint
? Associated avulsion
fracture is common
? Treatment
? Partial tear: thumb spica splint
? Complete tear: surgery
? Complication: chronic instability
? Bul rider's thumb = RCL injury
30
Mallet Finger (1)
? Extensor tendon disruption (DIP)
? Forced flexion of DIP (bal striking a ful y extended
digit)
? Avulsion fracture dorsal base of distal phalanx
? +/- avulsion fracture
? Treatment: splint in extension, hand referral
31
Mallet Finger (2)
32
Med-Chal enger ? EM
Mallet Finger (3)
Tear of
Avulsion fracture
Deformity resulting
extensor
of dorsal base of
from inadequate
tendon
distal phalanx
treatment
33
Metacarpal Fractures (Neck)
? Fracture of the metacarpal neck is most common
hand fractures
? Boxer's fracture: fracture of the neck of 5th mc
? All have volar angulation
? Ring & 5th mc tolerate greater angulation
?Ring < 35?, 5th < 45?
?Ulnar gutter splint
? Index and middle fingers
?Less mobility, tolerate less angulation (<15?)
?Radial gutter splint
Rotational displacement = unacceptable
34
Boxer's Fracture
35
Med-Chal enger ? EM
Metacarpal Fractures (Shaft)
? Angulation is unacceptable for 2nd and 3rd
metacarpals
? Angulation amounts that are acceptable:
Index 10? Long 20? Ring 30? Smal 40?
? All rotational deformities must be corrected
? Operative fixation is usual y required for 2nd
and 3rd metacarpals
? Ulnar gutter splints usual y fail to maintain any
significant correction of angulation
? Short-arm casting with "outriggers" do work
36
Metacarpal Fractures (Head)
?Intraarticular fractures
?Direct trauma or crush
?Laceration over MCP
suspect human bite
?Any displacement
gives poor outcome
?All require hand referral
37
Metacarpal Fractures (Special)
Bennett's Fracture
? Axial load with hand closed
? Ulnar aspect of base of thumb at metacarpal joint
? Intraarticular with dislocation or subluxation at the
CMC joint
? Anatomical reduction required, ORIF
Rolando Fracture
? Comminuted intraarticular, requires ORIF
? No subluxation dislocation of CMC joint
? Worse prognosis
Thumb spica + emergent ortho referral
38
Bennett's Fracture | Rolando Fracture
39
Flexor Tenosynovitis (1)
? Secondary to puncture wound of volar surface:
especial y cat bites
? Kanavel's signs
?Diffuse fusiform swel ing, erythema
?Pain on palpation proximal sheath
?Severe pain on extension
?Held in slightly flexed position
? Treatment: surgical I&D
40
Flexor Tenosynovitis (2)
41
Fingertip Injuries
? Zone 1: 2/3 of proximal nail bed preserved, no bone
exposure, heals with secondary intention
? Require surgical treatment
? Zone 2: exposed bone
? Zone 3: loss of entire nail bed plus exposed bone
ZONE II
International Classification
42
Finger Dislocations (1)
? DIP dislocation is uncommon
? PIP dislocation is common
? Dorsal dislocation very common (rupture of volar
plate, ulnar deviation 2? RCL rupture)
? Reduction: digital block: distraction and slight
hyperextension, then repositioned
? Splint at 30 ? flexion, refer
? Can't reduce?? (due to volar plate entrapment )
? MCP
? Less common then PIP dislocation
? Hyperextension, rupture of volar plate, dorsal
dislocation
? Volar plate is commonly entrapped in joint space
making closed reduction impossible
43
Finger Dislocations (2)
44
Finger Facts
? High pressure injection injury: OR
? Subungual hematoma requires
trephination
? Flexor digitorum profundus (FDP)
?Flexion of DIP joints
?Test: immobilize MCP
and PIP of same digit
? Flexor digitorum superficialis (FDS)
?Primary flexor of PIP
?Test: immobilize MCP and IP
of adjacent digit
45
Intrinsic Plus Splinting
"Safe Position"
20o
? Metacarpal and unstable proximal / middle
phalanx fractures
? Decrease "freeze" at MCP
? Decrease "freeze" at PIP
? "Blade of the hoe" position
46
Splinting Position
of the Hand
The thumb is
abducted slightly
away from the palm
Distal wrist / carpal fractures
47
Med-Chal enger ? EM
48
Colles' Fracture (1)
? Most common fracture in adults >50
? Distal radius at the metaphysis
? Dorsal displacement
? "Dinner fork" deformity
? Ulnar styloid fracture is common
? Treatment: closed reduction
Complication: median nerve injury
49
Colles' Fracture (2)
50
Colles' Fracture (3)
51
Smith's Fracture (1)
? "Reverse Col es"
? Volar displacement of distal radius
? Associated median nerve
and flexor tendon injury
? Closed reduction
Triquetrum
Fracture
? Most common dorsal
chip fracture of the wrist
? Pain on dorsum of wrist and ulnar styloid
? Painful to flexion
52
Smith's Fracture (2) Med-Chalenger ? EM
53
Guyon's Canal Syndrome
? A palmar ligament connects the pisiform and the hamate
forming a tunnel = Guyon's canal
? The ulnar nerve runs in this canal and is subject to
entrapment within it
? Cause numbness and tingling in the ring and smal finger
? Causes = canal cyst, repetitive trauma (cyclist [handlebar
neuropathy], golf, hitting basebal s)
? Splint
? Surgical y
decompress
54
Scapholunate Dissociation
?Most common ligamentous
injury of hand
?Commonly missed
?Fall outstretched hand
?> 3 mm widening of
scapholunate space
?Thumb spica, hand referral
>3 mm
55
Perilunate / Lunate Dislocation (1)
? Forceful hyperextension
? Median nerve injury common
? Lateral X-ray (most helpful)
Perilunate: capitate displaced, lunate aligned
Lunate: capitate aligned, lunate displaced
? X-ray: "piece of pie"
? Lunate fracture associated with avascular
necrosis
Complications: median nerve injury, scaphoid fracture
56
Perilunate Dislocation (2)
Scaphoid
Capitate
Lunate
57
Lunate Dislocation
Lunate
Capitate
58
Scaphoid Fracture
? Most common carpal fracture
Tenderness in "snuff box"
? Initial X-rays may be negative
? Thumb spica splint
Complication: avascular necrosis
? Repeat X-ray in two weeks (or bone scan in 3
days) or CT or MRI
59
Ulna, Radius, and Scaphoid Fracture
60
Med-Chal enger ? EM
High Pressure Injection Injuries
? Substance under high pressure is injected into the hand
? Grease, paint, hydraulic fluid
? Oil-based paint causes the most severe reaction (ischemia,
possible amputation)
? X-ray for radiopaque substance, subcutaneous air
? Complications: compartment syndrome, ischemia
? May appear benign initial y
? Requires emergency d?bridement and decompression
61
62
Carpal Tunnel Syndrome
? Entrapment of the median nerve
? May be worse at night
? Tinel's sign: tap volar wrist
paresthesias
? Phalen's sign: hyperflex wrist
paresthesias
? Risk factors: pregnancy, hypothyroid, DM, RA
DeQuervain's Tenosynovitis
? Overuse syndrome
? Dorsal and radial compartments
of the wrist
? Finkelstein's test: ulnar deviation
of the fisted hand reproduces pain
? Treatment: splint, NSAIDs, rest
63
Galeazzi Fracture (1)
? Distal radial fracture, usual y displaced
? Disrupted distal radio-ulnar joint
? Pain and swel ing of wrist
? Complication: ulnar nerve injury
? Treatment: ORIF
Galeazzi
G M
Radial fx
Ulnar fx
R
Monteggia
U
64
Galeazzi Fracture (2)
Galeazzi
Radial fx
Ulnar fx
Monteggia
65
Monteggia Fracture (1)
? Proximal ulnar shaft fracture, usual y displaced
? Proximal radial head dislocation
?Annular ligament disruption
? Pain and swel ing of elbow
? Complications
? Radial head fracture
? Radial nerve injury
? Nonunion
? Treatment in adults: ORIF
66
Monteggia Fracture (2)
Galeazzi
Radial fx
Ulnar fx
Monteggia
67
Med-Chal enger ? EM
Essex-Lopresti Injury
? Radial head fracture
? Dislocation of distal RU joint
? Interosseous membrane
disruption
? ORIF general y needed
? Severe wrist pain with
"negative" wrist films
? FOOSH mechanism
68
Ulnar Nightstick Fracture (1)
? Nondisplaced ulnar shaft fracture
? Common defense injury
? Complications include
? Missed Monteggia fracture
(radiohumeral dislocation)
? Radial nerve injury
? Nonunion
? Treatment
?Nondisplaced: splint, early ROM
?Displaced fracture may require ORIF
69
Ulnar Nightstick Fracture (2)
70
Both Bone Forearm Fracture (1)
? Requires great amount of force
? Nondisplaced fractures are very rare
? Requires ORIF
? Closed reduction is possible in children
? Complications
?Reduced ability to supinate and pronate
?Nonunion
?Neurovascular injury
Beware of Compartment Syndrome
71
Both Bone Forearm Fracture (2)
72
Volkmann's Contracture
? Inadequate circulation to the forearm
? Result is forearm pronation, flexion of wrist and
digits, paralysis of intrinsic muscles
? Caused by many compressive states
? Pain, digit swel ing and paraesthesias
? Seen with elbow and forearm fractures, tight
casts
? Irreversible damage in 6 hours
Patient with cast complaining of pain
and numbness in hand: cast must be
removed immediately
73
74
Nursemaid's Elbow
? History of being pul ed or swung by arm
? Forearm flexed and pronated, child reluctant to
move arm
? Subluxation of the radial head beneath the
anular ligament (becomes entrapped)
? Tear of annular ligament
? Peak ages 1-4
? X-rays not necessary
? Reduction: supinate forearm and flex elbow
75
Olecranon Bursitis (1)
? Acute or chronic inflammation of
bursa
? Common bursae affected:
olecranon (student's elbow),
prepatel ar bursa (carpet layer's
knee)
? Repetitive minor trauma (leaning
on elbow at work)
? Septic and nonseptic bursitis can
be difficult to distinguish
? Minimize labs
? Avoid I & D : aspirate instead
76
Olecranon Bursitis (2)
? Must consider septic bursitis
?Abrupt onset
?Swol en, hot, erythematous, tender
? Aspiration of bursal fluid is therapeutic and
diagnostic
? Septic bursitis
?Staph, Strep, MRSA
?Some may need IV antibiotics, debridement, open
irrigation and admission (most do not)
? Nonseptic
?Splint, elevate, compressive dressing
77
Epicondylitis
? Lateral (tennis elbow)
?Forearm extensor muscle
overuse
?Pain in lateral elbow with
wrist extension
?Treatment: avoidance,
rest, NSAIDs
? Medial (Little League elbow)
?Golf, throwing, pitching
?Forearm flexor muscle overuse
?Pain in medial elbow. Grip decreased 2? pain
?May have ulnar neuritis (paresthesias of ring and
smal fingers)
78
Elbow Dislocation
? Majority are posterior
? Vascular injury: brachial artery (consider angio)
? Nerve injury: ulnar nerve most common
? Medial epicondyle fractures common in children
? Treat early to avoid articular cartilage damage
? Avoid hyperextension to prevent bleeding
? Stability depends largely on coranoid fracture
79
Posterior Elbow Dislocation
Recheck vascular status
post-reduction to R/O
brachial artery injury from
the PROCEDURE!
Coronoid process
fracture
80
Med-Chal enger ? EM
Elbow Radiographic Abnormalities
? Fat pad sign
?Posterior fat pad is never
normal
?Intraarticular hemorrhage
?Intracapsular hemorrhage
?Occult radial head fracture
?Also seen with gout, vil onodular synovitis, and
some infections
? Anterior fat pad
?Smal fat pad may be normal
?Large fat pad (sail sign) is abnormal
81
Radial Head Fracture (1)
? Fal on outstretched hand (FOOSH)
? Radial head is driven against the capitel um
? Pain with passive rotation of the forearm
? Most common "occult" elbow fracture in adults
? Fracture classification
?Type I: nondisplaced
?Type II: marginal impaction, displacement and
angulation
?Type III: comminuted radial head
?Type IV: any of the above plus elbow
dislocation
82
Radial Head Fracture (2)
? Treatment
?Type I: brief sling and early range of motion
?Type II: same as type I, unless no
improvement or mechanical block
?Type III: radial head excision
?Type IV: treated for both dislocation and
fracture
83
Radial Head Fracture - Fat Pad Sign
84
Med-Chal enger ? EM
Supracondylar Fracture (1)
? Can be complete or incomplete
? Most common occult elbow fracture in children
? Posterior displacement (due to extension)
Rule out median nerve injury
? Complications
?Brachial artery and median nerve injury
?Vascular compromise
?Forearm compartment syndrome
?Volkmann's contracture
? X-ray may show posterior fat pad sign
? Displaced fractures require hospitalization for
neurovascular checks
85
Supracondylar Fracture (2)
86
Med-Chal enger ? EM
Anterior Humeral Line Test (1)
? Used to pick up "occult" supracondylar fractures
Anterior humeral line
? Normal: bisects middle
third of capitellum
Normal anterior humeral line in association
Abnormal: bisects the anterior
with anterior and posterior fat pads and a
third of the capitel um or
nondisplaced radial head fracture
passes in front of it
87
Anterior Humeral Line Test (2)
88
Normal
I
ncomplete supracondylar fracture
89
Shoulder Pain
? Extrinsic causes: cardiac, infectious, pulmonary,
abdominal (spleen) and neck
? Intrinsic causes
?Impingement syndrome: result of repetitive
overhead arm use. Includes rotator cuff
tendinitis, subacromial tendinitis and bursitis,
decreased active range of motion, ful passive
range of motion
?Adhesive capsulitis: painful and limited active
and passive range of motion, usual y
associated with a period of immobilization
90
Shoulder Dislocation Anatomy
? Axil ary nerve injury
? Suprascapular n. for
peripheral blocks
? Suprascapularis pul s
off the greater tubercle
? Rotator cuff = SITS
muscles
?Supraspinatus
?Infraspinatus
?Teres minor
?Subscapularis
91
Anterior Shoulder Dislocation (1)
? Mechanism: indirect forced abduction, extension and
external rotation
? Arm held in slight abduction and external rotation
? Subcoracoid is the most common type
? Hil -Sachs lesion: notch on posterior humeral
head (impression fracture)
? Bankart's lesion: labral tear +/- erosion or anterior
glenoid rim fracture
?Leads to joint laxity
?Younger patients, initial injury
? X-ray: need scapular "Y" and AP views
Complications: axillary nerve injury,
rotator cuff injury, avascular necrosis, adhesive capsulitis
92
Anterior Shoulder Dislocation (2)
Hill-Sachs Lesions
Hil -Sachs lesion = a compression fracture of the
posterolateral articular surface of the humeral head. Is
caused when the humeral head passes over the edge of the
anterior glenoid fossa.
It predisposes to recurrent dislocations
93
Anterior Shoulder Dislocation (3)
External Rotation for
Unstable / Recurring
Dislocations
94
Posterior Shoulder Dislocation
? Direct anterior blow to adducted and internal y
rotated arm
? Commonly missed on exam (can be bilateral)
Can result from fal s, seizure, electric shock
? Most common is the humeral head behind the
glenoid and beneath the acromion
? Arm is adducted and internal y rotated
? The scapular X-ray "Y" view is diagnostic
? Most complications are fractures
? Neurovascular injuries are less common than in
anterior dislocation
95
Rifle Barrel / Light Bulb Signs
Loss of normal elliptical overlap of
glenoid & humeral head
96
Luxatio Erecta
? Forearm locked over forehead
? Rarest of dislocations
? Forceful hyperabduction
? Treatment: traction
up and out
? Severe rotator cuff
injuries are the rule
? Scapular rotation STILL works
? Same neurologic injuries
97
Clavicle Fracture (1)
? Middle third
?Most common fracture in children
?Most involve middle third
?Treatment: sling
? Distal third
?Distal can be associated with ruptured coraco-
clavicular joint with significant medial elevation
?Treatment: depends on displacement
?Sling
?Displaced: ortho referral for ORIF
98
Clavicle Fracture (2)
? Medial third
?Uncommon
?Requires strong injury forces
?Diligent search for associated injuries
? Indications for surgery
?Displaced distal third
?Open
?Bilateral
?Neurovascular injury
Medial third: consider intrathoracic trauma
(subclavian artery and vein)
99
Clavicle Fracture (3)
Surgery
100
Humerus Fracture (1)
? Proximal fracture
? Injury to axil ary nerve
? Test deltoid sensation
? Midshaft distal fracture
? Radial nerve injury is common
? Test wrist drop and 1st web space sensation
? Rule out pathological fracture (e.g. multiple
myeloma)
101
Humerus Fracture (2)
? Midshaft fracture
? Spiral groove
? Radial nerve
? Wrist drop common
? Often a sling is enough
102
Rotator Cuff Injuries
? >40 years old
? Associated with muscle weakness and atrophy
? abduction and external rotation plus cuff
tenderness
? Supraspinatus, infraspinatus and teres minor
insert on greater tubercle ("SIT" muscles)
? Subscapularis inserts on lesser tubercle
? Unable to abduct or externally rotate
? Partial tears are more common
? Supraspinatus is most commonly injured
? MRI is diagnostic
103
Thoracic Outlet Syndrome (1)
? Compression of the brachial plexus, subclavian
vein or artery as they pass through the thoracic
outlet
? Associated with cervical rib
? 3 Types
?Neurologic
? Most common
?Venous
?Arterial
? Least common, most serious
104
Thoracic Outlet Syndrome (2)
? Most reliable test: elevated arm stress test
(EAST)
?Test for al 3 types of thoracic outlet syndrome:
raise hands above head, then open and close
fist for 3 minutes
?Positive test: unable to complete, paresthesias,
claudication
? Adson's test: palpate both radial pulses while
patient turns head from side to side. Loss of pulse
is a positive test (only tests for arterial thoracic
outlet syndrome)
105
106
Pelvic Fractures (1)
? MVCs and fal s
? Type I: avulsion (single bone)
?Conservative treatment
? Type II: single ring fracture
?Examples: ipsilateral rami, subluxation of
symphysis pubis
?Rare: look for type III, associated visceral
injuries
?Conservative treatment
107
Pelvic Fractures (2)
? Type III: double ring fracture
?Unstable, associated GU and visceral injuries
?Life-threatening hemorrhage more likely with
posterior fractures
?Immobilization
?External or internal fixation
?Early orthopedic consultation
?Embolization for treatment of hemorrhage
? Type IV: acetabulum fracture
?High energy (MVC) injuries
?Displaced fractures require surgery
108
Pelvic Avulsion Fracture
ASIS
All are
stable
Ischial tuberosity
109
Pelvic Disruption
"Open Book"
110
Malgaigne Disruption
Hemipelvic Migration
111
Stable Pelvic Fractures
112
Straddle Pelvic Fractures
113
The Hip
114
Hip Fractures
? Symptoms may be subtle (CT, MR when in doubt)
? External rotation, flexion, shortening
? Intertrochanteric fracture most common
? Femoral neck fractures in elderly females
? Subtrochanteric fractures (high energy) in young
Complication: aseptic necrosis
(femoral neck fracture)
115
116
Anterior Hip Dislocation
? Uncommon
? Groin mass
? External rotation
? Reduce ASAP
Posterior Hip Dislocation (1)
? Most common
? Mechanism: direct force
(knee vs. dashboard)
? Internal rotation, flexed,
adducted, shortened
? Reduce ASAP
? Complications: sciatic nerve, AVN
femoral head
117
Posterior Hip Dislocation (2)
Posterior
Anterior
118
Posterior Hip Dislocation (3)
119
Legg-Calve-Perthes Disease (1)
? Boys, ages 4-8. Presents with limp
? Idiopathic avascular necrosis of the femoral
head
? Sometimes bilateral
? X-rays may be normal (consider MRI)
? Bone scan is diagnostic
? Temperature and ESR are normal
Pain and limp are early signs
120
Legg-Calve-Perthes Disease (2)
121
Septic Arthritis
? Most common cause of painful hip in infants
? Hematogenous spread
? S. aureus (most common)
? Salmonel a in sickle cel
? N. gonorrhoeae in adolescents
? Dx: needle aspiration
Slipped Capital Femoral Epiphysis (1)
? Obese male adolescents, ages 10-16
? Etiology is unknown, may be bilateral
? Pain referred to knee, gradual onset
? X-ray "melting ice cream cone", AP, frog-leg
view
?
122
Treatment: ORIF
Slipped Capital Femoral Epiphysis (2)
123
Transient (Toxic) Synovitis
? Cause is unknown
? Associated with recent viral infection, al ergic
reactions, trauma
? Limp or inability to bear weight
? May have low grade fever and elevated ESR
? Diagnosis of exclusion (rule out septic hip)
? Treatment: NSAIDs, analgesics, home care
Most common cause of painful hip in children
124
The Femur
125
Femur Fracture (1)
? Males, fal s, MVAs
? Severe pain, unable
to bear weight
? Complications: hemorrhage,
neurovascular injury, fat emboli
? Splint the leg with traction splint
? Treatment: ORIF
? Potential major blood loss
126
Traumatic Myositis Ossificans
? Formation of bone
in muscle after injury
? Thigh muscles (quads)
most common affected
? Increased risk in
hemophilia and
thrombocytopenia
? Management: no weight bearing, ice, elevation,
wrap from foot to groin with knee flexed 90?
? Rest 2-3 days
127
128
Soft Tissue Knee Exam (1)
? ACL testing: secondary testing
?Lateral pivot shift test
? Valgus stress (pushing the lateral side of the knee
medial y), while simultaneously flexing the knee and
applying internal rotation of the foot
? A positive test: a "thud" or "jerk" at 10-20 degrees of
flexion (anterior subluxation of the tibia on the femur)
? Medial col ateral ligament (MCL) testing
?Perceived widening of the joint space when
medial pressure is applied over the lateral aspect
of the knee when the calf is stabilized
? Combined disruption of the MCL / PCL
?Manifest when medial pressure is applied over the
lateral aspect of the knee in extension and the
joint opens medial y
129
Soft Tissue Knee Exam (2)
BEST FOR ACL
130
Soft Tissue Knee Exam (3)
? McMurray test
? Patient supine / examiner grasps
heel and internal y rotates the leg
while applying valgus force on the
medial aspect of the knee
? A positive test is the detection
of a "popping" sensation, typical y
with associated joint line pain,
when the knee is ful y extended
from a flexed position (or locking)
? Apley compression test
? Patient supine on a low
table with knee flexed
? Examiner's shin is on
patient's thigh
? Pain on external rotation
of the tibia at the ankle
131
Soft Tissue Knee Exam (4)
MENISCUS
132
The "Terrible Triad"
? Significant force to the lateral aspect of the knee
? Medial col ateral ligament tear
? Medial meniscus
? Anterior cruciate (often hear / sense a loud "pop")
? Joint effusion present in the majority
Ottawa Knee Rules
? Age 55 or older
? Isolated tenderness of the patel a
? Tenderness at the head of the fibula
? Inability to flex to 90 degrees OR inability to bear weight
both immediately and in the ED (4 steps) (i.e. inability to
transfer weight twice on each lower limb)
? The rules are valid in children as wel as adults
133
Baker's Cyst
? Inflammation of the gastrocnemius bursa
? Painful, swol en popliteal fossa or calf
? Symptoms may mimic thrombophlebitis
? Dx: arthrogram or ultrasound
Osgood-Schlatter Disease (1)
? More technical name = patel ar tendon apophysitis
? Males 10-15 years, athletics
? Insidious onset, self-limited, traction injury to tibial
tuberosity, can be bilateral
? Pain, swel ing, erythema over ant. tibial tuberosity
? X-rays may be normal
? Treatment : NSAIDs, rest, avoid forced knee
extension
134
Osgood-Schlatter Disease (2)
Tibial Apophysitis
135
Osteochondritis Dissecans
? Subchondral fracture
? Cause unknown
? Adolescents, unilateral
? Medial femur most common
? X-ray may be negative
? Talar dome, capitel um
? Locked joint due to loose body
Patellar Dislocation (1)
? Adolescent females
? Usual y displaced lateral y
? Reduce by extension and manual medial
displacement
? Frequently recur
136
Patellar Dislocation (2)
137
Posterior Knee Dislocation
? Often reduce
? Reduce ASAP
spontaneously
? Arteriogram indicated
? Associated with injury to ? Signs of vascular injury
the popliteal artery
initially absent
? Peroneal nerve injury ? Delay of treatment >6-8 hrs
common
high amputation rate
138
Quadriceps Tendon Rupture
?Old, debilitated, steroids
?Fal , quadriceps
contraction with forced
knee flexion, inability to
extend knee
?Pain superior to patel a
?X-rays can show high-
riding patel a
139
Tibial Plateau Fracture (1)
? Axial compression and rotation
?Fal from height
?Auto vs pedestrian
? Bumper vs. knee
? CT may be helpful
? ORIF general y needed
? Associated injuries
?Neurovascular injury with unstable fracture
(acute or delayed)
?Lateral fractures: rule out deep peroneal nerve
injury (check first dorsal web space)
140
Tibial Plateau Fracture (2)
141
Tibial Plateau Fracture (3)
Comminuted (ORIF)
142
143
Compartment Syndrome
? Crush injury
? Pain, pal or,
? Fractures: distal radius,
paresthesia, paralysis,
proximal tibial shaft
pulselessness (5 "P"s)
? Prolonged compression
? Injury >30 mm Hg
? High pressure injection
? Indication for surgery:
injury
40-50 mm Hg
? Bleeding, infection,
? Irreversible damage
infiltration
?
4-6 hours
Bleeding disorders,
anticoagulants
? Treatment: fasciotomy
Most common: anterior tibial
compartment secondary to tibial fracture
The earliest symptom is pain
144
Gastrocnemius Rupture
? Forceful dorsiflexion with fal
? Athletic "push off" injury (tennis leg)
? Medial head most commonly injured
? Thompson's sign negative (calf squeeze
causes plantar flexion to occur and indicates
Achil es is intact)
? Differential: Baker's cyst, DVT
145
146
Achilles Tendon Rupture
? Diagnosis often delayed
? Middle aged men and basketbal
on ciprofloxacin....
? Sudden pain, "kicked in back of
ankle," feeling or hearing a "pop"
? Inability to palpate tendon or
defect noted, bulge or knot
palpated at proximal portion of
tendon
? Thompson test positive (failure
of the foot to plantar flex with calf
compression)
147
Ankle Dislocation
? Dislocation in four planes
?Anterior
?Posterior (most common)
?Lateral
?Upward displacement of talus (impaction)
? Associated with mal eolar fractures
? May be open
? Reduce emergently
? High incidence of complications
?Neurovascular compromise
?Conversion of closed to open
?Avascular necrosis
148
Ankle Dislocation
26
149
Ankle Dislocation
150
Ankle Sprains
? Most involve the lateral ligaments
? Anterior talofibular
? Calcaneofibular
? Posterior talofibular
? Most injuries are plantar flexion or inversion
? Deltoid ligament is medial. Isolated injury rare
? Treatment depends upon stability
?Unstable: splint, early orthopaedic referral
?Stable: rest, ice, compression and elevation
151
152
Med-Chal enger ? EM
Ottawa Ankle Rules
? Simple guidelines to identify patients with ankle or
midfoot injury who do not need X-ray
? Validated by numerous clinical studies
? Ankle X-rays are indicated if any of the fol owing
are present
?Inability to bear weight (both immediately and in
the emergency department),
?Bone tenderness along the posterior edge of
the distal 6 cm of either the lateral or medial
mal eolus
?Point tenderness over the proximal base of the
5th metatarsal
?Point tenderness over the navicular bone
153
Maisonneuve Fracture (1)
? External rotation of the ankle causing
?Rupture of medial ligament complex (deltoid
ligament)
?Associated proximal fibular fracture
? May require surgery
? Missed on ankle X-ray
Medial ankle tenderness & swelling:
consider Maisonneuve fracture
154
Maisonneuve Fracture (2)
Lateral mortise displacement + proximal fibular fracture
155
156
Calcaneal Fracture
? Mechanism: compression from fal
? Associated with
? Lumbosacral fractures
? Injury to the other calcaneus
? Other extremity injuries
? GU, renal injuries
? Most common tarsal bone fracture
? Bohler's angle (normal y 20-40o) may be
decreased with fracture
? CT may be indicated
? Harris view (axial view) is diagnostic X-ray
157
Bohler's Angle Diagram
158
Fifth Metatarsal Fracture (1)
? Dancer's
? Avulsion fracture base of 5th metatarsal
? At attachment of peroneus brevis
? Inversion injury
? Cast shoe only
? Jones'
?Transverse fracture
?Proximal diaphysis
?Common in athletes
? Running or jumping sports
?Increased incidence nonunion
?ORIF or cast
159
Fifth Metatarsal Fracture (2)
Dancer's
Fracture
160
Fifth Metatarsal Fracture (3)
Jones Fracture
161
Lisfranc's Fracture Dislocation (1)
? Tarsal-metatarsal joint
?Metatarsal base fracture
?Metatarsal dislocation
? Delay in diagnosis associated with long-term
morbidity
? Usual y 2? MVA
? Second metatarsal is critical for stability of the
midfoot (both transverse and longitudinal arches)
? May require ORIF
162
Lisfranc's Fracture Dislocation (2)
163
Tarsal Tunnel Syndrome
? Entrapment neuropathy
? Posterior tibial nerve (motor
to foot muscles and
sensation to the bottom
of the foot)
? Nocturnal pain is common
? Tinel's sign: tap on nerve
paresthesias
? Complication: "claw toe"
164
Other Foot Facts
? March fracture: stress fracture of the second
metatarsal, from pushing off
? Morton's neuroma: interdigital nerve neuropathy
? Metatarsalgia: pain, usual y in obese female with
recent weight gain
? Plantar fasciitis: sole pain (particularly painful
with first steps or arising in the morning)
? Sever's disease: apophysitis at Achil es tendon
insertion
165
Bone and Joint Infections
? Neonates: group B Streptococcus
? IVDA: Pseudomonas osteomyelitis
? Sickle cel : Gram negative osteomyelitis, Salmonel a
? Foot puncture wounds: Pseudomonas
? Cat bites: Pasteurel a multocida
? Fresh water wounds: Aeromonas
? Diabetic foot: polymicrobial
? Human bites: Eikenel a corrodens, Staph,
Strep, anaerobes
? Reptile bites: Salmonel a
166
Osteomyelitis (1)
? Trauma is common precipitating event
Early diagnosis: bone scan
? ESR usual y elevated
? Plain X-ray not helpful early in disease
? Femur and tibia common sites
Osteogenesis Imperfecta
? Children: blue sclerae, flaccid joints
? Frequent fractures, growth retardation
? Misdiagnosed as child abuse
? Fractures usual y stop after adolescence
167
Osteomyelitis (2)
168
169
Anatomy
? 4 lines
? Anterior longitudinal
? Posterior longitudinal
? Spinolaminar
? Spinous process
? Predental space
? Adults <3 mm
? Peds <5 mm
? Prevertebral space
?6 mm @ C2
?22 mm @ C6
170
4 Lines of C-Spine
171
Nerve Roots in the Arm
ROOT
REFLEX
SENSORY LOSS
MOTOR
DECREASED
WEAKNESS
C5
Biceps
Deltoid area
Deltoid (abduction)
Biceps (elbow
flexion)
C6
Biceps
Thumb and index Biceps (elbow
flexion)
Brachioradialis
Wrist extensors
C7
Triceps
Long finger
Triceps (elbow
extension)
C8
Little finger
Finger adduction
T1
Medial arm
Finger abduction
172
Nerve Roots in Leg
ROOT
REFLEX
SENSORY
MOTOR
DECREASED
LOSS
WEAKNESS
L4
Knee jerk
Knee, medial Knee
leg
extension
L5
Dorsum foot, Foot
big toe
dorsiflexion
S1
Ankle jerk
Lateral foot, Foot plantar
sole
flexion
173
C-Spine Injury (1)
? NEXUS study
? Patients who may not require C-spine X-rays
? Clinical criteria to rule out injury
?No posterior midline neck tenderness
?No intoxication
?No distracting injury
?Normal level of alertness
?No focal neurologic deficits
? 99% sensitive
174
C-Spine Injury (2)
? Cause: MVA most common
? Location: C5/6 most common in adults
? 10% of cervical fractures are associated with
another spinal fracture
? X-ray: 3 views (lateral, odontoid, AP)
Must see al 7 vertebrae
Adequate X-rays do not r/o fracture
175
C-Spine Injury (3)
176
Vertebral - Anatomy
Superior
Superior vertebral notch
articular process
Pedicle
Transverse process
Vertebral
Spinous
Body
process
Inferior vertebral notch
Inferior
articular process
Lamina
177
Stable Cervical Fractures
? Anterior subluxation
? Clay shoveler's fracture
? Posterior arch C1 fracture
? Unilateral facet dislocation
? Wedge fracture
178
Unstable Cervical Fractures
"Jefferson Bit Off A Hangman's Thumb"
? J - Jefferson Fracture (burst of C1)
? B - Bifacet dislocation +/- fracture
? O - Odontoid types II and III
? A - Any fracture/dislocation
? H - Hangman's fracture (posterior element C2)
? T - Teardrop fractures
179
Atlantoaxial Dislocation
? C1/2 disruption
? Rheumatoid arthritis, ankylosing spondylitis
? Unstable
Bilateral Facet Dislocation
? Flexion
? Unstable
? High incidence of cord injuries
? Subluxed >5 mm
180
Atlanto-Occipital Dislocation
181
C6-C7 Bilateral Facet Dislocation
182
Clay Shoveler's Fracture
? Avulsion fracture of spinous process
? C6, C7, T1
? Flexion injury
? Stable
Hangman's Fracture
? Bilateral fracture of the pedicles (neural arch)
of C2
? Forward displacement (traumatic
spondylolisthesis) of C2 on C3
? Unstable
? Extension mechanism
? Swischuk's line deviated >1.5 mm
183
C2 Pedicle Fracture
184
Hangman's Fracture
36
185
Jefferson Fracture
? Burst fracture of atlas (C1)
? Axial compression (e.g. diving injury)
? Lateral masses of C1 displaced outward
? Consider unstable
Posterior Neural Arch C1
? Hyperextension
? Stable when isolated fracture
? Arch may be congenital y absent
186
Jefferson Fracture
187
Posterior Neural Arch Fracture
188
Odontoid Fracture (1)
? Increase in prevertebral space
Classification
Type I: tip avulsion
Type II: at neck of dens
Type III: through body of C2
? Most common cervical fracture in children
? Types II and III unstable
? Atlanto-dens interval
? 3 mm (adults)
? 5 mm (peds)
189
Odontoid Fracture (2)
190
Pseudosubluxation C2 - C3 (1)
? Posterior alignment (Swischuk's line)
? Pediatric C-spine
? Allow 2-3 mm anterior misalignment
? Common below age 8
? The key to diagnosis is normal alignment of the
spinolaminal line
191
Pseudosubluxation C2-C3 (2)
192
Med-Chal enger ? EM
Teardrop Fracture (1)
? Flexion
?Extreme flexion
?Complete ligamentous disruption
?Unstable
? Extension (rare)
?Hyperextension, unstable
?Anterior longitudinal ligament avulses inferior
portion of vertebral body
?Associated with central cord syndrome
193
Teardrop Fracture (2)
194
Unilateral Facet Dislocation
? Rotational injury
and flexion
? Posterior ligament
complex disrupted
? Lateral X-ray:
"bow-tie deformity"
? Potential y unstable
195
Spinal Cord Injury
196
Spinal Cord Anatomy
? Posterior columns: vibration and position
(proprioception) sense
? Lateral corticospinal (pyramidal) tract: upper
motor neurons
? Anterior horn cel s: lower motor neurons
? Anterior spinothalamic tract: pain and
temperature sensation
197
Spinal Cord Syndromes
Posterior
columns
(vibration /
proprioception
Lateral
corticospinal
tract
(Upper motor
neuron)
Anterior horn
cells
(lower motor
neuron)
Spinothalamic
tract (pain /
temperature)
198
Anterior Cord Syndrome
? Compression of the cord
? Retropulsion of bony fragments
? Disc herniation
? Injury to anterior spinal arteries
? Flexion injury
? Complete motor paralysis below injury
? Vibration and proprioception preserved
? Loss of pain and temperature sensation
(hypalgesia) below injury
? Needs surgical intervention
199
Brown-Sequard Syndrome
? Unilateral cord injury (usual y in penetrating injury)
? Crossed findings below level
? Ipsilateral weakness, loss of position/vibration sense
? Contralateral loss of pain and temperature sensation
200
Central Cord Syndrome
? Hyperextension injury
? Older patients with DJD
? Weakness, arms > legs
? Also some loss of bladder control and some
decreased sensation (distal pain and temperature)
? Sacral sparing
(rectal tone present)
201
Transverse Cord Syndrome
? Trauma, tumors, transverse myelitis
? Complete loss of all sensory and motor
pathways below a certain level
? No sacral sparing
Posterior Cord Syndrome
? Trauma (extension), B12 deficiency, tertiary
syphilis
? Loss of position and vibration sensation only
202
SCIWORA
? Spinal Cord Injury Without Radiographic
Abnormalities
? Involves cervical cord
? More common in children but seen in al age
group
? Diagnosed by
?Thorough exam
?Normal radiographs
?MRI
? Early surgery beneficial in some
?Disc herniation
203
Neurogenic Shock = 70/70
? Also cal ed vasogenic shock
? Injury to sympathetic outflow
? Unopposed parasympathetic outflow (bradycardia)
? T1 and above
? Unlikely below T4 (r/o other causes of shock)
? Flaccid paralysis below lesion
? Hypotension (neurogenic): treat with fluids
? Loss of autonomic tone
? Loss of reflexes
? Warm, flushed, dry skin (heat loss = hypothermia)
? Distinguish from "Spinal Shock"
? Loss of sensation and motor paralysis with initial loss or
depression of al reflex activity below the level of injury (0-1
day) / initial return of reflexes (1-3 days) / hyperreflexia (1-4
weeks) / Hyperreflexia ? spasticity (1-12mo)
204
205
Lumbar Back Pain (1)
Overview
?Lumbar back pain is second only to URIs as a
cause of a symptom-related visit to a physician
?Most cases cannot be given a specific
pathoanatomic diagnosis
?Typical onset: age 30-45
?Most common cause of work-related disability
?Most common cause of disability in those under
age 45
?Can occur with and without risk factors
?Most (90+ %) resolves within weeks
206
Lumbar Back Pain (2)
General approach:
1. Determine if a systemic disease is causing the
pain : Search for "Red Flags"
2. Determine if there are conditions that may
amplify or prolong the pain (social or
psychological factors)
3. Determine whether there is neurologic
compromise that may require surgical evaluation
207
RED FLAGS in LBP
? Historical clues to exclude serious pathology
? History of cancer (pain not relieved rest)
? HIV positive
? Unexplained weight loss (suggests cancer or
other serious disorder)
? A history of chronic infections or fever
? Duration of pain (prolonged pain may be
associated with treatment failure, depression,
somatization, substance abuse, job
dissatisfaction, pursuit of disability)
? Presence of night time pain (may indicate a
more serious cause)
208
Cauda Equina Syndrome
? Cauda equina
syndrome = surgical
emergency
? Bowel / bladder
dysfunction (from
midline disk
protrusion / mass)
? Overflow
incontinence is
characteristic of
bladder dysfunction.
May also find
perianal anesthesia,
bilateral sciatica and
leg weakness
209
Lumbar Back Causes
? Mechanical (97%)
? Lumbar strain / sprain (70%)
? Degenerated disks / facets (10%)
? Herniated disks (4%)
? Osteoporotic compression fractures (4%)
? Spinal stenosis (3%)
? Spondylithesis (3%)
? Anterior displacement of one vertebra on another due
to a congenital defect in the pars interarticularis
? Spondylolysis = same defect without slippage (is as
common with back pain as without)
210
Spondylosis / Spondylolisthesis
211
LBP Work-up
? Image if signs of nonmechanical causes, trauma
or failure to improve at 4-6 weeks
? CBC / sed rate may be elevated in patients with
infections (CT / MR are more sensitive)
? Early CT / MR are discouraged without serious
findings because many asymptomatic patients
wil have positive findings
? Difficult to establish causality between findings
on imaging and symptoms
? MR is superior to CT in finding infections and
tumors. Both are comparable regarding
herniations and spinal stenosis
? Early imaging is advised in the elderly (over 65)
212
Spinal Stenosis (1)
? More common in the elderly
? Caused by facet hypertrophy / ligamentum flavum
thickening
? CT / MR are diagnostic
? Pain, numbness and tingling (pseudoclaudication)
? Can occur in one or both legs
? Often relieved by flexion and sitting
? Aggravated by extension
? Remains stable (70%) or worsens (15%) vs. most back
pain gets better
? Leg exercises, NSAIDS, PT, epidural steroids
? Decompressive laminectomy is not uniformly successful
213
Spinal Stenosis (2)
214
Burst Fracture
? Axial load
? Failure of anterior + middle columns (unstable)
? CT to rule out cord injury
Chance Fracture
? Flexion, distraction
? Seat belt injury
? Horizontal fracture, usual y L1 or L2
? Bowel, liver, spleen injuries are common
? Ileus is common
? Unstable (posterior ligament disruption)
215
Burst Fracture
216
Chance Fracture
217
Wedge Fracture
? Axial load with flexion
? L1 > L2 > T12
? Usual y stable
? Unstable if burst (>50% loss of anterior body
height)
? Salmon calcitonin spray in addition to other
treatments
? Mechanism of action regarding pain reduction is
unclear
? Inhibits bone removal by osteoclasts and promotes
bone formation by osteoblasts
218
Compression Fracture
219
Ortho Trivia (1)
? Adhesive capsulitis
Can result from prolonged
immobilization of the shoulder
? Congenital hip dislocation
? Asymmetry of groin
? Apparent limb shortening
? Ortolani click test
? Meralgia paraesthetica
Lateral femoral cutaneous nerve
compression where it passes
between the ilium and inguinal ligament
? Pregnant women
? Workmen with belts
? Burning lateral thigh pain
220
Ortho Trivia (2)
? Pediatric hip problems
? Legg-Calve-Perthes 4-8 years old
? Toxic synovitis 4-10 years old
? SCFE 10-16 years old
? Septic arthritis any age
? Torus fracture: cortex buckled but intact
? Greenstick fracture: cortex disrupted on one
side and intact on the other
? Lumbar disc syndromes
L4 : Absent knee jerk
L5 : Absent dorsiflexion of great toe
S1 : Absent ankle jerk, numbness
of lateral foot
221
Ortho Trivia (3)
? Paget's disease of bone
?Inflammatory condition of skeleton
?Rapid, chaotic bone resorption fol owed by
chaotic bone formation
?Enlarged, weak bones
?Asymptomatic or bone pain
?Calcium normal, alkaline phos.
?Bones fracture with minimal trauma
?Involvement of skul and vertebrae can lead to
neurologic symptoms
222
ORTHOPEDICS QUESTIONS
223
Regarding Salter Harris fractures,
which of the following is true?
A. The epiphyseal plate is stronger than the
supporting ligaments
B. Salter Harris II is the least common
C. X-rays may be negative in types I and II
D. Growth complications increase from types I
to V
E. Most involve the growth plate
OR 1
A 24 y/o patient was struck with a baseball
in the left index finger. The PIP is flexed
with the DIP extended. Which of the
following is true of this injury?
A. This description is consistent with a mal et
finger
B. Avulsion fractures are rarely associated with
this injury
C. This injury is caused by an extensor tendon
injury near the DIP
D. This injury is caused by a central slip
extensor hood disruption near the PIP
E. This description is consistent with a
gamekeeper's injury
OR 2
A 68 y/o female complains of hand pain
status post cat bite. Puncture wounds are
noted on the right index finger and middle
finger. Which of the following is
consistent with Kanavel's signs?
A. Severe pain on flexion
B. Fever
C. Pain on palpation of the proximal sheath
D. Swel ing at the puncture wound site only
E. Digit held in slight extension
OR 3
A 62 y/o patient fell injuring her wrist. She
has suffered the most common
ligamentous injury of the hand/wrist.
Which of the following is true?
A. ED Management includes placement of a
velcro wrist splint
B. The radiograph should show > 3mm
widening of the scapho-lunate space
C. The most common mechanism is a direct
blow from a blunt object
D. The capitate is aligned and lunate displaced
on the lateral radiographic view
E. This injury is rarely missed
OR 4
A 35 y/o patient fell injuring his wrist. His
radiographs show a distal radius fracture
with a disrupted radio-ulnar joint. Which
of the following statements is true?
A. The patient has suffered a Monteggia
fracture
B. This injury includes annular ligament
disruption
C. Radial nerve injury is a known complication
D. Ulnar nerve injury is not associated with this
injury
E. The patient has suffered a Galeazzi fracture
OR 5
A 36 y/o painter reports intermittent hand
paresthesias With raising his arms above
his head and opening and closing his fists
for three minutes, his symptoms are
reproduced. Which of the following is true?
A. The patient's diagnosis is associated with a
cervical disc herniation
B. The diagnostic maneuver described is the
Adson's test
C. The most common type of this anomaly is the
the vascular type
D. This pathology may include compression of
the brachial plexus and/or subclavian vessels
E. The least reliable diagnostic maneuver is
"EAST"
OR 6
An 8 y/o boy presents with right hip pain
for 1 week. His hip x-ray reveals a
subchondral fracture. Based on the most
likely diagnosis, which of the following is
true?
A. Typical y seen in boys age 8-12
B. The patient most likely has Legg-Calve-
Perthes disease
C. The typical patient is probably obese
D. Radiograph should shows a "melting ice
cream cone appearance"
E. Radiographic findings precede the symptoms
OR 7
A 34 y/o presents with pain, pallor,
paresthesias and weakness in his right leg
after suffering a tibial fracture 3 days
prior. Which is the most appropriate next
step?
A. Reapply the splint and arrange 24 hour
orthopedic fol ow-up
B. Change his pain medication regimen
C. Check compartment pressures
D. Repeat radiographs
E. Attempt closed reduction of his fracture
OR 8
In diagnosing Achilles tendon rupture,
which provocative test is likely to be
positive?
A. Homan's sign
B. Romberg
C. Thompson test
D. Hoover test
E. Lachman test
OR 9
A 45 y/o patient presents with ankle pain,
describing an inversion injury. Regarding
the Ottawa ankle rules, which of the
following would be criteria for
radiographic evaluation?
A. Point tenderness over the cuboid
B. Point tenderness over the base of the 4th
metatarsal
C. Tenderness at the anterior talo-tibial ligament
D. Inability to bear weight immediately and in
the ED
E. Bony tenderness at the anterior aspect of
the distal 6 cm of either maleoli
OR 10
A 19 y/o male roofer fell from 15 feet
landing on his feet. He complains of right
heal pain and cannot bear weight. Which
of the following is true, regarding
calcaneal fractures?
A. This fracture is the least common of al tarsal
bones
B. Boehler's angle would be expected to be >
40 degrees
C. This fracture may be associated with LS
spine fractures
D. CT has no utility in making this diagnosis
E. The mechanism of injury is from rotational
forces
OR 11
A 30 y/o female softball player reports an
acute onset of foot pain after jumping for a
ball. Her radiographs confirm a Jones
fracture. Which of the following is true
with respect to Jones fractures?
A. They are avulsion fractures of the base of the
5th metatarsal
B. They are uncommon in athletes
C. They are associated with a lower incidence
of non-union than avulsion fractures
D. They are located at the diaphysis of the 5th
metatarsal
E. They do not require splinting
OR 12
A 13 y/o sickle cell patient presents with
fever and leg pain. His radiographs show
signs of periosteal reaction. What is the
most likely etiologic agent for the
suspected diagnosis?
A. Eikenel a corrodens
B. E. coli
C. Pasteurel a multocida
D. Salmonel a
E. Methicil in resistance Staph aureus
OR 13
An 18 y/o patient presents with neck pain
status post MVC. Which of the following
findings is most suggestive of c-spine
fracture?
A. Predental space > 2 mm
B. Neck pain and weakness with shoulder
abduction
C. Prevertebral space > 10 mm @ C6
D. Predental space > 10 mm @ C4
E. Prevertebral space > 3mm @ C2
OR 14
An 84 y/o patient presents a cervical spine
injury. The patient has 2/5 muscle
strength at the upper extremities and 3/5
at the lower extremities bilaterally. Which
is the most likely diagnosis?
A. Anterior cord syndrome
B. Complete cord transection
C. Posterior cord syndrome
D. Central cord syndrome
E. Brown-Sequard syndrome
OR 15
A 16 y/o was involved in a MVC. He
complains of neck pain. You suspect this
patient is in neurogenic shock. Which of
the following is most consistent with that
diagnosis?
A. Hypertension
B. Pale, warm, diaphoretic skin
C. Warm, flushed, dry skin
D. Cool, pale and diaphoretic skin
E. Sparing of reflexes
OR 16
Which of the following are true of
compression or wedge fractures?
A. More common at T9 than L2
B. They are stable with 50% loss anterior
vertebral body height
C. They are usual y unstable
D. More common at L1 than T12
E. They are always caused by flexion
OR 17
Regarding pediatric hip problems,
which is true?
A. SCFE occurs between 3-7 years
B. Septic arthritis occurs most often between 6-10
years
C. Toxic synovitis occurs between 8-10 years
D. Legg-Calve-Perthes occurs between 4-8
years
E. Osgood Schlatter disease occurs between
10-14 years
OR 18
A pediatric patient with a GCS of 15 has
upper extremity weakness after falling and
injuring her head and neck. Which pair
best describes the diagnosis and the
confirmatory test?
A. SCIWORA ? MRI of the cervical spine
B. Eaton Lambert syndrome - CSF protein
C. Guil ain-Barr?-CSF protein
D. Subdural hematoma ? CT of the brain
E. Clay shoveler's fracture - cervical CT scan
OR 19
A 35 y/o patient presents with neck pain
following an MVC. He has a unilateral
facet dislocation C6 on C7. Which of the
following is most consistent with his
injury?
A. Decreased shoulder abduction
B. Medial arm numbness
C. Elbow extension weakness
D. 5th finger paresthesias with 5th finger adduction
weakness
E. Wrist extension weakness
OR 20
Orthopedics Answer Key
1. D
11.C
2. D
12.D
3. C
13.D
4. B
14.B
5. E
15.D
6. D
16.C
7. B
17.D
8. C
18.D
9. C
19.A
10.D
20.C
This post was last modified on 24 July 2021