1 lmcc orthopedic review lecture april, 2004 “back to basics” dr. p.r. thurston
TRANSCRIPT
11
LMCC Orthopedic Review Lecture
April, 2004
“Back to Basics”
Dr. P.R. Thurston
22
Syllabus
1. Diagnosis, Treatment & Complications of Fractures /Dislocations.
2. Diagnosis & Treatment of Arthritis.
3. Assessment and Management of Low Back Pain.
3
&
Fractures
Dislocations
44
Fractures
A discontinuity in the structural integrity of a bone.
Definition :-
A fracture occurs because the force applied exceeds the breaking strength of the bone so that the Load can no longer be transferred across that zone of the bone.
55
All fractures ultimately begin with kinetic energy, released by misadventure and applied to the human body.
Some of that energy is absorbed and some is transmitted to the surroundings.
Absorbed energy must be dissipated, ie. distributed, through the soft tissues and bones.
Fractures occur when the bone can not dissipate all of the energy absorbed.
Fractures
66
Thus :-
1 ) A fracture occurs when the energy transferred to a bone exceeds the ability of the bone to dissipate that energy.
2 ) Further energy dissipation produces :-
- comminution.
- soft tissue damage (open fractures).
- displacement.
- other fractures.
Fractures
77
DefinitionsFracture:- A discontinuity in the structural
integrity of a bone.
Infraction:- An incomplete fracture.
Dislocation:- Complete loss of contact of the articular surfaces of a joint.
Subluxation:- Non-concentric joint surfaces.
Reduction:- Returning a fracture or dislocation to an anatomical alignment.
Comminution:- Multiple fragments.
88
Bone is a two-phase material :-
Calcium HydroxyApatite Ca10(PO4)6(OH)2 = mineral
Osteoid Collagen type I and III = fibrous
Calcium is strong in compression, but weak in tension.
Osteoid is strong in tension, but weak in compression.
Mechanical Properties of BoneFractures
99
BUT :- (for adult bone)
Calcium is stronger in compression than Osteoid is in tension
And therefore :-
Bone always fails first in tension
Fractures
1010
For immature bone, this effect is reversed.
The Buckle or Torus fracture occurs because the bone fails in compression first.In children, the Osteoid is stronger than the Mineral phase.
Generally, the dislocation in youth becomes the fracture in the adult.
Fractures
1111
A bone consists of three areas :-
the Diaphysis
the Metaphysis
the Epiphysis.
Each region has its own Each region has its own fracture characteristics.fracture characteristics.
Fractures
1212
Bending
Torque
Direct
Traction
Compression
Intra-articular
Pediatric
Diaphyseal
Metaphyseal
Epiphyseal
Oblique
Spiral
Transverse
Mixed
Fractures
1313
Bending produces a transverse fracture line, with or without a lip.
When load is added, the lip becomes a butterfly fragment.
With more loading, the fracture line becomes oblique.
BendingFractures
1414
1515
- Rotatory shear produces a continually changing line of failure, giving the typical “Bayonet Spikes” at the ends of the bones.
- The greater the load the longer the fracture.
- These occur only in long bones and are referred to as:-
‘Spiral Fractures’
TorqueFractures
1616
$piral
The butterfly segment is different from the oblique bending fracture.
Torque
$$
Fractures
1717
If no butterfly, then the ends are Bayonet in appearance.
Fractures
1818
“tapping fractures”.
Fractures of “dying momentum”.
Tension produced on the opposite side of the bone.
Comminution produced on the impact side of the bone.
High energy injuries.
Direct BlowFractures
1919
Direct Blow
Transverse Fractures
Comminution on the opposite side to a bending fracture, ie. at the point of impact.
“The Nightstick Fracture”.
Fractures
2020
The Metaphysis is subject to all of the diaphyseal patterns plus:-
1) Traction – Avulsion.
2) Compression.
Traction – Avulsion.
MetaphysealFractures
21
are transverse since the tension is equal on both sides of the bone.
-are caused by ligament or tendon traction.
always occur adjacent to joints.
Metaphyseal
Traction-AvulsionFractures
2222
Traction – Avulsion.
Fractures
2323
Crush fractures
Impacted fractures
Usually comminuted
Usually axial skeleton
- Vertebrae
- Calcanei
Compression Fractures
2424
The Epiphysis is subject to all of the diaphyseal and metaphyseal patterns plus:-
1) Intra-articular Fractures.
2) Pediatric Fractures about the Epiphyseal plate.
EpiphysealFractures
2525
Intra-articular Fractures
- Always require accurate reduction.
- Usually require surgical treatment.
- Are often comminuted.
- Frequently threaten Post-traumatic Osteoarthritis.
EpiphysealFractures
2626
Pediatric Epiphyseal Fractures
- Produce fracture patterns specific to children.
- Always require accurate reduction.
- Can produce growth abnormalities.
- Salter-Harris Classification.
EpiphysealFractures
2727
Salter-Harris Classification
II IIII IIIIII
IVIV VV
Fractures
2828
Salter-Harris Classification
1) Fractures interfering with growing bones.
2) Worse prognosis with increasing number.
3) Probability of surgery increases with number.
Fractures
2929
A fracture can occur in :-
normal bone subject to abnormal forces.= Traumatic Fractures.
abnormal bone subject to normal forces. = Pathologic Fractures.
normal bone subject to cyclic forces.= Fatigue or Stress Fractures.
Fractures
30
Description
1) Displacement - Angulation
2 ) Closed or Open.
3 ) Simple or Comminuted.
4 ) Fracture Pattern eg. Spiral, Transverse etc.
5 ) Anatomical Area.
6 ) Mechanism.
Fractures
3131
Fracture Description
This fracture is angulated laterally, since it points laterally.
The distal fragment is tilted medially
3232
Description
Medially Displaced
Closed
Comminuted
Short Oblique
Fracture of the
Proximal Humerus
Caused by a direct fall
3333
Fracture Description
1) The distal fragment is always described with relation to the proximal segment.
2) Displacement = Translation of bone ends.
3) Angulation = Orientation of bone ends.
4) Angulation identifies to where the fracture points.
5) For clarity, the tilt of the distal fragment is often used to describe angulation.
3434
The Periosteal Bridge
The Periosteal Bridge is intact on the concave side of the fracture.
Reversal of the mechanism of the fracture tightens the bridge and stabilizes the fracture.
3535
The Periosteal Bridge
Tightening the periosteal bridge locks the fracture together.
Holding the bridge tight requires three point fixation.
“It takes a bent cast to produce a straight bone”
J. Charnley
36
Treatment
Closed or Open ( Surgical ).
- Both require an understanding of fracture healing.
- Closed requires reversal of mechanism of injury.
37
Indications for Closed Reduction
There is significant displacement.
Reduction is possible.
The reduction, if gained, can be held.
The fracture has not been produced by a traction force.
38
Indications for Open Reduction
1 ) There is a significant Displacement.
2 ) Open Fractures.
3 ) Intra-articular Fractures.
4 ) Un-reducible Fractures
5 ) Reductions that cannot be maintained in a cast.
6 ) Comminuted or Segmental Fractures.
7 ) Floating Joints.
8 ) Fractures with Neurovascular damage.
39
Open Fractures
Classification :-
1. < 1 cm., inside-out, little soft tissue damage.
= low potential for infection.
2. 1 cm. – 10 cms., outside-in, requires debridement, but no flap or skin graft.
= moderate potential for infection.
3. > 10 cms., outside-in, high energy, devitalized muscle, comminution or bone loss, soft
tissue loss.
40
Open Fractures
Classification :-
3A. No loss of soft tissue cover, no flap required.
3B. Flap required due to soft tissue stripping.
3C. Associated vascular injury.
4141
Type 1. Open Fracture = 6 mm, extend & debride
4242
Degloving Mechanism
Degloving Mechanism
4343
Type III C Injuries – Vascular Injury
Note pallor of the ankleNo pulses
4444
Fracture Complications
1. Pulmonary Fat Emboli
2. Compartment Syndromes
3. ‘Cast Disease’
4. Stress Fractures
5. Pathologic Fractures
4545
Pulmonary Fat Emboli :- A.R.D.S.
- Long bone fractures, burns, contusions.
- Interstitial pneumonitis due to free fatty acids
- S.O.B. & confusion in young adults.
- Axillary & Subconjunctival Petechiae.
- Serum lipase elevated.
- pAO2 reduced – if < 50 – 20% mortality.
- Ventillatory support
- Dexamethazone.
- 5 day course.
4646
Compartment Syndromes
- increased interstitial tissue pressure.- fractures, burns, tight dressings.
- normal pressure < 25 mm. Hg.- when the tissue pressure > venous capillary
pressure, but less than the arteriolar pressure.- 5 P’s
- pain.- pallor.- pulselessness.- paresthesias.- paralysis.
4747
Compartment Syndrome
Symptom: Pain out of proportion to that
expected for the injury.
Signs: 1. Loss of function of muscle due to
ischemia within the compartment.
2. Pain with passive stretch
3. Numbness etc. are LATE findings!
4. If neuro symptoms present, potential
for full neuro recovery is only 10 %
4848
Rx Compartment Syndrome
Release all compressive dressings / plaster.
Elevate extremity to heart level.
Fasciotomies.
4949
Rx Compartment Syndrome
Increased girth.
Pallor of the foot.
Recent surgery.
5050
4 compartment fasciotomy
5151
Compartment Syndrome
Careful monitoring.
Recognise it - 5 P’s
Call Orthopaedic Surgeon
Pressure measurements
5252
Stress or Fatigue Fracture
Repeated loading below acute failure threshold.
Eventual fatigue failure.
Military recruits, runners, aerobics.
Tibia, metatarsals, femoral neck.
Initial x-ray can be negative.
Bone tenderness – Bone scan.
5353
Pathologic Fractures
Failure through abnormally weakened bone
Minimal trauma – BEWARE
Osteoporosis Metastasis Tumour:- Benign,
Malignant (Myeloma).
Metabolic Bone Disease
5454
Pathologic Fractures
5555
Fractures
an understanding of the mechanism that produces them,
Ultimately, the treatment of fractures requires
5656
An understanding of the diagnostic tools available,
Fractures
5757
And the current technologies used in their treatment
Fractures
5858
Dislocations
The articular surfaces are no longer in contact.
Commonly affects -
Shoulders > PIP joints > Elbows > Ankles.
Often associated with fractures.
Often associated with neurologic injuries
5959
Shoulder Dislocations95 % anterior
1 % posterior
Luxatio erecta
Medial
Axillary nerve injury
Rapid reduction
6060
Shoulder Dislocations
Conscious sedation.
Traction reduction.
Immobilization.
Recurrent.
Voluntary
Habitual.
Multiaxial instability.
6161
Elbow Dislocation
Posterolateral.
Median nerve injury.
Ulnar nerve injury.
Rapid reduction.
Early mobilization.
6262
Back Pain
6363
Classification: Mechanical (MacKenzie)
Postural syndromenormal tissues become painful by the application of
prolonged stresses (sitting, bending etc)
Dysfunction syndromesoft tissues are shortened and stiff. Usually >30 year
old, poor posture, under exercised, reduced mobility
Derangement syndromeDisc derangement (tears and herniation)
6464
Causes and Classification of Back Pain: McNab
Viscerogenic Vasculogenic Neurogenic Psychogenic Spondylogenic
SpondylogenicOsseus:
Trauma Infection Neoplasms Inflammatory Metabolic (eg.Pagets) Deformities
– Soft tissues: Muscles SI joints Disc Facets
6565
Non operative Treatment of Back Pain
Do nothing
Activity modification
Medications
Exercise and physiotherapy
Braces
Manipulation
Massage therapy
Traction/inversion therapy
Vitamins/Supplements/Diets
Weight control
Every Suzanne Summers sponsored abs exerciser
6666
Degenerative Conditions of the Lumbar Spine
Congenital
Disc herniation
Degenerative Disc Disease
Spinal Stenosis
Degenerative Spondylolisthesis
Degenerative Scoliosis
“And when did you first notice that your back had gone out?”
6767
Congenital Anomalies
Congenital scoliosis
Arthrogryposis
6868
Congenital anomalies
Spina bifida
6969
Anatomy
Extension Flexion
7070
Three joint complex(Kirkaldy Willis, Farfan)
C ap su la r laxity
E n la rg em en t o f a rt icu la r p rocess
S u b lu xa tion
O s teop h yte fo rm ation
C artilag e d es tru c tion
S yn ovia l reac tion face t jo in t
D isc h ern ia tion
os teop h ytes
d ec rease d isc h e ig h t
In te rn a l d isc d is ru p tion
rad ia l tea r
D isc c ircu m feren c ia l tea rs
R ecu rren t ro ta tion a l s tra in
Instability
Lateral n. ent
Central stenosis
7171
Disc herniation
Ms J.H. 25 y.o. female presented with cauda equina syndrome
7272
Spinal stenosis
Symptoms:– unilateral radicular
pain– bilateral claudication– better with forward
flexion of trunk– better walking uphill– rare bowel/bladder
involvement
Signs:– usually no neuro signs– look for pulses– stress test
Investigations:– XR– CT– Myelo-CT– MRI
7373
Spinal stenosis
lateral AP
myelogram
Post myelogram CT
7474
Degenerative Spondylolisthesis
Most common cause of spinal stenosis
More common in women, hemisacralization of L5, diabetics and women with BSO
OA of hip also in 11-17%
7575
Isthmic spondylolisthesis
7676
Severe spondylolisthesis
7777
Time for a 10 minute break!
78
Pediatric Orthopedics
1. Developmental Dysplasia of the Hip.
2. Legg-Perthes Disease.
3. Slipped Capital Femoral Epiphysis.
4. Club Feet.
5. Osteomyelitis.
6. Septic Hip.
79
1. Talipes Equinovarus is the proper name for :-
a. Flat feet
b. In-toeing
c. Club feet
d. Knock knees
e. Wry neck
80
1. Talipes Equinovarus is the proper name for :-
c. Club feet
81
1. Talipes Equinovarus is the proper name for :-
a. Flat feet
b. In-toeing
c. Club feet
d. Knock knees
e. Wry neck
Pes Planus
Metatarsus Adductus
Genu Valgus
Torticolis
82
Talipes Equinovarus
congenital deformity of the footEquinus, Inversion, Adduction, Supination2 per 1000 live births50% bilateralM >F 2:1Serial corrective casts at birthSurgery if resistant
EARLY TREATMENT IS ESSENTIAL
83
2. Trendelenburg refers to :-
a. Leg length discrepancy
b. Gait abnormality
c. Knee recurvatum
d. Scoliosis
e. Hip Contracture
84
2. Trendelenburg refers to :-
b. Gait abnormality
85
2. Trendelenburg refers to :-
a. Leg length discrepancy – Apparent vs Real
b. Gait abnormality
c. Knee recurvatum – straightens past 1800
d. Scoliosis – lateral curvature, lordosis, kyphosis
e. Hip Contracture – Thomas test
86
3. All of these are signs of D.D.H. except :-
a. Limited Abduction
b. Ortolani Sign
c. Asymmetric Skin Folds
d. Galeazzi’s Sign
e. McMurray Sign
87
3. All of these are signs of D.D.H. except :-
e. McMurray Sign
88
3. All of these are signs of D.D.H. except :-
a. Limited Abduction
b. Ortolani Sign
c. Asymmetric Skin Folds
d. Galeazzi’s Sign
e. McMurray Sign
DislocatedReducible
Knee heightTorn Meniscus
Dislocated
8989
9090
91
Developmental Dysplasia of the Hip
Acetabular dysplasia
Femoral anteversion
Adduction Contracture
50% bilateral, F > M 8:1
Test ALL newborns at birth
Conservative Rx at birth – Pavlik, D.diaper
Surgical Rx if resistant
92
4. The most common congenital Spinal abnormality is :-
a. Scoliosis
b. Spina Bifida
c. Torticolis
d. Klippel – Feil Syndrome
e. Multiple Hereditary Osteochondroma
93
4. The most common congenital Spinal abnormality is :-
b. Spina Bifida
94
4. The most common congenital Spinal abnormality is :-
a. Scoliosis
b. Spina Bifida
c. Torticolis – ‘Wry Neck’
d. Klippel – Feil Syndrome – Congenital Fusion
e. Multiple Hereditary Osteochondroma
95
Spinal Bifida
defect of neural tube closure
Lumbar spine, commonly low
2 per 1000
myelodysplasia
Mild to complete paraplegia
Occulta, meningocoele, Myelomeningocoele
Bowel and bladder dysfunction
9696
9797
9898
5. Polydactyly
9999
6. Syndactyly
100100
7.
101101
Sprengel’s Deformity
Omovertebral Bone
102
8. A 6 year old boy with delayed physical development, convulsions, tetany, weakness, blue sclera and bony deformities is most likely suffering from :-
a. Physical Abuse
b. Ehlers – Danlos Syndrome
c. Osteogenesis Imperfecta
d. Multiple Hereditary Exostoses
e. Myositis Ossificans
103
8. A 6 year old boy with delayed physical development, convulsions, tetany, weakness, blue sclera and bony deformities is most likely suffering from :-
c. Osteogenesis Imperfecta
104
8. A 6 year old boy with delayed physical development, convulsions, tetany, weakness, blue sclera and bony deformities is most likely suffering from :-
a. Physical Abuse
b. Ehlers – Danlos Syndrome
c. Osteogenesis Imperfecta
d. Multiple Hereditary Exostoses
e. Myositis Ossificans
105
9. A 6 year old boy with delayed physical development, a rachitic rosary, weakness and bony deformities is most likely suffering from :-
a. Physical Abuse
b. Rickets
c. Scurvy
d. Osteitis Deformans
e. Myositis Ossificans
106
9. A 6 year old boy with delayed physical development, a rachitic rosary, weakness and bony deformities is most likely suffering from :-
b. Rickets
107107
9.
108108
9.
109109
Etiology Alkaline Calcium Phosphate Urea Phosphatase
Vitamin D Up Down Normal NormalDeficiencyRickets
Renal Up Down Up UpInsufficiency(Renal Rickets)
Renal Up Down Down NormalTubular Insufficiency(HypoPhosphatemia)
110110
10. This is :-
a. Osteomyelitis
b. Osteomalacia
c. Osteoporosis
d. Osteitis Deformans
e. Leprosy
111111
10. This is :-
d. Osteitis Deformans
112112
10. This is :-
a. Osteomyelitis
b. Osteomalacia
c. Osteoporosis
d. Osteitis Deformans
e. Leprosy
113
Osteitis DeformansPaget’s Disease
4% of pop. Over 40 yrs.
accelerated bone turnover
often assymptomatic
monostotic > polyostotic
loss of stature
AV shunting
pathologic bone
114
11. A child with knee pain has a ____ problem until proven otherwise.
a. Knee
b. Femoral
c. Tibial
d. Hip
e. Patella
115
11. A child with knee pain has a ____ problem until proven otherwise.
d. Hip Obdurator Nerve
116
11. All of the following are part of the differential of hip pain in a 6 year old, except :-
a. Femoral Osteomyelitis
b. Septic Hip
c. Transient Synovitis
d. Legg-Perthes Osteochondritis
e. Slipped Capital Femoral Epiphysis
117
11. All of the following are part of the differential of hip pain in a 6 year old, except :-
e. Slipped Capital Femoral Epiphysis
118
11. All of the following are part of the differential of hip pain in a 6 year old, except :-
a. Femoral Osteomyelitis
b. Septic Hip
c. Transient Synovitis
d. Legg-Perthes Osteochondritis
e. Slipped Capital Femoral Epiphysis
119
Ages for Hip Disease
D.D.H. Birth
Septic Hip Birth – 11
Legg-Perthes 3 – 11
Transient Synovitis 3 – 11
S.C.F.E. 11 - 16
120
12. Osteomyelitis in children is produced by what route of infection?
a. Direct extension from another focus
b. Hematogenous spread
c. Perforating wounds
d. Lymphatic spread
e. Septic hip
121
12. Osteomyelitis in children is produced by what route of infection?
b. Hematogenous spread
122
Osteomyelitis
Acute infection,metaphyseal
90% Staph.,20% mortality
100% growth abnormality
Periosteal elevation, osteolysis
Sequestrum, Involucrum
123123
13.
124124
13.
Paronychia
125125
14.
126126
14.
Felon
127
15. All of these are findings of a Herniated L5-S1 disc, except :-
a. Absent Achilles reflex
b. Lateral foot numbness
c. Sciatica
d. Low back pain
e. Extensor Hallucis Longus weakness
128
15. All of these are findings of a Herniated L5-S1 disc, except :-
e. Extensor Hallucis Longus weakness
129
15. All of these are findings of a Herniated L5-S1 disc, except :-
a. Absent Achilles reflex S1
b. Lateral foot numbness S1
c. Sciatica S1
d. Low back pain
e. Extensor Hallucis Longus weakness L5
f. Knee jerk L4
130
16. Avascular necrosis of the femoral head is associated with all of the following except :-
a. Steroid use
b. Alcohol
c. Deep sea diving
d. Lipid storage disease
e. Diabetes
131
16. Avascular necrosis of the femoral head is associated with all of the following except :-
e. Diabetes
132
16. Avascular necrosis of the femoral head is associated with all of the following except :-
a. Steroid use
b. Alcohol
c. Deep sea diving
d. Lipid storage disease
e. Diabetes
133133
17.
8 year old boy
What is the Diagnosis?
134134
17.
8 year old boy
Legg – Perthes
Osteochondosis
135
Legg-Perthe’s Disease
Osteochondrosis (avascular necrosis)
Proximal Femoral Epiphysis
Necrosis, revascularization, fragmentation, healing
3 – 11 yrs., M > F 4:1, 15% bilat.
Subluxation laterally, Coxa plana, Coxa magna
Osteoarthritis 50 yrs.
136
Osteochondroses
Freiberg’s Disease
Osgoode-Sclatter’s
Scheuermann’s
Kienbock’s
Osteochondritis Disecans
2nd Metatarsal Head
Tibial TubercleSpineCarpal Lunate
Lateral Femoral Condyle
18.
137137
19. Diagnosis?
138138
19. Gout
139
Gout
Urate crystalopathic arthritis
Crystals in periarticular tissues
Inconsistant elevated serum urate
Allopurinol and colchicine
Tophi in periarticular soft tissues
Deposits in non-articular cartilage
Juxta-articular erosions
140140
20.
L5
L4
Spondylolytic Spondylolisthesis
141
Spondylolisthesis
Lumbosacral junction defect
Spondylolysis of Pars Interarticularis
Traumatic or congenital
Acute – immobilize
Chronic - surgery
142
21. The Salter- Harris Classification is used to assess the severity of :-
a. Epiphyseal Fractures
b. Developmental Dysplasia of the Hip
c. Legg – Perthe’s Disease
d. Club Foot
e. Osteomyelitis
143
21. The Salter- Harris Classification is used to assess the severity of :-
a. Epiphyseal Fractures
144144
I II III
IV V
145145
22. What is this deformity?
146146
22. A Diner Fork Deformity
Probable Diagnosis?
147147
22. Colles Fracture
148
22. Colle’s Fracture
distal radial fracture
FOOSH
occurs at all ages
commonly 60 yrs. +
osteoporosis
intra-articular
149149
CR & K-Wires
150150
External vs Internal Fixation
151151
23. The common complication of this fracture is :-
152152
23. Proximal pole Avascular Necrosis
153153
154154
24. This is a :-
a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line
155155
24. This is a :-
a. Buckle Fracture
156156
This is a :-
24.
a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line
157157
Greenstick Fractures
24.
158158
25. Is this fracture treated by Closed or Open Reduction?
159159
ORIF
25.
160160
25. Fractures of Necessity
161161
26. What is the Diagnosis?
162162
26. Posterolateral Dislocation of the Elbow
163163
26. Reduction by traction.
TRACTION
164164
27. What is the Diagnosis?
165165
27. Anterior Dislocation of the Shoulder
166166
27. Reduction by traction
167167
28.
This is a :-
a. Supracondylar #
b. Olecranon #
c. Dislocation
d. Forearm #
e. Radial Head #
168168
28.
This is a :-
a. Supracondylar #
169169
28. Supracondylar Fracture
170
29. The complications of a Supracondylar fracture in children include all of the following except :-
a. Malunion
b. Volkmann’s Ischemic Contracture
c. Compartment Syndrome
d. Cubitus Varus
e. Peripheral Nerve Injuries
f. Pulmonary Fat Embolus
171
29. The complications of a Supracondylar fracture in children include all of the following except :-
f. Pulmonary Fat Embolus
172
29. The complications of a Supracondylar fracture in children include all of the following except :-
a. Malunion
b. Volkmann’s Ischemic Contracture
c. Compartment Syndrome
d. Cubitus Varus
e. Peripheral Nerve Injuries
f. Pulmonary Fat Embolus
173
30. The only sign of a Compartment Syndrome that is always
present is :-
a. Pain
b. Pallor
c. Pulselessness
d. Paresthesias
e. Paralysis
174
30. The only sign of a Compartment Syndrome that is always
present is :-
a. Pain
175
30. The only sign of a Compartment Syndrome that is always
present is :-
a. Pain
b. Pallor
c. Pulselessness
d. Paresthesias
e. Paralysis
176
31. Compartment pressures indicating the need for fasciotomy :-
a. 0 – 15 mms. Hg
b. 15 – 25 mms. Hg
c. > 25 mms. Hg
d. > 50 mms. Hg
e. > 75 mms. Hg
177
31. Compartment pressures indicating the need for fasciotomy :-
c. > 25 mms. Hg
178
Compartment Syndrome
fractures, crush injuries, burns
collapse of venous return compartment pressure > 25 mms. Hg
engorgement of muscle within
necrosis of muscle tissue
Volkmann’s Ischemic Contracture
Fasciotomy
179179
32. A 20 yr. old male with a fractured femur has findings of confusion,
tachypnea and conjunctival petechia. The most likely diagnosis is :-
a. Pneumonia
b. Pulmonary Fat Emboli
c. Cerebral Contusion
d. Cardiac Contusion
e. Transient Stress Reaction
180180
32. A 20 yr. old male with a fractured femur has findings of confusion,
tachypnea and conjunctival petechia. The most likely diagnosis is :-
b. Pulmonary Fat Emboli
181
32. Pulmonary Fat Embolus
2% - long bone #’s 10% - multiple #’s
tissue thromboplastin ---> extrinsic cascade VII
A.R.D.S. - aterial hypoxemia
petechia across chest, in axillae and conjunctiva
early fixation decreases PFE, but increases infection rates
no current lab tests or treatment protocol
182182
33. Name the Fracture :-
183183
33. Monteggia Fracture
184184
33. Monteggia Fracture
185185
33. Monteggia Fracture
186186
34. Name this fracture :-
187187
34. Name the fracture :-
Galeazzi Fracture
188188
GaleazziFracture
34.
189189
35. The commonest complication of this fracture is :-
190190
35. A Radial Nerve Palsy
191191
36. Does this fracture require surgery?
192192
36. Does this fracture require surgery?
Yes
193193
37. Does this fracture require surgery?
194194
37. Does this fracture require surgery?
No
195195
38. This patient most likely
has a fracture of the --------.
196196
38. This patient most likely
has a fracture of the --------.
Hip
197197
38. This patient most likely
has a fracture of the hip.
External Rotation
Shortening
Hip Flexion
198198
38.
199199
39. What’s the Diagnosis?
200200
39. Sub-Capital Hip Fracture.
201201
40. All of the following are complications of this fracture except :-
a. Malunion
b. Avascular necrosis
c. Fat emboli
d. Non-union
e. Thrombophlebitis
202202
40. All of the following are complications of this fracture except :-
c. Fat emboli
203203
40. Blood Supply of Femoral Head
204204
40. Save Head versus Replacement
205205
40. Subcapital Hip Fractures
1. Abduction
2. Minimally displaced
3. 50% Displaced
4. Completely Displaced
Garden Classification
206206
40. Subcapital Hip Fractures
1. Avascular Necrosis - 30%
2. Malunion - 30%
3. Non-union - 30%
4. Surgery required
5. Older population
6. Pathologic - Osteoporotic
Properties
207207
41. What’s the Diagnosis?
208208
41. Intertrochanteric Hip Fracture
209209
41. Intertrochanteric Fractures
210210
41. Intertrochanteric Fractures
Properties
1. Varus deformity
2. Well - Healing
3. Traumatic + Osteoporosis
4. Surgery required
5. Mid-range Age population
211211
42. What is the Diagnosis?
212212
42. What is the Diagnosis?
Subtrochanteric Hip Fracture
213213
42. Subtrochanteric Fractures
Properties
1. Non-union
2. Traumatic
3. Surgery required
214214
43.
Surgery or not?
215215
43.
Surgery or not?
Yes
216216
44. Surgery or not?
217217
44. Surgery or not?
Yes
218218
44. Ankle Fractures Eversion Injuries
219219
44. Ankle Fractures
Inversion
Injuries
220220
23 y.o. male
Basketball injury
Open fracture
Numbness dorsum toes
45. What is the approach to this fracture?
221221
Reduce dislocation
Sterile dressing
Splint extremity
Re-check NV status
IV Antibiotics
Tetanus
Surgery
45.
222222
46. Surgery or not?
223223
46. Surgery or not?
Yes
224224
47. Surgery or not?
225225
47. Surgery or not?
Yes
226226
47. Surgery or not?
Yes
227227
48. A 45 yr. old male, who was previously in good health, has sudden onset of transverse low back pain and right sided sciatica to his foot, after chopping wood at the cottage. Upon arising the following morning, he notices numbness on the outer border of his right foot and
some weakness in the right leg. He has no bowel or bladder problems.
The most likely diagnosis would be:-
a. Lumbar Muscular Strain.b. Herniated Lumbar Disc.c. Herniated Lumbosacral Disc.d. Cauda Equina Syndrome.e. Spinal Stenosis.
228228
48. A 45 yr. old male, who was previously in good health, has sudden onset of transverse low back pain and right sided sciatica to his foot, after chopping wood at the cottage. Upon arising the following morning, he notices numbness on the outer border of his right foot and
some weakness in the right leg. He has no bowel or bladder problems.
The most likely diagnosis would be:-
c. Herniated Lumbosacral Disc.
229229
49. Your initial approach to this problem would
include some or all of the following:-
a. Bedrest.
b. Anti-inflammatories.
c. Muscle Relaxants.
d. Spinal X-rays.
e. Physiotherapy.
f. Orthopedic/Neurosurgical referral.
g. CT-Myelogram or MRI
h. Discectomy
230230
49. Your initial approach to this problem would
include some or all of the following:-
a. Bedrest.
b. Anti-inflammatories.
c. Muscle Relaxants.
d. Spinal X-rays.
e. Physiotherapy.
f. Orthopedic/Neurosurgical referral.
g. CT-Myelogram or MRI
h. Discectomy??
231231
50. During the work-up for this problem, the patient complains that he has unaccountably soiled his underwear, without knowing it. Your response to this would be to:-
a. Reassure the patient that this is not serious
b. Order an urgent MRI
c. Get an urgent referral to Neuro/Orthopedics
d. Place the patient on immediate bedrest.
232232
50. During the work-up for this problem, the patient complains that he has unaccountably soiled his underwear, without knowing it. Your response to this would be to:-
c. Get an urgent referral to Neuro/Orthopedics
233233
50. During the work-up for this problem, the patient complains that he has unaccountably soiled his underwear, without knowing it. Your response to this would be to:-
a. Reassure the patient that this is not serious
b. Order an urgent MRI
c. Get an urgent referral to Neuro/Orthopedics
d. Place the patient on immediate bedrest.
234234
51. A lumberjack felling a tree is unfortunately struck on the back by the tree, knocking him to the ground and injuring his left lower extremity. In the ER, his left hip is in flexion, adduction and internal rotation. The most likely diagnosis is:-
a. Fracture of the Hip.b. Fracture of the Femur.c. Anterior Hip Dislocation.d. Posterior Hip Dislocation.e. Fracture of Pelvis.
235235
51. A lumberjack felling a tree is unfortunately struck on the back by the tree, knocking him to the ground and injuring his left lower extremity. In the ER, his left hip is in flexion, adduction and internal rotation. The most likely diagnosis is:-
d. Posterior Hip Dislocation.
236236
52. Which of the following signs and symptoms are consistent with a torn medial meniscus of the knee:-
a. Inability to squat
b. Pain on descending stairs
c. Locking
d. Recurrent effusions
e. All of the above.
237237
52. Which of the following signs and symptoms are consistent with a torn medial meniscus of the knee:-
a. Inability to squat
b. Pain on descending stairs
c. Locking
d. Recurrent effusions
e. All of the above.
238238
53. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle.
Your response to this situation would be to:-
a. Re-X-ray the ankle.
b. Remove the cast.
c. Measure the compartment pressures.
d. Instruct the patient to elevate the limb and prescribe an anti-inflamatory.
239239
53.. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle.
Your response to this situation would be to:-
b. Remove the cast.
240240
53. A 35 yr. old male falls jogging and sustains an undisplaced lateral malleolar fracture of the ankle. He is treated in a Below-knee Walking cast, but returns to the ER 24 hrs. later complaining of increased, persistent, burning pain at the ankle.
Your response to this situation would be to:-
a. Re-X-ray the ankle.
b. Remove the cast.
c. Measure the compartment pressures.
d. Instruct the patient to elevate the limb and prescribe an anti-inflamatory.
241241
54. The most common dislocations of the shoulder are:-
a. Medial.
b. Posterior.
c. Luxatio Erecta.
d. Anterior.
242242
54. The most common dislocations of the shoulder are:-
d. Anterior.
243243
55. Metastatic lesions to bone, of the following tumours, usually produce lytic defects except:-
a. Thyroid.
b. Pancreas.
c. Prostate.
d. Kidney.
e. Lung.
244244
55. Metastatic lesions to bone, of the following tumours, usually produce lytic defects except:-
c. Prostate.
245245
55. Metastatic lesions to bone, of the following tumours, usually produce lytic defects except:-
a. Thyroid.
b. Pancreas.
c. Prostate.
d. Kidney.
e. Lung.
246246
Th - Tha – That’s all folks!