Ortho (with UWorld)

head on collision

check for posterior hip dislocation

fracture remodeling

children have specific problems with supracondylar fx of humerus and any fx of growth plate

venous stasis ulcers

chronically edematous, indurated, and hyperpigmented skin above medial malleolus -painless ulcer with granulating bed, patient with varicose veins and frequent bouts of cellulitis -Duplex scan to dx -get support stocking, possible surgery (vein stripping, grafting) or endovascular ablation with laser or radio frequency

fat embolism syndrome

d/t fx of marrow-contained bone (femur), orthopedic surgery, pancreatitis sx: respiratory distress, neurologic dysfunction (confusion), petechia rash 24-72hrs following event tx: early immobilization of fx, supportive care

trochanteric burisits

d/t overuse, trauma, joint crystals, or infection c/o hip pain when pressure applied (external rotation, resisted abduction, sleeping) pain localized to outer thigh

meniscal tears

difficult to dx on X-ray, get MRI protracted pain and swelling, catching/locking that limits knee motion ("click" with extension) -patient stands on 1 leg with knee flexed 20 deg or passive flexion/extension, internal and external rotation causes pain, clicking or catching repair with trying to save as much meniscus as possible complete meniscectomy leads to degenerative arthritis -may be ass'd with medial collateral and ACL injury too

galeazzi fx

direct blow of distal third of radius, dorsal dislocation of distal radioulnar joint -required ORIF (cast if only dislocated)

monteggia fx

direct blow to ulna, diaphyseal fx of proximal ulna with anterior dislocation of the radial head

looking for the second, hidden fx

direction of force fall from height: land on feet...look for fx of lumbar/thoracic spine

cauda equina syndrome

distended bladder, flaccid rectal sphincter, perineal saddle anesthesia surgical emergency, immediate decompression

metastatic malignancy

eldlery with progressive back pain that is worse at night and unrelieved by rest or positional changes + weight loss -lytic: breast cancer at pedicles -blastic: prostate cancer -MRI to dx

mallet finger

extended finger is forcefully flexed (volleyball injury) and extensor tendon is ruptured -tip of finger remains flexed when the hand is extended (like a mallet) -splinting

colles fx

fall on outstretched hand, usually in old osteoporotic women -deformed, painful wrist looks like "dinner fork" -dorsal displacement, angulated fx of distal radius -tx closed reduction, long arm cast

ankle fx

falling on everted/inverted foot causing malleoli to break -AP/lateral/mortise xray to dx -ORIF if displaced fragments

arterial insufficiency ulcers

far away from the heart (tip of toes) look dirty, pale base devoid of granulation tissue -patient with arteriosclerotic occlusive dz (absent pulses, trophic change, claudication, rest pain) -Doppler for pressure gradient then CTA, MRA, surgical revascularization or angioplasty/stents

fractures

get 2 view X-ray: 90deg to each other, include joints above/below fx -get X-ray of bones "in line of force" that might also be broken broken bones that are not badly displaced/angulated or can be easily aligned by external manipulation can be immobilized in a cast ("closed reduction") severely displaced/angulated, cannot be easily aligned require surgery ("ORIF")

developmental dysplasia of the hip

hereditary, dx right after birth -uneven gluteal folds -PE shows that hips can be easily dislocated posteriorly with a jerk and "click" and then returned to normal with a "snapping" -get US to dx if equivocal (no X-ray) -tx abduction splinting with Pavlik harness for about 6 months

supracondylar fx of humerus

hyperextension of elbow in child who falls on hand with arm extended -ass'd vascular/nerve injuries common, leading to Volkmann contracture (brachial artery, median nerve) -tx casting/traction, watch for compartment syndrome

femoral neck fx

if displaced, compromise the tenuous blood supply of femoral head -replace femoral head with prosthesis: faster healing, earlier mobilization

diabetic ulcers

indolent, located at pressure points d/t neuropathy, fail to heal bc of microvascular dz

morton neuroma

inflammation of common digital nerve at third interspace, between 3/4 toes -neuroma is palpable, tender -from pointed shoes, high heels -tx analgesics, better shoes, surgical excision

gamekeeper thumb

injury of ulnar collateral ligament from forced hyperextension of thumb (skiing injury) -collateral laxity at the thumb-MCP joint -may lead to arthritis if untreated -get casting

jersey finger

injury to flexor tendon when flexed finger is forcefully extended -distal phalanx of injured finger does not flex with the others when making a fist -splinting

clavicular fx

junction of middle and distal thirds tx figure of 8 device, pulling back on shoulders to align bone, wear sling, ORIF -neuro exam and possible CTA if concern for subclavian or brachial plexus injury

knee injuries

knee swelling (if only pain, then usually not serious) = poor man's MRI

intertrochanteric fx

less likely to lead to avascular necrosis, tx ORIF -unavoidable immobilization = high risk for DVT/PE...need postop anticoagulation

hip pathology in children

look for hip pain or knee pain

facila fx, closed head injury

make sure to assess cervical spine

anterior cruciate ligament injury

more common than posterior injury severe knee swelling and pain +anterior drawer test +lachman test: knee flexed 20deg, grasp thigh, pull leg to elicit pain (posterior injury produces opposite findings) -MRI to dx -sedentary pts, tx immobilization and rehab -athletes, tx surgery (most common)

anterior dislocation of the shoulder

most common, patients hold their arm close to their body but rotated outward (shaking hands) -may be numbness over deltoid (axillary nerve) -AP/lateral xray to dx -may return with recurrent dislocations with minimal trauma

genu valgus (knock-knee)

normal from age 4-8, no tx

genu varum (bowlegs)

normal till age 3, no tx after age 3, d/t Blount dz (disturbance of medial proximal tibial growth plate) and get surgery

radial nerve injury

oblique fx of middle-distal thirds of humerus -patient unable to dorsiflex (extend) wrist -regain function when fracture reduced, arm placed on hanging cast or coaptation sling = no surgery -nerve paralysis = surgery

hip fx

old people who fall -affected leg is shortened, externally rotated -xray to dx

plantar fasciitis

older, overweight c/o of sharp heel pain when foot strikes ground and with palpation -worse in the AM -xray shows bony spur but not cause -spontaneous resolution in 12-18 mos or remove spur

slipped capital femoral epiphysis

orthopedic emergency -chubby/lanky boy, 13 yo complaining of groin/knee pain with limp -sitting with legs dangling, sole of affected leg points towards the other foot -limited hip motion, thigh cannot be internally rotated -xrays to dx, surgery to pin femoral head back in place

compartment syndrome

orthopedic emergency -forearm or lower leg -from prolonged ischemia + repercussion, crushing injuries, trauma -lower leg: d/t fx with closed reduction, pain with limited use, tender and tight, excruciating pain with passive extension, normal pulses, emergency fasciotomy

septic hip

orthopedic emergency -toddlers with febrile illness and can't move hip (will hold leg with hip flexed, slightly abducted and externally rotated) -^ESR -dx with aspiration of hip under general anesthesia (may need to openly drain)

gas gangrene

orthopedic emergency deep, penetrating dirty wounds within 3 days, patient is very sick, looking toxic and moribund -tenderness, swollen, discolored, gas crepitation tx PCN, clinda, debridement, hyperbaric O2

soft tissue infection

orthopedic emergency immunocompromised patients (DM, AIDS) -bacterial gangrene, necrotizing fasciitis -seen in extensive burns, widespread trauma leading to fulminating fungal infection -most feared is mucormycosis: area turns black, dx tissue bx -require repeated surgical excision of dead tissue + abx

open fracture

orthopedic emergency require cleaning in OR and suitable reduction in 6hrs

posterior hip dislocation

orthopedic emergency, femur driven backward (head-on collision where knees hit dashboard) -patient with shortened, adducted, internal rotated leg with hip pain -avoid avascular necrosis of femoral head

Osgood-Schlatter

osteochondrosis of the tibial tubercle -teeangers w persistent pain over tibia -aggravated by contraction of quadriceps -PE shows localized pain over tibia, no knee swelling -RICE, if not helpful then extension or cylinder cast for 4-6 weeks

tumors of children/young adults

osteogenic sarcoma: most common, 10-25yo, around knee (lower femur, upper tibia), "sunburst" pattern Ewing sarcoma: second most common, 5-15yo, diaphysis of long bones, "onion-skin" pattern sx: persistent low grade pain, invasion into soft tissue, usually primary tumors

rupture of achilles tendon

out-of-shape middle-aged men who subject themselves to severe strain -loud popping noise, fall clutching ankle -limited plantar flexion still ok but lots of pain, swelling, limping -casting in equinus position, several months or surgery

leg fx involving tibia & fibula

pedestrian hit by car PE shows angulation, X-ray to dx casting if easily reduced intramedullary nailing if can't be aligned ass'd with compartment syndrome, watch out for worsening pain in cast

popliteal artery injury

posterior dislocation of knee -check pulse, Doppler, CT angio -prompt reduction...delayed restoration of flow requires prophylactic fasciotomy

posterior dislocation of the shoulder

rare, usually after massive uncontrolled muscle contractions (seizure, electrical burn) -arm in protective position (close to bode, internally rotated) -xrays can easily miss, get axillary/scapular lateral views

pain with cast

remove and examine, orthopedic emergency

stress fx

risk factors: repetitive activities (running, gymnastics), abrupt increase in physical activity, inadequate calcium.vit D intake, decreased caloric intake -female athlete: low caloric intake + hypomenorrhea + low bone density sx: insiduious onset of localized pain, point tenderness, X-ray may be negative for 6 weeks tx: reduced weight bearing 4-6 weeks, referral to orthopedic if fx high risk for malunion (anterior tibial cortex, 5th metatarsal)

shoulder pain

rotator cuff impingement or tendinopathy: pain with abduction + external rotation, subacromial tenderness, normal ROM with positive impingement tests rotator cuff tear: weakness with external rotation otherwise similar to previous, age > 40 adhesive capsulitis: decreased passive and active ROM, more stiffness than pain biceps tendinopathy/rupture: anterior shoulder pain, pain with lifting/carrying/overhead reaching, weakness less common glenohumeral OA: uncommon, caused by trauma, gradual onset of anterior/deep shoulder pain, decreased active and passive abduction and external rotation

club foot (talipes equinovarus)

seen at birth, both feet turned inward: plantar flexion at ankle, foot inversion, adduction of forefoot, internal rotation of tibia -serial plaster casts to provide sequential correction...start wit adduction, then hind foot varus, lastly with equinus -Achilles tenotomy with braces -may require surgery, 9-12 months

torn meniscus

seen w harmless actions (walking, squatting), trauma when the knee is twisted/bent, degeneration pain, swelling, can't straighten leg

collateral ligament injuries

sideways blow to knee (medial blows disrupt lateral ligaments) -abduction = medial injuries (valgus stress test) -adduction = lateral injuries (varus stress test) knee flexed 30deg, passive add/abduction will produce pain on torn ligaments and allow for further displacement -cast or if multiple get surgery

traumatically amputated digits

surgically reattached when possible -clean digit with sterile saline, wrapped in saline-moisturized gauze, placed sealed plastic bag on bed of ice -don't place digit in antiseptic or alcohol, or on dry ice, don't let it freeze -use electric stimulation to preserve muscular function

tumors of adults

sx: localized pain, can be lytic (breast cancer in women, leading to pathologic fx) or plastic (prostate cancer in men), usually metastatic multiple myeloma: older men with fatigue, anemia, localized bone pain -xray shows multiple punched-out lytic lesions -bence-jones protein in urine, abnormal Igs (immunelectrophoresis) -tx chemo, thalidomide soft tissue sarcoma: relentless growth over several months, firm, fixed to surrounding structures -mets to lungs but not LNs -MRI to dx -incisional bx with wide local excision -tx RT, chemo

fx involving growth plate

tx by closed reduction if epiphyses and growth plate displaced laterally from metaphysics but are in 1 piece (fx does not cross epiphyses or growth plate and does not involve the joint) -if growth plate in 2 pieces, very precise alignment with open reduction and internal fixation to prevent uneven growth = deformity

femoral shaft fx

tx intramedullary rod fixation -if bilateral/comminuted, may lead to shock from internal blood loss (external fixation while patient stable) -if open, orthopedic emergency - require OR cleaning and closure within 6hrs -if multiple, fat embolism syndrome

gout

typical swelling, redness, pain of sudden onset at 1st MP joint in middle-ages, obese man with high serum uric acid -uric acid crystals from joint -tx indomethacin, colchicine then allopurinol/probenicid

carpal tunnel syndrome

women doing repetitive hand work -numbness, tingling in hands usually at night and radial 3.5 fingers (median nerve) -hanging hands limply for a few mins or tapping hand over carpal tunnel helps -tx splints and antiinflammatories, get electric studies to justify need for surgery (endoscopic release)

trigger finger

women, wake up in the middle of the night with finger acutely flexed and unable to extend it unless they pull it with the other hand, followed by painful "snap" -steroid injection for tx then surgery

scaphoid fx

young adult who falls on outstretched hand, c/o wrist pain -localized tenderness over anatomic snuffbox -if undisplaced, X-ray will be negative but thumb spica cast is indicated (X-ray will show fx 3 weeks later) -if X-ray shows displaced/angulated fx then ORIF, high rate of nonunion

tibial stress fx

young men subjected to forced marches -tenderness to palpation over bone area, X-rays normal at first get repeat in 2 weeks -tx with cast, crutches

ankylosing spondylitis

young men, chronic back pain with morning stiffness (pain worse at rest, better with activity) -sx are progressive, X-ray shows bamboo spine -antiinflammatories and PT to tx -ass'd with uveitis and IBD if HLA-B27

de quervain tenosynovitis

young mothers who as they carry baby,force their hand into wrist flexion and thumb extension to hold baby's head -pain along radila side of wrist and dorsal compartment -pain reproduced with holding thumb inside closed fist -splint and antiinflammatories, steroid injection or surgery to tx

acute hematogenous osteomyelitis

-kids with fever and severe localized pain in a bone w/o h/o trauma -xrays won't show anything for a few weeks -MRI to dx, tx abx

lumbar disk herniation

L4-L5, L5-S1 around 45 yo -several months of vague achy pain (from pressure on anterior spinal ligament) -sudden onset severe pain from event (lifting object) -radiates into to toes (big toe or little toe) -exacerbated by Valsalva (if not, then not a herniated disk) -patients cannot walk, hold affected leg flexed -straight leg produces excruciating pain -MRI to dx -usually spontaneous resolution with 3 weeks of strict bed rest, nerve block -surgery if neuro deficits worsening, emergency with caudal equine syndrome

marjolin ulcer

SCC of skin in chronic leg ulcer -constant healing and breaking down...untreated 3rd deg burns that undergo spontaneous healing or chronic draining sinuses from osteomyelitis -dirty, deep ulcer with heaped up tissue growth around edges -dx with bx -wide local excision and skin graft to tx

felon

abscess in the pulp of fingertip caused by neglected penetrating injury -throbbing pain, fever, ^WBCs, etc -pressure can build up leading to tissue necrosis, requiring surgical drainage urgently

scoliosis

adolescent girls with right-curved thoracic spine -hump noted over right thorax when bent -severe cases may caused pulmonary problems -braces to arrest progression, otherwise surgery

Legg-Calve-Perthes dz (avascular necrosis of the capital femoral epiphysis)

age 6 with insidious development of limping, decreased hip motion, and hip/knee pain -kids walk with antalgic gait and passive motion of the hip is guarded -dx with AP and lateral hip X-ray -tx casting/crutches, contain femoral head within the acetabulum

metacarpal neck fx

4th/5th or both when closed fist hits a hard surface -hand is tender, swollen, X-ray to dx -mild: closed reduction, ulnar gutter splint -kirschner wire, plate fixation for severe fx