Ortho

Front 1

Why is hip dislocation an emergency?

Back 1

The potential for AVN of the hip, the hip must be reduced ASAP

Front 2

What is myositis ossificans?

Back 2

hetertrophic ossification. Pathologic bone formation where it is not normally formed. Usually occurs after trauma or surgery in the thigh or hip area. Causes pain and limited ROM.

Ttx:RICE
immobilization for no more than 48 hours, then ROM exercises should be begun
-mature lesions can be considered for operative removal

Front 3

What is the etiology of referred hip or groin pain?

Back 3

-nephrolithiasis
-pelvic infection/inflammation/tumor
-hernias
-inguinal adenopathy
-radiculopathy

Front 4

What is the epidemiology of femoral neck fractures and intertrochanteric hip fractures?

Back 4

80% of femoral neck fractures occur in men around 72-77. Intertrochanteric hip fractures occur 8:1 times more commonly in women and about 10 years later.

Overall 3/4 of all hip fractures occur in post-menopausal women.

Front 5

Discuss AVN of the femoral head

Back 5

AVN = ischemic necrosis = osteonecrosis.

It presents as increasingly painful hip, buttocks, thigh or knee without history of trauma

atraumatic DDx
chronic corticosteroid therapy
alcoholism
sickle cell disease
dysbarism
chronic pancreaticis
protease therapy of HIV
traumatic ddx
hip dislocation
femoral neck fracture

AVN does not complicate intertrochanteric fractures because of improved blood supply

Front 6

What findings on the AP pelvic xray predict the need for transfusion?

Back 6

-open book pelvis
-any displacement of 0.5cm or more at any fracture site in the pelvic ring
-displaced symphysis pubis
-displaced obturator ring fracture

Front 7

What are the indications for venous and/or arterial angiographic embolizations in pelvic fractures?

Back 7

-venous embolization is ineffective (due to the presence of anastomoses and valveless collateral flow)

-Arterial embolization can be highly effective particularly with the following
-inadequate response to initial resuscitation (failure to maintain an SBP >90mmHg after the administration of 2U of prbc (persistent hypovolemia in a patient with a major pelvic fracture despite control from other sources)
-presence of contrast extravasation on admission CT
-large expanding hematoma on CT

POsterior arch disruptions are associated with the most severe hemorrhage and angiography should be considered at an early stage.

Front 8

What are radiographic clues to the presence of pelvic posterior arch fractures?

Back 8

-Avulsion of L5 transverse process
-Avulsion of ischial spine
-Avulsion of the lower lateral lip of the sacrum (sacrotuberous ligament)
-Displacement at the site of pubic ramus fracture
-Asymmetry or lack of definition of bone cortex at the superior aspect of the sacral foramina

Front 9

What are 2 mechanisms for acetabular fractures?

Back 9

1) forceful impact to a flexed knee (dashboard injury)
2) lateral impact

Front 10

What are signs and symptoms of acetabular fracture?

Back 10

Pain and inability to bear weight

Percussion of the sole of the foot or greater trochanter may reproduce the pain.

Front 11

What xray views should you obtain to evaluate acetabular fractures?

Back 11

Judet views

Front 12

What nerve is commonly injured in acetabular fractures and how do you test it?

Back 12

The sciatic nerve
Sensory - lateral aspect of the lower leg and sole of the foot
Motor - Hamstrings

Front 13

What is the classification of acetabular fractures?

Back 13

Type A - Single column fractures
Type B - Two column fractures, T-type, portion of the acetabulum remains attached to the ileum
Type C - Two column fractures, T-type, no portion of the acetabulum remains attached to the axial skeleton

Front 14

What are the two common mechanisms for coccyx fractures?

Back 14

-fall in the sitting position
-kick

xrays are not usually required

Front 15

What is the usual mechanism for open-book pelvic fractures and what are the hallmark findings on xray

Back 15

-AP compression
-Widening at the pubic symphysis >2.5cm and SI joint widening

Front 16

Describe the 2 types of sacral fracture

Back 16

Transverse fractures - not considered pelvic ring fractures
Vertical fractures - involve the pelvic ring, result from high-energy injuries. Classified as being lateral to the sacral foramina, through the sacral foramina or medial to the sacral foramina. (high risk of neurological function, increases as the fracture line moves more medially)

Front 17

What are the priorities in managing high-energy pelvic ring fractures in the ED

Back 17

-identify the patients who are in hemorrhagic shock and resuscitate them with IVF and blood (resuscitate)
-recognize that patients with posterior arch fractures are at higher risk (recognize)
-identify associated injuries and notify trauma surgeon (evaluate)
-stabilize the pelvis with a pelvic wrap, alert ortho for possible ex-fix or c-clamp (stabilize)
-control bleeding - consider angiography early. Pelvic packing during laparotomy is also an option (control pelvic bleeding)

Front 18

Who gets pelvic avulsion fractures and what are the 4 main types

Back 18

Commonly occur in older children and teenagers involved in athletic activities.

1) ischial tuberosity avulsion during strenuous contraction of the hamstrings
2)iliac crest epiphyseal avulsion by contraction of the abdominal muscles
3)ASIS avulsion by forceful contraction of the sartorius
4)AIIS avulsion with forceful contraction of the rectus femoris (kicking a ball)

Front 19

What is a straddle fracture and what is an associated injury

Back 19

Four pillar injuries with fractures of both pubic rami on both sides of the pubic symphysis. Also called a butterfly segment

May have concomitant injury to the posterior arch as well as genitourinary tract.

Front 20

What is Tile's Classification

Back 20

Classification of Pelvic Fractures
Type A - Stable, posterior arch intact
A1 avulsion fractures of the innominate bone
A2 Iliac wing fracture (Duverney), minimally displaced pelvic ring fractures, transverse fractures of the sacrum or coccyx
Type B - partially stable, incomplete disruption of the posterior arch (rotationally unstable, vertically stable)
B1 open book #
B2 lateral compression injury
Type C - unstable, complete disruption of the posterior arch (vertically and rotationally unstable)
includes iliac, sacroiliam and vertical sacral injuries
C1- Unilateral C
C2 - Unilateral C/ Unilateral B
C3 - bilateral C

Front 21

Describe the Young-Burgess Classification of Pelvic Fractures

Back 21

1. AP Compression
I. Symphysis diastasis < 2.5cm
II. Symphysis diastasis >2.5cm, sacrospinus, anterior sacroiliam ligament disruption, results in rotational instability
III. Symphysis diastasis >2.5cm, with complete disruption of the anterior and posterior SI ligament, results in complete rotation and vertical instability
2. Lateral Compression
I. Sacral crus injury on ipsilateral side
II. Sacral crush injury with disruption of the posterior SI ligaments, iliac wing fracture may be present, rotationally unstable
III. Severe internal rotation of the ipsilateral hemipelvis with external rotation of contralateral side, roatationally unstable
3. Vertical shear
Vertical displacement of the symphysis and sacroiliac joints resulting in compete rotational and vertical instability

Combined mechanisms - any combination of the above mechanisms.

Front 22

What is the value of inlet/outlet radiographs of the pelvis

Back 22

Allows better visualization of sacral # and SI joint disruptions.
(AP + inlet + outlet will show all clinically impt #s) so will CT.

Front 23

What is the normal width of the pubic symphysis and the SI joints?

Back 23

-Normal width of the pubic symphysis is </=5mm and may have a small 1-2 mm vertical offset.
-The SI join is normally 2-4mm wide

Front 24

Why should you use a fully open technique when performing a DPL in the presence of a pelvic fracture?

Back 24

A fully open technique makes it less likely that you will accidentally aspirate a retroperitoneal hematoma that has dissected up the anterior abdominal wall

One should also use the supra-umbilical approach

Front 25

Unstable blunt trauma patient with pelvic fracture and DPL positive by cell count only - Lap or Angio

Back 25

Embolization before Lap

Front 26

Pelvic trauma + blood at the urethral meatus

Back 26

Retrograde urethrogram and cystogram

Front 27

Gross hematuria = what?

Back 27

Urethrography
IVP
Cystography
CT
(some combination of these tests)

Front 28

What are signs and symptoms of S2-S5 injury?

Back 28

Bowel and bladder dysfunction
Perineal sensory deficits
Sexual Dysfunction

Front 29

AP compression fractures of the pelvis are strongly associated with what thoracic injury?

Back 29

Thoracic aorta rupture is 5-8x more likely

Front 30

What are the sources of pelvic bleeding in trauma?

Back 30

Arterial
Venous
Marrow
+/- coagulopathy

Front 31

What are the possible fates of an enlarging pelvic hematoma

Back 31

-May stay retroperitoneal
-May dissect up anterior abdominal wall
-May rupture through the peritoneum causing loss of tamponade

Front 32

What physical exam maneuvers should you perform in positive pelvic fracture?

Back 32

-inspect urethral meatus for blood
-careful rectal and vaginal exam to r/o open # (if there is rectal violation, the patient may require a diverting colostomy)

Front 33

What is the definition of acute low back pain?

Back 33

pain lasting less than 6 weeks duration

Front 34

Why do 95% of disk herniations occur at L4/L5 and L5/S1 levels?

Back 34

Because the posterior longitudinal ligament (which forms the border between the intervertebral disks and vertebral canal, thins as it run inferiorly

Front 35

At what level does the spinal cord end in adults?

Back 35

L1-L2 interspace

Front 36

What is the definition of spondylolisthesis?

Back 36

Slippage of one vertebral body on the other

Front 37

What is spondylolysis?

Back 37

bilateral pars interarticularis defects in an affected vertebrae (this may be a cause of spondylolisthesis.)

Front 38

What are the 4 cannot miss diagnoses that cause low back pain?

Back 38

-spinal fracture
-cauda equina
-spinal infection
-metastatic disease

Front 39

What is sciatica?

Back 39

It is an L5 or S1 radiculopathy described as a pain radiating from the low back to the leg (distal to the knees)

Front 40

What is a positive straight leg raise?

Back 40

The presence of back pain which radiates past the knee when the leg is elevated 30-70 degrees.

Front 41

What is the reverse SLR test?

Back 41

Have the patient lying prone and extend the hip. Pain will be elicited if there is irritation at L3 or L4.

Front 42

What physical exam maneuvers can be used to detect functional back pain?

Back 42

-SLR test sitting instead of supine. (if it is positive when supine but negative when sitting this suggests non-physiologic back pain)
-apparent superficial tenderness or non dermatomal sensory loss or widespread non dermatomal pain.
-back pain elicited by pushing down on the patient's scalp against the c-spine -> this maneuver axially loads only the cervical and not the lumbar spine.
-patients overreact during the examination

Front 43

What diagnoses should be considered in elderly patients with low back pain?

Back 43

-worrisome diagnoses
-degenerative spondylolithesis
-spinal stenosis

Front 44

Should you perform a lumbar puncture to evaluate for CSF infection when you suspect a spinal infection?

Back 44

No, because there is a risk of seeding the cerebrospinal fluid with bacteria

Front 45

Wht are indications for LS spine X-rays in patients with lower back pain?

Back 45

-age <18, >50
-history of malignancy or unexplained weight loss
-any history of fever, immunocompromise or IVDU
-recent trauma other than simple lifting
-progressive neuro deficits or other findings suggesting of caudal equine syndrome
-prolonged duration of symptoms (>4-6 weeks)

Front 46

What is the grading system for spondylolisthesis?

Back 46

Grade 1 - less than 25% slippage
Grade 2 - 25-50% slippage
Grade 3 - 50-75% slippage
Grade 4 - greater than 75% slippage

Front 47

What is spondylitis?

Back 47

Osteomyelitis of the vertebral bone which on x-ray appears as erosion of contiguous vertebral endplates and a shortened disk space height.

Front 48

What is the most common organism that causes spinal infections? What organism is seen in IVDU?

Back 48

Staph aureus
Pseudomonas

Front 49

What are the branch points in the algorithm for management of back pain that is worrisome for malignancy?

Back 49

-is there a history of previous cancer?
-is there evidence of radiculopathy?

Front 50

What is the management of patients who have back pain, no history of cancer, no radiculopathy but a history suggestive of malignancy (i.e. weight loss or back pain worse at night)

Back 50

-plain radiography
-cbc and ESR
(If positive X-ray or elevated ESR >100mm/hr) an urgent CT or MRI should be done within 3-7 days.

Front 51

What emergency causes of thoracic pain must be considered before musculoskeletal pain?

Back 51

-PE
-AD
-esophageal disease

Front 52

What is different about the anatomy of the spinal cord in the thoracic area?

Back 52

At the thoracic level, the space around the spinal cord is smaller than at the lumbar level - the thoracic cord is thicker and significant neurologic abnormalities may result from minimal spinal canal impingement

Front 53

What factors should prompt basic radiologic studies for the presence of other conditions in patients with thoracic pain?

Back 53

-clinical suspicion
-unexplained symptoms
-extremes of age
-concern for trauma, tumor, infection, GI or vascular pathology
-prolonged symptoms

Front 54

What is the definition of chronic back pain?

Back 54

-lasting greater than 3 months

Front 55

What cancers typically metastasize to bone?

Back 55

-prostate
-breast
-lung
-thyroid
-kidney

Front 56

What is the presentation of an L5 radiculopathy?

Back 56

-decreased sensation in the great toe webspace
-weakness in great toe dorsiflexion
-normal reflexes

Front 57

What is the presentation of a S1 radiculopathy?

Back 57

-decreased sensation on the lateral foot
-weakness in plantar flexion of the foot
-diminished/absent ankle reflex

Front 58

Is SLR sensitive or specific for sciatica?

Back 58

SLR is sensitive but not specific

Front 59

Is reverse SLR sensitive or specific for sciatica?

Back 59

rSLR is specific but not sensitive

Front 60

Where is vertebral osteomyelitis (aka spondylitis) usually found?

Back 60

anterior subchondral vertebral bone (this is the most vascular area, most osteomyelitis is spread hematogenously)

Front 61

What is the approach to low back pain and suspicion of cancer?

Back 61

-known CA + radiculopathy -> emergency MRI
-known CA + no radiopathy -> xrya and labs (probably urgent[3-7 days] MRI)
-no known CA + radiculopathy (ESR and X-ray, if positive MRI, if negative outpatient f/u)
-no known CA + no radiculopathy (ESR and X-ray and then outpatient workup vs MRI)

Front 62

What are signs and symptoms of spinal infection?

Back 62

-fever
-back pain at rest
-midline spinal tenderness

Front 63

What are characteristics of back pain from neoplasm?

Back 63

-pain at rest
-pain worse at night
-unexplained weight loss
-history of malignancy
-pain > 1month in duration

Front 64

What is a blood test of interest in back pain?

Back 64

ESR
>100 mm/hr is predictive of infection or neoplasm

Front 65

What are classic signs of ankylosing spondylitis?

Back 65

-Morning back stiffness
-Relieved by Exercise

Front 66

What are the causes of caudal equine syndrome?

Back 66

-massive central disc herniation
-epidural abscess
-malignancy
-hematoma
-trauma

Front 67

What is the most sensitive sign for cauda equine syndrome?

Back 67

Urinary retention
(this has a sensitivity of 90%)

Cauda equina is unlikely if PVR is 100-200cc

Front 68

Which patients are at risk of spinal infections (epidural abscess or vertebral osteomyelitis)?

Back 68

-IVDU
-immunocompromised (DM, HIV, CRF, long term corticosteroids)
-alcoholics
-elderly with recent blunt trauma to the back
-pts with indwelling catheter
-pts with recent bacterial infection

Front 69

What are referred cases of acute low back pain?

Back 69

cholecystitis
pancreatitis
PE
AAA
nephrolitiasis
pneumonia
ovarian torsion
pyelonephritis
retroperitoneal mass or hematoma
AD

Front 70

Most metastatic spine disease occur at what part of the spine?

Back 70

T-spine

Front 71

What are indications for surgery in spinal stenosis?

Back 71

progressive neurologic deficits
progressive pseudoclaudication
intractable pain

Front 72

What are the role of X-rays in detecting vertebral mets?

Back 72

-xrays miss 10-17% of vertebral mets. (Cancer needs to erode at least 50% of the bone before becoming radiographically apparent)

Front 73

Where do the majority of lumbar disk herniations occur?
In which direction do the herniations mostly occur?

Back 73

-L4/L5 (L5 nerve root)
L5/S1 (S1 nerve root)

Mostly posterolateral bulge

Front 74

What is sciatica?

Back 74

L4/L5 or L5/S1 radiculopathy
pain radiating down the posterior aspect of the leg from sciatic nerve root irritation

Front 75

Within what time frame should a dislocated hip be reduced and why?

Back 75

6-12 hours after dislocation because it significantly decreases the incidence of AVN

Front 76

What is the classic position of a leg with a femoral neck fracture?

Back 76

-external rotation
-abduction
-slight shortening

Front 77

What is the classic position of a leg with an intertrochanteric hip fracture?

Back 77

-internal rotation
-mild shortening

Front 78

What neuromuscular structures can be injured with subtrochanteric femur fractures?

Back 78

-femoral nerve
-arterial injury

Front 79

What injuries can result in sciatic nerve injury?

Back 79

posterior hip dislocaiton
hip fracture

Front 80

What are 3 methods to identify inconspicuous femoral neck fractures?

Back 80

-examine Shenton's line
-evaluate the medial and lateral cortical lines for S and reverse S curvatures (Lowell's smooth S and reverse S)
-look for disruption of the trabecular lines as they pass from the femoral shaft to the femoral head

Front 81

What percentage of hip fractures are radiographically occult?

Back 81

2-10%

Front 82

Why should MRI be used to diagnose occult hip fractures?

Back 82

Because CT has a 66% misdiagnosis rate, while MRI has 100% accuracy. Bone scan is also an option but must be delayed 72 hours after the injury

Front 83

In which injuries is the use of a traction splint contraindicated?

Back 83

pelvic injuries
patellar fractures
ligamentous knee injuries
tibia fracture
fibula fracture
open fracture

Front 84

Define Open Fracture

Back 84

Any fracture in which a break in the integrity of the skin or soft tissue allows communication with the fracture and its hematoma

Front 85

What are potential complications of total hip replacement?

Back 85

-Loosening of the prosthesis
-component wear
-infection
-surrounding femoral fracture
-DVT
-post operative dislocation

Front 86

What position has the most risk of resulting in prosthesis dislocation?

Back 86

Flexion at 90 degrees, adduction, internal rotation (eg. standing up from the toilet)

Front 87

Which muscles are involved in the following avulsions of the femur/hip: ASIS, AIIS, ischial tuberosity. How are these injuries managed.

Back 87

ASIS - Sartorius
AIIS - rectus femoris
(both are managed conservatively)
Ischial Tuberosity - Hamstrings
(managed conservatively if <2cm displacement. If displaced >2cm may benefit from operative fixation

Front 88

What is the most important etiologic factor in femoral neck fractures?

Back 88

Age-related bone loss

Front 89

What are the most common complications of femoral neck #s?

Back 89

AVN (20% of patients)
nonunion

Front 90

How are intertrochanteric hip fractures classified?

Back 90

By the number of parts that the fracture produces:
two part - one part connected to the femoral head and the other attached to the shaft
three part - a two part plus either greater or less trochanter fracture
Four part - as above, but involves both trochaters

Front 91

What are EM pitfalls related to intertrochanteric hip fractures?

Back 91

-70% of patients are under-resuscitated (they may be severely dehydrated or have up to 3U of blood loss)
-Associated fractures may be present
-distal radius
-proximal humerus
-rib fractures
-compression fractures of the T and L spine (typically T12 or L1)

Front 92

Where do subtrochanteric fractures occur?

Back 92

Between the lesser trochanter and the proximal 5cm of the femur

Front 93

What 2 groups of patients get subtrochanteric fractures?

Back 93

1.Elderly patients (fall, pathological fracture through metastatic lesions, Pagets, osteogenesis imperfect, osteomalacia)
-victims of extreme high trauma

Front 94

What is the mechanism and epidemiology of femoral shaft fractures?

Back 94

-young adults
-high-energy trauma

Front 95

What injuries are associated with femoral shaft fractures?

Back 95

ligamentous damage to the knee (though proper evaluation of the knee in the ED is not possible in most cases)

Front 96

Describe how stress fractures occur?

Back 96

-Normal bone is repeatedly subjected to sub maximal forces
-this stimulates the bone to remodel and strengthen
-Osteoblasts are unable to lay down new bone and remodel fast enough so bone fails

Front 97

What X-ray views should be obtained if stress fracture of the femoral neck is suspected?

Back 97

AP, lateral and oblique views

Front 98

If X-rays are negative, but femoral neck stress fracture is strongly suspected?

Back 98

-Obtain MRI
-If positive for stress fracture image the other side

Front 99

Where are tensile trabecular fibers located in the femoral neck?

Back 99

Lateral aspect of the femoral neck

Front 100

Where are compressive trabecular fibers located in the femoral neck?

Back 100

Medial aspect of the femoral neck

Front 101

What is the pattern of injury associated with pedestrian vs car?

Back 101

Head
Chest
Pelvis
Arm
Femur

Front 102

What is the pattern of injury associated with motorcyclist vs car?

Back 102

Pelvis and ipsilateral leg

Front 103

In what percentage of hip dislocations are serious associated injuries found?

Back 103

Up to 95% of patients

Front 104

How are hip dislocations classified?

Back 104

Anterior
Posterior
Central
Inferior (rare, mostly found in children)

Front 105

What defines a fracture-dislocation of the hip?

Back 105

An associated ace tabular or femoral head fracture

Front 106

What is the position of the injured extremity in posterior hip dislocation?

Back 106

adducted, internally rotated, and flexed

Front 107

What is the position of the injured extremity in anterior hip dislocation?

Back 107

Abduction, slight flexion and external rotation

Front 108

What are the most sensitive signs of sciatic palsy?

Back 108

Weakness of extensor hallucis longus (big toe extension ?dorsiflexion)

Front 109

What are subtle radiographic signs that may assist physicians in making the diagnosis of hip dislocation?

Back 109

-position of the lesser trochanter (post disloc is internally rotated therefore lesser trochanter not seen, ant disloc is externally rotated therefore lesser trochanter more visible)
-size of the femoral head (post = head appears smaller, ant = head larger)
-Inegrity of Shenton's line

Front 110

What is Shenton's line?

Back 110

A smooth curved line drawn on a hip radiograph along the superior border of the obturator foramen and medial aspect of the femoral metaphysics (disruption of this line should raise suspicion of a femoral neck fracture or hip dislocation)

Front 111

Is an acetabular fracture a contraindication to hip reduction?

Back 111

No, it may make the reduction more difficult

Front 112

What are contraindications to closed reduction of hip dislocation

Back 112

-Femoral neck fracture
-The presence of other fractures in the dislocated limb (relative contraindication)

Front 113

What are 2 methods of hip relocation?

Back 113

-Allis maneuver
-Stimson technique

Front 114

Can closed reduction of a hip dislocation and femoral head fracture be attempted?

Back 114

Yes, only if it cannot be reduced of is unsatisfactorily reduced will open reduction be required

Front 115

What are the reduction techniques for prosthetic hips?

Back 115

The same as those for native hip dislocations

Front 116

What should be done with a dislocated prosthetic hip?

Back 116

Consultation with an orthopaedic surgeon (this diagnosis does not carry the same urgency because there is no risk of AVN)
-Traction on the sciatic nerve is the compelling reason for early reduction

Front 117

What are hard signs of vascular injury?

Back 117

-active or pulsatile hemorrhage
-expanding or pulsatile hematoma
-diminished or absent pulse
-auscultated bruit
-palpable thrill
-evidence of limb ischemia

Front 118

What injuries are commonly associated with femoral nerve injury

Back 118

Femoral and iliac arteries

Front 119

What are the motor, sensory and reflex deficits associated with femoral nerve injury?

Back 119

Motor - problem with knee extension (rising from sitting, walking upstairs)
Sensory - anterior thigh, medial lower leg (reliable - superior and medial to patella)
Diminished/absent DTR of knee

Front 120

What injuries typically affect the femoral nerve?

Back 120

-Penetrating trauma to pelvis, groin, or thigh
-Hematoma within abdominal wall or iliopsoas muscle

Front 121

What injuries typically injure the sciatic nerve?

Back 121

-Penetrating injury to the hip, thigh, or buttock
-Posterior hip dislocations and fracture dislocations

Front 122

What are the deficits associated with sciatic neuropathy?

Back 122

-Paralysis of hamstrings and all muscles below the knee (complete)
-Weakness of extensor hallucis longus(partial)
Sensory loss below the knee and posterior thigh, plantar aspect of foot
-Diminished absent ankle reflexes

Front 123

What is different about the paediatric hip?

Back 123

Large portions of the paediatric hip are radiolucent?

Front 124

What is the Delbert classification system?

Back 124

This is the classification system used for paediatric proximal femur fractures
Type 1 - physis
Type 2 - transcervical
Type 3 - cervicotrochanteric
Type 4 - intertrochanteric

Front 125

What are the categories of abnormalities associated with a limb?

Back 125

-pain
-muscle weakness
-structural alteration
-sensory deficit
-cerebellar or vestibular imbalance

Front 126

What are 4 key predictors of septic arthritis?

Back 126

T >38.5
non-weight bearing (refusal or inability)
ESR >40mm/hr
wbc >12,000

Front 127

What is the most common region of bone for osteomyelitis to develop in adults? in children?

Back 127

Adults - metaphysis
Children - physis

Front 128

What are the most affected joints in septic arthritis?

Back 128

Knee and hip

Front 129

In what patient population is SCFE most commonly seen?

Back 129

Boys 10-17 years of age - during the period of rapid growth

Front 130

What is Perthes disease?

Back 130

AVN of the paediatric femoral head

Front 131

When does Perthes disease occur?

Back 131

Between the ages of 4 and 8, 5x more common in boys than girls.

Front 132

What is Klein's line?

Back 132

If a line is drawn along the superior margin of the femoral neck, part of the femoral head should lie above the line, if not, then the clinician should consider SCFE.

Front 133

What are signs and symptoms of a complete muscle tear?

Back 133

-palpable depression
-severe spasm, swelling, ecchymosis, tenderness
-loss of muscle function

Front 134

What are features of iliopsoas strain?

Back 134

-it may cause severe abdo pain
-you should X-ray the femur to r/o avulsion fracture of the lesser trochanter

Front 135

Describe the Allis maneuver

Back 135

-Pt supine
-Have assistant stabilize the pelvis
-bring hip to 90 degrees
-provide anterior traction with internal/external rotation
-bring leg out in traction when reduced

Front 136

What is the orthopaedic management of a femoral shaft fracture?

Back 136

-ORIF with intramedullary rods

Front 137

When is postoperative re-fracture of the femur most likely?

Back 137

-early, during callus formation
-after hardware removal

Front 138

What is the orthopaedic management of femoral neck fractures?

Back 138

-non-displaced -> non operative if impacted
-displaced or non-impacted -> ORIF vs arthroplasty

Front 139

What are complications of subtrochanteric hip fractures?

Back 139

-poor healing
-may be associated with fat embolism

Front 140

What is the Gustilo classification of open fractures? What are the implications?

Back 140

Type I - <1cm
Type II - 1-10cm (some soft tissue damage)
Type III - >10cm with extensive soft tissue damage
IIIa - adequate soft tissue coverage
IIIb - inadequate soft tissue coverage
IIIc - associated with arterial injury requiring repair for limb salvage

The implication is that Type II and III require gram-negative coverage (amino glycosides)

Front 141

What are indications for further testing to r/o occult hip fractures?

Back 141

-painful hip, can't ambulate, x-ray negative
-elderly with hip pain, >3 weeks, even if they can ambulate

Front 142

Should traction be used for femoral fractures?

Back 142

-Traction can cause potentially damaging tension on the nerve and artery and increases the potential for AVN
-If a patient arrives in traction, it should be removed

Front 143

What attaches to the small concavity in the centre of the femoral head?

Back 143

-ligamentum teres

Front 144

What are occult management issues in hip fractures?

Back 144

Dehydration
Electrolyte issues
Rhabdomyolysis/hyperkalemia
Syncope vs seizure
Other injuries

Front 145

How much blood can be lost into a femur fracture?

Back 145

3 units

Front 146

What is the management of SCFE?

Back 146

-No weight bearing
-immediate orthopedic consultation

Front 147

What are the complications of SCFE?

Back 147

AVN
Chondrolysis (loss of cartilage)

Front 148

What is an apophysis?

Back 148

The apophysis is a cartilaginous structure that serves as a site for tendons to insert on growing bone

Front 149

Name 3 apophyseal injuries

Back 149

-Osgood Schlatter
-Sever's disease (posterior heel calcaneus mass)
-Medial epicondylitis (little leaguers elbow)

Front 150

What is the blanch sign of steele?

Back 150

A crescent shaped area of increased density in the proximal femoral neck (superimposition of posteriorly displaced epiphysis on femoral neck)

Front 151

What are the 3 compartments of the knee joint?

Back 151

Patellofemoral
Medial tibiofemoral
Lateral tibiofemoral

Front 152

What are the 4 components of the quadriceps femoris muscle?

Back 152

rectus femoris
vastus medialis
vastus lateralis
vastus intermedius

Front 153

What is per anserinus?

Back 153

The three pronged tendinous structure that is the conjoined insertion of sartorius, semi-tendinosus and gracilis

Front 154

What are the boundaries of the popliteal fossa?

Back 154

Biceps femoris (laterally)
semi-membranosus and semi-tendinosus (medially)
gastrocnemius (inferiorly)

Front 155

What is found within the popliteal space?

Back 155

-popliteal vein and artery
-peroneal nerve
-tibial nerve

Front 156

Why is there a high incidence of artery injury with knee dislocation?

Back 156

Because the popliteal artery is firmly anchored at the proximal and distal ends of the popliteal fossa

Front 157

What injuries result in common peroneal nerve injury?

Back 157

-injury to the fibular head
-prolonged compression

Front 158

What are signs and symptoms of peri-patellar tendinitis

Back 158

Localized pain at the quadriceps or patellar tendon (aka jumper's knee)

Front 159

What is plica syndrome?

Back 159

Non-specific medial femoral condyle symptoms (brought on by activity or prolonged sitting)

Front 160

What is the orthopaedic management of knee ligament injuries?

Back 160

Partial tears -> conservative
Collateral ligaments (isolated) -> conservative
ACL -> depends on activity level
PCL ->typically non-operative
combo -> usually operative

Front 161

Which meniscus is more vulnerable?

Back 161

Medial (lateral meniscus is more mobile)

Front 162

Which part of the meniscus heals?

Back 162

Peripheral 1/3 (vascular part)

Front 163

Who gets IT band syndrome?

Back 163

High mileage runners

Front 164

What are signs and symptoms of IT band syndrome?

Back 164

Pain at the lateral femoral condyle
-aggravated by repetitive knee movement
-appears after consistent mileage

Front 165

What is the treatment patellofemoral pain syndrome?

Back 165

-Quad strengthening exercises
-brace support
-activity modification
- NSAIDs

Front 166

What are alternatives to arteriography in evaluation of kneed dislocation. How do you immobilize patients following knee dislocation?

Back 166

-ABIs (serially)
-color flow doppler
(immobilize in long leg posterior slab in 20 degrees flexion)

Front 167

What are complications of knee dislocation?

Back 167

-neurovascular injury
-DVT
-compartment syndrome
-pseudoaneurysm
-arterial thrombosis

Front 168

What are pitfalls in the diagnosis of patellar fractures?

Back 168

-bipartitie/multipartite patellas (common variant)
-get comparison view

Front 169

What are RF for patellar dislocation

Back 169

-Patellofemoral joint laxity
-Genu valgum
-decreased quad strength
-previous dislocation
-extensor mechanism rupture
-Large Q angle

Front 170

What is the Q angle?

Back 170

The Q angle is measured with quads contracted - angle formed by lines drawn on an anterior posterior radiograph from the tibial tubercle to the centre of the patella and from the centre of the patella to the ASIS

Front 171

Where does AVN occur in the knee?

Back 171

-At the medial femoral condyle

Front 172

Describe the pivot shift test?

Back 172

-Grab foot, internally rotate tibia, apply valgus stress, then flex
- amount of pivot determines severity of ACL injury

Front 173

What are the aetiologies of palpation tenderness @ the following locations
Above patella
Patella
Inferior to the Patella
Joint line tenderness
Inferomedial Patella
Tibial tubercle

Back 173

Above patella -quadriceps tendon
Patella - prepatellar bursitis
Inferior to the Patella - Patella tendinitis
JLT - meniscus
Inferomedial patella - pes anserine bursitis
Tibial tubercle - Osgood Schlatter

Front 174

What knee injuries predispose to osteoarthritis

Back 174

May occur after
-ACL tears
-Meniscal damage/meniscectomy
-cartilage injury

Front 175

What is the most effective intra-articular knee analgesia?

Back 175

5mg morphine in 25cc NS

Front 176

What is the difference between laxity in the collateral ligament stress test at 0 degrees and at 30 degrees

Back 176

If lax in full extension, the injury is more severe (secondary restraints are disrupted - ACL, PCL etc.)

Front 177

What steps are involved in fracture healing?

Back 177

-hematoma formation
-infammatory phase
-resorption of the hematoma
-procallus
-callus
-bony union

Front 178

What is delayed union?

Back 178

-union that takes longer than usual

Front 179

What is malunion?

Back 179

When a residual deformity exists

Front 180

What is nonunion

Back 180

Failure of a fracture to unite

Front 181

What is the triangular metaphyseal fragment in a SH II referred to?

Back 181

Thurston Holland Sign

Front 182

In what joints do SH type V fractures occur most commonly?

Back 182

Knee and ankle

Front 183

Describe the 5 types of SH injuries

Back 183

Type I - slip in the zone of proximal calcification
Type II - fracture of the physis extending into the metaphysis
Type III - fracture of the physis extending into the epiphysis
Type IV - fracture of the physis extending into the metaphysis and physis
Type V - crush injury of the epiphyseal plate

Front 184

Why are some #s only visible 7-10d after injury?

Back 184

Absorption widens the radiolucent line, allowing the defect to be visualized

Front 185

What is the most commonly missed fracture?

Back 185

The 2nd fracture

Front 186

What are antibiotic recommendations for open #s?

Back 186

Grade 1 - Cefazolin
Grade 2 and 2 cefazolin and gentamycin

Front 187

What is the exception to the antibiotic for open # rule?

Back 187

Open phalangeal #s in fingers with intact digital arteries probably do not require antibiotics

Front 188

What are late complications of undiagnosed vascular injuries?

Back 188

-thrombosis
-AV fistulae
-Aneurysm
-False Aneurysm
-tissue schema with limb dysfunction

Front 189

What is neuropraxia?

Back 189

Contusion of a nerve with disruption of the ability to transmit impulses (paralysis is transient and sensory loss is slight)

Front 190

What is axonotmesis?

Back 190

Injury to nerve fibers within their sheaths - spontaneous healing is still possible

Front 191

What is neurotmesis?

Back 191

Severing of a nerve, usually requiring surgical repair

Front 192

What is the O-Riain wrinkle test?

Back 192

Soaking a normally innervated digit in warm saline for 20 min causes the digit pulps to wrinkle. THe presence of wrinkling probably indicates the nerve is intact, absence of wrinkling may be more difficult to interpret.

Front 193

With what injury is compartment syndrome most commonly associated with?

Back 193

Long bone fractures of the tibia

Front 194

With what other injuries/in what other situations has compartment syndrome been described?

Back 194

-thigh, forearm, arm, hand, foot fractures
-soft tissue injury
-surgical positions
-IV injections

Front 195

At what compartment pressure does inadequate perfusion and relative schema occur?

Back 195

Within 20 mmHg of the patient's diastolic pressure (w/in 30 mmHg of the MAP)

Front 196

What is the hallmark finding in compartment syndrome?

Back 196

Pain out of proportion to the injury

Front 197

What are other reliable signs of compartment syndrome?

Back 197

-pain on passive stretching
-pain on active flexion of muscles
-hypoesthesia or paresthesia in nerves crossing the compartment

Front 198

What is the indication for fasciotomy in compartment syndrome?

Back 198

Compartment Pressure >30mmHg or pressures w/in 30mmHg of the patient's MAP

Front 199

Should the limb with compartment syndrome be elevated?

Back 199

No, elevation does not improve venous outflow and it reduces arterial inflow.

Front 200

What can occur with compartment syndrome?

Back 200

-rhabdomyolysis
-hyperkalemia
-myogobinuria

Front 201

Which bones are particularly prone to AVN?

Back 201

-Femoral head
-talus
-scaphoid
-lunate
-capitate
(and navicular)

Front 202

What nerve injury may accompany:
scapular neck, body, or spine injury?
supracondylar fracture?
elbow dislocation?
-olecranon fracture?
shoulder dislocation or proximal humerus?
sacral fracture?
acetabular fracture?
hip dislocation?
knee dislocation?
lateral tibial plateau fracture?
Colle's?
Pisiform?
Monteggia?
Femoral shaft?
Fibular head?

Back 202

-suprascapular nerve
-radial, median, ulnar
-posterior: median or anterior: ulnar
-ulnar
-axillary nerve
-cauda equina
-sciatic nerve
-femoral nerve
-tibial or peroneal nerve
-peroneal nerve
-median
-ulnar
-peroneal
-peroneal

Front 203

What is the definition of complex regional pain syndrome Type 1?

Back 203

-A pain syndrome that develops after an initiating noxious event
-Extends beyond the distribution of a single nerve
-Disproportionate to the inciting event

(Often in distal areas, assc with edema or changes in blood flow)

Front 204

What is the definition of complex regional pain syndrome Type II?

Back 204

A pain syndrome that develops after an initiating noxious event where there is demonstrable peripheral nerve injury.
-Extends beyond the distribution of a single nerve
-disproportionate to the inciting event

Front 205

What are the 9 criteria to diagnose RSD/CRPS I?

Back 205

-allodynia
-burning pain
-edema
-color or hair growth changes
-sweating changes
-temperature changes
-radiographic changes
-quantitative vasomotor distribution
-triple-phase bone scan consistent with RSD
1 point per positive criterion and half a point if equivocal
(>5 criteria means probably RSD)

Front 206

What is a fracture blister?

Back 206

Tense blisters or bullae that accompany high-energy injuries in areas of relatively little skin coverage

Front 207

Where do fracture blisters typically occur?

Back 207

Ankle>elbow>foot>knee

Front 208

What do fracture blisters indicate?

Back 208

-increased underlying tissue pressure

Front 209

What is the difference between subluxation and dislocation?

Back 209

Subluxation is partial loss of continuity between two articulating surfaces while dislocation is complete loss of continuity between two articulating surfaces

Front 210

How are dislocations described?

Back 210

According to the direction of the distal segment relative to the proximal segment

Front 211

What is the definition of a sprain?

Back 211

-ligamentous injury resulting from an abnormal motion of a joint

Front 212

What are the degrees of sprain (ligamentous injury)?

Back 212

I- ligament stretching without tear
II partial tear of a ligament, mild or moderate instability
III - complete tearing of a ligament - gross instability

Front 213

What is the treatment for complete/nearly complete ligamentous disruption?

Back 213

Urgent orthopedic consultation

Front 214

What is a strain?

Back 214

An injury to the musculotendinous unit

Front 215

What are the 3 joints in the shoulder and what is the pseudo articulation?

Back 215

-acromioclavicular
-glenohumeral
-sternoclavicular

pseudoarticulation : scapulothoracic

Front 216

What is the most moved joint in the body?

Back 216

the SCJ (sternoclavicular joint)

Front 217

What 5 structures are immediately posterior to the SCJ?

Back 217

-great vessels
-trachea
-esophagus
-thoracic duct
-lung apices

Front 218

What is the most important stabilizer of the SCJ?

Back 218

-costoclavicular ligament

Front 219

What are the most important stabilizers of the ACJ?

Back 219

-the coracoclavicular ligaments (conoid and trapezoid)

Front 220

What is the most impt restraint to anterior glenohumeral dislocation?

Back 220

The anterior band of the inferior glenohumeral ligament

Front 221

What muscles insert on the greater tuberosity of the humerus?

Back 221

-supraspinatus
-infraspinatus
-teres minor

Front 222

What muscle inserts onto the lesser tuberosity of the humerus?

Back 222

-subscapularis

Front 223

What muscles cross the glenohumeral articulations and are involved in humeral fracture dislocations

Back 223

-pectoralis major
-latissmus dorsi
-teres major

Front 224

What are extrinsic sources of shoulder pain?

Back 224

-cervical spine disorders
-thoracic outlet obstruction
-pancoast tumor
-referred pain (cardiac, diaphragm, LL pneumonia, spleen, ectopic, GB disease, gastric and pancreatic disease)

Front 225

What are the sensory and motor components of C5?

Back 225

-lateral arm
-deltoid

Front 226

What are the sensory and motor components of C6?

Back 226

-lateral forearm and thumb
-biceps

Front 227

What are the sensory and motor components of C7?

Back 227

-tip of the long finger
-thumb extensors

Front 228

What are the sensory and motor components of C8?

Back 228

-tip of the little finger and medial forearm
-finger flexors

Front 229

What are the sensory and motor components of T1?

Back 229

-medial arm
-hand interossei

Front 230

What is the three view series for shoulder radiographs?

Back 230

-true AP
-trans-scapular lateral (Y)
-axillary lateral

Front 231

Which type of clavicular # is the most common?

Back 231

-middle 1/3

Front 232

What are the subtypes of distal 1/3 clavicular #s?

Back 232

Type I - minimal displacement, coracoclavicular ligament intact
Type II - torn coracoclavicular ligament associated with displacement (these are unstable)
Type III - involves the articular surface (the acromioclavicular joint)

Front 233

Which clavicular #s require immediate Orthopedic consultation?

Back 233

-open #s
-#s associated with neurovascular compromise

Front 234

Which clavicular #s require urgent orthopaedic referral?

Back 234

-type II lateral clavicular #s
-severely comminuted or displaced fracture of the middle third
->20mm shortening

Front 235

What is atlantoaxial rotatory displacement?

Back 235

It is an injury in children that is associated with clavicle #s. Patients present with a clavicle fracture, head bent towards the fracture but turned away. These patients should have their C-spines CT'd

Front 236

What is the most important aspect of scapular fractures?

Back 236

The fact that there is a high incidence of associated injuries: ipsilateral lung, chest wall and shoulder girdle components

Front 237

What is the therapy for a scapular fracture?

Back 237

-analgesia
-immobilization in a sling

Front 238

Which scapular #s may require operative intervention?

Back 238

-displaced acromial fractures
-severely displaced coracoid#s
-scapular neck #s
-glenoid fossa #s

Front 239

What are the 4 segments involved in proximal humerus #s?

Back 239

-anatomic neck
-surgical neck (humeral shaft)
-greater tuberosity
-lesser tuberosity

Front 240

What is the definition of displacement in the Neer classification of proximal humeral #s?

Back 240

-a segment is considered displaced if it is angled >45 degrees or separated >1cm from a neighbouring segment

Front 241

What are the 4 major categories of fracture in the Neer classification of proximal humerus #s?

Back 241

-minimal displacement
-2 part
-3 part
-4 part
(anterior and posterior dislocations are included)

Front 242

What is the treatment for a minimally displaced proximal humerus fracture?

Back 242

Sling or sling and swath

Front 243

When should an orthopaedic surgeon be consulted in the presence of a proximal humerus #?

Back 243

-any 2,3 or 4 part fractures
-any fracture-dislocation

Front 244

What are impression #s? What is the management?

Back 244

Impression fractures are fractures resulting from shoulder dislocation
-posterior dislocations may cause anteromedial impression fractures
-anterior dislocation may cause posterolateral impression fractures aka Hill Sachs deformity.
If they involve <20% of the articular surface they are usually stable, if they involve >20% of the articular surface they may require surgery)

Front 245

What are potential complications of proximal humerus fractures?

Back 245

-adnesive capsulitis
-AVN
-myositis ossificans
-neurovascular injuries (brachial plexus, axillary artery, axillary nerve)

Front 246

What is particular about epiphyseal proximal humerus fractures?

Back 246

They need to be followed closely and referred early to orthopaedics because of the potential for growth disturbance.

Front 247

What is the grading and management of SCJ injuries?

Back 247

Type I - mild sprain with stretching of the sternoclavicular and costoclavicular ligaments -> sling
Type II - subluxation of the joint (rupture of the SCL) ->sling and refer
Type III - complete rupture of the SCL and CCL -> closed reduction

Front 248

What is the best radiologic study for SCJ dislocation?

Back 248

CT

Front 249

How do you reduce anterior SCJ dislocations?

Back 249

- elevate shoulders by placing a roll between the shoulders
-downward traction of 90degrees abducted/extended arm
+/- inward pressure on medial clavicle

Front 250

What is the modified Rockwood classification of ACJ dislocations?

Back 250

Type I - AC ligament sprain
Type II - disruption of the AC ligament
Type III - disruption of the AC ligament, the coracoclavicular ligament and muscle attachments
IV - same as III but clavicle in trapezius
V - same as III but exaggerated distance
VI - same as III but clavicle inferior

Front 251

Are there special X-ray view for the ACJ?

Back 251

Yes, view that use 1/3 to 2/3 less intensity

Front 252

What is the normal coracoclavicular distance?

Back 252

11-13 mm

Front 253

Should stress views of the ACJ be ordered?

Back 253

No, they lack efficacy in distinguishing type II from type III injuries

Front 254

What is the management of ACJ dislocation?

Back 254

I + II - conservative with a sling
III - unclear, evidence that OR not better (early ortho referral)
IV/V/VI - surgical

Front 255

What is a Bankart lesion?

Back 255

Avulsion of the anteroinferior glenohumeral ligament with capsulolateral detachment

Front 256

In what directions can the glenohumeral joint dislocate?

Back 256

-Anterior (most common)
-Posterior
-Superior (rare)
-Inferior (rare)

Front 257

What positions can the humeral head assume post anterior shoulder dislocation?

Back 257

Subcoracoid
Subglenoid
Subclavicular
Intrathoracic

Front 258

How do you assess axillar nerve motor and sensory?

Back 258

motor - deltoid and teres minor (shoulder abduction)
sensation - over lateral aspect of the shoulder

Front 259

What fractures may be associated with shoulder dislocation?

Back 259

-Hill-sachs deformity
-Bankart lesion
-avulsion of greater tuberosity

Front 260

What is the landmark for intra-articular anesthetic shoulder injection? What is injected?

Back 260

2cm inferior to the lateral edge of the acromion. 20cc of 1% lidocaine over 30s

Front 261

What are possible techniques for reduction of an anterior shoulder dislocation?

Back 261

-Stimson
-Traction-countertraction
-Forward elevation
-Snowbird Technique
-External rotation of Liedelmeyer
-Scapular manipulation

Front 262

Which methods of shoulder relocation are no longer recommended?

Back 262

-Kocher maneuver
-Hippocratic method

Front 263

What did Itoi and coworkers find regarding shoulder immobilization?

Back 263

Improved outcomes with immobilization in external rotation. (These findings have not been duplicated)

Front 264

What are the possible complications of shoulder dislocations?

Back 264

-fractures
-neurovascular injuries
-rotator cuff tears
-recurrence

Front 265

What is transient anterior subluxation (dead arm syndrome)?

Back 265

Sudden sharp shoulder pain and weakness while performing an abduction and external rotation

Front 266

What is the most common misdiagnosis of posterior dislocation?

Back 266

Adhesive capsulitis

Front 267

What are radiologic findings in posterior shoulder dislocation?

Back 267

AP shows loss of the half-moon elliptical overlap of the humeral head and glenoid fossa
-distance between the anterior glenoid rim and articular surface of the humeral head increased ('rim' sign)
-humeral head has a 'light bulb' or 'drumstick' appearance
-true AP shows overlap between glenoid fossa and humeral head
-reverse Hill sachs deformity

Front 268

How is the diagnosis of posterior shoulder dislocation confirmed?

Back 268

Using an orthogonal view (axillary, transscapular or apical oblique)

Front 269

How is closed reduction of a shoulder posterior dislocation done?

Back 269

Under concious sedation
-Axial traction in line with humerus
-gentle pressure on posterior displaced head
-external rotation

Front 270

How do you immobilize a reduced posterior shoulder dislocation?

Back 270

External rotation with slight abduction

Front 271

What is luxatio erecta?

Back 271

Interior glenohumeral dislocation

Front 272

How does luxatio erecta present?

Back 272

Pt has arm locked overhead in 110-160 degrades abduction

Front 273

What radiographic features can be used to distinguish luxatio erecta from subglenoid anterior dislocation?

Back 273

-humeral shaft lies parallel to the spine of the scapula on AP view in luxatio erecta (in subglenoid anterior dislocation the humeral shaft lies parallel to the chest wall.

Front 274

How is closed reduction of luxatio erecta achieved?

Back 274

Traction-countertraction

Front 275

What are potential complications associated with luxatio erecta

Back 275

-neuropraxic brachial plexus lesions
-axillary artery thrombosis

Front 276

What are pathognomic findings of scapulothoracic dislocation?

Back 276

-massive soft tissue swelling of the shoulder
->1cm displacement of the scapula on AP chest radiograph

Front 277

Injuries to what structures are associated with scapulothoracic dislocations?

Back 277

-Vascular lesions
-Severe neurologic injuries

Front 278

What is contained in the subacromial space?

Back 278

-Long head of the biceps
-rotator cuff
-subacromial bursa

Front 279

What is the subacromial painful arc?

Back 279

60-120 degrees abduction

Front 280

What is the acromioclavicular painful arc?

Back 280

120-180 degrees

Front 281

What are the 3 stages of Neer impingement syndromes

Back 281

Stage 1 - dull ache around deltoid after strenuous exercise
Stage 2 - more severe pain, particularly at night
Stage 3 - significant tendon degeneration after a prolonged history of tendinitis and bursitis

Front 282

What is the function of the rotator cuff?

Back 282

Dynamic stabilizer of the glenohumeral joint

Front 283

What are the functions of infraspinatus and trees minor?

Back 283

-external rotators

Front 284

What is the function of supraspinatus?

Back 284

First 30 degrees of shoulder abduction

Front 285

What is the function of subscapularis

Back 285

Internal rotators

Front 286

What is the presentation of an acute rotator cuff tear?

Back 286

-Usually associated with a specific traumatic event
-point tenderness over the site of rupture (greater tuberosity)
-palpable defect
-discrepancy between active and passive ROM (no active mvmt possible)
-Cannot initiate shoulder abduction (large tear)

Front 287

What is the hallmark radiographic sign of complete rotator cuff tear?

Back 287

Superior displacement of the humeral head. The space between the humeral head and the undersurface of the acromion is <6mm

Front 288

What is the treatment for acute rotator cuff tear?

Back 288

-Sling
-Prompt ortho referral (OR within 3 weeks)

Front 289

What is the treatment for chronic rotator cuff tear?

Back 289

-pain control
-shoulder rehab program

Front 290

What are treatment options for painful arc symptoms?

Back 290

-NSAIDs
-modification of activities
-physiotherapy and strengthening
-subacromial steroid injection
-decompression surgery

Front 291

What are the functions of the biceps?

Back 291

-flexion at the elbow
-supination at the elbow
-stabilizes glenohumeral joint

Front 292

What is Yergason's test and what does it test for?

Back 292

Supination against resistance with the arm adducted and elbow flexed.
+ test reproduces the pain of bicipital tendinitis

Front 293

What are the two types of biceps tendon rupture and which is more common?

Back 293

Distal and proximal
Proximal ruptures are more common

Front 294

What are signs and symptoms of proximal biceps rupture

Back 294

-popeye appearance (distal retraction of muscle)
-+ Luddington sign (difference in muscle contour when the arms are behind the head
-arm supination weakened
-strong elbow flexion (intact coracobrachialis and short head of the biceps)

Front 295

What is the management of biceps rupture?

Back 295

-immobilization of elbow at 90degrees
-ortho referral within 72 hours

Front 296

What are the 3 clinical presentations of calcific tendonitis?

Back 296

-silent
-subacute
-acute

Front 297

What are management options for acute calcific tendinitis?

Back 297

-sling
-NSAIDs
-analgesia
-+/- subacromial local anesthetic injection
-subacromial corticosteroids (controversial because this may delay calcium reabsorption)
-early shoulder ROM

Front 298

What is a distinguishing feature of adhesive capsulitis?

Back 298

A sense of mechanical restriction on passive testing

Front 299

What are the 3 articulations of the ankle?

Back 299

-inner surface of the medial malleolus with medial surface of the talus
-distal tibial plafond with talar dome
-lateral malleolus with lateral process of the talus

Front 300

What are the talocrural joints?

Back 300

the 3 articulations of the ankle and the tibiofibular joint

Front 301

Which ligaments support the ankle joint?

Back 301

-syndesmotic ligaments
-lateral collateral ligaments
-medial collateral ligaments

Front 302

What views make up the ankle radiographic series?

Back 302

-AP
-lateral
-mortise

Front 303

What is the appearance of an ankle effusion on x-ray?

Back 303

-tear drop shaped density displacing the normal fat adjacent to the anterior or posterior margin of the joint capsule

Front 304

What does an ankle effusion suggest?

Back 304

the possibility of a subtle intraarticular injury (i.e. osteochondral # of the talar dome)

Front 305

How is the mortise view taken?

Back 305

With the ankle in 15-25 degrees of internal rotation

Front 306

What is the mortise view important for?

Back 306

Evaluating the congruity of the articular surface between the dome of the talus and the mortise

Front 307

What is the maximum distance for the medial clear space?

Back 307

4mm

Front 308

According to the Ottawa Ankle Rules, when are ankle radiographs required?

Back 308

-bone tenderness at the posterior edge of the distal 6cm or the tip of the lateral malleolus
-bone tenderness at the posterior edge of the proximal 6cm of the tip of the medial malleolus
-Inability to WB for at least 4 steps immediately after injury and at the time of evaluation

Front 309

According to the Ottawa Foot rules when are foot radiographs required?

Back 309

-bone tenderness at the navicular bone
-bone tenderness at the base of the 5th
-inability to WB for at least 4 steps immediately after injury and at the time of evaluation

Front 310

What fractures do the Ottawa ankle and Ottawa foot rules detect?

Back 310

-malleolar zone fractures and midfoot zone fractures

Front 311

What are the 2 classification systems for ankle fractures?

Back 311

-Lauge Hansen
-Danis Weber

Front 312

Which ankle #s require ortho ED consultation?

Back 312

Unimalleolar fractures
displaced medial malleolar fracture
medial malleolar fracture with lateral collateral ligament rupture
displaced lateral malleolar fracture
lateral malleolar fracture with deltoid ligament rupture
lateral malleolar fracture with widened medial clear space
unimalleolar fracture with syndesmotic diastasis
fibula fracture at or proximal to the tibiotalar joint line
displaced posterior malleolar fracture
posterior malleolar fracture involveing more than 25% of the joint surface

all bimalleolar fractures
all trimalleolar fractures
all intraarticular fractures with step deformity
all open fractures
all pilon fractures

Front 313

What is the treatment for chip avulsion #s of the ankle?

Back 313

-Avulsed fragments of <3mm and minimally displaced can be treated as an ankle sprain
->3mm or significantly displaced -> splinting and outpatient orthopedics referral

Front 314

What is the focus of the Danis-Weber classification?

Back 314

It focuses on the location of the fibular fracture in relation to the tibiotalar joint

Front 315

Describe Danis-Weber A, B and C and management of each

Back 315

A- fibular # below the tibiotalar joint
1 - isolated fibular fracture: NWB >/=3 weeks
2: concomitant deltoid ligament injury -> ortho consult
3: concomitant posterior malleolus fracture-> ortho consult
B-fibular # at the level of the tibiotalar joint
ortho consultation
C - fibular # proximal to the tibiotalar joint line (frequently disrupts the distal tibiotalar syndesmosis)
ortho consultation

Front 316

What is the usual mechanism for medial malleolar #s?

Back 316

Eversion and external rotation (abducting force)

Front 317

What antibiotic should be added as a 3rd antibiotic for farm or soil related crush injuries? why?

Back 317

Penicillin G
Because of clostridium perfringens

Front 318

What are delayed complications of ankle fractures?

Back 318

Malunion
Nonunion
Osteopenia
Traumatic arthritis
Chronic Instability
Ossification of the Interosseous membrane
CRPS

Front 319

What is a pilon fracture? What it the primary deforming force?

Back 319

-fracture of the distal tibial metaphysis
-axial compression

Front 320

Which ligament is most commonly injured in ankle sprains? which is the 2nd most common?

Back 320

anterior talofibular ligament
calcaneofibular ligament

Front 321

Which population of patients are more likely to have distal tibiofibular syndesmotic ligaments injuries?

Back 321

athletes

Front 322

Descrive the grading system for ligamentous injuries?

Back 322

Grade I - stretching without grossly evidence tearing or instability
Grade II - partial tear with moderate joint instability
Grade III - complete tear of the ligament with marked instability

Front 323

What is the fibular compression test? how do you perform it?

Back 323

-a test that reveals fibular and syndesmotic injuries
-examiner places fingers over the fibula and the thumb over the tibia at the mid calf and squeezes the 2 bones. Pain along the fibula suggests a fibular fracture ro an intraossesous membrane or syndesmotic ligament disruption

Front 324

What are indications for stress testing in ankle injuries?

Back 324

-rupture of 2 or more ligaments is suspected
-a suspected isolated ankle fracture in which the presence of an additional ligament rupture would influence management
-possibility of concomitant syndesmotic injury
-follow up evaluation of acute ankle injury once pain and swelling have subsided
-chronically symptomatic ankle

Front 325

What are common ankle stress tests?

Back 325

Anterior drawer test (ATFL)
Inversion stress test (ATFL and CFL)
External rotation stress test (distal tibiofibular syndesmotic ligament injury)

Front 326

Should stress radiographs of the ankle be done?

Back 326

No, they generally do not influence emergency management

Front 327

What is the differential diagnosis for presumed ankle sprain?

Back 327

-lateral collateral ligament sprain
-peroneal tendon dislocation
-osteochondral # of the talar dome
-# of the posterior process of the talus
-# of the lateral process of the talus
-# of the anterior process of the calcaneus
-midtarsal joint injury
-# of the base of the 5th

Front 328

what analgesics can be used in ankle sprain?

Back 328

-NSAIDs
-acetaminophen
-oral opioids
-topical diclofenac gel

Front 329

What is functional instability?

Back 329

Patient's subjective sensation that the ankle gives way during activity

Front 330

What is mechanical instability?

Back 330

Ligamentous laxity which allows ankle joint movements beyond the physiologic range

Front 331

What soft tissue abnormalities cause chronic ankle pain?

Back 331

-synovial impingement
-peroneal tendon subluxation or dislocation
-loose bodies
-ATF syndesmotic ligament injury
-degenerative arthritis

Front 332

What are bone related causes of chronic pain?

Back 332

osteochodral fragment
anterior calcaneal process #
lateral talus process #
anterior and posterior impingement

Front 333

Why is weak plantar flexion still possible in complete Achilles tendon ruptures?

Back 333

-tibialis posterior
-toe flexors
-peroneal muscles

Front 334

What is the Thompson test?

Back 334

-a maneuver to assess the integrity of the achilles tendon.
-squeezing the calf muscles should cause passive plantar flexion of the foot

Front 335

When should an MRI or US be performed for suspected Achilles rupture?

Back 335

Diagnostic uncertainty (otherwise it is a clinical diagnosis)

Front 336

Where do the peroneal tendons run?

Back 336

They use the fibular groove (posterior peroneal sulcus) as a pulley for midfoot insertions

Front 337

Where do the peroneal tendons insert?

Back 337

peroneus brevis -> tuberosity of the 5th metatarsal
peroneus longus -> medial cuneiform and base of the 1st metatarsal

Front 338

What structure maintains the peroneal tendons against the fibular groove?

Back 338

Superior peroneal retinaculum (attaches to the distal fibular and the calcaneus)

Front 339

What are signs and symptoms of peroneal dislocation?

Back 339

-pain and snapping sensation over the posterolateral ankle
-weakened eversion
-tender over the retromalleolar area
-inability to actively evert the foot when held in dorsiflexion

Front 340

What is the function of the tibialis posterior tendon?

Back 340

plantar flexion and inversion

Front 341

What is the course of tibialis posterior?

Back 341

uses medial malleolus as a pulley and inserts onto the navicular, medial cuneiform and bases of the 2nd through 5th metatarsals

Front 342

What is a cause of unilateral flat foot?

Back 342

Tibialis posterior rupture (resulting in unopposed peroneus brevis)

Front 343

What tendon is the primary dorsiflexor of the foot?

Back 343

tibialis anterior

Front 344

What is the common misdiagnosis of tibialis anterior rupture?

Back 344

-lumbosacral radiculopathy or peroneal palsy (because of foot drop)

Front 345

What is dancer's tendinitis?

Back 345

Flexor hallucis longus tendinitis (great toe flexor)
Symptoms include medial malleolus edema and pain on passive extension of the 1st MTP in neutral position

Front 346

What is the ED management of ankle dislocation?

Back 346

-neurovascular assessment
-tendon function assessment
-reduction (should not be delayed if obvious or neuromuscular compromise or tenting)

Front 347

How is reduction of a dislocated ankle achieved?

Back 347

-knee flexed at 90 degrees
-distraction followed by gentle force to reverse the direction of the dislocation
-reverse the direction of the dislocation

Front 348

What are 3 anatomic/functional regions of the foot?

Back 348

Hindfoot (calcaneus/talus)
Midfoot (navicular/cuboid/cuneiform)
Forefoot (metatarsals/phalanges/sesamoids)

Front 349

What are the articulations of the talus/calcaneus called and how many articulations are there?

Back 349

The subtalar joint
There are 3 articulations

Front 350

What are the nerves that provide innervation to the foot?

Back 350

-deep peroneal
-superficial peroneal
-posterior tibial
-saphenous
-sural

Front 351

What joints are primarily involved in inversion and eversion of the foot?

Back 351

the subtalar joints

Front 352

What are the 3 standard views of the foot and what structures are they useful in evaluating?

Back 352

-AP midfoot and forefoot
-lateral hindfoot
-oblique midfoot and forefoot

Front 353

What are additional radiographic views?

Back 353

Coned views
WB views
45 degree external oblique
Harris (axial) views - to visualize the calcaneus and subtalar joints

Front 354

What percent of the population has sesamoid bones/accessory ossicle centres in the foot?

Back 354

30%

Front 355

What are the most common accessory ossification centres?

Back 355

os trigonum
os tibiale externum
os peroneum
os vesalinum

Front 356

What joints of the foot in particular can be visualized on CT?

Back 356

subtalar
calcaneus
tarsometatarsal (lisfranc)

Front 357

What is specific about the talus

Back 357

It is the only bone in the lower extremity with no muscular attachments and is held in place by the malleoli and ligamentous attachments

Front 358

Is there a risk of AVN with talar fractures?

Back 358

Yes

Front 359

What is the most common tarsal fracture? what is the 2nd most common tarsal fracture?

Back 359

-calcaneus (most common)
-talus (2nd most common)

Front 360

What is the mechanism for talar chip and avulsion fractures?

Back 360

The same as ankle sprains

Front 361

What # has been associated with snowboarding? What is it's management

Back 361

lateral talar process #s
Large displace if >2mm
comminuted: excision
chip: below the knee cast for 6 weeks

Front 362

What are minor talar #s?

Back 362

chilp/avulsion #s of the superior neck and head
lateral, medial and posterior aspects of the body
lateral process fractures
osteochondral fractures

Front 363

What is the most common major talar # and what is the mechanism?

Back 363

Talar neck #
extreme dorsiflexion of the foot

Front 364

What #s are commonly associated with talar neck #s?

Back 364

oblique/vertical medial malleolus fracture
calcaneal fracture
vertebral compression fracture

Front 365

What is the Hawkins classification of talar neck #s?

Back 365

Type I - no displacement
Type 2 -subtalar subluxation
Type 3 - dislocation of the talar body from the ankle and subtler joint

Front 366

What is often the treatment for major talus #?

Back 366

open reduction/internal fixation

All of them require orthopedic consultation in the ED

Front 367

what is the treatment of minor talar 3s?

Back 367

NonWB below the knee case or posterior plaster slab
# fragments >5mm may require excision

Front 368

What is the differential diagnosis for presumed ankle sprain?

Back 368

Lateral collateral ligament sprain
Peroneal tendon dislocation
Osteochondral fracture of the talar dome
# of the posterior/lateral process of the talus
# of the anterior process of the calcaneus
Midtarsal joint injury
# of the base of the 5th

Front 369

How are major talar fractures reduced?

Back 369

Grasp the hind/mid foot ->longitudinal traction and plantar flexion

Front 370

What is the most significant complication of major talar #?

Back 370

AVN

Front 371

What are other potential complications of talar #?

Back 371

-skin infection
-skin necrosis
-post traumatic arthritis
-malunion
-delayed union
-nonunion
-predisposition to peroneal tendon dislocation

Front 372

What is the difference between osteochondral fracture and OCD?

Back 372

Osteochondral #s are injuries that involve cartilage and subchondral bone while OCD is a subacute or chronic talar dome defect that may be caused by an osteochondral fracture

Front 373

When should you think of osteochondral fracture and what should be done?

Back 373

Persistent unexplained ankle pain after "sprain" -> this requires orthopaedic evaluation

Front 374

What is subtalar dislocation?

Back 374

simultaneous disruption of the talocalcaneal and talonavicular joints (without tibiotalar disruption)

Front 375

What is the most common mechanism for calcaneus #?

Back 375

Fall without direct axial compression

Front 376

What associated injuries should be should be considered in calcaneal fractures?

Back 376

compartment syndrome
vertebral compression

Front 377

What is a Harris view and what is it used for?

Back 377

-axial view of the foot
-calcaneal tuberosity, subtalar joint, sustentaculotalar joint

Front 378

What assessments are critical in the management of calcaneal #s?

Back 378

Whether the # involves the subtaler joint
the degree of depression of the posterior facet

Front 379

What measurement can be used to determine compression # of the calcaneus?

Back 379

Boehler's angle

Front 380

How is Boehler's angle measured? What is the interpretation?

Back 380

-Lateral foot view
it is the angle between the posterior tuberosity and apex of the posterior facet and the apex of the posterior facet and apex of the anterior process
An angle of <20 degrees is suggestive of a compression #

Front 381

What is Chopart's joint?

Back 381

The mid tarsal joint composed of talonavicular and calcaneocuboid joints

Front 382

How do midtarsal joint injuries occur?

Back 382

Forced dorsiflexion

Front 383

Why are mid foot injuries difficult to identify?

Back 383

-difficult to see on X-ray because of under penetrated and oblique orientation
-pain is often ill-defined and poorly localized

Front 384

What is a significant risk associated with navicular fractures?

Back 384

AVN (much like scaphoid in the hand)

Front 385

What is the most common mid foot #?

Back 385

navicular #

Front 386

What is the ED management of navicular fractures?

Back 386

-outpatient ortho f/u - usually treated with a walking cast for 4-6 weeks
-if intra-articular then ortho consult should be in the ED

Front 387

What is another name for cuboid fracture?

Back 387

nutcracker fracture because the cuboid is crushed between the bases of the 4th and 5th metatarsals and the anterior calcaneus

Front 388

What are cuboid fractures associated with?

Back 388

they are associated with fractures of the posterior malleolus

Front 389

What is the best radiographic view for the evaluation of the cuboid?

Back 389

Oblique view of the standard foot radiographic series

Front 390

What should be considered in any cuboid or cuneiform #

Back 390

A Lisfranc injury

Front 391

What is the management of cuboid #s?

Back 391

All warrant ortho assessment

Front 392

What is Lisfranc's joint?

Back 392

The tarsometatarsal joints collectively (bases of the 1st 3 metatarsals with their respective cuneiform and the 4th and 5th metatarsals with the cuboid)

Front 393

What si the function of the tarsometatarsal joints?

Back 393

They act to allow supination and pronation of the forefoot

Front 394

What are the 3 mechanisms associated with Lisfranc injuries?

Back 394

-rotational forces
-axial loads
-crush injuries

Front 395

What are 3 classifications of Lisfranc injuries?

Back 395

isolated - one or more metatarsals displaced away from the others
homolateral - all 5 metatarsals displaced in the same direction
divergent - metatarsals splayed outward in both medial and lateral directions

Front 396

What injuries may be associated with Lisfranc injuries?

Back 396

-associated metatarsal #s
-fractures of the cuboid, cuneiform, or navicular
-vascular injury (dorsalis pedis branch dives between the 1st and 2nd metatarsal)

Front 397

What is the normal radiographic anatomy of the midfoot?

Back 397

The 1st 4 metatarsals should each line up with their respective tarsal articulation along their medial edge on AP and oblique radiographic views
-the tarsals should also line up dorsally with the metatarsals on the lateral view

Front 398

What are findings suggestive of a Lisfranc injury?

Back 398

-widening between the 1st and 2nd or 2nd and 3rd metatarsal bases
-any fracture around the Lisfranc joint

Front 399

What fractures are particularly common indicators of Lisfranc injury?

Back 399

-# of the 2nd metatarsal bone (fleck sign - virtually pathognomic of a tarsometatarsal joint disruption)
-cuboid #
-cuneiform #s

Front 400

What is the ED management of a Lisfranc injury?

Back 400

-obvious injury -> ortho consult in the ED
-suspected lisfranc sprain -> casting and ortho referral

Front 401

What are complications associated with Lisfranc injuries?

Back 401

-degenerative arthritis
-compartment syndrome
-residual pain
-unequal metatarsal pressure
-loss of metatarsal arch
-CRPS

Front 402

How can you determine whether a fracture has entered the knee joint?

Back 402

The methylene blue test: inject MC into the tibiofemoral joint (at a site distant from the skin injury), emergence of methylene blue from the skin lesion confirms an open joint

Front 403

What are complications of distal femur fractures?

Back 403

-Thrombophlebitis
-Fat embolus syndrome
-delayed union
-malunion

Front 404

What is the most common mechanism for tibial plateau injury?

Back 404

strong valgus force with axial loading

Front 405

How common are lateral plateau #'s? medial plateau #'s?

Back 405

Lateral 55-70%
Medial 10-23%

Front 406

What is a Segond fracture?

Back 406

-Bone avulsion of the lateral tibial plateau (site of lateral capsular ligament attachment)
-it is an important marker of ACL disruption and anterolateral rotatory instability

Front 407

What is the most important aspect of the initial exam in a patient with suspected tibial plateau fracture?

Back 407

-the neuromuscular exam
(especially for popliteal artery injury or peroneal nerve palsy)

Front 408

Which ligaments are most commonly injury in tibial plateau fractures?

Back 408

ACL and MCL

Front 409

What 4 factors determine the prognosis of tibial plateau fractures?

Back 409

-degree of articular depression
-extent and separation of the condylar fracture lines
-diaphyseal-metaphyseal comminution and dissociation
-integrity of the soft tissue envelope

Front 410

What is the revised Hohl classification?

Back 410

A classification system for tibial plateau #s
1- Minimally displaced (<4mm depression or displacement)
2- Displaced
-local compression
-split compression
-total depression
-splint
-rim
-bicondylar

Front 411

How should a patient with a tibial plateau fracture be immobilized?

Back 411

-non-circumferential splint
-pt should not bear weight on the limb until seen by an Orthopedist

Front 412

What are early complications of tibial plateau #s

Back 412

-wound infection
-loss of reduction
-compartment syndrome

Front 413

In what patient population are tibial spine fractures commonly seen

Back 413

-children and adolescents (because ligaments are stronger than the adjacent physeal plates)

Front 414

How do fractures of the intercondylar eminence occur?

Back 414

Tibial spine -> knee twisting
Intercondylar eminence -> hyperflexion, hyperextension

Front 415

Which radiographic view provides a clearer look at the intercondylar area?

Back 415

-tunnel view

Front 416

What is the fabella?

Back 416

A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment

Front 417

What is the classification of tibial spine fractures?

Back 417

Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent
Type III - complete separation of fracture from fracture bed
IIIA - complete displacement
IIIB displacement and rotation

Front 418

When should a growth plate injury (SH-1) be assumed?

Back 418

-juxta-articular tenderness
-negative radiographs

Front 419

What is osteochondritis dessicans?

Back 419

Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone

Front 420

Where is OCD commonly seen?

Back 420

Lateral aspect of the medial femoral condyle

Front 421

What is the fabella?

Back 421

A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment

Front 422

What is the classification of tibial spine fractures?

Back 422

Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent
Type III - complete separation of fracture from fracture bed
IIIA - complete displacement
IIIB displacement and rotation

Front 423

What is the fabella?

Back 423

A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment

Front 424

When should a growth plate injury (SH-1) be assumed?

Back 424

-juxta-articular tenderness
-negative radiographs

Front 425

What is osteochondritis dessicans?

Back 425

Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone

Front 426

What is the classification of tibial spine fractures?

Back 426

Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent
Type III - complete separation of fracture from fracture bed
IIIA - complete displacement
IIIB displacement and rotation

Front 427

When should a growth plate injury (SH-1) be assumed?

Back 427

-juxta-articular tenderness
-negative radiographs

Front 428

Where is OCD commonly seen?

Back 428

Lateral aspect of the medial femoral condyle

Front 429

What is osteochondritis dessicans?

Back 429

Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone

Front 430

What is the fabella?

Back 430

A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment

Front 431

What is the classification of tibial spine fractures?

Back 431

Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent
Type III - complete separation of fracture from fracture bed
IIIA - complete displacement
IIIB displacement and rotation

Front 432

Where is OCD commonly seen?

Back 432

Lateral aspect of the medial femoral condyle

Front 433

What is the fabella?

Back 433

A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment

Front 434

When should a growth plate injury (SH-1) be assumed?

Back 434

-juxta-articular tenderness
-negative radiographs

Front 435

What is osteochondritis dessicans?

Back 435

Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone

Front 436

What is the classification of tibial spine fractures?

Back 436

Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent
Type III - complete separation of fracture from fracture bed
IIIA - complete displacement
IIIB displacement and rotation

Front 437

When should a growth plate injury (SH-1) be assumed?

Back 437

-juxta-articular tenderness
-negative radiographs

Front 438

Where is OCD commonly seen?

Back 438

Lateral aspect of the medial femoral condyle

Front 439

What is osteochondritis dessicans?

Back 439

Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone

Front 440

What is the fabella?

Back 440

A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment

Front 441

What is the fabella?

Back 441

A sesamoid bone located in the lateral head of the gastrocnemius muscle. In some people it may be mistaken for an intraarticular loose body or fracture fragment

Front 442

Where is OCD commonly seen?

Back 442

Lateral aspect of the medial femoral condyle

Front 443

What is the classification of tibial spine fractures?

Back 443

Type I - incomplete avulsion with no displacement (minimal elevation)
Type II - incomplete avulsion, minimal displacement of the anterior 1/3 of the fracture fragment, posterior portion adherent
Type III - complete separation of fracture from fracture bed
IIIA - complete displacement
IIIB displacement and rotation

Front 444

When should a growth plate injury (SH-1) be assumed?

Back 444

-juxta-articular tenderness
-negative radiographs

Front 445

What is osteochondritis dessicans?

Back 445

Partial or total separation of a segment of articular cartilage and subchondral bone from underlying bone

Front 446

Where is OCD commonly seen?

Back 446

Lateral aspect of the medial femoral condyle

Front 447

What is osteonecrosis? What is a common site for it?

Back 447

Disruption of the blood supply to bone causing infarction.
-May occur in the knee

Front 448

What are the components of the extensor mechanism?

Back 448

-quadriceps muscles
-quadriceps tendon
-medial and lateral retinacula
-patella
-patellar tendon
-tibial tubercle

Front 449

What are 4 signs and symptoms of extensor mechanism disruption?

Back 449

-acute onset pain/swelling/ecchymosis with palpable defect
-loss or limitation in ability to actively extend knee (usually seen in last 10 degrees of extension)
-patella alta (patellar tendon rupture)
-patella baja (quadriceps tendon rupture)

Front 450

How soon should treatment for acute extensor mechanism injury be instituted?

Back 450

-within 2-6 weeks

Front 451

What is the function of the patella?

Back 451

It increases the effective lever arm of the quadriceps by providing anterior displacement of the quadriceps tendon

Front 452

Are patellar fractures intra-articular?

Back 452

-all except small avulsion fractures of the rim

Front 453

What is the most common patellar fracture pattern?

Back 453

Transverse

Front 454

Why do patients with non-displaced transverse patellar fractures retain limited functional ability for active extension?

Back 454

Because the retinaculum and extensor mechanism remain intact

Front 455

What radiologic views are obtained to evaluate the patellar for #?

Back 455

AP, lateral and sunrise

Front 456

What is the management of patellar fractures with preserved knee extension?

Back 456

Long leg cast/knee immobilizer
partial weight bearing

Front 457

What is the most common type of patellar dislocation?

Back 457

Lateral extra-articular dislocation

Front 458

What is the patellar apprehension sign?

Back 458

The manifestation of anxiety and anticipatory reactions observed in a patient when the examiner attempts to slide the non-displaced patella laterally (this test indicates a tendency for patellar subluxation or dislocation)

Front 459

What should be done after successful reduction of a patellar dislocation

Back 459

Immobilization in full extension for 3-6 weeks

Front 460

What is the treatment for an incomplete rupture of gastrocnemius

Back 460

Cast in plantar flexion for 8 weeks

Front 461

What is the treatment for complete gastrocnemius tear?

Back 461

surgical repair

Front 462

What are shin splints? signs and symptoms?

Back 462

Anterior tibial pain during or after exercise.
-Typically patients have tenderness at the middle/lower 1/3 of the tibia

Front 463

What is the treatment for shin splints?

Back 463

-Rest, NSAIDs, ice, supportive footwear

Front 464

What is the most common isolated knee injury?

Back 464

-MCL injury

Front 465

What is a maisonneuve fracture?

Back 465

Proximal fibular # with medial malleolar# or deltoid ligament tear (also involves complete tear of the syndesmotic ligament joining the tibia and fibula)

Front 466

What is the treatment of fibular shaft fractures?

Back 466

Symptomatic non-weight bearing to weight-bearing progressively as tolerated, unless severely displaced or associated with a peroneal nerve deficit

Front 467

What is the usual history of stress #s

Back 467

-Recent increase in active
-Training on a hard surface
-inadequate footwear
Pain with activity alleviated by rest

Front 468

What are typical sites for stress fractures?

Back 468

-tibia (shaft)
-femur
-fibula
-tarsals (navicular)
-metatarsals

Front 469

What is the role of plain films in suspected stress fractures?

Back 469

X-ray is diagnostic in only 30% of patients at initial presentation (MRI can diagnose the condition earlier and more accurately then plain films)

Front 470

What is the treatment for stress fracture?

Back 470

Decrease activity for 3-6 weeks

Front 471

Tibial tubercle fractures: population, mechanism, class and treatment

Back 471

-adolescent boys
-violent flexion of knee against contracted quadriceps

Watson-Jones Classificaiton
I-incomplete avulsion -> cast
II - complete avulsion, extra-articular -> reduce and cast
III - complete avulatio, intra-articular -> ORIF

Front 472

How is Osgood Sclatter distinguished from a tibial tubercle #?

Back 472

-more chronic
-less functional disability
-no hemarthrosis
-irregular apophysis on xray

Front 473

What is a toddler's fracture?

Back 473

Non-displaced spiral # of the distal tibia in a child 9mo-3 years

Front 474

How is motor/sensory function of the peroneal nerve evaluated?

Back 474

-ankle and big toe dorsiflexion (deep peroneal nerve), sensation in the first web space
-active foot eversion (superficial peroneal nerve) sensation in dorsal lateral foot

Front 475

What are complications of tibial shaft fractures?

Back 475

-Anterior compartment syndrome
-peroneal nerve injury

Front 476

How is integrity of the post-tibial nerve assessed?

Back 476

Presence/absence of plantar sensation

Front 477

What is the treatment of tibial shaft #s?

Back 477

Long leg posterior splint/slab in 20 degrees flexion

Front 478

What is the contents of the 4 lower leg compartments?

Back 478

Anterior:
-tibialis anterior
-long toe extensors
-deep peroneal nerve
-anterior tibial artery

Lateral:
-foot evertors (peroneus longus and brevis)
-superficial peroneal nerve

Superficial Posterior
-strong ankle plantar flexors (gastrocnemius, soleus, plataris)
-sural nerve

Deep posterior:
-tibialis posterior
-long toe flexors
-posterior tibial and peroneal arteries
-tibial nerve

Front 479

What are the X-ray findings in osteoarthritis?

Back 479

-Joint space narrowing
-osteophytes
-subchondral sclerosis
-bony cysts

Front 480

Define a Baker's cyst. What is the treatment?

Back 480

-herniation of the synovial membrane through the posterior aspect of the knee capsule
-There is no treatment required, they spontaneously disappear

Front 481

What are the 4 lower leg compartments?

Back 481

Anterior
Lateral
Superficial Posterior
Deep Posterior

Front 482

What is the pain in popliteus tendinitis?

Back 482

Tenderness in the posterior/posterolateral aspect of the knee

Front 483

What are signs and symptoms of pre-patellar bursitis and what is the differential diagnosis?

Back 483

(aka housemaid's knee)
Swelling/effusion overlying the lower pole of the patella

Ddx - septic bursitis

Front 484

Who gets pes anserine bursitis?

Back 484

Obese women with OA or runners
(tenderness and puffiness at the anteromedial tibia)

Front 485

What joints make up the wrist?

Back 485

DRUJ
Radiocarpal joint
midcarpal joints

Front 486

What separates the wrist from the carpals?

Back 486

The triangular fibrocartilage

Front 487

What is the function of the extrinsic ligaments of the wrist?

Back 487

Link carpals to the DR, DU, and MCs

Front 488

Which ligaments are most important to provide stability to the wrist?

Back 488

Proximal and distal arcades on the volar aspect of the wrist

Front 489

What is the space of poirier?

Back 489

A space between the ligamentous volar arcades in the wrist which is devoid of ligamentous support

Front 490

Which carpal bones are at creates risk of AVN?

Back 490

Scaphoid, lunate and capitate

Front 491

Where does the radial nerve cross the wrist?

Back 491

At the dorsum of the wrist near the radial styloid

Front 492

Where does the ulnar nerve cross the wrist?

Back 492

Along the dorsum of the wrist near the ulnar styloid

Front 493

Where does the median nerve cross the wrist?

Back 493

On the volar aspect of the wrist within the carpal tunnel

Front 494

What are the borders of the anatomic snuffbox?

Back 494

Radial abductor pollicis longus and extensor pollicis brevis
Ulnar - EPL

Front 495

What is the radial length measurement?

Back 495

The distance by which the radial styloid extends post the articular surface of the ulna, normally 9-12mm

Front 496

What is the radial inclination?

Back 496

The ulnar slant of the articular surface of the radius - normal 15-25degrees

Front 497

What is the normal volar tilt of the radius on a lateral X-ray?

Back 497

10-25 degrees

Front 498

What is the normal alignment of bones on the lateral wrist X-ray?

Back 498

radius->lunate->capitate->3rd metacarpal all in line or within 10 degrees

Front 499

What is the normal scapholunate angle?

Back 499

30-60 degrees

Front 500

What is the normal capitolunate angle

Back 500

0-30 degrees

Front 501

What is the pronator quadratus line?

Back 501

A linear fat collection on the volar surface of the wrist just anterior to the radius and ulna, with fractures it is volarly displaced or obliterated

Front 502

What is the most commonly fractured carpal bone?

Back 502

the scaphoid

Front 503

What are physical exam findings of scaphoid fracture?

Back 503

pain in the anatomic snuffbox
pain on resisted supination
pain on axial loading of the thumb MC
pain on minimal thumb movement

Front 504

Which scaphoid #s are most at risk of AVN?

Back 504

Those of the proximal pole

Front 505

What are physical exam findings of a lunate #

Back 505

pain on the dorsum of the wrist
pain on axial loading of the D3 metacarpal
pain on palpation just distal to lister's tubercle

Front 506

How are lunate fractures treated?

Back 506

Immobilization in a short arm cast

Front 507

Whan is Keinbock's disease?

Back 507

Post traumatic AVN of the lunate

Front 508

What is the second most commonly fractured carpal done?

Back 508

the triquetrum

Front 509

Why is the pisiform unique?

Back 509

It is a sesamoid bone the lies within the FCU tendon

Front 510

What is a possible complication of pisiform #?

Back 510

Ulnar nerve injury from impingement in Guyon's canal

Front 511

What is the standard radiographic series of the wrist?

Back 511

PA
Lateral
Oblique
all in neutral position

Front 512

What radiological view may be requested if there is concern for a pisiform #?

Back 512

Carpal tunnel view
or
supinated oblique view

Front 513

What should be done for pisiform fracture with ulnar nerve compression?

Back 513

Ortho consult for urgent surgical decompression

Front 514

What are the best X-ray views to see #s of the hook of the hamate?

Back 514

Carpal tunnel view
Reverse oblique (supinated)

Front 515

What views are used to see trapezium fractures?

Back 515

Slightly pronated oblique view
or
Roberts view - true AP of the trapezium

Front 516

What is the treatment for a trapezium #?

Back 516

Immobilization in thumb spica unless displaced or involving the carpometacarpal joint

Front 517

Which carpal bone #s are immobilized in a thumb spica?

Back 517

Scaphoid
Trapezium
(all others are immobilized in a short arm)

Front 518

Which #s should alert the physician to a possible occult perilunate instability?

Back 518

Scaphoid #
Radial styloid #
Capitate #
Triquetrum #

Front 519

What is stage I carpal instability?

Back 519

Scapholunate dissociation (terry thomas sign, signet ring sign)

Routine xrays may be normal - order a clenched fist AP view with ulnar deviation if clinical suspicion of scapholunate ligament injury

Front 520

What is stage II carpal instability?

Back 520

Perilunate dislocation, capitate dorsally dislocated

The PA view shows overlap of the distal and proximal carpal row

Front 521

What is stage III carpal instability?

Back 521

Identical to stage II but with triquetral dislocation on PA view

Overlap of the triquetrum on the lunate or hamate

Front 522

What is stage IV carpal instability?

Back 522

Lunate dislocation (triangular shaped lunate) on PA
Spilled teacup on lateral

Front 523

What neuro finding may be associated with lunate or perilunate dislocation?

Back 523

decreased 2 point sensory discrimination in the distribution of the median nerve

Front 524

What is the gold standard for identifying and grading scapholunate injury?

Back 524

Arthroscopy

Front 525

What is stage II carpal instability?

Back 525

Perilunate dislocation, capitate dorsally dislocated

Front 526

What is stage III carpal instability?

Back 526

Identical to stage II but with triquetral dislocation on PA view

Front 527

What is stage IV carpal instability?

Back 527

Lunate dislocation (triangular shaped lunate) on PA
Spilled teacup on lateral

Front 528

What neuro finding may be associated with lunate or perilunate dislocation?

Back 528

decreased 2 point sensory discrimination in the distribution of the median nerve

Front 529

What is the gold standard for identifying and grading scapholunate injury?

Back 529

Arthroscopy

Front 530

Which colles #s merit close f/u with Ortho?

Back 530

>20% angulation
dorsal comminution
intra-articular extension

Front 531

Which colles # should be immediately referred to Ortho?

Back 531

-open #
-neurovascualr compromise
-unable to reduce

Front 532

What are signs of an incomplete colles # reduction?

Back 532

-intra-articular stepoff >1mm
-radial inclination <15 degrees
-volar tilt less than neutral
-loss of radial length >2mm

Front 533

What is a Smith's fracture?

Back 533

A transverse # of the radial metaphysis with volar displacement and volar angulation

Front 534

What is a complication of cast holding for Smiths#?

Back 534

median nerve compression

Front 535

What is a Barton's #?

Back 535

An oblique intraarticular # of the rim of the distal radius with displacement of the carpus along with the # fragment

Front 536

What is the management of a Barton's #?

Back 536

Orthopedic consultation for reduction and stabilization

Front 537

What is a Hutchinson's #?

Back 537

A chaffeurs or radial styloid #

Front 538

What is the management of a Hutchinson #?

Back 538

non-displaced-> short arm cast
displaced - reduction (many ligaments attach to the DR therefore accurate # reduction is critical)

Front 539

What is a possible complication of radial styloid #s?

Back 539

Scapholunate dissociation

Front 540

What are clinical findings of DRUJ injury?

Back 540

-MOI with hyperpronation or supination
-sudden onset of pain with 'snapping' sensation in the wrist, limited ROM and swelling
-tenderness on ulnar aspect
-crepitus with supination and pronation
-prominence or loss of normal prominence of ulnar styloid (compared with normal side)

Front 541

Why are the clinical findings of DRUJ important?

Back 541

Because X-rays are often read as normal

Front 542

What # is commonly associated with DRUJ dislocation?

Back 542

Radial head #

Front 543

What is the treatment of DRUJ injuries?

Back 543

Ortho consult for ORIF
Closed reduction with forearm supinated and long arm cast x 6 weeks can often be successful

Front 544

What forms the carpal tunnel?

Back 544

The transverse carpal ligament and the volar aspect of the carpals

Front 545

What is the contents of the carpal tunnel?

Back 545

FPL
4x FDS
4x FDP
median nerve

Front 546

Which conditions may mimic carpal tunnel syndrome?

Back 546

Cervical radiculopathy
Thoracic outlet obstruction

Front 547

What is the most sensitive provocative test for CTS?

Back 547

Wrist flexion (Phalen's) test

Front 548

What is the confirmatory test for CTS?

Back 548

Nerve conduction studies

Front 549

What is nonoperative treatment for CTS?

Back 549

Splinting the wrist in neutral position

Front 550

What is the Essex Lopresti lesion?

Back 550

Longitudinal rupture of the interosseous membrane that joins the diaphyseal shafts of the radius and ulna and radial head fracture. This lesion renders the forearm unstable, painful and weak
MRI is the diagnostic test of choice

Front 551

What is the main stabilizer of the DRUJ?

Back 551

TFC

Front 552

What is the radial line used to assess?

Back 552

For radial head dislocation

Front 553

What is the treatment for undisplaced forearm #s in adults?

Back 553

-long arm cast
-f/u in 1 week to assess for displacement

Front 554

What is the treatment for displaced ulnar or radial shaft #s?

Back 554

Splint and ortho for OR

Front 555

What is the most significant complication of either radial or ulnar shaft fractures?

Back 555

Compartment syndrome

Front 556

What is a nightstick #?

Back 556

An ulnar shaft #

Front 557

What is the treatment for undisplaced ulnar shaft fractures?

Back 557

Distal 1/3 fo ulna -> short arm
Proximal 2/3 of ulna -> long arm cast

Front 558

What is the definition of a displaced ulnar fracture?

Back 558

->10 degrees of angulation
-displacement of >50% the diameter of the ulna

Front 559

What is associated with ulnar shaft #?

Back 559

Radial head dislocation (Monteggia)

Front 560

What nerve injury may be present with Monteggia #?

Back 560

Radial

Front 561

What is a Monteggia #?

Back 561

Proximal/mid ulnar shaft # and radial head dislocation

Front 562

What is a Galleazi #?

Back 562

# of the middle/distal 1/3 of the radius and DRUJ dislocation/subluxation

Front 563

What is the management of a Galleazi fracture?

Back 563

OR

Front 564

What is plastic deformation?

Back 564

Bending of the bone without overt #

Front 565

What are the standard radiographic views of the hand?

Back 565

AP
Lateral
Oblique

Front 566

What inserts onto the proximal phalanx of the digits of the hand?

Back 566

Nothing

Front 567

What inserts onto the middle phalanx of the hand digits?

Back 567

FDS
extensor tendons

Front 568

How is rotational deformity assessed?

Back 568

It is judged clinically by the relationship of the finger to the adjacent normal fingers

Front 569

What is the management of an undisplaced stable phalangeal #?

Back 569

Dynamic splinting (buddy taping)

Front 570

If a phalangeal # is successfully reduced, how should it be casted?

Back 570

The finger and wrist should be immobilized

Front 571

How are metacarpal #s divided?

Back 571

Those involving D1
Those involving D2-D5

Front 572

How much lateral angulation, dorsal angulation and shortening can finger metacarpals accommodate?

Back 572

Lateral angulation
D2-D5 10-15 degrees lateral angulation

Dorsal angulation
D2-D3 - 10-15 degrees
D4 - 40-45 degrees
D5 - 50-70 degrees

3-4mm shortening

Front 573

What can you do if you strongly suspect a metacarpal head # but the initial X-ray is negative?

Back 573

Brewerton or Ball catcher's view

Front 574

What is the safe or functional position for hand immobilization?

Back 574

20-30 degree wrist extension
90 degree metacarpal flexion
DIP and PIP extension

Front 575

Why are metacarpal neck #s difficult to manage?

Back 575

They are inherently unstable

Front 576

How much angulation is allowed for metacarpal neck #s?

Back 576

2 and 3 - 15 degrees
4 - 35 degrees
5 - 45 degrees

Front 577

What are the landmarks for a metacarpal neck # splint?

Back 577

Just below the elbow to just proximal to the PIP

Front 578

What is the reduction technique for metacarpal neck #s?

Back 578

Volar pressure over the metacarpal shaft
Dorsal pressure over the metacarpal head

Front 579

What are the 3 types of metacarpal shaft #s?

Back 579

Transverse
Oblique
Comminuted

Front 580

How should metacarpal shaft #s be immobilized?

Back 580

A gutter splint including the wrist and the entire metacarpal shaft but not the MCP if the # is proximal to the metacarpal neck

Front 581

What is the management of metacarpal base #s?

Back 581

immobilization
referral to a hand surgeon

Front 582

What are intra articular #s involving D1 metacarpal?

Back 582

Bennetts
Rolando

Front 583

What is the management of a Bennett's fracture?

Back 583

Immobilization in a thumb spica
referral to a hand surgeon

Front 584

What is a Bennett's fracture?

Back 584

Intra-articular # of the base of the thumb metacarpal with sublimation of the CMC joint

Front 585

What is a Rolando's fracture?

Back 585

comminuted # of the base of the thumb metacarpal

Front 586

What is the purpose of the S-H classification?

Back 586

To direct treatment and predict outcomes

Front 587

What is the most common ligament injury in the hand?

Back 587

PIP dislocation

Front 588

What is skier's thumb?

Back 588

UCL injury of D1 from forced abduction

Front 589

What testing should be done to diagnose UCLinjury?

Back 589

Valgus stress in extension and 30 degrees of flexion

Front 590

What criteria are used to diagnose UCL injury?

Back 590

>35 degrees of laxity or >15 degrees of laxity compared to the uninjured side

Front 591

How many extensor tendon zones are there?

Back 591

8

Front 592

What is mallet finger?

Back 592

A closed disruption of the distal extensor tendon

Front 593

What is the MOI in mallet finger?

Back 593

Forceful flexion of the DIP

Front 594

What are the 3 types of mallet finger?

Back 594

Type 1 - tendon rupture
II - tendon rupture and small avulsion
III - tendon rupture and avulasion 25-33% articular surface

Front 595

What is the treatment for mallet finger?

Back 595

DIP immobilization in hyperextension for 6-8 weeks

Front 596

How do you repair extensor tendon lacerations?

Back 596

5-0 or 4-0 non-absorbable sutures
figure of 8 stitch

Front 597

What is a Boutonniere deformity?

Back 597

Flexion at the PIP
Hyperextension of MP and DIP

Front 598

What is the injury if a Boutonniere injury develops?

Back 598

Disruption of the central extensor tendon

Front 599

What is necessary in human bite wounds?

Back 599

Operative exploration, irrigation, debridement

Front 600

What is empiric antibiotic treatment for human bite?

Back 600

Amox-clav
pen allergy
clinda and fluoroquinolone

Front 601

What is associated with palmaris longus laceration?

Back 601

Median nerve laceration

Front 602

What is the management of a flexor tendon injury in the absence of a hand surgeon?

Back 602

Irrigation, close the wound, splint wrist at 30 degrees flexion, MCP 70 degrees of flexion, IP 15 degrees flexion

Front 603

How do you classify amputations?

Back 603

As open #s administer
Initial IV cephalosporin dose and then PO antibiotics

Front 604

What is the management of a clenched fist wound?

Back 604

-debride/irrigate
-tetanus
-xray to exclude FB
-splint/elevate
-IV abx
-hand surgeon

Front 605

What is contraindicated in high pressure injection injuries?

Back 605

Digital block (may increase pressure in the compartment)

Front 606

What defines a partial amputation?

Back 606

The presence of interconnecting tissue between the proximal and distal portion

Front 607

What should be done with an amputated part?

Back 607

Cover with saline soaked gauze, place in a dry plastic bag and put on ice

Front 608

What are classic indications for re-implantation?

Back 608

-multiple digits
-thumb
-wrist and forearm
-sharp amputation with minimal to moderate avulsion proximal to the elbow
-single digits amputated between PIP and DIP
-all pediatric amputations

Front 609

What are classic contraindications to re-implantation?

Back 609

-unstable patients with other life-threatening injuries
-multilevel
-self-inflicted
-single digit proximal to FDS
-serious underlying disease vascular, CHF, DM
-extremes of age

Front 610

How many compartments exist in the hand?

Back 610

10

Front 611

What is neuropraxia?

Back 611

Loss of nerve function but axon intact

Front 612

Which nerve injury in the hand should be considered for re-approximation?

Back 612

-motor median and ulnar
-digit injury proximal to DIP crease on radial aspect of index and ulnar aspic of little finger and both sides of the thumb

Front 613

What is a felon?

Back 613

An infection of the pulp of the finger

Front 614

What is the treatment of a felon?

Back 614

Lateral incision of the finger, ulnar of II-IV radial of I and V

Front 615

What is the treatment of a herpetic whitlow?

Back 615

-prevent transmission
-cover with a dry dressing
-oral acyclovir for those that are immunocompromised or frequent recurrences
-resolves spontaneously in 3-4 weeks

Front 616

What are the cardinal signs of flexor tenosynovitis?

Back 616

Tenderness along the flexor sheath
-symmetrical swelling
-pain on passive extension
-flexed posture of the fingers

Front 617

What is the treatment for flexor tenosynovitis?

Back 617

-IV abx (ancef or ceftriaxone if GC is suspected)
-early -> anti staphylococcal penicillinase or cephalosporin
-splint
-consult

Front 618

What is contained in the anterior compartment of the upper arm?

Back 618

biceps brachii
brachialis
coracobrachialis
median, ulnar and musculocutaneous nerve
brachial artery

Front 619

What is contained in the posterior compartment of the upper arm?

Back 619

-radial nerve
-triceps

Front 620

In what injuries is the radial nerve particularly susceptible?

Back 620

midshaft # of the humerus

Front 621

Which fractures pose a risk to the ulnar nerve?

Back 621

those of the medial condyle

Front 622

Which elbow bursae are clinically important?

Back 622

-olecranon bursa
-radiohumeral bursa
-bursa that cushions the biceps tendon from the radial head

Front 623

What is the only dependable early sign of compartment syndrome?

Back 623

pain

Front 624

What is the most likely cause of a posterior fat pad sign on elbow X-ray?

Back 624

adults - radial head #
child - supracondylar fracture

Front 625

How do you determine Baumann's angle?

Back 625

The angle between one line drawn through the midshaft of the humerus and another drawn through the capitellum growth plate

Front 626

What is the order of appearance and fusion of ossification centres?

Back 626

Capitellum 1-2
Radius 4-5
Internal epicondyle 4-5
Trochlea 8-10
Olecranon 8-9
Externa epicondyle 10-11

Front 627

What features suggest a pathologic #?

Back 627

Thinning of the cortex
Abnormal osteoblastic or osteoclastic activity

Front 628

What is the management of isolated radial nerve palsy in humeral fractures?

Back 628

Treat conservatively - assumed to be neuropraxia

Front 629

What is the management of radial nerve palsy post reduction?

Back 629

Assumed to be entrapment therefore go to OR

Front 630

Which patients with humeral shaft #s require emergent orthopaedics?

Back 630

-open
-comminuted
-concomitant # in the forearm
-radial nerve injury
-severely displaced injuries

Front 631

What is the classification of supracondylar fractures?

Back 631

Type I - minimal to no displacement
Type II - at least one cortex intact
Type III - completely displaced, no cortex intact

Front 632

When should a supracondylar fracture be reduced in the ED?

Back 632

Vascular compromise which threatens the viability of the limb

Front 633

What is important about supracondylar # reduction?

Back 633

Only one attempt should be made, multiple attempts increase the likelihood of neuromuscular injury

Front 634

What is the most common reason for losing a radial pulse in supracondylar #s, what is the management?

Back 634

-Swelling

Mgmt
-reduce #
-avoid flexing to 90 degrees
-elevate the arm

Front 635

What is the most common complication of a flexion supracondylar #?

Back 635

injury to the ulnar nerve by the proximal fragment

Front 636

What is a transcondylar #?

Back 636

Fracture that passes through both condyles within the joint capsule (it is most commonly seem in elderly)

Front 637

What is the intercondylar #?

Back 637

T or Y shaped # with separation of condyles from each other and from the proximal humerus

Front 638

What is the 2nd most common elbow # in children?

Back 638

Lateral condyle #

Front 639

What is the treatment for lateral condyle #?

Back 639

non-displaced -> cast
displaced -> closed or open reduction

Front 640

What type of SH# are medial condyle #s in kids?

Back 640

SH-IV

Front 641

What is particular about medial condyle #s in kids?

Back 641

xray will not show a # in those <9 because the trochlea does not ossify until the age of 9

Front 642

When is operative treatment recommended for medial condyle #s in children?

Back 642

Displacement >2mm

Front 643

What is key to analyzing humeral condyle #s?

Back 643

The lateral trochlear ridge, it's involvement is likely to result in instability

Front 644

How should you immobilize lateral condylar #s in adults?

Back 644

Posterior plaster splint in supination and wrist extension

Front 645

How should you immobilize a medial condyle # in an adult?

Back 645

Posterior plaster splint with wrist in flexion and forearm in pronation

Front 646

How do injuries to the capitellum occur?

Back 646

FOOSH where the radial head jams up

Front 647

When do #s of the trochlea and capitellum most often occur?

Back 647

Posterior elbow dislocation

Front 648

Which humeral epicondyle ismore commonly #d?

Back 648

medial

Front 649

What are the mechanisms of injury for medial epicondyle #s?

Back 649

-posterior elbow dislocation
-little league elbow
-arm wrestling

Front 650

What is little league's elbow?

Back 650

Avulsion of the medial epicondyle or compression # of the radial head/lateral condyle

Front 651

What are the mechanisms for olecranon #?

Back 651

-direct blow
-forceful contraction of the triceps

Front 652

Which neuromuscular structure is most vulnerable in olecranon #?

Back 652

ulnar nerve

Front 653

What are physical findings of an olecranon #?

Back 653

-pain
-palpable deformity
-inability to extend the elbow against force

Front 654

What is the treatment for an olecranon #?

Back 654

undisplaced ->immobilize with frequent RA to ensure there is no displacement

displaced-> immediate ortho

Document the presence of ulnar nerve involvement

Front 655

What is the typical mechanism for radial head and neck #s?

Back 655

indirect mechanism typically FOOSH

Front 656

In addition to # of the radial head what other structures are typically damaged?

Back 656

-articular surface of capitellum
-collateral ligament injury

Front 657

What are the classifications of radial head #s?

Back 657

I- undisplaced
II - marginal # (<30% articular surface) with displacement
III - comminuted # of the entire radial head
IV - any of the above and elbow dislocation

Front 658

What is the management of radial head #s?

Back 658

Type I - sling
Type II - immobilize with trail of ROM, excision of the radial head if failed
III-IV - usually radial head excision
IV - reduce elbow dislocation

Front 659

What does elbow dislocation mean?

Back 659

Disruption of the relationship between the humerus and olecranon

Front 660

In what directions can elbows dislocate?

Back 660

post - most commonly
ant/medial/lateral

Front 661

What is the ideal position for reduction of a posterior elbow dislocation?

Back 661

flexed @ 30 degrees and supinated distal traction applied

Front 662

What is the most serious complication of elbow dislocation?

Back 662

Vascular compromise

Front 663

Which vessel is injured in posterior elbow dislocation?

Back 663

Brachial

Front 664

Where does biceps tendon rupture most commonly occur?

Back 664

Proximal portion of the long head

Front 665

What can fractures be confused with on X-ray?

Back 665

nutrient arteries
soft tissue folds
bandages or overlying materials
anomalous bones
calcified soft tissue
accessory ossicles and sesamoids

Front 666

What are the complications of fractures (10)?

Back 666

Hemorrhage
Vascular injuries
Nerve injuries
Osteomyelitis
Fat emboli syndrome
Complex regional pain syndromes (reflex sympathetic dystrophy and causalgia)
Compartment syndrome
Avascular necrosis
Fracture blisters
Complications of immobilization

Front 667

What are the complications of immobilization?

Back 667

Pneumonia
UTI
Wound infection
DVT
PE
Decubitus ulcers
Muscle atrophy
Stress ulcers

Front 668

What is fat embolism syndrome?

Back 668

The presence of fat globules in the lung parenchyma and peripheral circulation after a long bone fracture or major trauma

Front 669

What is the presentation of fat embolism syndrome?

Back 669

Surgery 1-2 days post injury or intramedullary nailing
Fever, tachycardia
Dyspnea, respiratory distress, hypoxemia
Confusion and deteriorating mental status
Petechial rash
Retinal changes
Thrombocytopenia

Front 670

What is the treatment for fat embolism syndrome?

Back 670

Supportive
the mortality is 20%

Front 671

What is compartment syndrome?

Back 671

Increased pressure in a closed nonexpandable compartment
May be caused by
1) increased compartment contents
2) decreased compartment volume
3) external pressure

Front 672

What is the physiology of compartment syndrome?

Back 672

At compartment pressures above the DBP there is circulatory compromised and tissue hypoxia due to the reduced arteriovenous gradient at the tissue. The body responds by releasing histamine in an attempt to dilate capillaries and increase blood flow. Eventually you have impairment of the venous and arterial flow resulting in ischemic necrosis of muscles and nerves

Front 673

What are causes of compartment syndrome that result in increased compartment contents?

Back 673

Bleeding - major vascular injury, coagulation disorder, and anticoagulant therapy
Increased capillary filtration - reperfusion after ischemia (bypass grafting, embolectomy, cardiac catheterization, lying on a limb)
trauma - fracture, convulsion
intensive use of a muscle - exercise, seizures, eclampsia, tetany
burns - thermal or electrical
intra-arterial drub injection
orthopedic surgery - tibial osteotomy, hauser's procedure, reduction and internal fixation of fractures
snakebite

Front 674

What are causes of compartment syndrome that resulting in increased capillary pressure?

Back 674

Venous obstruction - phlegmasia cerulea dolens, ill-fitting leg brace, venous ligation
diminished serum osmolarity - nephrotic syndrome
Miscellaneous - infiltrated infusion, pressure transfusion, leaky dialysis cannula, popliteal cyst

Front 675

What are causes of compartment syndrome with decreased compartment volume?

Back 675

Closure of fascial defects
excessive traction on fractured limbs

Front 676

What are causes of compartment syndrome resulting from external pressure on the compartment?

Back 676

Tight cases, dressings or air splints
lying on the limb

Front 677

What compartment is most often involved in compartment syndrome?

Back 677

anterior compartment of the leg

Front 678

What are locations of compartment syndrome?

Back 678

Leg - anterior, lateral, superficial and deep posterior
Thigh - quadriceps
Buttock - gluteal
Hand - intraosseous
Forearm -dorsal and volar
arm - deltoid and biceps

Front 679

What are the reliable indicators of compartment syndrome?

Back 679

Pain disproportionate to the injury
hypoesthesia and paresthesia
sensation of tenseness within the compartment

Front 680

What is the treatment of compartment syndrome?

Back 680

Fasciotomy within 12 hours

Front 681

What are complications of compartment syndrome? (9)

Back 681

Rhabdomyolysis
Hyperkalemia
Myoglobinuria
Renal failure
Lactic acidosis
infection
Tissue loss
Loss of nerve and muscle function
contracture

Front 682

What conditions are associated with the development of tendinopathy?

Back 682

Advanced age
smoking
obesity
steroid use
fluoroquinolone use
DM
CRF
RA
SLE

Front 683

What are contraindications to cryotherapy?

Back 683

Absolute:
-severe cold allergy (with hives and joint pain)
-Raynaud's phenomenon and disease

Relative:
Some rheumatoid conditions
paroxysmal cold hemoglobinuria with renal dysfunction

Front 684

What are the interossei muscles (function, innervation, testing)

Back 684

There are 7 interossei
They adduct and abduct the fingers
innervated by the ulnar nerve
test them by placing the palm flat, extend the finger and move it side to side

Front 685

What are the lumbricals (function, innervation)

Back 685

muscles that flex the MCP joints and extend the IP joints
the radial two are innervated by the median nerve and the ulnar two are innervated by the ulnar nerve

Front 686

What are the extensor tendons?

Back 686

They are tendons with origins in the forearm and insertion in the hand
9 tendons with 6 compartments
1 - APL and EPB
2 - radial wrist extensors
3 - EPL
4 - EDC (extensor digitorum communis), EIP (extensor indicis proprius)
5 - extensor digiti quinti proprius (EDQP)
6 - ECU

Front 687

What is the vascular supply to the hand?

Back 687

Radial artery which terminates in the deep palmar branch
Ulnar artery which terminates as the superficial palmar arch

Front 688

What deformity occurs with radial nerve palsy?

Back 688

Wrist drop
(fingers in flexion and thumb is adducted)

Front 689

What deformity occurs with ulnar nerve palsy?

Back 689

claw-hand
Duchenne sign - clawing of D4 and D5 -> hyperextension at the MCP and flexed at the IP

Front 690

What deformity occurs with median nerve palsy?

Back 690

absence of flexion of the thumb, index DIP and PIP, weakness of thumb abduction and opposition

Front 691

What is normal 2-point discrimination?

Back 691

2-5mm at the fingertips
7-10mm at the base of the palm
7-12mm at the dorsum of the hand

Front 692

What is trigger finger and what is the treatment?

Back 692

Stenosing tenosynovitis - pathologic nodular swelling of a long flexor tendon resulting in intermittent painful blocking of flexion or extension usually at the MCP joint

treatment - injection of local anesthetic and corticosteroid, splint in extension and referral to a hand surgeon

Front 693

In which position are angular finger deformities best assessed?

Back 693

Fingers in full extension

Front 694

In which position are rotational finger deformities best assessed?

Back 694

fingers flexed

Front 695

When is surgical intervention indicated for metacarpal fractures?

Back 695

2-3mm shortening
1mm articular surface off
>25% articular involvement

Front 696

What are acceptable angulations for metacarpal shaft fractures?

Back 696

0-0-10-20
D2-D3 - no angulation tolerated
D4 - <10 degrees tolerated
D5 - <20 degrees tolerated

Front 697

What associated injury can occur with metacarpal base fractures?

Back 697

Injury to the motor branch of the ulnar nerve resulting in paralysis of intrinsic muscles of the hand

Front 698

What is the management of extra-articular thumb metacarpal fracture?

Back 698

Acceptable angulation: 20-30 degrees
Closed reduction
immobilize with the thumb IP extended using a thumb spica

Front 699

What is the difference between a Bennett's and Rolando fracture?

Back 699

Bennett's is a fracture at the base of the thumb metacarpal with dislocation of the CMC joint

Rolando's is a comminuted fracture at the based of the thumb metacarpal with a Y or T shaped pattern

Front 700

What radiographic finding is pathognomic of a complex MCP dislocation?

Back 700

The presence of a sesamoid bone in the wodened joint space. This requires operative intervention

Front 701

How do you reduce MCP dislocations?

Back 701

Flex the wrist to relax the flexor tendons
Apply firm pressure over the dorsum of the proximal phalax in the distal and volar direction

Front 702

What is the treatment of a UCL (Gamekeeper's thumb)?

Back 702

Partial -> thumb spica cast for 4 weeks
Complete -> surgical repair within 3 weeks

Front 703

What is a swan neck deformity (cause and anatomic basis)

Back 703

Lateral bands displace proximally and dorsally resulting in extension of the PIP joint and flexion of the DIP joint
-it is the result of an untreated mallet finger

Front 704

What is the zone classification of extensor tendons?

Back 704

Zone I - distal phalanx and DIP
Zone II - middle phalanx
Zone III - PIP joint
Zone IV - proximal phalanx
Zone V - MCP joint
Zone VI - dorsum of the hand
Zone VII/VIII - wrist and forearm

Front 705

What is important about Zone V injuries

Back 705

Any injury over the MCP are assumed to be human bite wounds.
Xrays are mandatory
Operative exploration, debridement and irrigation are mandatory
Treatment should be with timentin or clinda plus a fluoroquinolone

Front 706

Why do palmaris longus lacerations have diagnostic significance?

Back 706

Palmaris longus is not a functionally significant wrist flexor but 80-90% of the time it is associated with a concomitant median nerve laceration

Front 707

What is no man's land?

Back 707

From the distal palmar crease to the midportion of the middle phalanx

Front 708

What are concerns with high-pressure injuries and what is their management?

Back 708

Compartment syndrome and high amputation rate

Mgmt:
IV antibiotics
tetanus
analgesia
splinting and elecation
urgent plastics consult for surgical decompression and debridement
digital blocks are contraindicated

Front 709

What are the warm and cold ischemia times for amputated parts?

Back 709

warm: 6-8 hours
cold: 12-24 hours

the more proximal the amputation the less ischemia time the amputated part can tolerate

Front 710

What is a paronychia?

Back 710

localized superficial infection or abscess involving the lateral nail fold

Front 711

Describe the anatomy of the extensor mechanism of the finger?

Back 711

The extensor mechanism of the PIPI joint is a trifurcation of the extensor tendon into the central slip which attaches to the dorsal base of the middle phalanx and the two lateral bands which continue distally and attach to the distal phalanx

Front 712

What is a collar button abscess?

Back 712

A palmar space infection that has spread to the dorsum of the hand

Front 713

What ligaments are the most important in maintaining carpal stability?

Back 713

Scapholunate
Lunotriquetral

Front 714

What are the important landmarks on the wrist exam?

Back 714

Anatomic snuffbox: just distal to the radial styloid
Scaphoid tubercle: just distal and palmar to the radial styloid
Lister's tubercle: on the dorsum of the wrist just ulnar to the radial styloid, scapholunate ligament is just distal to it
triquetrum: just distal to the ulnar styloid in the proximal carpal row
Pisiform: at the base of the hypothenar muscles just distal to the distal wrist crease
Hook of the hamate: 1cm distal and radial to pisiform

Front 715

What is proper positioning on a PA wrist view?

Back 715

The distal radius and ulna should not overlap at their distal articulation and the axis of the 3rd metacarpal should parallel that of the radius

Front 716

What is proper positioning on a lateral wrist view?

Back 716

the radius and ulna should overlap one another and the radial styloid should be centered over the distal radial articular surface

Front 717

What is the purpose of a wrist PA view in ulnar or radial deviation?

Back 717

to better identify carpal ligament injuries

Front 718

What is the purpose of a lateral view in max flexion or extension?

Back 718

to better identify carpal ligament injuries

Front 719

What is the purpose of a clenched-fist wrist AP view?

Back 719

exposes the scapholunate ligament injury, it pushes the capitate into the proximal carpal row

Front 720

Who typically gets scaphoid fractures and what is the mechanism of injury?

Back 720

Young adults 15-30
post FOOSH

Front 721

Where is the scaphoid most commonly fractured?

Back 721

Through the waist

Front 722

What % of scaphoid fractures are not detected on xrays taken soon after injury?

Back 722

14%

Front 723

What should be done when a patient has clinical findings of a scaphoid fracture but no fracture on xray

Back 723

Below elbow thumb spica and repeat xray in 10-14d
MRI
CT
Below elbow thumb spica and bone scan in 3-4d

Front 724

What is the sensitivity of MRI for detecting acute scaphoid fractures?

Back 724

100%

Front 725

What is the duration of cast immobilization for scaphoid fracture?

Back 725

12weeks
(longer for more proximal fractures)

Front 726

Which scaphoid fractures require operative repair?

Back 726

Displaced >1mm
Scapholunate angle > 30-60 degrees
capitolunate angle >0-30 degrees

Front 727

Which patients fracture their lunate more commonly?

Back 727

Those with congenitally short ulna's because of compromised triangular fibrocartilage

Front 728

What are physical findings in patients with a lunate fracture?

Back 728

Pain over the dorsum of the wrist exacerbated by axial loading of the long metacarpal
tenderness to palpation of the depression just distal to Lister's tubercle

Front 729

What are complications of a lunate fracture?

Back 729

Non-union
AVN
Carpal instability

Front 730

What should be done when a patient has clinical findings of lunate fracture but no fracture is seen on X-ray?

Back 730

Immobilize in a short arm cast until fracture can be excluded by CT or MRI

Front 731

What is the mechanism of injury leading to triquetral fracture?

Back 731

Direct blow to the bone
FOOSH -> dorsal chip fracture

Front 732

What radiographic view allow for better visualization of a triquetral fracture?

Back 732

Standard lateral view of the wrist

Front 733

What is the management of a triquetral fracture?

Back 733

Short arm cast or splint for 4-6 weeks

Front 734

What are clinical findings of pisiform fracture?

Back 734

Tenderness over the ulnar aspect of the volar wrist crease exacerbated by wrist flexion and ulnar deviation
Paresthesias in the ulnar nerve distribution
Hand clumsiness rom intrinsic muscle dysfunction

Front 735

What is the treatment of a pisiform fracture?

Back 735

Short arm cast or splint for 3-4 weeks
If there is evidence of ulnar nerve compromise you should consult ortho for possible urgent surgical decompression

Front 736

What are the mechanisms of injury leading to hamate fracture?

Back 736

Direct blow to the palm
FOOSH
the use of hammers
vibration from equipment

Front 737

What are the clinical findings in patients with a hamate fracture?

Back 737

Pain over the hypothenar eminence with decreased grip strength
Pain on palpation of the hamate

Front 738

What is the treatment for hamate fractures?

Back 738

Immobilization in a short arm cast

Front 739

What is the treatment for a trapezium fracture?

Back 739

immobilization in a thumb spica for 6 weeks

Front 740

When should a patient with a trapezium fracture be referred to ortho for ORIF?

Back 740

Displaced fracture
Fracture involving the carpometacarpal joint

Front 741

What carpal bone fractures are rare and uncommon?

Back 741

Rare: hamate, capitate, trapezoid
Uncommon: lunate, trapezium

Front 742

What are the complications of carpal dislocation injuries

Back 742

Median nerve injury
Chronic carpal instability with resultant degenerative joint disease

Front 743

What is the gold standard for identifying and grading scapholunate injuries?

Back 743

Arthroscopy

Front 744

What is DISI?

Back 744

Dorsal intercalated segment instability

dorsiflexion of the lunate relative to the capitate, increased scapholunate angle and increased capitolunate angle.

Most common pattern of carpal instability

Front 745

What is VISI?

Back 745

volar intercalated segment instability

volar flexion of the lunate relative to the capitate resulting in decreased scapholunate angle and increased capitolunate angle

Front 746

What is the definition of a Colle's fracture?

Back 746

Transverse fracture of the radial metaphysis
Dorsally displaced and angulated
Located within 2 cm of the radial articular surface
possible intra-articular extension
associated fracture of the ulnar styloid is common

Front 747

Which patients with Colles fracture require an ortho consult in the ED?

Back 747

Unsuccessful closed reduction
Open fracture
Neurovascular compromise

Front 748

Which patients with Colles fracture require close ortho follow-up?

Back 748

Significant displacement (>20degrees)
Marked comminution
Intra-articular extension

Front 749

What is the definition of a Barton's fracture?

Back 749

oblique intraarticular fracture of the rim of the distal radius
displacement of the carpus and the fracture fragment
classic bartons -> dorsal
volar bartons -> volar

Front 750

What is a Hutchison's fracture?

Back 750

intra-articular fracture of the radial styloid

Front 751

What is the management of a Hutchison/Chauffeur's fracture?

Back 751

Non displaced: short arm cast immobilization for 4-6 weeks
Displaced: ortho consult for ORIF

Front 752

What is carpal tunnel syndrome?

Back 752

Neuropathy of the median nerve at the wrist resulting from compression of the median nerve within the carpal tunnel

Front 753

What are 5 factors that determine the success of non-operative management for CTS?

Back 753

Age >50
Duration > 10months
constant paresthesia
Stenosing flexor tenosynovitis
Positive Phalen's test at less than 30s (0/5 67% of patients were cured by medical therapy, 4-5/5 no patient was cured by medical management

Front 754

What nerve may be injured in medial epicondyle fractures?

Back 754

ulnar nerve

Front 755

what nerve may be injured in olecranon fracture?

Back 755

ulnar nerve

Front 756

What are the different positions of humeral shaft fractures

Back 756

if the fracture is proximal to the pectoralis major attachement the proximal fragment abducts and internally rotates and the distal fragment is displaced medially

if the fracture is between the insertion of the pectoralis major and deltoid insertion proximal fragment displaced medially and distal fragment displaced laterally

if the fracture is distal to the deltoid insertion the distal fragment is proximally displaced because of the triceps and coracobrachialis

Front 757

What population of patients get intercondylar fractures?

Back 757

Adults 50-60 with direct trauma to elbow
This requires an emergent ortho consult for ORIF

Front 758

What is the management of a capitellum fracture?

Back 758

ORIF

Front 759

What is the management of a trochlear fracture

Back 759

If non-displaced -> posterior splint x 3 weeks
If displaced -> ORIF

Front 760

What is the technique for reduction of medial, lateral and anterior elbow dislocations?

Back 760

medial and lateral -> same technique as posterior except that the patient's arm should be in slight extension

anterior -> distal traction of the wrist and a backward pressure on the forearm, while grasping the distal humerus (more common vascular impairment with emergency ortho referral)

Front 761

What are the risk factors for proximal biceps rupture?

Back 761

It is often associated with impingement
Middle aged athletes or physical laborers with repetitive microtrauma to the tendon

Front 762

What is the pathophysiology of distal biceps rupture?

Back 762

Avulsion from the insertion on the radial tuberosity

Front 763

What is the MOI of distal biceps rupture?

Back 763

unexpected extension force applied to the arm flexed at 90 degrees

Front 764

What are the physical findings in distal biceps rupture

Back 764

weakness of elbow flexion and supination
visible deformity and palpable defect of the biceps muscle belly

Front 765

What is the differential diagnosis for shoulder pain?

Back 765

Referred pain from the neck
-OA of c-spine
-disk herniation
-muscular spasm or strain

Referred pain from the chest/abdomen
-ACS, PE, pneumonia, ruptured ectopic, splenic injury, BTD, perforated viscus, any condition causing irritation of the diaphragm

Vascular injury
-acute thrombosis of the axillary artery

Neurologic injury
-brachial plexus injury
-thoracic outlet obstruction

MSK pain
-fracture
-AC joint separation
-shoulder dislocation
-rotator cuff tendinitis
-subacromial bursitis
-long head of biceps tendinitis
-rotator cuff tear
-biceps tendon rupture
-labrum tear/SLAP lesion
-adhesive capsulitis
-scapulothoracic dysfunction
-OA

Front 766

What is the motor evaluation for the brachial plexus?

Back 766

C2-4 trapezius
C5 deltoid
C6 biceps
C7 thumb extensors
C8 finger flexors
T1 hand interossei

Front 767

What is the sensory evaluation of the brachial plexus?

Back 767

C5 lateral arm
C6 lateral forearm and thumb
C7 tip of the long finger
C8 tip of the little finger and medial forearm
T1 medial arm

Front 768

What are the standard radiographic views required to assess the shoulder?

Back 768

True AP (35 degrees oblique) because there is no bony overlap
Transscapular lateral (Y view)
Axial lateral (projects the glenohumeral join in cephalocaudal plain, useful to define the relationship of the humeral head with the glenoid fossa)

Front 769

What neurovascular injuries are associated with acromion process injuries?

Back 769

brachial plexus

Front 770

What neurovascular injuries are associated with coracoid process injuries?

Back 770

brachial plexus and axillary artery

Front 771

What neurovascular injuries are associated with scapular neck, body or spine injuries?

Back 771

suprascapular nerve

Front 772

What neurovascular injuries are associated with proximal humerus injuries?

Back 772

brachial plexus, axillary nerve and artery

Front 773

What neurovascular injuries are associated with anterior shoulder dislocation?

Back 773

axillary nerve

Front 774

What is the classification of scapular fractures?

Back 774

Type 1 - acromion process, scapular spine, coracoid process
Type 2 - scapular neck
Type 3 - intra-articular
Type 4 - body fractures (most common)

Front 775

What can be confused with an acromial fracture?

Back 775

Os acromiale (unfused acromial process epiphysis
this is present in 3% of the population and bilateral in 60%

Front 776

What is the management of scapular fractures?

Back 776

Search for associated injuries

body, spine and non-displaced acromial fractures-> conservative treatment with analgesia, immobilization and passive shoulder exercises

displaced acromial fracture with impingement on the glenohumeral joint,scapular neck and glenoid fossa -> surgical treatment

Front 777

Compare the presentation of anterior and posterior sternoclavicular dislocations?

Back 777

Anterior- due to indirect anterolateral force to the shoulder, then backward roll of the shoulder. Reduction by the EP in the ED.

Posterior - less common, more severe pain, possible harseness, dysphagia, dyspnea and paresthesias in the upper extremity. It results from a direct blow to the medial clavicle or posterolateral force to the shoulder and inward roll. Reduction by ortho is preferred though reduction by EP in the ED if airway or vascular compromise

Front 778

HOw do you reduce SCJ dislocations?

Back 778

Patient supine
Place a rolled sheet between the shoulder blades
Apply traction to the arm that is extended at abducted.
PUsh (anterior) or Lift (posterior) the claivicle back into place

Front 779

What is the most common mechanism for inferior shoulder dislocation?

Back 779

hyperabduction

Front 780

What is the most common mechanism for posterior shoulder dislocation?

Back 780

Seizures
FOOSH
Direct blow to the anterior shoulder

Front 781

What is the clinical presentation of anterior, posterior and inferior shoulder dislocation?

Back 781

anterior - arm held in slight abduction and external rotation, squared off, appearance, indistinct coracoid, anterior fullness

posterior- arm held in adduction and internal rotation, squared off, prominant coracoid, humeral head may be palpable

inferior - arm locked overhead,humeral head may be palpable along the lateral chest wall, elbow flexed and forearm rests on head

Front 782

What are the xray findings for anterior, posterior and inferior shoulder dislocation?

Back 782

anterior - hill-sachs lesion, bankart lesion

posterior - loss of elliptical ovelap of the humeral head and glenoid fossa, humeral shaft parallel to the chest wall, rim sign: increased distance between the anterior glenoid rim and the articular surface of the humeral head,light bulb appearance

inferior - the superior articular surface of the humeral head appears inferior to the glenoid fossa, humeral shaft parallel to the spine of the scapula

Front 783

What are the physical findings in the 3 stages of shoulder impingement?

Back 783

Stage 1 - tenderness over the supraspinatus and anterior acromion, painful arc 60-120, positive Neers and Hawkins

Stage 2 - crepitus in the joint and as above

Stage 3 - findings of rotator cuff tear

Front 784

What is the pathophysiology of adhesive capsulitis?

Back 784

inflammatory reaction resulting in the formation of adhesion within the capsule

Front 785

What is the presentation of adhesive capsulitis?

Back 785

Typically diabetic women between 40 and 60
Limitation of all shoulder movements
pain severe at night and localized over deltoid
sense of mechanical restriction on PROM

Front 786

What is the treatment for adhesive capsulitis?

Back 786

NSAID
intraarticular steroid injection
ortho referral for surgery after 6mo of failed conservative treatment

Front 787

What is the differential for low back pain?

Back 787

Localized common
Uncomplicated musculoskeletal back pain
intervertebral disk herniation
spinal stenosis
spondylolithesis
osteoarthritis
fracture

Infection
spondylitis
epidural abscess
diskitis
herpes zoster

malignancy
breast/lung/prostate
multiple myeloma
lymphoma
leukemia
primary cord/extradural tumors
osteoid osteoma

Peds
spondylolisthesis/spondylolysis
severe scoliosis
scheurmanns disease

Rheumatologic
ankylosing spondylitis
psoriatic arthritis
reiter's
PMR

VAscular
AVM
epidural hematoma
AAA

Biliary pathology
pancreatitis
PUD
Diverticulitis
REnal colic
Pyelonephritis
Prostatis
Cystitis

Menstrual cramps
Spontaneous abortion
labor
ectopic preg
PID
endometriosis
ovarian cyst
ovarian torsion

sickle cell crisis

Functional
Somatization
Depression
Malingering
Fibrositis

Front 788

What are red flags associated with vertebral fracture?

Back 788

recent significant tauma
recent mild trauma in >50
osteoporosis
Age>70

Front 789

What are red flags for epidural abscess or vertebral osteomyelitis?

Back 789

fever
IVDU
recent bacterial infection
immunocompromised
alcoholism

Front 790

What are red flags for cauda equina

Back 790

bilateral lower extremity pain
weakness or paresthesia
urinary retention
loss of rectal sphincter tone
saddle anesthesia

Front 791

What are red flags for back pain caused by malignancy?

Back 791

history of CA
age >50
unexplained weight loss
low back pain worse at rest or night

Front 792

What are red flags for back pain related to AD?

Back 792

syncope
unequal BP in upper extremities
pulse deficit of the lower extremities

Front 793

What are red flags for back pain related to AAA?

Back 793

syncope
Tachycardia
hypotension
pulsatile abdominal mass

Front 794

What does back pain in patients <18 years of age suggest?

Back 794

Spondylolysis +/- spondylolisthesis
malignancy
osteomyelitis
Sheuermanns disease (kyphosis and uneven growth)

Front 795

What is the management of spondylolisthesis?

Back 795

The majority can be managed conservatively with analgesia and lifestyle changes (limited contact sports)
For patients with refractory or severe back pain, outpatient MRI and NSx referral for possible operative decompression is recommended

Front 796

What is the classic history associated with spinal stenosis?

Back 796

Older patient (>55) with subacute or chronic pain and lower extremity radiculopathy that occurs with walking and is relieved with rest and bending forward at the waist.
Patient can walk uphill without pain but experiences pain when walking down hill

Front 797

What is the typical presentation of disk herniation?

Back 797

Age 30-50
low back pain and radiculopathy exacerbated with coughing, sitting or any movement
Positive SLR test
Presence of sciatica

Front 798

What are the indications for surgical treatment of disk herniation?

Back 798

Duration of pain >4-6 weeks
Intractable pain
Worsening motor or sensory deficit

Front 799

What is the differential diagnosis for thoracic back pain?

Back 799

Uncomplicated MSK back pain
Spinal cord and nerve root pathology
Vertebral column disease
Disk infection
Primary neurologic disease
Degenerative and autoimmune arthropathy
Herpes Zoster
Vascular disease (thoracic aortic dissection, ACS, pulmonary embolism)
Thoracic cavity pathology (pleuritis, pericarditis, pneumonia, esophageal pathology)
Intraperitoneal and retroperitoneal abdominal pathology (PUD, pancreatitis, hepatobiliary disease)

Front 800

How can you clinically r/o a pelvic open fracture?

Back 800

Rectal and vaginal exam
look for skin wound in the pelvic area

Front 801

What are clinical signs of a pelvic fracture?

Back 801

Rotation of the iliac crests
Tenderness on palpation of the pelvis
leg length discrepancy
Cullen's sign and Grey Turner's signs indicating retroperitoneal hemorrhage
Blood at the meatus and introits
Perineal ecchymosis or hematoma
Vaginal and rectal exams leading to identification of a presacral hematoma or bony spicule due to an open pelvic fracture

Front 802

Are routine AP radiographs of the pelvis always required for patients who sustained blunt trauma?

Back 802

No need for pelvis X-ray if the patient is

asymptomatic
alert
normal physical exam of the pelvis
no distracting injury

Front 803

What are the radiographic clues to identifying anterior column and posterior column acetabular fractures on AP radiograph of the pelvis?

Back 803

Iliopectineal line -> landmark for the anterior column
Ilioischial line -> landmark for the posterior column
Posterior wall -> larger more lateral, visualized more easily than the medial wall
Anterior wall -> smaller more medial
Acetabular tear drop -> composite shadow of the inferomedial structures of the acetabulum, the ilioischial lind should pass through the teardrop on a true AP view of the pelvis

Front 804

What is the management of a coccygeal fracture?

Back 804

Xrays are not mandatory
Bedrest
Stool softeners
Analgesia
Sitz baths may relieve the muscle spasm
Use an inflatable rubber donut cushion
Alternate sitting on the side of each buttock
Sitting on a hard chair rather than a soft chair

Front 805

What are the 3 compartments of the thigh?

Back 805

Anterior
Medial
Posterior

Front 806

What structures are found in the anterior compartment of the thigh?

Back 806

Quadriceps femoris
Sartorius
iliacus
Psoas
Pectineus
Lateral femoral cutaneous nerve
Femoral artery and vein

Front 807

What structures are found in the medial compartment of the thigh?

Back 807

Gracilis
Adductor longus
Adductor magnus
Obturator externus
Obturator nerve
Profundus femoris artery
Obturator artery
Obturator vein

Front 808

What structures are found in the posterior compartment of the thigh?

Back 808

Biceps femoris
Semitendinosus
Semimembranosus
Adductor magnus
Sciatic
Posterior femoral cutaneous
Profundus femoris artery branches

Front 809

What are the types of hip fracture?

Back 809

Femoral neck
intertrochanteric
trochanteric
subtrochanteric
femoral shaft

Front 810

What nerve can be injured in femoral shaft fractures?

Back 810

peroneal nerve

Front 811

What is the Garden classification of femoral neck fractures and their treatment?

Back 811

Garden 1 - incomplete or impacted fracture
ttx: controversial between non-surgical vs internal fixation

Garden 2 - complete fracture but non displaced
ttx: closed reduction and internal fixation

Garden 3 - complete fracture with partial displacement
ttx: closed reduction and internal fixation

Garden 4 complete fracture with total displacement
ttx: closed reduction and internal fixation

Front 812

What are the indications for hemiarthroplasty of the hip in patients with femoral neck fractures?

Back 812

age>70
poor general health that would prevent a second operation
neurological disease
severe osteoporosis
pathologic fracture
pre-existing hip disease
inadequate closed reduction
displaced fracture which is several days old

Front 813

What are the contraindications to hemiarthroplasty of the hip in patients with femoral neck fractures?

Back 813

preexisting sepsis
young patient
failure of internal fixation devices

Front 814

When is AVN a concern in hip injuries?

Back 814

Hip dislocations
Femoral neck fractures

Front 815

What is the differential diagnosis for a painful hip without an obvious fracture?

Back 815

Referred pain (lumbar spine, hip or knee)
Herniation of a lumbar disk
diskitis
occult fracture
AVN of the femoral head
DJD or OA
toxic synovitis
septic arthritis
osteomyelitis
tumor (lymphoma)
bursitis
tendonitis
ligamentous injury of the knee or hip
DVT
arterial insufficiency
iliopsoas abscess
retroperitoneal hematoma
inguinal hernia
inguinal lymphadenopathy
sports related hernia
GU complaints
Peds
Occult fracture
toxic synovitis
SCFE
Perthes disease

Front 816

What are the mechanisms of injury in posterior and anterior hip dislocation?

Back 816

posterior: MVC dashboard injury presenting with hip flexed, adducted and internally rotated

anterior: MVC dashboard injury presenting with hip flexed abducted and externally rotated

Front 817

Which nerves are injured in posterior and anterior hip dislocations?

Back 817

posterior: sciatic (especially the peroneal branch)

anterior: femoral nerve and vessels

Front 818

Describe the stimson technique for posterior hip dislocation reductions?

Back 818

-Patient prone with affected leg hanging over the edge of the bed
-knee and hip are flexed at 90 degrees
-assistant stabilizes the pelvis
-operator applies downward traction in line with femur
-femoral head is gently rotated, assistant pushes greater trochanter anteriorly toward the acetabulum

Front 819

What is the post reduction management of a hip dislocation?

Back 819

Test ROm of the hip
verify neurovascular status of the limb
place injured extremity in a knee immobilizer
abduction pillow to prevent redislocation
post-reduction films
ortho consult

Front 820

When do dislocations of prosthetic hips most commonly occur?

Back 820

within 3 months post surgery

Front 821

What clinical tests can be used to diagnose ACL injuries?

Back 821

Anterior drawer
Lachman's test
Pivot shift test

Front 822

What clinical tests can be used to diagnose PCL injuries?

Back 822

Posterior drawer
Posterior sag sign

Front 823

What clinical tests can be used to diagnose LCL and MCL injuries?

Back 823

Collateral ligament stress tests

Front 824

What clinical tests can be used to diagnose meniscus injuries?

Back 824

McMurray test
Apley's test

Front 825

What injury is frequently associated with tibial spine fractures?

Back 825

ACL rupture

Front 826

What causes patella alta?

Back 826

Rupture of the patellar tendon

Front 827

What causes patella baja?

Back 827

rupture of the quadriceps tendon

Front 828

What is the management of a patellar fracture?

Back 828

Nondisplaced - long leg cast for 4-6 weeks and fu with ortho

Displaced - ORIF

Front 829

What clinical test can be used to identify patients at risk for patellar subluxation?

Back 829

Apprehension test
Anxiety and anticipatory reactions observed in the patient when the examiner attempts to slide the non-displcaed patella laterally

Front 830

What knee injury presents in 10-20 year olds and is worse with climbing stairs and prolonged flexion?

Back 830

Patellofemoral syndrome

Front 831

What knee injury presents as lateral knee pain in a distance runner?

Back 831

Iliotibial band syndrome

Front 832

What knee injury presents with knee pain due to repetitive jumping?

Back 832

Jumper's knee or peripaterlla tendinitis

Front 833

What knee injury presents in runners as posterior or posterolateral knee pain

Back 833

popliteus tendinitis

Front 834

What knee injury presents as anterior tibial pain during or after exercise?

Back 834

Shin splints or periostitis

Front 835

Name all the bursa around the knee

Back 835

Suprapatellar
Prepatellar
superficial infrapatellar
anserine
deep infrapatellar

Front 836

List the structures (bony and ligamentous) of the ring providing stability around the talus

Back 836

Tibial plafound
Medial Malleolus
Deltoid ligament
Calcaneus
Lateral collateral ligaments
Syndesmotic ligaments

Front 837

List radiographs in the standard ankle series?

Back 837

AP
Lateral
Mortise

Front 838

What are limitations of the Ottawa ankle rues?

Back 838

They do not apply to subacute or chronic injuries
They do not apply to paediatrics (**)
They only apply to inversion and "rolled ankle" injuries
They do not apply to forefoot and hindfoot injuries
They do not apply to multiply injured, intoxicated or otherwise difficult to assess patients

Front 839

What is the mechanism of lateral malleolar fractures?

Back 839

Inversion and internal rotation (adducting force)

Front 840

What is a pilon fracture and what is the mechanism of injury?

Back 840

A comminuted fracture of the distal tibia which results from the head of the talus being driven into the tibial plafond. The MOI is axial compression

Front 841

What injuries are commonly associated with pilon fractures?

Back 841

Calcaneal fractures
Tibial plateau fractures
femoral neck fractures
acetabular fractures
lumbar fractures

Front 842

What are mechanisms of Achilles tendon rupture?

Back 842

Direct trauma
Sudden unexpected dorsiflexion
Forced dorsiflexion of the plantar flexed foot
Strong push off of the foot with simultaneous knee extension and calf contraction

Front 843

What are the xray features of achilles tendon rupture?

Back 843

Opacification of Kager's triangle

Front 844

What are clinical features of peroneal tendon dislocation?

Back 844

Snapping sensation
Tenderness and swelling over the lateral retromalleolar area
Inability to evert the foot when held in dorsiflexion

Front 845

What is the management of peroneal tendon dislocation?

Back 845

CT/MRI confirmation
Orthopedic referral
Well molded cast in plantar flexion

Front 846

What is the most common midfoot fracture?

Back 846

Navicular fracture

Front 847

What differentiation must be made about base of the 5th metatarsal fractures?

Back 847

True Jones - transverse diaphyseal fracture (>15mm distal to the proximal end of the bone)
PseudoJones - fracture of the tuberosity (avulsion by the plantar aponeurosis/peroneus brevis)

Front 848

What is the management of metatarsal base fractures?

Back 848

Nondisplaced MT 1-4 -> below the knee cast
All other MT 1-4 -> ortho consult ? Lisfranc injury

Front 849

List 3 general causes of foot pain that must be considered in the differential for nontraumatic foot pain

Back 849

Reflex sympathetic dystrophy
Retained FB
Stress fractures