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124 Cards in this Set
- Front
- Back
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define diaphyseal fx
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fx to shaft of bone
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define metaphyseal fx
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b/t shaft and growth plate
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define epiphyseal fx
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fx of growth plate to joint
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define volar defect in alignment
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volar angulation of fracture in AP plane when comparing prox and distal fx fragments
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define dorsal angulation in alignment
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dorsal angulation of fracture in AP plane when comparing prox and distal fx fragments
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define varus deformity of alignment
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medial angulation of distal fx fragment in coronal plane
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define valgus deformity of alignment
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medial angulation of distal fx fragment in coronal plane
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define apposition
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amount of contact in fracture surfaces (complete, partial, absent)
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define bayonet apposition
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not only 100% displaced but also overlapping
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define dislocation
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total disruption of joint surface
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define subluxation
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partial disruption of joint surface
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define syndesmosis
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slightly movable articulation where contiguous bony surfaces are connected with interosseous ligament
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what is the radiographic evidence of union?
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bridging of the fracture in at least 3 cortices as seen on orthogonal projections
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what is the time point to define delayed union?
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6 months post fracture
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what is the generally accepted upper limit for shortening of the lower extremity?
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1 inch
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two most notorious places for occult fracture?
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scaphoid (10-20%) hip (5%)
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position of MCP joint during splinting?
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60-90 flex
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position of wrist during splinting?
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20-30 extension
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position of elbow during splinting?
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90 flex
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position of shoulder during immobilization?
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adducted and internally rotated
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position of knee during splinting?
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20-30 flexion
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position of ankle during splinting?
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neutral
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how can you slow plaster splint hardening?
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salt in water or lower temp
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when plaster over orthoglass for splinting?
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unstable fx requiring reduction
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when is reduction of fracture emergent?
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sooner is always better, but if perfusion is absent or signs of vascular or nerve injury.
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when is ER fx reduction contraindicated?
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Open fx, fx requiring immediate operation, fx where healing will occur adequately w/o reduction (kids etc), sedation or anesthesia too risky, supracondylar fx unless no perfusion
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what are the 4 steps to fracture reduction?
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distraction- longitudinal force to pull fx fragments apart
disengagement- "recreate the injury" reapposition- force in the opposite direction of that which caused the injury release- release of distraction force |
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possible complications of closed fx reduction?
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closed to open fx, soft tissue trauma or compartment syndrome, neurovascular injury
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general indications for operative fx management?
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displaced intraarticular fx, assoc arterial injury, unable to get closed reduction, fx through metastatic lesion, early mobilization is desirable
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define grade I open fx? (gustilo and anderson classification)
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< 1cm open wound, no sign of contamination
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define grade II open fx? (gustilo and anderson classification)
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lac is >1cm but <10 cm, moderate contamination,
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define grade IIIA open fx? (gustilo and anderson classification)
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large soft tissue involvement (usually >10 cm) high contamination, adequate soft tissue coverage of the bone (may be able to close w/o graft)
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define grade III B open fx? (gustilo and anderson classification)
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large soft tissue involvement (usually >10 cm) high contamination, bone stripping of soft tissue (B for bone stripping)
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define grade III C open fx? (gustilo and anderson classification)
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large soft tissue involvement (usually >10 cm) high contamination, circulatory injury (C for circulatory)
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what delay after open fracture has been shown to increase infection rates?
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3 hours
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fx associated with gunshots treated as open or closed?
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closed
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is it safe to remove nail in ER from nailgun injury?
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yes, if not near vasulature and not into joint.
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what do you have to check for before removing nail in nail gun injury?
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nails held into gun with copper wire. if wire barb still on nail, then head of nail needs to be cut and nail pulled the rest of the way through.
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indications for femoral n. block for pain control
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femoral neck fx, intertroch fx, femoral shaft fx
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MCC infectious arthritis in young healthy ppl?
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gonorrhea
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Dx? young healthy pt with migratory arthritis with chills, fever, and tenosynovitis involving the wrist or ankle extensor tendon sheaths.
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gonococcal septic arthritis
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Dx? Kiddo with polyarthritis and fever. pts have carditis and may have skin lesions, typically erythema marginatum.
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rheumatic fever
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Dx? Pt presents with a polyarthritis appearing in the form of a symmetric, peripheral joint involvement that may be intermittent or migratory. These patients are usually afebrile and may have a light sensitivity rash. The antinuclear antibody (ANA) test positive.
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SLE
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most common microbe in septic arthritis?
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staph (50%)
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most common microbe in septic arthritis in pts w/ h/o RA, DM, or polyarticular involvement?
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staph (80%)
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gram neg microbes are more common in what populations for septic joint?
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immunocompromised, elderly, IVDA, open wounds
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where does septic joint 2/2 hematogenous spread often occur in IVDA?
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SI joint
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what is the incidence of iatrogenic septic joint from aspiration?
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1:10,000
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risk factors for septic joint?
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age >80, DM, RA, joint prosthesis, joint surgery, concurrent skin infection
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if pt has septic joint in sternoclavicular joint, what should be suspected?
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IVDA- look for other sequelae
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when is ortho consult needed for arthrocentesis?
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hip joints (difficult) and prosthesis (inc risk for infection)
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what synovial fluid tests should be ordered with arthrocentesis?
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culture, gram stain, cell count, crystal exam, lactate, LDH
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ABX for septic joint?
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if gonococcal can do ceftriaxone 1g and zithromax.
if not, Nafcillin and ceftriaxone 1g -OR- vanc and cipro if pen allergy or suspect MRSA |
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things that make gout worse or can precipitate attack?
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urate metabolism disorders, loop diuretics, cold, EtOH
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preferred order of synovial fluid labs if there is only small amount of fluid?
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culture, crystal, gram stain, cell count
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Treatment for gout?
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NSAID: indomethacin
If recalcitrant--> colchicine If neither works--> prednisone stop diuretics analgesics |
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type of crystal seen in pseudogout?
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calcium pyrophosphate
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population which pseudogout usually seen?
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elderly
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treatment for pseudogout?
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NSAIDs
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what type of arthritis is seen with RA?
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symmetric, progressive polyarthritis
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major SE with plaquenil?
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retinal lesions
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major SE with sulfasalazine?
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GI upset, rash
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major SE with methotrexate?
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Rash, GI upset, pulm toxicity, hepatitis, immune suppression, teratogenesis
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major SE with Imuran?
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GI upset, abd pain, leukopenia, immune suppression, hepatitis
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crescent shaped hemorrhage seen below either malleolus is indicative of what?
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ruptured baker's cyst
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what happens if you heparinize a baker's cyst?
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you can get continued bleeding to the calf which may eventually lead to compartment syndrome
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what cardiac complication is common with RA?
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pericarditis
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what is the phsyiologic pathology in RA?
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autoiummune attack on synovial structures leading to hyperproliferation of synovial fluid inciting inflammation of the fluid as well as the periarticular structures
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what is the mainstay treatment for SLE?
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prednisone
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microbe responsible for lyme's dz?
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borellia burgdorferi
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tick species responsible for lyme's dz?
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ixodes
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enemic region for lyme's dz?
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new england, upper midwest, pacific northwest
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initial presentation of lyme's dz?
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erythema migrans, fatigue, malaise, fever, arthralgia, HA, ST, LAD
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presentation of stage 2 lyme's dz?
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fluctuating meningitis sx, facial palsy, radicular neuropathy. migratory arthritis,
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ABX for early lyme's?
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doxy 100mg bid x 10 days -OR-
amoxycillin 500 PO qid x 10 days |
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ABX for late lyme's?
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rocephin 2g qday x 14 days
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presentation of ankylosing spondylitis?
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gradual onset of back discomfort (often dull and difficult to localize), onset before 40 years of age, persistence of discomfort for 3 months or longer, and morning stiffness that improves with exercise.
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what are some non-MSK manifestations of ankylosing spondylitis?
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fatigue, wt loss, iritis, pulm fibrosis, aortic insufficiency (2/2 fibrosis), bradyarrythmias.
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standard criteria to diagnose ankylosing spondylitis?
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presence of sacroiliitis. Radiographic changes range from vague loss of definition of the edge of the SI joint with some sclerosis to more definite sclerosis, indistinct margins, erosions, and subsequent fusion
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what is the pathology responsible for reactive arthritis?
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infection at distant site then several weeks later pt has reactive arthritis
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what joints are usually affected in reactive arthritis?
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knees and ankles. very rare for UE to be involved.
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what is the presentation for reiter's syndrome?
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"can't see, can't pee, can't climb a tree"
conjunctivitis urethritis arthritis |
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treatment of reactive arthritis?
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NSAIDs, consider steroids
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what is arthritis associated with IBD called?
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enterohepatic spondyloarthropathy
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what is the lower age limit for temporal arteritis and polymyalgia rheumatica?
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50
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presentation for polymyalgia rheumatica?
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pain in shoulder, neck, pelvic girdle. difficulty getting out of bed, up from chair, combing hair (proximal muscles)
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presentation for temporal arteritis?
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(1) individuals >50 years old with (2) new headache, (3) temporal artery tenderness or decreased pulse, (4) ESR >50 mm/h, and (5) an abnormal biopsy showing vasculitis. Possessing three of these five criteria is 93% sensitive and 91% specific for the diagnosis.
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why is temporal arteritis emergent?
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potential for vision loss
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tx for temporal arteritis if no visual sx?
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prednisone
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tx for temporal arteritis if visual sx present?
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IV solumedrol 250mg q6h
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define salter harris type I? tx in ED?
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through epiphyseal plate, difficult to differentiate b/t type V so splint and quick referral to ortho
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define salter harris type II? tx in ED?
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fracture through the metaphysis proximal to the epiphyseal plate (above SALTR mnemonic), tx is splint and non-emergent ortho referral
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what is the treatment for non-displaced salter harris fx III, IV, V?
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splint, ortho referral in 3-5d
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what view give best view of torus fx of distal radius?
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usually lateral wrist XR
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when do you need to reduce a distal radius torus fx?
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if angulation is >18 deg
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what kind of splint for distal radius torus fx?
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short arm volar or sugar tong
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what is the time parameter for f/u to ortho for distal radius torus fx?
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w/i 5d
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what kind of splint for distal radius greenstick fx?
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volar splint
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when do you have to reduce distal radius greenstick fx in the ED?
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if angulation greater than 15 deg, then closed reduction and long arm splint
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what other fx are you worried about if distal radius fx?
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ulnar styloid and distal ulnar as well as possible ulnar dislocations
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what is the order for ossification of the elbow?
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CRITOE (capitulum at 1yo, radial head at 3 yo, internal epicondyle at 5 yo, trochlea at 7yo, olecranon at 9yo, external epicondyle at 11yo)
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what is the anatomical position for anterior humeral line on lateral elbow XR?
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ant edge of humerus should bisect middle of capitellum
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what is the anatomical position for radiocapitellar line on lateral elbow XR?
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through axis of the radius and points directly at the capitellum
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what is important documentation in the physical exam for elbow fractures?
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complete neurological exam (high risk for neuro dmg) and signs of compartment syndrome in the distal forearm (pallor, tense compartment, pulses paresthesias etc)
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tx for all elbow fx?
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need immediate ortho consultation 2/2 large risk for nerve injury. place in long arm splint while awaiting transfer
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what is the anatomical deformity in nursemaid's elbow?
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radial head subluxation
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common age distribution in nursemaid's?
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6mo- pre-teen but most commonly 1yo-3yo
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how does nursemaid's usually happen?
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longitudinal traction on extended arm with wrist in pronation (kid yanked up by arm by taller adult), tears annular ligament
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what is the ligamentous injury in nursemaids?
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annular ligament tear
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how to reduce nursemaids?
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forearm supination and then flex at elbow -OR- hyper-pronate forearm and flex at elbow
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what fractures in kiddos are usually signs of NAT?
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rib fx in kids of any age esp. multiple ribs
tib/fib, humerus, femur in < 18 mo femur in non-ambulatory kids metaphyseal-epiphyseal fx in < 5yo |
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when do epiphyseal plates close?
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puberty
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what is another name for torus fracture?
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buckle fx
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what is the dreaded outcome from physial injury?
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limb length discrepency (1-10% prevalence)
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how is risk of growth disturbance related to salter-harris classification?
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inc risk with inc number category
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most common mechanism for distal radius fx?
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FOOSH
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most common time of life for distal radius fx?
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adolescent 2/2 highest growth velocity
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what is the dreaded complication of compartment syndrome?
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volkman's contracture (severe muscular fibrosis and neuropathy)
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where should you suspect the injury if an ambulatory child will not walk, but will crawl?
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foot
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what is antalgic gait?
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stance phase shortened to avoid pain
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what is trendelenburg gait?
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pathology in hip shift in torso over affected leg in stance phase
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what is steppage gait?
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inability to dorsiflex foot- pt will flex at hip and knee to clear foot
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what is vaulting gait?
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knee pain or quad weakness causes pt to keep leg stiff
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what are the kocher criteria for septic joint in kiddos?
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WBC >12k, ESR >40, fever, won't bear weight
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