Ortho Flashcards

Question

Outline 4 basic fracture lines

Answer 1

Transverse - occurs at a right angle to the long axis of the bone Oblique - runs oblique to the long axis of the bone Spiral - from a rotational force, a torque, and encircles the shaft of a long bone in a spiral fashion Comminuted - fracture with more than two fragments

Answer 2

Metatarsals Cuneiform Navicular Calcaneus Tibia Fibula Femoral shaft Femoral neck

Answer 3

1. Control hemorrhage in field w/ sterile pressure dressing after removing gross debris (wood, clothing, leaves) 2. Splint w/out reduction, unless vascular compromise 3. Irrigate w/ NS, cover w/ NS-soaked sponges after arrival in ED 4. Begin IV ABX ppx, usually Cefazolin for grade I, add Gentamycin for grades II-III. 5. Give tetanus ppx, including tetanus Ig for large crush wounds.

Answer 4

GRADE 1-2 = Ancef 2g IV q8h GRADE 3 = add Gentamycin 2-5mg/kg IV q24h OR CTX 2g IV q24h only Soil contamination = add Metronidazole 500mg IV q8h Farm-related or Fecal contamination = add Penicillin G 2mill units IV q4h for clostridial contamination Water contamination SEA = Levofloxacin 750mg IV q24h + Metronidazole 500mg IV q8h FRESH = PipTazo 4.5g IV q6h

Answer 5

- fingers and toes - crush injuries - vigorous irrigation and debridement, as long as digital arteries intact - infxn rare

Answer 6

- thrombosis - arteriovenous fistulae - aneurysm - false aneurysm - tissue ischemia with limb dysfunction - amputation

Answer 7

Distal radius = Median Elbow injury = Median or Ulnar Shoulder dislocation = Axillary Sacral fracture = Cauda equina Acetabulum fracture = Sciatic Hip dislocation = Sciatic Femoral shaft fracture = Peroneal Knee dislocation = Tibial or Peroneal Lateral tibial plateau fracture = Peroneal

Answer 8

- Isolated soft tissue trauma - Prolonged procedures in lithotomy position - Prolonged tuck position (knees to chest) for lumbar surgery - Coma - Spontaneous hemorrhage - Interstitial intravenous injections - Application of excessive traction in treatment of fracture

Answer 9

Bleeding: - Major vascular injury - Coagulation disorder - Anticoagulant therapy Reperfusion: - Arterial bypass grafting - Embolectomy - Ergotamine ingestion - Cardiac catheterization - Lying on limb Trauma: - Fracture - Seizure convulsions Intensive muscle use: - Exercise - Seizures - Eclampsia - Tetany - Muscle hypertrophy Burns: - Thermal - Electrical Intraarterial drug injection Interstitial infiltration Leaky dialysis cannula Venous obstructions: - Phlegmasia cerulea dolens - Ill-fitting leg brace - Tight cast - Venous ligation Procedures/Surgery: - ORIFs - Excessive traction on fractured limbs - Closed fascial defects Nephrotic syndrome Popliteal cyst

Answer 10

AVN Compartment syndrome Complex regional pain syndrome Fat embolism syndrome Fracture blisters Hemorrhage Nerve injuries Vascular injuries

Answer 11

Contractures Wound infection Decubitus ulcers Muscle atrophy DVT PE Delirium Psychosis PNA Stress GI ulcers UTI

Answer 12

- Compartment syndrome - Thermal injury - Pressure sores - Bacterial and fungal infections (especially if wound under casted area) - Pruritic dermatitis

Answer 13

1. Distal tibia and proximal fibula 2. Calcaneus (Os calcis) and Lumbar spine 3. Ring structures (pelvis or mandible)

Answer 14

Absolute: - Severe cold allergy (hives & joint pain) - Raynaud disease Relative: - Rheumatoid conditions - Paroxysmal cold hemoglobinuria --> renal dysfnc & secondary HTN

Answer 15

First degree: - minor tearing of ligament - minimal joint tenderness - no abnormal joint movement Second degree: - partial tear of ligament - tender, mod hemorrhage, some abnormal motion Third degree: - complete tearing of ligament - stressing joint leads to grossly abnormal motion - may have XR finding

Answer 16

First 48-72 hours, +/- crutches for LE

Answer 17

First degree: - minor tearing of musculotendinous unit - characterized by minor swelling, local tenderness, and minimal restriction of movement Second degree: - fibrous tearing along a continuum but without complete disruption - Swelling, ecchymosis, and loss of strength are more marked. Third degree: - complete disruption of the musculotendinous unit - resultant separation of muscle from muscle, muscle from tendon, or tendon from bone. *Accompanying avulsion fracture may be present on XR in second- or third-degree

Answer 18

- Increased age - Decreased blood supply and decreased tensile strength - Muscle weakness and imbalance - Insufficient flexibility - Male - Obesity - Smoking - Malalignments - Training errors - Improper equipment - DM - CKD - RA - SLE - Steroids - Fluoroquinolones

Answer 19

Tendinosis is chronic painful conditions of the tendon - "degenerative" changes to tendon

Answer 20

UE: - Rotator cuff - Radial wrist = de Quervain’s tenosynovitis - Hand extensors at lateral humeral epicondyle = tennis elbow - Wrist flexors at medial epicondyle = golfer elbow LE: - Achilles tendon - Patellar tendon = jumping sports - Biceps femoris - Semitendinosus and Semimembranosus = hamstring syndrome - Posterior tibial tendon = shin splints - Iliotibial band

Answer 21

Shoulder Wrist Hand Neck Knee Ankle Foot Mandible

Answer 22

Can be traumatic, infectious, related to systemic illness Olecranon Greater trochanter of femur Prepatellar Anserine bursa around knee

Answer 23

1) New back pain with neurologic findings in a patient with a malignancy history 2) Back pain and symptoms of epidural compression syndrome 3) Back pain with infectious cause symptoms 4) Back pain with gross muscle weakness or paralysis 5) Back pain with severe or progressive neurologic deficits

Answer 24

Recent significant trauma Sensation of ripping/tearing Associated chest or abdominal pain History of cancer Anticoagulant use Intravenous drug use Immunocompromised status History of prolonged glucocorticoid use History of osteoporosis History of abdominal aortic aneurysm Patient >50 years Unrelenting night or rest pain Worsened with cough, Valsalva, sitting Unexplained weight loss Recent bacterial infection (skin/soft tissue, pneumonia, urinary tract infection) Recent GI/GU procedure Failure to improve after 6 weeks of conservative therapy Bowel, bladder, and/or sexual dysfunction Saddle anesthesia

Answer 25

Abnormal vital signs—hypotension, hypertension, tachycardia, fever Unequal blood pressure readings in the upper extremities Murmur of aortic insufficiency Pulse deficit or circulatory compromise of the lower extremities Pulsatile abdominal mass Urinary retention Urinary or stool incontinence Loss of rectal sphincter tone Severe or progressive neurologic deficit Focal lower extremity weakness New ataxia or difficulty walking Decreased perianal sensation

Answer 26

1) Nicotine dependence 2) Alcohol abuse 3) Obesity 4) Depressive disorders

Answer 27

1) Extraspinal Pathology - aortic dissection - bacterial IE - PE - PNA - pleural effusion - MI - ruptured AAA - esophageal dz - penetrating PUD - pancreatitis - pancreatic Ca - biliary colic - cholecystitis - cholangitis - renal colic - perinephric abscess - pyelonephritis - gonadal torsion - PID - endometriosis - pregnancy - prostatitis - herpes zoster - retroperitoneal hemorrhage - psoas abscess 2) Spinal Pathology - cauda equina syndrome - spinal epidural abscess or hematoma - vertebral osteomyelitis - infectious discitis - fracture (traumatic, pathologic) - malignancy (metastatic, leukemia/lymphoma, multiple myeloma, spinal cord tumor) - transverse myelitis - spondylitis (ankylosing, psoriatic) - spondylolysis or spondylolisthesis - disc herniation - degenerative disease (discs, facet joints) - spinal osteoarthritis - isolated sciatica - spinal stenosis 3) MSK or Nerve Root Pain - acute muscle strain - acute ligamentous sprain - osteoporosis - spinal curvature (lordosis, kyphosis) - osteoid osteoma - nonspecific low back pain

Answer 28

- SCI 2/2 compression, inflammation, ischemia - acute or insidious gradual - LE sensory defs, loss of pain, weakness, gait disturbance - UMN signs INTACT: hyperreflexia, hypertonia, (+) Babinski, bladder dysfnc

Answer 29

- injury of nerve root - pain, sensory abnormal, weakness - isolated issue compared to multilevel myelopathies

Answer 30

Fever back pain focal neurologic deficits

Answer 31

MRI with contrast

Answer 32

lung ca prostate ca breast ca multiple myeloma lymphoma

Answer 33

Disc herniation at L4/5 or L5/S1 Spinal Abscess Spinal Hematoma Spinal Fractures Lumbar Spondylosis Tumours to spine

Answer 34

- bladder dysfunction (most common) - bowel dysfunction - sexual dysfunction - saddle anesthesia (highest predictive value) - unilateral or bilateral radiculopathy (worse with recumbent positioning, weakness, paresthesias)

Answer 35

CES-I = Incomplete - reduced bladder sensation - decreased desire to void - strained micturition - decreased urinary stream CES-R = Retention - complete retention - overflow incontinence

Answer 36

- MS - SLE - Sarcoidosis - Vasculitis - VZV - HSV - CMV - EBV - Enterovirus - TB - Lyme - Syphilis

Answer 37

- unilateral - worsened with movement - alleviated with rest not associated with complaints of numbness, weakness, bowel or bladder dysfunction - Pain may radiate generally to the buttocks or posterior thigh areas, but not past the knee

Answer 38

1) new urinary retention 2) disturbance of saddle sensation 3) use of anticoagulants

Answer 39

IVDU Spinal surgery Pott disease = TB of spine

Answer 40

- history of cancer - unexpected weight loss - trauma - chronic steroid use - anticoagulation - fever - immunocompromised - injection drug use - spinal surgery

Answer 41

History of malignancy or unexplained weight loss Fever with localized back pain Immunocompromised status History of injection drug use or bacteremia History of anticoagulant use Trauma of high force relative to patient History of recent spinal procedure or surgery New weakness of extremities Sensory level or saddle anesthesia Abnormal reflexes, including positive Babinski sign Urinary retention or incontinence with post-void residual volume >100 mL Sphincter dysfunction: loss of sphincter tone or bowel incontinence

Answer 42

Exercise therapy Topical capsaicin Topical lidocaine patch NSAIDs Acetaminophen Short course opioids Short course benzos

Answer 43

Single pulse dose steroid --> dexamethasone 6-10mg IV Taper of prednisone 60mg, 40mg, 20mg PO x5 days each for total 15 days

Answer 44

Epidural Abscess: --> Vancomycin 20mg/kg IV load, then 15-20mg/kg q8-12h AND --> Metronidazole 500mg IV q8h AND --> CTX (q12), Cefotaxime (q6), Ceftazidime (q8h), or Cefepime (q8) all 2g IV *Cefepime or Ceftazidime when considering Pseudomonas Spinal Osteomyelitis: INTRAVENOUS: --> Cefazolin (q8), CTX (q12), Cefotaxime (q6), Ceftazidime (q8h), or Cefepime (q8) all 2g IV AND --> Vancomycin 20mg/kg IV load, then 15-20mg/kg q8-12h ORAL: --> Ciprofloxacin 750 mg PO BID OR --> Septra DS 1 tab PO BID

Answer 45

Dexamethasone 10mg IV x1

Answer 46

Spinal epidural abscess Compressive neoplasm Osteomyelitis Fracture Other compressive spinal lesions

Answer 47

* Mechanical overload and repetitive microtraumas Intrinsic: - age - gender - blood type O - obesity - tobacco use - malalignment - joint laxity - muscle weakness - imbalance Extrinsic: - ergonomics - equipment changes - abnormal movements - excessive duration of activity - increased frequency & intensity of activity - environmental conditions Additionally: - excessive protein intake - systemic diseases (CAD, DM, gout) - medication use (statins, fluoroquinolones)

Answer 48

TENDINOPATHY - Bicipital tendinopathy = long head biceps - Tennis elbow = extensor tendons - Acute tendinopathy of wrist = flexor carpi ulnaris - de Quervain's tenosynovitis = EPB + APL BURSITIS - Bursitis of shoulder = supraspinatus tendon & subdeltoid bursa - Student's elbow = olecranon bursa - Ischial bursitis = posterior ischial tuberosity - Trochanteric bursitis = gluteus medius & minimus - Housemaid's knee = prepatellar bursa - Infrapatellar bursitis - Heel bursitis = Achilles tendon

Answer 49

1) Hemorrhagic phase 2) Inflammatory phase 3) Proliferative phase 4) Formative phase 5) Remodeling phase 12 weeks to regain prior strength Full recovery 3-6 months

Answer 50

Tendon rupture Ligamentous injury (sprain) Inflammatory arthritis (e.g., rheumatoid) Fractures (e.g., avulsion, stress) Tumors Tenosynovitis Osteochondrosis (e.g., Osgood-Schlatter disease) Bursitis Septic arthritis Osteoarthritis Foreign bodies Rhabdomyolysis Osteomyelitis Nerve entrapment syndromes Tendon sheath infections (e.g., pyogenic)

Answer 51

- Impingement occurs because of position interposed btwn humeral head and acromion. - Greater tuberosity of humerus impinges supraspinatus against undersurface of anterior third of acromion

Answer 52

- Long head of biceps may impinge due to location btwn supraspinatus & subscapularis tendons in rotator interval

Answer 53

- osteophytic changes - subacromial bursitis - bicipital tendinopathy - calcific tendinopathy

Answer 54

- Empty can/Jobe - Drop arm - Shrug sign - Neer - Hawkins-Kennedy

Answer 55

- Yergason - Speed

Answer 56

Female Age 30-60 DM Thyroid d/o Nephrolithiasis Genetic predisposition

Answer 57

Calcific tendinopathy of the supraspinatus tendon - pain during resorptive phase - pain in response to local chemical pathologic disorder or direct mechanical irritation - decreased ROM - Can dx with XR and US - tx with percutaneous needle lavage and steroid injection

Answer 58

- Tennis Elbow - insertion of extensor carpi radialis brevis onto lateral epicondyle of humerus - exacerbated by wrist extension and supination

Answer 59

Cozen's - resisted wrist ext Maudsley's - resisted D3 extension

Answer 60

- golfer's elbow - insertion of flexor carpi radialis onto medial epicondyle - exacerbated by wrist flexion and pronation

Answer 61

- APL & EPB (Abductor Pollicis Longus and Extensor Pollicis Brevis) - thickening of extensor retinaculum over dorsal wrist - result of intrinsic overuse & degenerative mechanisms - PAIN at radial styloid process - exacerbated by abduction of thumb, ulnar deviation of wrist - F 6x more likely > M - Age > 40yr

Answer 62

Finkelstein's - passively flexed thumb Eichhoff's - thumb in fist and ulnar deviate

Answer 63

- Jumper's knee - pain at inferior pole of patella

Answer 64

DM CKD ankylosing spondylitis reactive arthritis gout pseudogout fluoroquinolones statins moderate alcohol intake middle-long distance running

Answer 65

- middle aged, untrained athlete applying excessive force w/ pop, weakness, struck feeling DX by 2+ of: - Palpable 2-6cm defect proximal to insertion - positive Thompson test - increased passive ankle dorsiflexion - decreased plantar flexion strength

Answer 66

Gastrocnemius Soleus Tibialis posterior Flexor digitorum longus Flexor hallucis longus Peroneus brevis Peroneus longus

Answer 67

- loss of the fibrillar echotexture - focal tendon thickening - diffuse thickening - focal hypoechoic areas - extended hypoechogenicity - irregular and ill-defined borders - microruptures - intratendinous calcifications - peritendinous inflammatory edema

Answer 68

Identify the cause of discomfort Eliminate the sources of the primary tendinopathy Institute treatment modalities Analgesic medications (e.g., NSAIDs) Protection Relative rest Optimal loading (e.g., ergonomic alterations) Application of ice, compression, and elevation as necessary Educate patients regarding the underlying mechanical causes Modify patient behavior to minimize or eliminate sources of continuing irritation (e.g., biofeedback, coaching) Enhance the patient’s diet (e.g., add vitamin D sources) Refer patients for appropriate follow-up care and early rehabilitation.

Answer 69

trauma prolonged pressure gout pseudogout RA psoriatic arthritis S. aureus infection idiopathic nearby cellulitis complication of aspiration or injection

Answer 70

Trauma (minor or repetitive) Occupational trauma DM Atopic dermatitis RA Gout EtOH abuse

Answer 71

RA SLE Scleroderma Gout Pseudogout Ankylosing spondylitis Hypertrophic pulmonary osteoarthropathy Oxalosis Whipple disease (bacterial dz that affects many organ systems, including MSK w/ joint involvement) Idiopathic hypereosinophilic syndrome

Answer 72

ORAL: --> Dicloxacillin 500 mg PO QID OR --> Septra DS 1-2 tabs PO BID OR --> Clindamycin 300 mg PO QID IV: Vanco for MRSA risk

Answer 73

- skin atrophy over the bursa - persistent pain - development of septic bursitis - bleeding - postinjection flare as a result of release of microcrystals - tendon rupture

Answer 74

MONTEGGIA - Fracture of junction of proximal & middle thirds of ulna w/ anterior dislocation of radial head - PIN injury (weak thumb or finger ext) - FOOSH with forced pronation or direct blow to ulna - Cast in supination in KIDS

Answer 75

NIGHTSTICK - fracture of ulna (or radius, or both) - defence wound from blow to forearm

Answer 76

Same as Galeazzi! - Closed fracture of radius at middle third–distal third junction, DRUJ injury, but ulna intact

Answer 77

POTT or BIMALLEOLAR - bimall or just distal fibular 4-7cm above lateral mall

Answer 78

ROLANDO - Comminuted intraarticular fracture at base of the first metacarpal; frequently Y- or T-shaped - via axial load with metacarpal in partial flexion - worse prognosis than Bennett * thumb spica x 4 weeks

Answer 79

SMITH *Reverse of the Colles fracture - garden spade deformity - Extraarticular fracture of the distal radius with volar displacement of distal fragment - median nerve compression common - usually results from fall with force to back of hand - more likely unstable and require surgery

Answer 80

STENER - gamekeeper’s thumb - Avulsion of the ulnar corner of the base of the proximal phalanx of the thumb - Bony equivalent of rupture of the ulnar collateral ligament Thumb spica

Answer 81

TEARDROP - Wedge-shaped fracture of the anteroinferior portion of the vertebral body, displaced anteriorly - Commonly involves a ligamentous injury - may produce neurologic injury

Answer 82

THURSTON HOLLAND FRAGMENT w/ SH2 - Triangular metaphyseal fragment that accompanies the epiphysis in Salter-Harris type II fractures

Answer 83

TILLAUX - Isolated avulsion fracture of the anterolateral aspect of the distal tibial epiphysis - Occurs in older adolescents (12–15 years) after the medial parts of the epiphyseal plates close but before the lateral part closes - external rotation force places stress on anterior talofibular ligament

Answer 84

Degenerative Infectious Inflammatory

Answer 85

- Pt age - Time course (acute <7d, subacute 7d-3w, chronic 3w-mos) - Timing of symptoms - Hx of trauma to joint - Associated systemic symptoms - Description of pain - Location of pain - Aggravating/alleviating factors

Answer 86

- septic arthritis - gout - pseudogout - osteoarthritis - trauma - hemarthrosis

Answer 87

- RA - psoriatic arthritis - PMR - enteric arthritis - ankylosing spondylitis

Answer 88

- gonococcal arthritis - lyme arthritis - acute rheumatic fever - endocarditis - reactive arthritis - viral arthritides - gout - pseudogout

Answer 89

- C-spine instability - Pericarditis - Pulmonary nodules - Anemia

Answer 90

- Cutaneous plaques (most commonly elbows, knees) - IBD

Answer 91

- Uveitis/Iritis - Cardiac abnormalities - Aortic Regurgitation - IBD

Answer 92

- Conjunctivitis - Urethritis - Oral ulcerations

Answer 93

- Erythema chronicum migrans - Cardiac conduction abnormalities - Bell's palsy

Answer 94

Tophi - nontender collections of uric acid crystals in subcut tissue near affected joints

Answer 95

JONES criteria --> Must have elev Strep Ab titre OR (+) rapid Strep test/GAS throat cx --> 2 Major or 1 Major + 2 Minor for diagnosis MAJOR: - Joint pain (migratory polyarthritis) - Carditis (on echo/Doppler) - Subcutaneous Nodules - Erythema marginatum - Sydenham chorea MINOR: - Arthralgia - Prolonged PR interval - Fever - ESR > 60 mm - CRP > 3.0 mg/dL

Answer 96

Soft-tissue swelling only

Answer 97

Subchondral bone destructions Periosteal reaction Loss of joint space

Answer 98

- Chondrocalcinosis - Asymmetric joint space narrowing

Answer 99

1) Asymmetric joint space narrowing - worsened by WB views 2) Sclerosis of juxta-articular bone 3) Osteophytes 4) Bone spurs 5) Subchondral cysts 6) Minimal to no osteoporosis

Answer 100

Symmetric joint space narrowing Osteoporosis of periarticular bone Marginal erosions

Answer 101

1) obtain joint fluid for possible infection or crystals 2) drain large hemarthrosis 2/2 trauma or injury 3) inject medication into joint 4) evaluate a laceration for possible extension into joint

Answer 102

Absolute: - area of cellulitis or SSTI Relative: - coagulopathy

Answer 103

Introducing infection Bleeding Pain Allergic rxn to injected meds

Answer 104

1) >50,000 WBC/mm3 2) >90% PMNs 3) positive gram stain *prothetic joint is >1100/mm3 >60% PMNs

Answer 105

Gout = monosodium urate crystals - needle shaped - negative birefringent Psuedogout = calcium pyrophosphate crystals - rhomboid shape - positively birefringent

Answer 106

- Young children - Age >80 - Immuncompromised - HIV - DM - Hemodialysis - Endocarditis - IVDU - Hip or knee prosthesis - Prosthetic joints w/ recent intra-articular steroids - Recent joint surgery - Skin infection - RA - Gout - Pseudogout

Answer 107

Neonates and infants: - S. aureus - GBS Children: - S. aureus - GAS - Strep pneumoniae - Kingella kingae - Lyme Adolescents and young adults: - S. aureus - Neisseria gonorrhea Older adults: - S. aureus - Streptococcus sp. - Gram-negative rods Sickle cell: - S. pneumonia - Salmonella (more commonly osteomyelitis) IVDU: - S. aureus - Pseudomonas - Gram-negative rods Prosthetic joint: - S. aureus - Coagulase-negative Staphylococcus - Streptococcus sp. - Gram-negative rods

Answer 108

Initial: --> IV cephalosporin 2g (CTX, cefepime, ceftazidime, cefazolin) PLUS --> vancomycin 20mg/kg IV x1, then q8-12h OR --> linezolid 600mg IV OR --> daptomycin 6mg/kg IV Gram POS cocci: ?MRSA - ensure MRSA coverage as above Gram NEG bacilli: --> CTX 2g IV q24h Gram NEG diplococci: --> CTX 2g IV q24h PLUS --> azithromycin 1000mg PO for Chlamydia coverage

Answer 109

1) PO NSAIDs (if low - mod GI risk factors) 2) Topical NSAIDs *or topical capsaicin or lidocaine 3) Acetaminophen 4) Corticosteroid injection 5) Physical therapy referral 6) Cold therapy 7) Bracing 8) PO Duloxetine (start with FMD) *add PPI if mod-high GI risks

Answer 110

Hep B (sign of early infection) Hep C HIV Parvovirus B19 Rubella virus/vaccination Alphaviruses (Chikungunya) Flaviviruses (Dengue, Zika, West Nile)

Answer 111

Immunocompromised Women Pregnancy IVDU Multiple sex partners

Answer 112

Oligoarthritis (2-4 joints) - Wrist, knee, ankle - Modest effusions Diffuse migratory arthralgias Fever Small painless, nonpruritic skin lesions - papules, pustules, vasculitic

Answer 113

- CTX 2g IV or IM q24h + azirthomycin 1g PO for Chlamydia coverage

Answer 114

- Older adults - Obesity - HTN - DM - Thiazide diuretic use - Cyclosporin use

Answer 115

*Purine-rich diet - meats - beer - legumes - seafood - shellfish, anchovies

Answer 116

MTP1 Other MTPs & Tarsals Knee Ankle Hand

Answer 117

1) Double contour sign - one hyper echoic line of crystals, one of bony surface 2) Wet clumps of sugar - chronic tophi with heterogeneous centre and hypo echoic rim

Answer 118

1) NSAIDs - Indomethacin - Naproxen - Ibuprofen - prompt start with onset of pain, continue until 24hrs after symptom resolution 2) Colchicine - inhibits formation of microtubules - ++risk of OD, small therapeutic window - avoid in renal and hepatic insufficiency 3) Steroids - Intra-articular inj or PO - prednisone 40mg PO x5-7 days * Can do combo therapy, but avoid PO NSAIDs + PO Steroids

Answer 119

- Elderly - Prior trauma to joint - Recent joint surgery - Hemochromatosis - Amyloidosis - Hypothyroidism - HyperPARAthyroidism

Answer 120

- Knee is #1 - Hips - Ankles - MCPs - wrists - elbows - shoulders - spine

Answer 121

- NSAIDs - Steroids (systemic or intra-articular) - Colchicine - maybe MTX, IL-1 inhibitors, anti-TNFa agents

Answer 122

Early - migratory myalgia and arthralgias, with Erythema migrans rash Late - asymmetric arthritis w/in 6mos of infxn, large joint effusions Large joints, knees

Answer 123

PPX: *engorged tick found, >24-36h attached in endemic area --> Doxycycline 200mg PO x1 (4.4mg/kg for kids) EARLY ACUTE DZ: --> Doxycycline 100mg PO BID x 10 days LATE ARTHRITIS: --> Doxycycline 100mg PO BID x 28 days *Can substitute Amoxicillin 50mg/kg/DAY divided into q8h (max 500mg/dose) for tetracycline allergy, pregnant pt, children *If failed PO tx, CTX 2g IV q24h for mod-severe persistent arthritis

Answer 124

--> Benzathine Penicillin 1.2mill units IM x1 OR --> Penicillin V 500mg PO q8h x 10 days OR --> Amoxicillin 500mg PO q12h x 10 days OR --> Clarithromycin 250mg PO q12h x 10 days (for pen allergy) For Arthritis: --> ASA 50-100mg/kg/day PO divided to q6h (no effect on cardiac) OR --> Hydrocortisone 1-2mg/kg/day PO slowly taper over 2-4 weeks (better for cardiac involvement) Ongoing PPX: --> Penicillin PO or IM qMonthly x 5 years or until adulthood (recurrence rate 8-10% w/in 5 yrs)

Answer 125

- Lay patient supine - Passively lift their extended leg - If pain at 30deg or more, positive test - Pain down the ENTIRE leg! (Not just in low back or to the knee)

Answer 126

Symmetrically in PIPs and MCPs, feet too - stiff and sore in AM, improved with movement Progressive articular deterioration - Ulnar deviation - Swan neck deformities - Boutonniere deformities - Joint subluxations

Answer 127

NSAIDs DMARDs (biologic and non-biologic) Immunosuppressants Corticosteroids Exercise Diet Stress reduction Cryotherapy PT Massage Surgery (synovectomy, arthroplasty, or arthrodesis)

Answer 128

- Ankylosing spondylitis (AS) - Reactive arthritis - Psoriatic arthritis - Enteropathic arthritis (associated w/ IBD)

Answer 129

- Sacroiliac joint - Multiple distal/peripheral joints - Pathologic changes @ Entheses (ligament & tendon insertion sites) - RF (-) - HLA-B27 (+)

Answer 130

- Male - Younger <40 yrs - Chronic back pain, insidious onset - XR = sacroilitis & bamboo spine - Extra-articular = Uveitis, urethritis, vasculitis (even of aorta) - Entheses = plantar fasciitis, Achilles tendinopathy

Answer 131

NSAIDs Anti-inflammatories DMARDs

Answer 132

- Ages 20-40 - Asymmetric polyarthritis - LE joints - 2-6 wks after dysentery or cervicitis/urethritis - Extra-articular = conjunctivitis, uveitis, oral ulcers - Chlamydia, Salmonella, Shigella, Yersinia, Campylobacter

Answer 133

NSAIDs ABX tx for Chlamydia NO ABX for diarrheal/dysentery bacteria

Answer 134

Range of presentations: - Asymmetric oligoarthropathy - Symmetric polyarthropathy - Spondylitis - DIP joint involvement (vs PIP/MCP in other rheum) - Arthritis mutilans

Answer 135

NSAIDs Local corticosteroid injections DMARDs NO systemic steroids

Answer 136

Acute - accompanies GI flares Asymmetric, Migratory Polyarthritis - usually knees

Answer 137

Sulfasalazine Intra-articular steroid injections NOT NSAIDs (exacerbate GI symptoms)

Answer 138

1) Fibromyalgia 2) Polymyalgia rheumatica 3) Scleroderma

Answer 139

1) Anteroposterior compression fractures = Open-book 2) Vertical shear fractures = Malgaigne 3) Fractures w/ significant displacement * Likely major blood loss req'ing transfusions

Answer 140

--> Fracture caused by an injury that would be insufficient to fracture normal bone - older adults - involve Anterior column of Acetabulum - Comminuted - Severe impaction of femoral head

Answer 141

Angiography & embolization Pelvic packing Invasive fixation *combination of above

Answer 142

Posterior pelvic arch --> Superior gluteal artery Pubic rami --> Obturator + Internal pudendal arteries

Answer 143

1) Iliolumbar 2) Anterior Sacroiliac 3) Posterior Sacroiliac 4) Sacrospinous 5) Sacrotuberous * Stabilizing force of the posterior pelvis * Disruption of any = mechanically unstable pelvic fracture

Answer 144

Type A: --> Stable, posterior arch intact - Avulsion fractures - Isolated iliac wing fracture - Pubic rami fractures - Minimally displaced ring fracture - Transverse fractures of the sacrum or coccyx Type B: --> Partially stable, incomplete disruption of the posterior arch - Rotationally unstable - Vertically stable - 2/2 AP injuries = open-book fractures - 2/2 Lateral compression injuries - Unilateral or Bilateral Type C: --> Unstable, complete disruption of the posterior arch - Rotationally & Vertically unstable - Iliac, Sacroiliac, and Vertical sacral injuries - 2/2 Vertical shearing forces - Unilateral or Bilateral

Answer 145

AP Compression: I. Symphysis diastasis <2.5 cm II. Symphysis diastasis >2.5 cm = Rotational instability - Sacrospinous + Anterior sacroiliac ligament disruption III. Symphysis diastasis >2.5 cm = Complete Rotational & Vertical instability - Complete disruption of Anterior + Posterior sacroiliac ligament Lateral Compression w Pubic Rami #s: I. Sacral crush injury on ipsilateral side II. Sacral crush injury with disruption of Posterior sacroiliac ligaments = Rotational instability - Iliac wing fracture may be present (crescent fracture) III. Severe internal rotation of ipsilateral hemipelvis with external rotation of contralateral side = Rotational instability - "Windswept" pelvis Vertical Shear: - Vertical displacement of symphysis and sacroiliac joints = Complete Rotational & Vertical instability Combined Mechanisms: Any combination of above

Answer 146

TYPES I + II = Stable, Non-op TYPES III + IV = Operative Type I = Anterior pelvic ring # only --> IA - Unilateral --> IB - Bilateral Type II = Nondisplaced Posterior pelvic ring # --> IIA - Nondisplaced and isolated posterior --> IIB - Sacral crush injuries with anterior disruption --> IIC - Nondisplaced sacral, sacroiliac, or iliac # with anterior disruption Type III = Displaced unilateral posterior pelvic ring # with an anterior pelvic ring # --> IIIA - Displaced unilateral ilium # --> IIIB - Displaced unilateral sacroiliac fracture-dislocation --> IIIC - Displaced sacral # Type IV = Displaced bilateral posterior # --> IVA - Bilateral iliac fractures or sacroiliac disruptions --> IVB - Spinopelvic dissociation, bilateral vertical fractures through sacral ala with horizontal component --> IVC - Fracture is a combination of different posterior instabilities

Answer 147

4-Pillar Injury = #s of Pubic Rami on both sides of Symphysis Pubis --> Butterfly segment - direct blow with straddle mechanism - can occur w/out posterior arch disruption OR +/- lateral compression or vertical shearing - GU tract often injured as well *MUST CT to r/o posterior #s +/- Cystogram

Answer 148

DUVERNEY - isolated iliac wing fracture - direct trauma to iliac crest - usually lateral compression * Consult Ortho in ED - can extend into acetabulum, and may require ORIF - can be associated with major -non-pelvic injuries

Answer 149

Above S4 = Neurologic injury common - Operative when not intact Below S4 = Unlikely neuro issues - Conservative non-op mgmt Flexion injury = struck to lower back by heavy load while bending over OR direct forces to sacrum, fall from significant height *Get pelvic outlet view

Answer 150

Iliac crest = Abdominal muscles ASIS = Sartorius + Tensor fascia lata AIIS = Restus femoris Greater trochanter = Gluteus medius + minimus Lesser trochanter = Iliopsoas Ischial tuberosity = Hamstrings Body of pubis & Inf pubic rami = Adductors/Gracilis

Answer 151

Neoplasm Paget disease Dietary osteomalacia Radiation therapy

Answer 152

Rami fractures on the contralateral side after lateral compression injury to pelvic

Answer 153

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

Answer 154

Zone I = lateral to the sacral foramina (sacral ala) Zone II = transforaminal Zone III = central sacrum medial to the foramina - may involve central spinal canal * high risk of neurologic complications as zones increases ** radiographic diagnosis of this fracture hinges on examination of the symmetric cortical lines that are normally present at the superior margins of the sacral foramina on the anteroposterior view. Disruption, distortion, or asymmetry of these lines is an important marker of sacral fractures.

Answer 155

Dermal wound Vaginal wound Rectal wound

Answer 156

I— Posterior urethra intact but stretched II— Partial or complete pure posterior injury with tear of membranous urethra above the urogenital diaphragm III— Partial or complete combined anterior/posterior urethral injury with disruption of the urogenital diaphragm IV— Bladder neck injury with extension into the urethra IVA— Injury of the base of the bladder with peri-urethral extravasation simulating a true type IV urethral injury V— Partial or complete pure anterior urethral injury

Answer 157

L5 Sensory deficit—dorsum of foot and lateral calf Weakness—anterior tibial compartment S1 and S2 Sensory deficit—posterior aspect of the leg, sole and lateral foot, genitalia Weakness—hip extension, knee flexion, and plantar flexion S2–S5 Sensory deficit - to perineum Weakness - sexual dysfunction, bowel/bladder dysfunction

Answer 158

- Inability to WB - Pain in hip area with percussion of heel - Pain in hip area with pressure to greater trochanter

Answer 159

Type A: Fractures of one column of the acetabulum (anterior or posterior column). Type B: Transverse (T-type) fractures through both anterior and posterior columns; a portion of the acetabulum remains attached to the proximal ilium. Type C: Transverse (T-type) fractures through both anterior and posterior columns; no portion of the acetabulum remains attached to the axial skeleton.

Answer 160

Fall into sitting position Kicked in the behind area Birthing process

Answer 161

- Limited activity - Stool softeners - Non-opioid analgesia - Hot baths - Rubber donut cushion for sitting - Sit in hard chair If pain persists >8wks - Local steroid injection - Coccygectomy

Answer 162

- Age >60yr - Any pelvic fracture - Complex acetabular fractures - Associated injuries - Time to surgery >2wk

Answer 163

- Trauma during childbirth - Sacrococcygeal neuropathy - Infections - Local tumors - Faulty posture - midline disk herniation - lumbar facet arthropathy - compression of the sacral roots - neuralgia from sacral plexopathy

Answer 164

*Severe mechanisms of injury (MVC, ped vs vehicle, fall >10ft) - Symptomatic pain - Examination is compromised by dec LoC - Distracting injuries

Answer 165

Pubic symphysis = 5mm SI joints = 2-4mm

Answer 166

- Shock index ≥0.9 - Hypothermia - Inc Lactate - Tile B+C fractures - Open-book fractures - Displaced obturator ring fractures - Obvious vertical displacement of the posterior pelvis - Displacement ≥0.5 cm of any fracture site in the pelvic ring PLUS displaced symphysis pubis

Answer 167

- limited ROM - mod to severe pain - obvious deformity - joint effusion - significant tenderness or crepitus over any bony prominence or radial head

Answer 168

Adults - Radial head fracture Children - Supracondylar fracture Inflammation Infection

Answer 169

Radial nerve injury - wrist drop - cannot extend fingers and thumb

Answer 170

Men Ages 40-60 Smoking DM CKD SLE RA Steroid use Fluoroquinolone use

Answer 171

Radial - sensation dorsum of hand - motor wrist extension Median - sensation palmar D3 tip - motor A-OK sign Ulnar - sensation palmar aspect D5 - motor abduct fingers

Answer 172

Sugar Tong Splint and Sling OR Hanging Cast Check radial nerve Ortho should see within 48hrs

Answer 173

Extension type - AIN other is Flexion type - Ulnar

Answer 174

1. Anterior Humeral Line - lateral XR - line along anterior surface of humerus thru the elbow - should transect middle third of capitellum 2. Baumann's angle - AP XR - intersection of line down middle of humerus and second line thru growth plate of capitellum = 75deg - deviation >5-10deg ABNORMAL

Answer 175

CRITOE = Capitellum = 1 Radial head = 3 Internal (medial) epicondyle = 5 Trochlea = 7 Olecranon = 9 External (lateral) epicondyle = 11

Answer 176

Type I: Minimal or no displacement *splint/cast for comfort Type II: Displacement of the fracture but with the posterior cortex intact --> IIA: No rotational component --> IIB: Some rotational component *reduction, casting, monitor for compartment syndrome *percutaneous pinning Type III: Displaced, no cortical contact, periosteal contact --> IIIA: No rotation of the fracture --> IIIB: Rotation present *sedation+reduction *posterior splint *percutaneous pinning Type IV: Complete disruption/displacement *operative mgmt

Answer 177

Elderly with fragile, osteoporotic bones Extension type more common *Internal fixation, or elbow arthroplasty

Answer 178

*Open reduction and rigid internal fixation Avoid manipulation unless NV compromise

Answer 179

- Lateral condyle more common - Involvement of the trochlear ridge makes it unstable - Surgical fixation if displaced >3mm Lateral, or >2mm Medial (A) Normal anatomy. (B) Lateral trochlear ridge not in fracture fragment (stable). (C) Lateral trochlear ridge included with fracture fragment (unstable).

Answer 180

Fracture of Capitellum - usually from impact of the radial head from FOOSH

Answer 181

Medial epicondyle fractures more common - often involves apophysis of flexor tendons Children & adolescents - "Little Leaguers elbow" turned into avulsion fracture Ulnar nerve injury *Displacement cut off 5mm, surgical if >5mm Posterior splint in flexion and pronation

Answer 182

Usually adults Check ulnar nerve status Check displacement on XR with elbow at 90deg - If displacement >2mm, need surgery - Can have radial head dislocation as well (A) Olecranon fracture with displacement (B) Fracture accompanied by radial head dislocation

Answer 183

Usually FOOSH injury Look for fat pad on XR, may be only sign of fracture if also tender Type I: - nondisplaced fractures *sling Type II: - fractures involving less than 30% of the articular surface with more than 2 mm displacement - including impaction or angulation *immobilize short term and sling Type III: - comminuted fractures of the entire radial head *likely ORIF Type IV: - any of the previous types with elbow dislocation

Answer 184

Brachial artery Median nerve

Answer 185

Subluxation of Radial Head = "Pulled Arm" Ages 1-4yr F > M, L > R NO XRs needed if simple and story fits Reduce by: - Hyperpronation reduction OR - Supination-Flexion reduction

Answer 186

C-spine d/o's Thoracic outlet issue Myocardial issues Diaphragmatic irritations

Answer 187

Supraspinatus - Empty Can Infraspinatus & Teres Minor - External Rotation Subscapularis - Internal Rotation

Answer 188

C2 to C4: - Sensory - Neck to Shoulder tip - Motor - Trapezius C5: - Sensory - Lateral upper arm - Motor - Elbox flexion C6: - Sensory - Lateral forearm & thumb - Motor - Wrist extension C7: - Sensory - Tip of D3 - Motor - Elbow extension C8: - Sensory - Medial forearm & tip D5 - Motor - Finger flexion T1: - Sensory - Medial upper arm - Motor - Finger abduct

Answer 189

1) Middle 1/3 2) Lateral 1/3 3) Medial 1/3

Answer 190

Type I: - stable and minimally displaced because the coracoclavicular ligament remains intact Type II: - associated with a torn coracoclavicular ligament and likely displaced because the proximal fragment lacks any stabilizing forces Type III: - injuries involve the articular surface.

Answer 191

- Open fractures - NV injuries - Skin tenting - >2cm shortened (overlap) - Severely comminuted - Type II lateral fracture - Interposition of soft tissues

Answer 192

I = Processes fractures (IA Acromion, IB Scapular Spine, IC Coracoid) II = Neck fractures III = Glenoid fractures IV = Body fractures

Answer 193

Based on relationship of fracture fragments, and how displaced they are 4 distinct segments - Articular surface - Greater tuberosity - Lesser tuberosity - Humeral shaft *Segment considered displaced if angled >45deg or separated by >1cm (1) Minimal displacement (2) Two-part displacement (3) Three-part displacement (4) Four-part displacement - when present, anterior and posterior dislocations included as part of classification

Answer 194

Axillary nerve Axillary artery Brachial plexus

Answer 195

Adhesive capsulitis AVN Myositis ossificans formation (bone grown in muscles)

Answer 196

Grade 1: - Mild sprain of sternoclavicular & costoclavicular ligaments Grade II: - Subluxation of joint (anterior or posterior) 2/2 disruption of the sternoclavicular ligament and capsule Grade III: - Complete rupture of the sternoclavicular and costoclavicular ligaments results in a grade III injury = True Dislocation *<25 years old, these may represent SH1 injuries if the medial clavicle epiphysis is unfused

Answer 197

- Compression or Laceration of great vessels - Tracheal injury - Hoarseness - Dysphagia - Dysphonia - Tracheoesophageal fistula - Tracheal compression - PTX - Thoracic outlet syndrome - Brachial plexus injuries

Answer 198

I - Sprain of AC ligament II - Subluxation - AC rupture - CC ligament sprain - <50% bone width displacement upward III - Dislocation - AC + CC ligaments ruptured - Detachment of deltoid + trap insertions IV - Posterior Dislocation - All ligaments ruptured V - Superior Dislocation - All ligaments ruptured - 100-300% increased coracoclavicular distance VI - Inferior Dislocation - All ligaments ruptured ## Footnote Type 3+ refer to Ortho

Answer 199

Traumatic or Nontraumatic Primary or Recurrent Subcoracoid or Subglenoid - (or Subclavicular or Intrathoracic)

Answer 200

Large Hill-Sachs deformity Bony Bankart’s lesion Glenoid rim fracture

Answer 201

Bankart = injury of anteroinferior glenohumeral ligament with capsulolabral detachment Bony Bankart = same above but includes fracture of anteroinferior glenoid rim

Answer 202

Compression fracture of posterolateral aspect of humeral head caused by forceful impingement against the anterior rim of glenoid

Answer 203

1) Stimson (hanging weight): - Patient prone with dislocated shoulder hanging over edge of bed - Attach a 10-15 lb weight to the wrist or lower forearm providing traction in forward flexion. - Reduction usually occurs over 20–30 min 2) Traction/Countertraction: - Apply traction along abducted arm while assistant using folded sheet wrapped across the chest applies countertraction 3) External rotation: - Patient seated or in supine, involved arm is slowly and gently adducted to the side. - Elbow is flexed to 90 degrees, and slow, gentle external rotation is applied to achieve reduction 4) Cunningham: - Patient sitting, adduct the affected arm and place elbow in full flexion resting against operator’s shoulder - Operator provides traction by placing their wrist on patient’s forearm while patient shrugs shoulders superiorly and posteriorly. - Operator adds massage to trapezius, deltoid, and biceps 5) Milch: - Patient supine and HOB 20–30 degrees. - Affected arm is held by wrist and slowly abducted and externally rotated. The operator stops whenever resistance to motion is encountered and continues when the patient is relaxed. - If humerus has not reduced by 90 degrees of abduction and 90 degrees of external rotation, gentle longitudinal traction is applied along the humerus while free hand exerts lateral and superior pressure on humeral head 6) FARES: * Variation of Milch (FAst, REliable, and Safe) - Adds oscillation in a vertical direction while the affected arm is abducted. 7) Scapular manipulation: - Apply traction (manual or hanging weights), and manipulate scapula by rotating the inferior tip medially and stabilizing the superior and medial edges with the opposite hand - Patient in seated position and second operator applies traction in the forward horizontal position

Answer 204

Subacromial Subglenoid Subspinous

Answer 205

Lightbulb sign - internal rotation of humeral head Rim sign - inc space btwn anterior glenoid rim and articular surface of humeral head Reverse Hill Sachs - impaction fracture of anteromedial humeral head Trough sign - curvilinear density parallel to articular cortex of humeral head, after reverse Hill Sachs

Answer 206

- Superior aspect of humeral head is forced below inferior rim of glenoid - arm locked overhead in 110-160 degrees of abduction, elbow flexed, and forearm rests on top of head - Neurapraxia of brachial plexus common - Thrombosis of axillary artery a risk - on XR, humeral shaft is parallel to scapular spine - reduce with traction, countertraction

Answer 207

* >1 cm of lateral displacement of scapula on AP CXR is pathognomonic - Massive local soft tissue swelling of the shoulder, clavicle distraction. - Vascular injuries to subclavian, axillary, brachial vessels. - Severe neurologic injuries, brachial plexus

Answer 208

Popeye sign Ludington sign

Answer 209

Silent Subacute - Enlargement and softening of the deposit lead to narrowing of the subacromial space, resulting in impingement under the acromial arch Acute - severe inflammatory reaction within and around the deposit

Answer 210

Female Age 40-60 Thyroid disease DM

Answer 211

A-OK - median Extend thumb (or wrist) - radial Abduct fingers - ulnar

Answer 212

Dorsum, D1 webspace = radial D3 = median D5 = ulnar

Answer 213

Rupture of terminal tendon on DIP = Mallet injury

Answer 214

1) Fusiform swelling of digit 2) Tenderness along tendon sheath 3) Digits held in flexion at rest 4) Pain with passive extension of the digit

Answer 215

Trephination without antibiotics

Answer 216

Thenars: (median nerve) - Abductor Pollicis Brevis - Flexor Pollicis Brevis - Opponens Pollicis Hypothenars: (ulnar) - Opponens Digiti Minimi - Flexor Digiti Minimi - Abductor Digiti Minimi - Adductor Pollicis (ulnar) - Lumbricals (ulnar + median) - Interossei (ulner)

Answer 217

Extensors: (radial) APL, EPB / EPL / ECRL, ECRB / EI, EDC / EDM / ECU - Abductor Pollicis Longus - Extensor Pollicis Brevis (PIN) - Extensor Pollicis Longus - Extensor Carpi Radialis Longus - Extensor Carpi Radialis Brevis - Extensor Indicis - Extensor Digitorum Communis - Extensor Digiti Minimi - Extensor Carpi Ulnaris

Answer 218

APL, EPB, EPL - Abductor Pollicis Longus - Extensor Pollicis Brevis - Extensor Pollicis Longus

Answer 219

Volar displacement of the lateral bands of the digit. - Abnormal PIP flexion while DIP extended 3 bands = 1 central slip + 2 lateral bands - CS inserts at base of middle phalanx - Lats insert at base of distal phalanx - Covered/held together by the transverse retinacular ligament

Answer 220

FCR, FCU, PL, FDP, FDS, FPL Wrist Flexors: - Flexor Carpi Radialis (median) - Flexor Carpi Ulnaris (ulnar) - Palmaris Longus (median) Digit Flexors: (median) - Flexor Digitorum Profundus (median + ulnar) - Flexor Digitorum Superficialis - Flexor Pollicis Longus

Answer 221

A2 and A4 Prevent bowstringing

Answer 222

Allen test (A) Both arteries are compressed with the patient’s hand in a fist. (B) Pressure over the ulnar artery is released while compression on the radial artery is maintained. (C) Capillary perfusion is assessed and then the test is repeated by reversing which vessel is compressed.

Answer 223

= Intrinsic Plus Position - Volar splint - Wrist extension 30 deg - MCP flexion 90 deg - PIP + DIP extension

Answer 224

- Open fractures - Partial amputations - Complete amputations - Displaced intra-articular fractures - Fractures that do not maintain reduction

Answer 225

Mallet Finger - dorsal injury - inability to extend at DIP - extensor tendon involved, may have avulsion # Jersey Finger - volar injury - inability to flex at DIP - flexor digitorum profundus tendon involved, may have avulsion #

Answer 226

SEYMOUR - transverse fracture of distal phalanx at the physis in Peds = SH1 or SH2 - typically crush injury in a door, etc. - may have associated nail bed injury (avulsion of nail at germinal matrix) = OPEN # - Keflex 50mg/kg/day divided into QID x 7-10 days

Answer 227

Analgesia Splinting 2-4weeks, allow movement at DIP PPx ABX for nail bed/soft tissue injuries - Hand specialist referral for irreducible fracture or if "open"

Answer 228

- Protective splinting 2 weeks - Hand specialist referral if unstable reduction

Answer 229

- Splinting from distal to middle phalanx, 3-4 weeks - keep PIP mobile - passive ROM exercises after immobilization until pain free

Answer 230

- strict 6 week DIP immobilized splinting - neutral or hyperextension

Answer 231

* <5mm shortening >5mm may result in extensor lag

Answer 232

REVERSE BENNETT - fracture-dislocation of 5th metacarpal base - Unstable due to pull of extensor carpi ulnaris tendon

Answer 233

Intrinsic-plus / Neutral volar splinting 3-4 weeks F/u Hand specialist in 1 week

Answer 234

Jahss maneuver - MCP + PIP joints flexed to 90 deg - apply upper/dorsal pressure thru proximal phalanx and downward volar pressure over metacarpal

Answer 235

Lateral XR of PIP joint V sign = dorsal widening of joint where there is minimal subluxation Fracture at volar plate/base of mid phalanx + dorsal subluxation of PIP joint

Answer 236

Unrepaired mallet finger, where there is dorsal subluxation of the lateral bands at the PIP Hyperextension at PIP Flexion at DIP

Answer 237

PIP held in maximal flexion Pt tries to extend PIP - if central slip intact, NO ext @ DIP - if central slip ruptured, YES ext @ DIP

Answer 238

Over dorsal MCPs, injury to sagittal band Type I = no tendon instability Type II = tendon subluxation or snapping Type III = complete tendon disruption *snapping relocation of the extensor mechanism with active extension

Answer 239

Type I = completely avulsed tendon migrating proximally through the flexor sheath into the palm - risk for compromised vascular supply to tendon, surgery ASAP 7-10 days Type II = complete avulsion with proximal retraction to the level of the PIP joint. - risk for compromised vascular supply to tendon, surgery ASAP 7-10 days Type III = avulsed tendon retracts only to the level of the A4 pulley - less concern for vascular compromise, though surgery still recommended within 7-10 days.

Answer 240

- Associated open fractures or dislocations - Grossly contaminated wounds - Bites - Arterial injury - Wound overlying the tendon cannot be closed in ED

Answer 241

Overuse/Repetitive forceful flexion Inflammatory joint disease DM Hypothyroidism

Answer 242

- NSAIDs - MCP blocking splint @ slight flexion for 6-10 weeks - corticosteroid injection (higher risk recurrence) - surgical release of A1 pulley

Answer 243

If hematoma covers >50% nail bed = Trephinate with sterile 18g needle

Answer 244

Zone I = distal to bony distal phalanx - heal by secondary intention Zone II = area between the distal phalanx and lunula - may need rev amp to cover with skin Zone III = proximal to the lunula - amp of distal phalanx to DIP I + II usually keep full fnc. III usually needs amp to DIP.

Answer 245

- amputation of thumb - multiple adjacent digits - pediatric patients - clean + sharp amputations

Answer 246

- severely crushed wounds - severely contaminated wounds - pt with significant co-morbidities - multi-level amputations of same digit

Answer 247

* Traumatic removal of a ring from a digit, that pulls off tissue Class I: Circulation adequate Class II: Circulation inadequate Class III: Complete degloving injury or complete amputation

Answer 248

* Separation of nail from nail plate at distal end Trauma Fungal infxn Thyroid disease Psoriasis Chemotherapy

Answer 249

- Ancef or CTX - analgesia - surgical debridement

Answer 250

Fibrosis of palmar fascia - tightening of fascia creating a cord that limits motion of specific finger or area of palm - PAINLESS Refer to hand specialist for: - percutaneous needle aponeurotomy - collagenase injections - open surgery

Answer 251

Age >40 yrs Male Northern European Alcohol use Smoking Liver disease Thyroid disease DM Repetitive movements

Answer 252

Carpal tunnel view

Answer 253

Radial --> Ulnar Proximal 4: Scaphoid Lunate Triquetrum Pisiform Distal 4: Trapezium Trapezoid Capitate Hamate

Answer 254

Scapholunate Lunotriquetrial

Answer 255

Radiocarpal joint DRUJ interface with TFCC - triangular fibrocartilage complex = Articular disk

Answer 256

Scaphoid Lunate Capitate

Answer 257

Carpal arch: Scaphoid Trapezium Pisiform Hamate & Flexor retinaculum

Answer 258

Median nerve Flexor Pollicis Longus x1 Flexor Digitorum Profundus x4 Flexor Digitorum Superficialis x4

Answer 259

Single or repetitive blunt impact on hypothenar eminence with injury to hook of hamate (FRACTURE) resulting in thrombosis of superficial palmar arch of ulnar artery

Answer 260

AVN of lunate

Answer 261

1) Radial styloid extends 9-12mm beyond articular surface of ulna (AP view) 2) Ulnar slant of distal radius is 15-25 degrees (AP view) 3) Normal volar tilt of 10-25 degrees (Lat view) 4) Intra-articular step-off >1mm

Answer 262

3 arcuate lines that are drawn along articular surfaces of carpal bones - widening, step-off, or changes suggest pathology

Answer 263

Clenched fist Scaphoid Carpal tunnel

Answer 264

Tuberosity + Distal pole Waist (most common) Proximal pole

Answer 265

Triquetral body Dorsal cortical chip

Answer 266

Body Trapezial ridge

Answer 267

Median nerve injury Chronic carpal instability Degenerative arthritis

Answer 268

Stage I = Scapholunate dissociation - Terry Thomas sign - widening of scapholunate joint on PA XR >3mm Stage II = Perilunate dislocation - capitate dorsally dislocated - abnormal carpal arcs on PA XR - lunate remains articulated with radius Stage III = Midcarpal dislocation - capitate +triquetrum dislocation Stage IV = Lunate dislocation - Piece of Pie sign (PA XR) - Spilled Tea Cup sign (Lat) - volar rotation of lunate - lunate not on top of radius

Answer 269

Distal - Colles Diaphysis - Galeazzi Head - Essex-Lopresti

Answer 270

Piano key test (+) = ulnar head springs back like piano key after being depressed volarly and released Ballottement test (+) = radius is grasped firmly by examiner while ulna is fixed between examiner’s other thumb and index finger. Pressure is applied to ulna in dorsal and volar directions. Increased displacement relative to contralateral wrist suggests instability

Answer 271

- Females - Chronic - Progressive - Repetitive overuse - Gradual onset of numbness, paresthesia, and pain in median nerve distribution (D1-3 + D4 radial aspect) - Bilateral often - Worse at night & after activity

Answer 272

- decreased grip strength - hand clumsiness - thenar atrophy - trophic ulceration of the fingertips

Answer 273

- RA - hypothyroidism - DM - renal failure - CHF - acromegaly - collagen vascular diseases - pregnancy - menopause

Answer 274

Phalen = flex wrists for 1 min Weakness with thumb abduction Tinel sign = pain/paresthesias with light tapping over tunnel Durkan test = apply pressure over tunnel * highest sens & spec

Answer 275

- C6 or C7 radiculopathy - Raynaud syndrome - median nerve compression at pronator teres - brachial plexopathy

Answer 276

* primarily clinical dx - Nerve conduction study - MRI - U/S

Answer 277

(1) age >50 years, 2) symptom duration >10 months (3) constant paresthesias (4) stenosing flexor tenosynovitis (5) positive Phalen test at <30s

Answer 278

Splinting (all day or just night) Steroid injection NSAIDs

Answer 279

- distal radius fractures - lunate & perilunate dislocations - EPL tendon rupture - fracture-dislocations - hemorrhagic conditions - bleeding d/o - OAC use - infections - vascular disorders - any edema @ wrist

Answer 280

1) fluid in the first dorsal extensor tendon compartment tendon sheath 2) thickening of the APL and EPB tendons

Answer 281

Thumb spica NSAIDs Steroid injections

Answer 282

= Oarsman Syndrome (or Crossover) - overuse tendinopathy 2/2 rowing orweightlifting - 4-8cm proximal to de Quervain's pain at radial aspect of wrist - Inflammation where muscle bellies of APL + EPB crossover bellies of ECRL + ECRB

Answer 283

- post-Streptococcal infection - Chlamydia - Salmonella - Shigella - B. burgdorferi (Lyme disease) - Yersinia - Rubella virus - HBV - Adenoviruses - Parvovirus - EBV

Answer 284

Volar (Superficial & Deep) - Flexors of hand & wrist (PL, FDS, FCR, FPL, FDP, FCU) - Ulnar nerve - Ulnar artery - Median nerve - Radial artery - Radial nerve - AIA & AIN Dorsal - Finger extensors (EDM, ECU, EPL, EDC) - Long thumb adductor (APL) - PIA & PIN Mobile wad of Henry - ECRB & ECRL - Brachioradialis

Answer 285

Nonunion Malunion Infection Neurovascular injury

Answer 286

>50% displacement >8deg angulation Involvement of prox 1/3 of ulna Instability @ DRUJ or PRUJ

Answer 287

AP VIEW: Widened space btwn distal radius & ulna >2mm Radius appears relatively shortened LATERAL VIEW: Dorsal displacement of ulnar head Ulnar styloid fractured at its base

Answer 288

Positive ulnar variance Widened DRUJ - may need 'grip view'

Answer 289

Within 6hr - Increased risk of AVN as time goes on

Answer 290

MRI - although not practical in ED

Answer 291

Women Postmenopausal over 50yrs

Answer 292

ANTERIOR 5 Muscles: - Quadriceps femoris - Sartorius - Iliacus - Psoas - Pectineus Nerve: - Lateral femoral cutaneous Vessel: - Femoral artery & vein MEDIAL 3 Muscles: - Gracilis - Adductor longus - Obturator externus Nerve: - Obturator Vessels: - Profundus femoris artery - Obturator artery & vein POSTERIOR 4 Muscles: - Biceps femoris - Semitendinosus - Semimembranosus - Adductor magnus Nerves: - Sciatic - Posterior femoral cutaneous Vessels: - Profundus femoris artery branches

Answer 293

Osteoporosis

Answer 294

- Hormonal changes related to aging - Genetic predisposition - Vitamin D deficiency - Lack of physical activity - Smoking

Answer 295

ATRAUMATIC Chronic Corticosteroid Chronic Alcoholism Sickle cell disease Dysbarism Chronic pancreatitis HIV MEDS TRAUMATIC Post-hip dislocation Post-femoral neck fracture Athlete w/ energy deficit or overtraining

Answer 296

AVN Lt femoral head

Answer 297

Myositis Ossificans of the Proximal End of the Femur 2/2 direct blow to muscle or repeated minor trauma Persons w/ Hemophilia at risk

Answer 298

Calcific Trochanteric Bursitis

Answer 299

Breast Lung Thyroid Kidney Prostate

Answer 300

Nephrolithiasis PID Osteomyelitis Malignancies Inguinal & Femoral hernias LNA

Answer 301

External rotation Abduction Shortening

Answer 302

Anterior = Femoral nerve Posterior = Sciatic nerve

Answer 303

Referred pain (lumbar spine, hip, or knee) AVN of femoral head Degenerative joint disease or OA Lumbar disk herniation Diskitis Transient synovitis of hip Septic arthritis Bursitis Tendonitis Ligamentous injuries of knee or hip Occult fracture SCFE Perthes’ disease Tumour (Lymphoma) DVT Arterial insufficiency Osteomyelitis Iliopsoas abscess Retroperitoneal hematoma Inguinal hernia Inguinal LNA Genitourinary complaints Sports-related hernia

Answer 304

Metastatic Metabolic Endocrine dzs

Answer 305

Shenton lines Normal & Reverse S curves Tracing of trabecular lines

Answer 306

Suspected pelvic fracture Patellar fracture Ligamentous knee injury Tibia or Fibula fracture Open fractures w/ exposed bone

Answer 307

TYPE I - <1cm - Minimal soft tissue damage - Mechanism = Bone edge pierces outward TYPE II - 1-10cm - Moderate soft tissue damage, w/out nerve, arterial, or periosteal stripping TYPE III - >10cm - Extensive muscle devitalization - Nerve & Arterial involvement - Mechanism = High-energy & velocity GSWs

Answer 308

Femoral Nerve Block Fascia Iliacus Block

Answer 309

A = Avulsion fracture of Lt ASIS by Sartorius B = Avulsion fracture of Rt AIIS by Restuc Femoris

Answer 310

Older age Male sex Psychiatric illness ESRD CHF Institutionalized pts

Answer 311

AVN Non-union ------------ PE Osteomyelitis Septic arthritis

Answer 312

Number of Parts 2 = fem head + shaft 3 = GT or LT also #d 4 = both trochanters #d

Answer 313

Lt Greater Trochanter fracture - displaced superior & posterior

Answer 314

Fat embolism

Answer 315

- Ligamentous knee damage - Hip fracture - Fracture-dislocations - Femoral neck fracture - Supracondylar femoral fracture - Patellar fracture

Answer 316

Lt Anterior (Obturator) Hip Dislocation

Answer 317

Total dislocation time Severity of the injury Number of reduction attempts Presence of comorbidities

Answer 318

Hip flexed Adducted Internally rotated

Answer 319

Weakness of extensor hallucis longus = great toe extension AND Weakness of ankle dorsiflexion Numbness over foot dorsum

Answer 320

1) Appearance of lesser troch - hidden in posterior - visible in anterior 2) Size of femoral head - smaller in posterior - larger in anterior 3) Shenton line - smooth, curved line drawn along Superior border of Obturator Foramen & Medial aspect of Femoral Metaphysis - would be abnormal in either dislocation

Answer 321

AVN femoral head Traumatic arthritis Permanent sciatic nerve palsy Joint instability

Answer 322

Femoral neck fracture Distal fractures in dislocated extremity

Answer 323

Lt posterior hip dislocation

Answer 324

Allis (posterior & obturator) - pt supine, pelvis stabilized by assistant - w/ knee flexed, apply steady traction - bring hip to 90deg flexion w/ traction and gentle rotation - once reduced, bring hip to extended position Stimson (posterior) - pt prone, leg hanging over bed - hip & knee flexed 90deg - assistant stabilizes pelvis - apply downward traction in line w/ femur, gently rotate fem head - when reduced, bring hip to extension Captain Morgan (posterior) - pt supine, stabilize pelvis - provider puts foot up on bed, pt's pop fossa over provider knee - provider lifts their leg, gentle downward on pt ankle, and gentle rotate leg Whistler (posterior) - pt supine, stabilize pelvis - pt contra leg flexed hip & knee, foot on bed - provider arm under ipsilat knee, hand on contra knee, other hand on ipsilat ankle - provider stands up with arm strong, puts traction on femur, gentle rotation of hip Traction-Countertraction (anterior pubic) - pt supine - longitudinal leg traction - hyperextend and IR, assistant downward pressure on fem head

Answer 325

Sensation deficit superior and medial to patella (anterior thigh) Weakness of knee extension Decreased or Absent DTR of knee

Answer 326

Sensory loss posterior thigh & below knee Weakness of hamstrings & all muscles below knee - Extensor hallicus longus weakness Decreased or Absent DTR of ankle

Answer 327

Posterior Anterior - pubic - obturator Central - thru acetabulum Inferior - Luxatio erecta femoris

Answer 328

ONLY injuries w/in last 7d XR w/ ANY one of: 1. Age > 55 yrs 2. Inability to walk at least 4 steps at time of injury AND in ED 3. Inability to flex knee to 90deg 4. Isolated patellar tenderness 5. Tenderness over fibular head

Answer 329

HARD - Angio or OR exploration if any (+): - Absent pedal pulses - Cool mottled foot - Expanding popliteal hematoma - Palpable thrill - Pulsatile hemorrhage - Classic 5 Ps (pain, pallor, paresthesia, poikliothermia, paralysis SOFT - CTA of Duplex US if any (+): - Decreased pulse relative to uninjured side - Significant hemorrhage at time of injury - Nonexpanding hematoma - Foot or leg paresthesias

Answer 330

ABI >0.9 over 24h period - check q3-4h after knee dislocation

Answer 331

ACL - Prevents anterior displacement of tibia in relation to femur PCL - Prevents posterior displacement of tibia in relation to femur MCL - Prevents valgus deviation LCL - Prevents varus deviation

Answer 332

Lachman test

Answer 333

Posterior drawer test Posterior sag sign

Answer 334

McMurray Test Apley Test

Answer 335

anterior - hyperextension posterior - dashboard injury medial lateral rotary

Answer 336

DVT Compartment syndrome Pseudoaneurysm Arterial thrombosis Heterotopic ossification

Answer 337

Strong valgus force with axial loading - fall from height - MVCs

Answer 338

Segond Fracture Bone avulsion of lateral tibial plateau - Site of attachment of LCL - usually accompanied by ACL disruption

Answer 339

ACL and MCL

Answer 340

RA Gout SLE Hyperparathyroidism Iatrogenic immunosuppression in organ transplant pts Chronic steroid use Fluoroquinolone use

Answer 341

1) Acute onset of pain, ecchymoses over anterior aspect of knee & a palpable defect in patella bone, or quadriceps/patella tendon 2) Loss or limitation of active leg extension w/ extension lag during last 10deg of maneuver 3) High-riding patella (patella alta) w/ patellar tendon rupture & superior retraction 4) Low-riding patella (patella baja) w/ quadriceps tendon rupture & inferior retraction

Answer 342

Lateral knee XR w/ flexed knee 30deg. = Patellar tendon length / Patellar length - Normal 0.8 - 1.2 - Patella Baja < 0.8 - Patella Alta >1.2

Answer 343

Knee passively extended while inferomedially directed pressure is applied to patella

Answer 344

Patello-femoral pain syndrome Iliotibial band syndrome Peripatellar Tendinitis Plica syndrome (redundant folds of synovium) Popliteus tendinitis Bursitis

Answer 345

Gluteal weakness Quadriceps weakness Patellar subluxation Prepatellar bursitis Arthritis Meniscal tears Quadriceps/Patellar tendinopathy

Answer 346

WBC >50k Neutrophils 90%

Answer 347

ANTERIOR Muscles: - tibialis anterior - long toe extensors Vessels: - anterior tibial artery Nerve: - deep peroneal nerve = sensation to first web space of foot LATERAL Muscles: - peroneus longus - peroneus brevis Nerve: - superficial peroneal nerve = sensation to dorsum of foot SUPERFICIAL POSTERIOR Muscles: - gastrocnemius - plantaris - soleus Nerve: - sural nerve = sensation lateral side of foot & distal calf DEEP POSTERIOR Muscle: - tibialis posterior - long toe flexors Vessels: - posterior tibial artery - peroneal artery Nerve: - tibial nerve = sensation to plantar aspect of foot

Answer 348

Type 1: secondary ossification centre fracture (near patellar tendon insertion) Type 2: fracture extends btwn primary & secondary ossification centres Type 3: fracture extends to primary center of ossification Type 4: entire proximal tibial physis fractured Type 5: sleeve avulsion fracture from secondary ossification centre PLUS: Type A: non-displaced Type B: displaced

Answer 349

Compartment syndrome (highest risk 24-48 hrs) Infection - shallow easily exposed bone Nerve injury - “foot off the brake, to the right, and on the gas” DVT Pseudoaneurysm Fat embolism Delayed healing - average union 20-30 weeks Malrotation CRPS

Answer 350

Talar dome osteochondral lesions Nondisplaced fracture of lateral posterior process of Talus Fracture of anterior process of calcaneus

Answer 351

Ankle sprain Achilles tendon rupture Syndesmosis injury ± proximal tibial fracture Retinaculum rupture Tendon dislocation Monoarthropathies Charcot joint Foot fracture Pathologic fracture

Answer 352

ANKLE XR if malleolar region pain & 1+ of: - Tender at posterior distal 6cm or tip of lateral malleolus - Tender at posterior distal 6cm or tip of medial malleolus - Inability to WB at least 4 steps immediately after injury AND in ED FOOT XR if midfoot pain & 1+ of: - Tender at navicular - Tender at base of fifth metatarsal - Inability to WB at least 4 steps immediately after injury AND in ED

Answer 353

A = below tibiotalar joint - WBAT w/ brace or boot & Ortho f/u B = at level of tibiotalar joint - NWB, Ortho in ED C = above tibiotalar joint - NWB, Ortho in ED

Answer 354

Lateral collateral ligament sprain Peroneal tendon dislocation Osteochondral lesion of the talar dome Fracture of the posterior process of the talus Fracture of the lateral process of the talus Fracture of the anterior process of the calcaneus Midtarsal joint injury Fracture of the base of the fifth metatarsal Achilles tendon injury

Answer 355

AP VIEW: Fleck sign—bony fragment between medial cuneiform and second metatarsal Lateral displacement of second metatarsal with respect to middle cuneiform >2 mm widening between medial cuneiform and second metatarsal >1 mm widening between first and second metatarsals or medial and middle cuneiforms and metatarsals LATERAL VIEW: Dorsal subluxation of the metatarsals at the tarsometatarsal joint Talometatarsal angle >15° Reduced plantar distance between medial cuneiform and fifth metatarsal

Answer 356

Tibial plafond Medial malleolus Deltoid ligaments Calcaneus Lateral collateral ligaments Syndesmotic ligaments

Answer 357

All open fractures Pilon fractures Bimalleolar fractures Trimalleolar fractures Tillaux fractures in children Displaced medial malleolar fractures Displaced lateral malleolar fractures

Answer 358

SLE RA DM CKD Hyperparathyroidism Gout Fluoroquinolones Steroid INJECTIONS

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