Intro

Question 1

Types of fractures

Answer 1

1. Oblique
2. comminuted- shattered into 2+ pieces
3. spiral/torsion
4. compounded- breaks through skin
5. Greenstick (incomplete)- one side of bone breaks and the other is bent
6. transverse- horizontal
7. simple (n)o surrounding damage

Question 2

How do you stabilize a long bone fracture

Answer 2

• plate and screws outside the bone

- rod inside in bone

Question 3

describe the healing of a fracture

Answer 3

hematoma and granulation tissue–> cartilaginous callus–> bony callus and cartilaginous remnants (about 6 weeks)–> re-modeling (about 3 months)

Question 4

Dead bone and fibrous tissue in a nonunion fracture, that prevents new bone formation from occurring

Answer 4

Non-union

Question 5

When can a mal-union fracture be called a non-union fx

Answer 5

6 months

*can be seen at 3 months though

Question 6

Treatment of a non-union tx

Answer 6

• if asymptomatic– nothing
• if symptomatic- open it up, scrap the bad stuff out, put in bone graph, and secure with nail and the healing process starts over again

Question 7

Types of fracture displacement include -

Answer 7

1. angulation,
2. rotation,
3. change of bone length, and
4. loss of alignment

Question 8

For fingers and forearm, directional displacement is described as __ or __, for all other bones __ or __

Answer 8

radial or ulnar

medial or lateral

Question 9

Most displaced fractures result in more than one type of displacement. Displacement combinations:

Answer 9

1. Oblique fracture
2. Lateral displacement
3. Shortening
4. Valgus angulation
5. Internal rotation

Question 10

Degrees of angulation can be measured using

Answer 10

1. Appex volar or dorsal angulation, or
2. medial angulation can be termed ‘varus’, (much worse)
3. lateral angulation can be termed ‘valgus’.

Question 11

What should you do with an open fracture/dislocation

Answer 11

Orthopaedic emergency!!
1st- check pulse
2nd- check nerve function
3rd- reduce it

*Always document the neurovascular status before AND after reduction!!!!

Question 12

What type of fracture in a kid should worry you for abuse?

Answer 12

femur fracture in kids less than 1 y/o

Question 13

What do you need to be worry about with compound fractures?

Answer 13

1. Neurovascular injury

2. compartment syndrome (always document if there is a sign of compartment syndrome- in femur and tibia fx especially)

Question 14

When do you get CTs

Answer 14

1. Good for bone details,
   Ex. Comminuted (tells you how many fragments, how big they are, where are they going)
2. always get for calcaneus fx

Question 15

When do you get MRIs

Answer 15

primarily for soft tissue, stress fractures, and bone infection

Question 16

What do T2 and T1 MRIs highlight?

Answer 16

T2= H20, is white= get for herniation

T1= bone is white= get for osteomylitis

Question 17

When are bone scans helpful?

Answer 17

*abnormalities in bone which are triggering the bone’s attempts to heal

1. CA
2. stress fracture

Question 18

When do you order a PET

Answer 18

1. CA
2. check blood flow
3. see how organs are working

-takes glucose as your tracer bc all cells need sugar to survive

**NEVER ORDER A PET SCAN FOR SCREENING

Question 19

When are U/s order

Answer 19

tendon ruptures

Question 20

When is a DEXA scan ordered

Answer 20

(bone density scan)

osteoporosis

Question 21

describe the HPI for an orho injury

Answer 21

PQRST

1. Location and if possible “pin-point location”
2. Pain: palliative, provocative (What makes the pain worse or better)
3. Q: quality (sharp, dull, stabbing pain)
4. R: radiation
5. S: severity (1-10, or mild. Mod etc.)
6. T: Time of injury, duration of symptoms, etc.
7. What, when, where…

Question 22

How do you perform/document a knee injection

Answer 22

1. Knee prepped in usual sterile fashion with betadine
2. Use A mixture of 5cc of 1% Xylocaine without epinephrine and 4cc of 0.25 % Marcaine without epinephrine, with 1cc of Kenalog 40mg/cc injected intra-articularly using the superior-lateral approach.
3. bandaid placed
4. give handout about signs/sx of allergic rxn, infection and complications
5. use ice, rest, NSAIDS prn for comfort

*always document consent as well

Question 23

How do you perform/document a knee aspiration

Answer 23

1. Skin prepped with Betadine
2. injected with 1% Lidocaine without epinephrine subcutaneously followed by joint aspiration using the superior-lateral approach. Aspiration of ___cc of clear, yellowish fluid with a positive string test.
3. Plan to send synovial fluid for Gram Stain with cultures / sensitivities, WBC cell count (purple top tube) and crystals.

*always document consent as well

Question 24

Treatment of open fractures

Answer 24

1. Decreased infection rate if diagnosed accurately and with formal Incision and Drainage surgery as soon as possible.
2. Broad spectrum IV antibiotics ASAP
3. Skeletal stabilization with splints or with external fixation.
4. Wound vac for large soft tissue defect if indicated.

Question 25

Clues to an open fracture

Answer 25

1. non-weight baring 2. a lot of pain 3. looks deformed 4. blood out of a small opening with shiny stuff on blood = bone marrow *open fracture until proven otherwise--> need Abx, wash out

Question 26

Describe the different classes of open fractures according to the Gustilo, Mendoza and Williams Classification

Answer 26

``` I: wound less than 1cm, low energy II: wound less than 10cm, moderate energy III: wound over 10cm, high energy IIIA: adequate tissue coverage IIIB: massive contamination IIIC: vascular injury ```

Question 27

Tx of Grade I, II and III open fractures

Answer 27

I: IV 1st generation cephalosporins II: IV 1st generation ceph and Gentamycin III: above and consider anaerobic antibotics (pcn, clindamycin, flagyl) AND 3+ needs surgery right away w/in 6 hrs *Unless you have had a tetanus booster within 5 years of the injury, you will also be given a tetanus shot

Question 28

External fixation of an open fracture is often initial tx secondary to

Answer 28

soft tissue injury or possible infection **Keep it nice and tight so you can fix it later (allow soft tissue to go down)

Question 29

When do you use a wound vacuum?

Answer 29

1. Wound is not bleeding but is oozing--> put a wound vacuum on a LOW pressure so it doesn’t suck up granulation or clot 2. Good for deep infections and transport

Question 30

How do you dx compartment syndrome

Answer 30

Pressure 30 or greater mm Hg(intra-compartment pressure) or 20 units of Hg discrepancy in diastolic BP between the two extremities. *Use a Stryker needle into the compartment to measure the compartment pressure

Question 31

Compartment syndrome commonly follows major traumas such as:

Answer 31

1. gun shot wounds (GSW) 2. crush injuries (foot, leg, hand) 3. long bone fractures (tibia, femur, forearm) 4. dislocations (foot, knee, wrist) 5. bites (animal or human) 6. pediatric distal humerus fracture 7. Third degree burns

Question 32

5 P's of compartment syndrome

Answer 32

signs and sx 1. PAIN out of proportion 2. Pallor 3. paralysis 4. Paresthesias 5. Pulseless (big trouble if this)

Question 33

tx of compartment syndrome

Answer 33

The only effective treatment is fasciotomy

Question 34

Signs/Sx of Cauda Equina Syndrome

Answer 34

1. Pain and Weakness 2. Saddle parasthesias (usually early) 3. Paralysis 4. Bowel/Bladder dysfunction (overflow bladder incontinence and loss of bowel control)--no anal tone w/ rectal exam 5. Absence or diminished Deep Tendon Reflexes

Question 35

tx of Cauda Equina Syndrome

Answer 35

1. emergent MRI | 2. emergent surgical decompression

Question 36

How do you dx septic arthritis

Answer 36

1. joint aspiration w/ synovial fluid labs w/ WBC (usually infected if over 50K and over over 100K), gram stain, cultures, and crystals 2. Young adults rule out N. gonorrhea

Question 37

Presents: pt holding extremity in position of comfort and with severe pain with range of motion.

Answer 37

septic arthritis

Question 38

adverse outcome of septic arthritis

Answer 38

1. cartilage damage w/ possible length discrepancy (physeal arrest) in children 2. sepsis 3. death

Question 39

tx of septic arthritis

Answer 39

1. Incision and drainage 2. irrigation 3. Abx

Question 40

Morning stiffness and pain, joint effusion and hypertrophy of DIPJs (Heberden’s nodes) are common

Answer 40

OA

Question 41

Bouchard’s nodes of PIPJs and ulnar deviation of MCPJs

Answer 41

RA

Question 42

how do you dx RA

Answer 42

Labs: 1. RF (+ in 80% of cases) 2. Anti-citrulline Ab ANA 3. HLA 4. ESR, CRP

Question 43

What are the following nodules associated with? 1. Heberden's Nodules 2. Bouchard's ndoules of PIPJs 3. Gouty nodules

Answer 43

1. Heberden's Nodules: OA 2. Bouchard's ndoules of PIPJs: RA 3. Gouty nodules: gout

Question 44

Crystalline Deposition Diseases

Answer 44

1. Gout 2. Pseudo-gout 3. Calcium Pyrophosphate Deposition Dz

Question 45

- Crystals in the synovium and other tissues with subsequent inflammatory response. - Abrupt episodes of severe joint pain with usually a single joint involvement

Answer 45

Crystalline Deposition Diseases (Gout / Pseudo-gout / Calcium Pyrophosphate Deposition Dz.)

Question 46

A definitive diagnosis of gout is based upon the identification of

Answer 46

monosodium urate (MSU) crystals in synovial fluid or a tophus

Question 47

great toe erythema and swelling with severe pain even to light touch.

Answer 47

Podagra *it is the first presentation of gout in 50% of new cases

Question 48

Calcium pyrophosphate deposition disease (CPPD), aka pseudogout, consists of the deposition of ___ crystals into soft tissue

Answer 48

calcium pyrophosphate crystals