Orthopedics 01

Front 1

Extrinsic causes of joint pain

Back 1

Neurologic (nerve root compression, herpes), generalized (fibromylagia, polymyalgia, sickle cell), referred pain, and pain originating from surrounding organs

Front 2

Intrinsic causes of joint pain

Back 2

Articular (arthritis, neoplastic, traumatic), and non-articular such as bursa, tenons, ligaments, muscle

Front 3

Signs suggesting an open fracture?

Back 3

Continuous bleeding from puncture site or fat droplets in blood

Front 4

The four X-ray rule of 2s

Back 4

2 sides, 2 views, 2 joints (joint above and below), and 2 times (before and after reduction)

Front 5

What is the difference between varus and valgus angulation?

Back 5

Varus - apex away from midline; valgus - toward midline

Front 6

What are the indications for open reduction? Use the mnemonic NO CAST

Back 6

Non-union, Open fracture, Neurovascular Compromise, intra-Articular fracture, Salter-HArris 3,4,5, polyTrauma

Front 7

Reasons for splinting?

Back 7

Reduces pain and further damage to vessels, nerves, and skin; reduces inadvertently converting closed to open fracture, facilitates patient transport

Front 8

What is heterotopic ossification?

Back 8

Formation of bone in abnormal locations, such as muscle, secondary to pathology

Front 9

What is avascular necrosis?

Back 9

Ischemia to bone due to disrupted blood supply; commonly in bones covered by cartilage or with distal to proximal blood supply

Front 10

Healing of a fracture at 0-3 weeks?

Back 10

Hematoma, macrophages surround fracture site

Front 11

Healing of a fracture at 3-6 weeks?

Back 11

Osteoclasts remove sharp edges, callus forms within hematoma

Front 12

Healing of a fracture at 6-12 weeks?

Back 12

Bone forms within the callus, bridging fragments

Front 13

Healing of a fracture at 6-12 months?

Back 13

Cortical gap is bridged by bone

Front 14

Healing of a fracture at 1-2 years?

Back 14

Normal architecture is achieved through remodelling

Front 15

How do you clinically evaluate healing of a fracture?

Back 15

No longer tender to palpation or stressing on physical exam

Front 16

How do you evaluate the healing of a fracture with x-rays? (what do you look for?)

Back 16

Trabeculae cross fracture site, visible callus bridging site on at least 3 of 4 cortices

Front 17

Early local fracture complications

Back 17

Compartment syndrome, neurological injury, vascular injury, infection, implant failure, fracture blisters

Front 18

Early systemic fracture complications

Back 18

Sepsis, DVT, PE, ARDS secondary to fat embolism, hemorrhagic shock

Front 19

Late local fracture complications

Back 19

Mal/non-union, AVN, osteomyelitis, HO, post-traumatic osteoarthritis, joint stiffness, CRPS type I/RSD

Front 20

Orthopedic emergencies? Use the mnemonic VON CHOP

Back 20

Vascular compromise, Open fracture, Neurological compromise/cauda equina syndrome, Compartment syndrome, Hip dislocation, Osteomyelitis/septic arthritis, unstable Pelvic fracture

Front 21

What is Buck's traction?

Back 21

A system of weights, pulleys and ropes that are attached to the end of a patient's bed exerting a longitudinal force on the distal end of a fracture, improving its length, alignment, and rotation

Front 22

Emergency measures in open fractures

Back 22

Remove obvious foreign material --> irrigate with saline --> cover in sterile dressings --> immediate IV antibiotics --> tetanus or immunoglobulin as needed --> reduce and splint --> NPO and prepare for OR

Front 23

Most common route of infection in septic joint?

Back 23

Hematogenous

Front 24

Most common causes of septic joint in adults?

Back 24

Staphylococcus aureus; consider coagulase-negative Staphylococcus in patients with prior joint replacement and Neisseria gonorrhea in sexually active adults

Front 25

Risk factors for septic joint

Back 25

Age >80, DM, RA, prosthetic joint, recent surgery, skin infects, IVDA, alcoholism

Front 26

Clinical presentation of septic joint

Back 26

Inability/refusal to bear weight, localized joint pain, erythema, warmth, swelling, pain on active and passive ROM, +/- fever

Front 27

Investigations done in suspected septic joint

Back 27

X-ray (r/o fracture), ESR, CRP, WBC, blood cultures; joint aspirate, and listen for heart murmur (to r/o endocarditis)

Front 28

Treatment of septic joint

Back 28

IV antibiotics, empiric therapy, adjust following joint aspirate C&S results; needle aspiration if small, urgent decompression and surgical drainage if large joint

Front 29

Plain film findings in septic joint

Back 29

0-3 days usually normal; 4-6 days joint space narrowing and destruction of cartilage

Front 30

Plain film findings of osteomyelitis

Back 30

Soft tissue swelling*, lytic bone destruction*, and periosteal reaction (formation of new bone); *generally not seen until 10-12 days after onset of infection

Front 31

Most common organisms causing osteomyelitis

Back 31

Staphylococcus aureus; consider Salmonella typhi in sickle cell and Gram negative in neonates and immunocompromised

Front 32

Most common route of infection for osteomyelitis

Back 32

Hematogenous or exogenous (open fractures, surgery, local infected tissue)

Front 33

Common sites of osteomyelitis

Back 33

Long bones (children) and vertebra (adults)

Front 34

Joint aspirate findings in septic joint

Back 34

>80,000 WBCs, protein >4.4, joint << blood Glucose, no crystals and positive Gram stain

Front 35

Investigations in suspected osteomyelitis

Back 35

Bone biopsy, blood culturem aspirate cultures, ESR; CRP, CBC (leukocytosis; x-ray, bone scan, MRI most sensitive and specific (use for diabetic foot or vertebral involvement)

Front 36

Treatment of osteomyelitis

Back 36

IV antibiotics, empiric therapy, adjust following blood and aspirate culture results; surgical decortication and drainage +/- local antibiotics if abscess or does not improve after 36 hours on IV antibiotics; worst case amputation

Front 37

What is compartment syndrome?

Back 37

Increased interstitial pressure in an anatomical compartment (forearm, calf) where muscle and tissue are bounded by fascia and bone with little room for expansion; interstitial pressure exceeds capillary perfusion pressure leading to muscle necrosis (4-6 hours) and eventually nerve necrosis

Front 38

The etiology of compartment syndrome can be divided into intracompartmental and extracompartmental. What are the intracompartmental causes of compartment syndrome?

Back 38

Fracture (tibial shaft, pediatric supracondylar fractures and forearm), crush injury, and ischemia-reperfusion injury

Front 39

The etiology of compartment syndrome can be divided into intracompartmental and extracompartmental. What are the extracompartmental causes of compartment syndrome?

Back 39

Constrictive dressing (circumferential cast, poor positioning during surgery), circumferential burn

Front 40

Pathogenesis of compartment syndrome

Back 40

Front 41

The 5 P's of compartment syndrome

Back 41

Pain, pallor (late finding), paresthesia, paralysis (late finding), and pulselessness (late finding)

Front 42

Clinical presenation of compartment syndrome

Back 42

Pain with active contraction of compartment and passive stretch, swollen and tense compartment, suspicious history

Front 43

Most important sign of compartment syndrome? Symptom?

Back 43

Increased pain with passive stretch; most important symptom is pain out of proportion to injury

Front 44

Non-operative treatment of compartment syndrome?

Back 44

Remove constrictive dressings (casts, splints), elevate limb at the level of the heart

Front 45

Operative treatment of compartment syndrome

Back 45

Urgen fasciotomy; 48-72 hours post-op - wound closure +/- necrotic tissue debridement

Front 46

Investigations in compartment syndrome

Back 46

Usually not necessary as it's a clinical diagnosis; measure compartment with catheter after clinical diagnosis is made

Front 47

Complications of compartment syndrome

Back 47

Rhabdomyolysis, renal failyre secondary to myoglobinuria, Volkmann's ischemic contracture

Front 48

Etiology of cauda equina syndrome?

Back 48

Compression or irritation of lumbosacral nerve roots below L2; decreased space in the vertebral canal below L2; common causes - herniated disk +/- spinal stenosis, vertebral fracture and tumor

Front 49

Clinical features of cauda equina syndrome

Back 49

Acute, motor (LMN signs), autonomic signs (urinary and fecal incontinence), sensory - low back pain radiating to legs, bilateral sensory loss or pain, saddle anesthesia, sexual dysfunction

Front 50

Treatment of cauda equina syndrome

Back 50

urgen investigation and decompression (<48 hours) to preserve bowel, bladder and sexual function and to prevent progression to paraplegia

Front 51

Prognosis of cauda equina syndrome

Back 51

Improved markedly with surgical decompression; recovery correlates with function at initial presentation: if unable to walk, unlikely to walk after surgery

Front 52

What is thoracic outlet syndrome?

Back 52

Impingement of subclavian vessels and brachial plexus nerve trunk

Front 53

Etiologies of thoracic outlet syndrome

Back 53

Congenital - cervical rib, trauma, degenerative - osteoporosis, arthritis

Front 54

Clinical features of thoracic outlet?

Back 54

Neurogenic (ulnar and median nerve motor and sensory), arterial (fatigue, weakness, coldness, ischemic pain, paresthesia), venous (edema, venous distention, collateral formation, cyanosis)

Front 55

Treatment of thoracic outlet syndrome

Back 55

Conservative - physiotherapy, posture and behaviour modification, surgical - removal of first or cervical rib

Front 56

Mechanism of anterior hip dislocation

Back 56

Posteriorly directed blow to knee with hip widely abducted

Front 57

Management of hip dislocation

Back 57

Examine for neurovascular injury --> reduce hip dislocation ASAP (<6h) to decrease risk of AVN of the femoral head -> hip reduction for 6 weeks post-reduction

Front 58

Clinical features of anterior hip dislocation

Back 58

Shortened, abducted, externally rotated limb

Front 59

Treatment of anterior hip dislocation

Back 59

Closed reduction under conscious sedation/GA, post-reduction CT to assess joint congruity

Front 60

Mechanism of posterior hip dislocation

Back 60

Severe force to knee with hip flexed and adducted; e.g., knee into dashboard in a motor vehicle collision (MVC)

Front 61

Clinical features of posterior hip dislocation

Back 61

Shortened, adducted and internally rotated limb

Front 62

Treatment of a posteriorly dislocated hip

Back 62

Closed reduction under conscious sedation/GA only if associated femoral neck fracture; ORIF if unstable, intra-articular fragments or posterior wall fracture; post-reduction CT to assess joint congruity and fractures; if reduction is unstable, put in traction for 4-6 weeks

Front 63

Most common type of hip dislocation

Back 63

Posterior

Front 64

Mechanism of central hip dislocation

Back 64

Traumatic injury where femoral head is pushed medially through acetabulum

Front 65

Possible complications of all hip dislocations

Back 65

Post-traumatic osteoarthritis, AVN, fracture of femoral head, neck, or shaft; sciatic nerve palsy in 25% (10% permanent), HO, thromboembolism - DVT/PE

Front 66

What are the four joints in the shoulder?

Back 66

Glenohumeral, acromioclavicular (AC), sternoclavicular (SC), and scapulothoracic

Front 67

Factors causing shoulder instability

Back 67

Shallow glenoid, loose capsule, ligamentous laxity

Front 68

Shoulder passive ROM

Back 68

Abduction - 180; adduction - 45; flexion - 180; extension - 45; internal rotation - level of T4; external rotation - 40-45

Front 69

Describe the Rochester method to reduce dislocations

Back 69

Patient lies supine with hip and knee flexed on injured side; surgeon stands on patient's injured side; surgeon passes one arm under patient's flexed knee, reaching to place that hand on patient's other knee; with other hand, surgeon grasps patient's ankle on injured side, applying traction, while assistant stabilizes pelvis; reduction via traction, internal rotation, then external rotation once femoral head clears acetabular rim

Front 70

What is the most commonly dislocated joint in the body?

Back 70

The glenohumeral joint, since stability is sacrificed for motion

Front 71

Prognosis of shoulder dislocation

Back 71

Recurrence rate depends on age of first dislocation: <20 - 65-95%; 20-40: 60-70%; >40: 2-4%

Front 72

Specific complications of shoulder dislocation

Back 72

Rotator cuff or capsular tear, shoulder stiffness; injury to axillary nerve/artery, brachial plexus; recurrent/unreducted dislocation (most common complication)

Front 73

Mechanism of anterior shoulder dislocation

Back 73

Abducted arm is externally rotated/hyperextended, or blow to posterior should; involuntary, usually traumatic; voluntary, atraumatic

Front 74

Symptoms of anterior shoulder joint dislocation

Back 74

Pain, arm slightly abducted and external rotated with inability to internally rotate

Front 75

Findings on shoulder exam in anterior shoulder dislocation

Back 75

"Squared off" shoulder, positive apprehension tests, positive relocation test, positive sulcus sign

Front 76

What is considered a positive apprehension test?

Back 76

Patient looks apprehensive with gentle shoulder abduction and external rotation to 90 degrees since humeral head is pushed anteriorly and recreates feelings of anterior dislocation

Front 77

What is considered a positive relocation test?

Back 77

A posteriorly directed force applied during the apprehension test relieves apprehension since anterior sublluxation is prevented

Front 78

What is considered a positive sulcus sign?

Back 78

Presence of subacromial indentation with distal traction on humerus indicates inferior shoulder instability

Front 79

Investigations in suspected anterior shoulder dislocation

Back 79

X-rays: AP, trans-scapular, and axillary views

Front 80

Radiographic findings in anterior shoulder dislocation

Back 80

Axillary view: humeral head is anterior; trans-scapular/scapular Y view: humeral head is anterior to the centre of the "Mercedez-Benz sign"

Front 81

What is a Hill-Sachs lesion?

Back 81

Compression fracture of posterior humeral head due to forceful impaction of an anteriorly dislocated humeral head against the glenoid rim

Front 82

Treatment of anterior shoulder dislocation

Back 82

Closed reduction with IV sedation and muscle relaxation; obtain post-reduction x-rays; check post-reduction NVS; sling for 3 weeks (avoid abduction and external rotation), followed by shoulder rehabilitation (dynamic stabilizer strengthening)

Front 83

Mechanism of posterior shoulder dislocation (5%)

Back 83

Adducted, internally rotated, flexed arm; FOOSH; 3 E's (epileptic seizure, EtOH, electrocution); blow to anterior shoulder

Front 84

Clinical features of a posterior shoulder dislocation

Back 84

Arm is held in adduction and internal rotation; external rotation is blocked; anterior shoulder flattening, prominent coracoid, palpable mass posterior to shoulder; posterior apprehension ("jerk") test

Front 85

What is posterior apprehension test?

Back 85

With patient supine, flex elbow 90 degrees and adduct, internally rotate the arm while applying a posterior force to the shoulder; patient will "jerk" back with the sensation of subluxation

Front 86

Investigations in suspected posterior shoulder dislocation

Back 86

X-rays: AP, trans-scapular, axillary

Front 87

AP x-ray findings on posterior shoulder dislocation

Back 87

Partial vacancy of glenoid fossa and >6mm space between anterior glenoid rim and humeral head (positive rim sign), humeral head may resemble a lightbulb due to internal rotation (lightbulb sign)

Front 88

Axillary x-ray findings on posterior shoulder dislocation

Back 88

Humeral head is posterior

Front 89

Trans-scapular view findings on x-ray in posterior shoulder dislocation

Back 89

Humeral head is posterior to centre of "Mercedez-Benz sign"

Front 90

Other x-ray findings in posterior shoulder location

Back 90

Reverse Hill-Sachs lesion (75% of cases): divot in anterior humeral head; reverse bony Bankar lesion: avulsion of the posterior glenoid labrum from the bony glenoid

Front 91

Treatment of posterior shoulder dislocation

Back 91

Closed reduction, obtain post-reduction x-rays, check post-reduction neurovascular status, sling in abduction and external rotation for 3 weeks, followed by shoulder rehablitation

Front 92

Muscles of the rotator cuff

Back 92

SITS: Supraspinatus, Infraspinatus, Teres minor, Subscapularis

Front 93

How do you screen out rotator cuff tears?

Back 93

No night pain (SN 87.7%); No painful arc (SN 97.5%); No impingement signs (SN 97.2%); no weakness

Front 94

Describe the traction-countertraction method of reducing a shoulder dislocation

Back 94

Assistant stabilizes torso with a folded sheet wrapped across the chest while the surgeon applies gentle steady traction

Front 95

Describe the Stimson method of reducing a shoulder dislocation

Back 95

While patient lies prone with arm hanging over table edge, hand a 5lb (2.3kg) weight on wrist for 15-20 minutes

Front 96

Describe the Hippocratic method of reducing shoulder dislocations

Back 96

Place heel into patient's axilla and apply traction to arm; perhaps the safest method of shoulder reduction

Front 97

Nerve root of biceps reflex

Back 97

C5/C6

Front 98

Nerve root of the brachioradialis reflex

Back 98

C6

Front 99

Nerve root of the triceps reflex

Back 99

C7/C8

Front 100

Nerve root of the patellar reflex

Back 100

L2-L4

Front 101

Nerve root of the ankle jerk reflex

Back 101

S1/S2