Ortho E1 -Emphasized and topic list ONLY

What is Trendelenburg’s Gait?

abductor lurch towards affected painful hip

What causes Osteonecrosis in the hip?

femoral neck fx

What supplies the femoral head w/ blood?

lateral and medial circumflex femoral arteries

What is a Femoral neck fx?

intracapsular hip fx: fx disrupts blood supply of femoral head → nonunion and osteonecrosis/AVN are common

What is an Intertrochanteric hip fx?

extracapsular: need more fixation than fem. neck fx; malalignment → shortening of limb, risk of malunion; lower rate of nonunion or osteonecrosis

How does a fx of the proximal femur present?

s/p fall, hip pain in groin, inability to bear weight, referred pain to the knee, decompression ROM

What is a common complication of a proximal femur fx?

avascular necrosis

Review femur fx descriptions

:)

If a pt has a fx of the proximal femur, how will their legs sit when lying supine?

injured limb will be in external rotation and ABducted

*if displace will also be shorter

What causes dislocation of the hip?

high energy trauma (MVA or fall)

What is the position of the leg in posterior hip dislocations?

*90%

flexion, internal rotation & ADDuction

What position is the leg in w/ anterior hip dislocations?

*rare

external rotation, ABduction, mild flexion

How do posterior hip dislocations present on xrays?

affected femoral head appears smaller & lower than C/L side d/t being further away; normal femoral head

How do anterior hip dislocations look on a xray?

affected femoral head appears larger and higher than C/L side d/t being closer; normal femoral head

How does a Hamstring strain present?

common in athletes; “pop” or pain in posterior thigh; severe bruising follows

What is greater Trochanteric Bursitis?

inflammation of the greater trochanteric bursa

How does greater trochanteric bursitis present?

hip pain, inc w/ walking or climbing stairs, +tenderness w/ pressure over greater trochanter bursa

What testing needs to be done for trochanteric bursitits?

Xray to r/o bony anomaly

What is the tx for Trochanteric Bursitis?

rest, heat, NSAIDs, injection at point of maximal tenderness

What are S&S of AVN?

20-40 yo; gradual onset of hip pain 4-6 mon, slight limp w/ walk, inc groin pain w/ IR, s/p fall or trauma, can also be caused by alcoholism and long term steroid use

What is the tx for AVN?

ortho consult

What testing is done for AVN?

plain films: AVN evident or fx; later, necrosis of femoral head

MRI: assists in dx

What is Slipped Capital Femoral Epiphysis?

progressive displacement of the upper portion of the femur occurs in relation to the capital femoral epiphysis

When does Slipped Capital Femoral Epiphysis occur?

slip thru the physis during adolescent growth spurt

Where do blood vessels to the epiphysis travel?

run along the side of the femoral neck; disruption can result in loss of blood supply to the epiphysis

How does Slipped Capital Femoral Epiphysis present?

adolescent (10-15) M > F; obese, AA > causians/hispanic; inc pain in groin/medial thigh/knee, Trendelenburg’s gait

What would an xray of SCFE show?

apparent varus angulation of epiphysis: “ice cream falling off cone”

“Kline’s lines” - loss of intersection of ephiphysis by femoral neck

“pistol grip deformity” - chronic stage

What population does Legg-Calve-Perthes Diseases affect?

4-8 yo males

Which affects a younger demographic?

Legg-Calve-Perthes

What is Legg-Calve-Perthes?

hip disorder caused by AVN of the whole femoral head

What are S&S of Legg-Calve-Perthes?

limp -MC, ± pain, limited abduction & IR, Trendelenburg’s gait, atrophy of thigh, calf, & buttocks, unequal leg length, groin pain

How does OA of the hip present?

achey pain over hip, pain in ant. groin that radiates to medial knee, dec ROM

What will plain films of hip DJD show?

(+) arthritis

What would an Xray of Legg-Calve-Perthes show?

AVN of femoral head

What is the MC site of acute osteomyelitis?

Metaphyseal end of long bone near joints (knee common)

What is the tx for acute osteomyelitis?

IV abx 4-6 weeks

(Cefazolin, Clindamycin, Vanc, FQ -if Pseudomonas)

What are sx of acute osteomyelitis?

+ hx trauma, RA, immunocompromised, DM, sickle cell, IV drug use; limp, fever, swelling/heat/erythema to soft tissue

What is the gold standard for diagnosis of acute osteomyelitis?

Open biopsy & bone aspiration

When treating acute osteomyelitis, what should be done before giving abx?

Joint aspiration

What is the MC pathogen for acute osteomyelitis?

Staph aureus

What is the MC cause of chronic osteomyelitis?

Open fx or wound of extremities

What are sx of chronic osteomyelitis?

s/p open fx, fever, pain, soft tissue swelling/inflammation, cellulitis

What would you see on an Xray showing Chronic osteomyelitis?

irregular sclerotic bone destruction w/ areas of radiolucency & involcrum (dead bone)

What is the tx for chronic osteomyelitis?

Ortho & ID consults, I&D, IV abx

What medication can you give to slow benign bone tumors?

Biphosphonates

What is an Osteochondroma?

cartilage-capped bony spur arising on the external surface of a bone; usually long bone near knee or proximal humerus

What is an Osteochondroma look like on an XR?

bone arising from stalk or "bump" on bone

Where are enchondromas commonly found?

Hands/fingers, Metaphysis of long bones

What does an Enchondroma show on an XR?

lucency of hands/fingers or matrix calcification of long bones on XR, usually an incidental finding

What are the MC locations of Ewing's sarcoma?

Femur, Pelvis, Upper arm, Ribs in diaphysis

What population most commonly presents with Ewing's sarcoma?

5-20 yo; MC- males

What type of bone tumor may mimic symptoms of osteomyelitis? (fever, pain, weight loss)

Ewing's sarcoma

What does Ewing's sarcoma show on an XR?

lytic lesions w/ "onion peel" appearance

What is the tx for Ewing's sarcoma?

Chemo, surgery, radiation

Which joints does Osteoarthritis MC affect?

weight bearing joints (LEs & spine)

How does Osteoarthritis present?

stiffness, dec ROM, pain worsening w/ movement and relieved w/ rest, tender to palpation, deformity

What is the MC location of Osteoarthritis?

knee joints

What is the MC type of arthritis?

Osteoarthritis

Which type of arthritis is symmetric?

RA

Which joints are spared in RA?

DIP

What extraarticular manifestations can RA cause?

nodules, vasculitis, pericarditis, tenosynovitis, scleritis

How does Rheumatoid Arthritis present?

morning stiffness, symmetric swelling, nodules, +RF, radiologic changes, claw deformity of foot, ulnar drifting

Who is MC affected by Reactive Arthritis?

young men

What causes reactive arthritis?

inflammation triggered by GI or GU infxn (STDs and dysenteric)

*Chlamydia, Gonorrhea, Shigella, Salmonella, Campylobacter

What is the triad of sx associated with reactive arthritis?

Conjunctivitis, Urethritis, Oligoarticular arthritis

(can't see, can't pee, can't climb a tree)

What antigen might be present in some pts (63%) w/ Reactive Arthritis?

HLA-B27

What does Psoriatic arthritis show on an XR?

Pencil-in-cup deformity = joint destruction; resorption of terminal phalanges

*aggressive and destructive

What demographic is most affected by Psoriatic arthritis?

M=F 1:1; onset in 30s

What is the tx for psoriatic arthritis?

DMARD- methotrexate

What differentiates Psoriatic arthritis from RA?

DIP joint involvement and absence of nodules

Gout or Pseudogout:
Bony erosions & spurs on XR

Gout

Gout or Pseudogout:
Punctate or linear calcifications of cartilage (chondrocalcinosis)

Pseudogout

Gout or Pseudogout:

Negatively birefringent urate crystals

Gout

Gout or Pseudogout:

Weakly positive birefringent rhomboid-shaped crystals

Pseudogout

Gout or Pseudogout:

Serum uric acid (+)

Gout

What is the tx for gout?

Indomethacin -1st line, Colchicine -2nd line, NSAIDs, steroids

Long term: Allopurinol or Probenecid (inc urine excretion)

What is the tx for pseudogout?

Joint aspiration, Intra-articular steroids, NSAIDs

Acute: Colchicine

What is a precursor to Osteoporosis?

Osteopenia

What is the GOLD standard for diagnosing osteoporosis?

DEXA

Normal bone density T score

+1.0 to -1.0

T scores less than ____ indicate osteoporosis

-2.5

T scores between ____ and ____ indicate osteopenia

-1.0 to -2.5

T score of -1.0 has ___x risk of fractures

2x

T score of -2.0 has ___x risk of fractures

4x

T score of -3.0 has ___x risk of fractures

8x

What are the sx of CRPS?

pain is out of proportion to what would be expected after the original injury (distal to site of injury); affects extremities

What is the hallmark pain quality for CRPS?

Burning or throbbing

What is Spondylolisthesis?

slipping of the vertebrae + fx

What is Spondylolysis?

dissolution or loosening of a vertebra + stress fx

What is Spondylosis (stenosis)?

degenerative disease of a vertebrae and disc; narrowing of spinal canal

Which type of Kyphosis is seen in adolescents?

*starts ~11 yo

Scheuermann’s

What would imaging of Scheuermann’s Kyphosis show?

Schmorl’s nodes, discs are flattened & irregular, thickened ant longitudinal ligament, vertebral bodies are wedged; > 40 degree curve

What is the MC curve in idiopathic scoliosis?

R thoracic

What are S&S of Scoliosis?

“rib hump”, lateral curvature > 10 degree, F>M 11-13 yo

What is the tx for Scoliosis at a 10-25 degree angle?

PT & monitor

What is the tx for Scoliosis at a 25-45 degree angle?

brace & PT

What is the tx for Scoliosis at a >45 degree angle?

surgery & PT

What causes Spondylolysis?

repetitive injury on pars causes a stress fracture

Where do the majority of Spondylolysis cases occur?

L5

What is bilateral spondylolysis?

spondylolisthesis