E2 Ortho- Review

Elevation of intracompartmental pressure to a degree that compromises blood flow to involved muscles and nerves

Compartment syndrome

_____ AKA below knee amputation

Transtibial amputation

Compartment syndrome most commonly occurs after a _____ fracture

Tibia

What is the most common involved compartment in compartment syndrome?

Anterior compartment

Pressures > _____ mmHg in 1/4 compartments is dangerous

40 mmHg

6Ps of Compartment Syndrome

Pain, Paresthesia, Pallor, Paralysis, Pulselessness, Poikilothermia

Where does the paresthesia radiate to with anterior/lateral compartment syndrome?

Dorsal aspect of foot

Where does the paresthesia radiate to with posterior compartment syndrome?

Plantar aspect of foot

True or False: Compartment syndrome can be due to prolonged running/walking and symptoms resolve after 30 minutes of stopped activity

True (exertional compartment syndrome)

What do you use to test for compartment syndrome?

Indwelling catheter or needle with a pressure monitor

Clinically significant pressure in compartment syndrome

> 30 mmHg

Dangerous pressure in compartment syndrome

> 40 mmHg

Tx for acute compartment syndrome

Fasciotomy

Is chronic/exertional compartment syndrome an emergency?

No

Is acute compartment syndrome an emergency?

Yes

Hallmark symptom of patellar/quadriceps tendinitis

Anterior knee pain

Gradual onset of pain in the anteromedial aspect of the distal 1/3 of leg

Shin splints

Pt presents with pain on the anteromedial aspect of their leg after increasing their running activity. States that they have been running on hard, uneven surfaces. Most likely dx?

Shin splints

Shin splints AKA ______

Medial tibia stress syndrome

Tx for shin splints

Rest, ice, NSAIDs, PT

Hairline/microscopic break in bone caused by microtraumatic, cumulative overload on bone such as overtraining, incorrect biomechanics, fatigue, poor nutrition and osteoporosis

Stress fracture

What testing is done to confirm the diagnosis of a stress fracture?

MRI

70% of amputations are due to ____

DM, Infections, PVD

20% of amputations are due to _____

Trauma

Amputation at the transmetatarsal or tarsometatarsal level

Midfoot amputation

What amputation:

Poor funx and difficult prosthetic management. The retained talus and calcaneus frequently are pulled into equinus and WB place excessive pressure on the amputation site.

Hindfoot amputation

What leg amputation is the better one to have due to increased knee function?

Below Knee Amputations

What test is good for diagnosing proximal DVT/clot formation?

Duplex US

What is the gold standard to confirm DVT?

Venography

What is the gold standard to confirm PE?

Pulmonary angiography

"Knocked knee"

Valgus

"Bowed leg"

Varus

Valgus or Varus: pushing on knees laterally

Valgus

Valgus or Varus: pushing on knees medially

Varus

What special test:

Examiner applies force in the lateral direction to the ankle from the medial aspect and force in the medial direction of the knee from the lateral aspect. Positive test shows medial instability of the knee.

Valgus stress test

What special test:

Examiner applies force in the medial direction to the ankle from the lateral aspect and force in the lateral direction of the knee from the medial aspect. Positive test shows lateral instability of the knee.

Varus stress test

+ Valgus stress test = (MCL/LCL) injury

MCL

+ Varus stress test = (MCL/LCL) injury

LCL

+ Anterior drawer test = ______

Torn ACL

What special test:

Patient supine, hip flexed, knee flexed at 90 degrees. Patient foot stabilized by examiner sitting on foot. Examiner "pulls" tibia forward/anterior

Anterior drawer test

What special test:

Patient supine, with knee flexed at 30 degrees. Femur stabilized with one hand and tibia is pulled anterior with the other hand. Tests for ACL tears/injuries.

Lachman test

What diagnostic study is used to diagnose meniscal injuries?

MRI

+ McMurray test = ____

Meniscal tear

+ McMurray and + Apley's Compression test

Meniscal tear

Tx for meniscal tear

Menisectomy/Arthroscopy

______ AKA "Jumper's knee"

Patellar tendinitis

What is the most sensitive physical exam test for an ACL injury?

Lachman test

What diagnostic study is used for ACL/PCL/MCL/LCL injuries?

MRI

+ Lachman test and + Anterior drawer test

ACL injury

The "Terrible"/"Unhappy" triad

ACL, MCL & Meniscal tears

+ Posterior drawer test

PCL injury

What diagnostic study would you order for a patellar fracture?

Plain film: AP, Lateral, & Sunrise view

What is the most common patellar dislocation?

Lateral dislocation

Are patellar dislocations more common in females or males? Why?

Females due to excessive Q angle

+ Apprehensive test

Patellar dislocation

XR shows + patella alta (superior appearing) think _____

Patella tendon rupture

On exam patient cannot actively extend their knee and there is a palpable defect inferior to the patella. Possible dx?

Patella tendon rupture

What is a "true" knee dislocation?

Tibiofemoral dislocation

What should you check in a tibiofemoral dislocation?

Pulses for vascular compromise

Which is a medical emergency & requires STAT ortho consult and reduction: Patellar dislocation or Tibiofemoral dislocation

Tibiofemoral dislocation

Pain and swelling in the anterior knee over the tibial tuberosity commonly seen in adolescent athletes. Possible dx?

Osgood-Schlatter disease

What is the most common form of knee arthritis?

Osteoarthritis

75 y/o patient with a history of knee trauma 20 years ago presents with gradual onset of knee pain x months. Patient states that the pain wakes them up at night. Patient is obese. Most likely dx?

Osteoarthritis

______ AKA Runner's knee

Patellofemoral syndrome

What is the most commonly injured ligament in an ankle sprain?

Anterior talofibular ligament

+ Homan's sign = _____

DVT

+ Thompson's test = _____

Achille's tendon rupture

Absence of plantar flexion when calf is squeezed

+ Thompson's test (Achille's tendon rupture)

The medial clear space of the ankle should not exceed _____ mm on XR

4 mm

90% of all ankle injuries are due to ______ injuries- sprains

Inversion

A trimalleolar ankle fracture involves the _____

Medial, lateral, and posterior malleolus

A bimalleolar ankle fracture involves the _____

Medial and lateral malleolus

Flat foot arch

Pes planus

Elevated longitudinal arch of foot

Pes cavus

Pain in the morning with 1st step, think ______

Plantar fascitis

A Lisfranc fracture is a ______ fracture

Midfoot

Oblique, comminuted fracture of distal tibia that extends through the tibiotalar articular surface

Pilon fracture

75% of patients with a Pilon fracture have _____ involvment

Fibula

Tx for Pilon fracture

Ex-fix then ORIF

Fracture of the 5th metatarsal

Jones fracture

What trauma causes a Jones fracture?

Inversion

Pain located between the 3rd and 4th metatarsal head

Morton's neuroma

What special test:

Patient lies supine, examiner grabs around metatarsal head and squeezes heads together- resulting in pain between 3rd & 4th metatarsal head

Morton's neuroma

Tx for Morton's neuroma

Steroid injection

Fell forward and landed on an outstretched hand think ______

Colle's fracture

Fell forward and landed on a flexed wrist think ______

Smith's fracture

Landed on an outstretched hand with hyperpronated forearm think ________

Monteggia fracture & Galeazzi fracture

What special test:

Reproduction of pain when patient is asked to pronate the forearm, extend, and radially deviate the wrist against resistance and it reproduces pain in the lateral epicondyle

Cozen test

What special test:

Palpating the patient's lateral epicondyle with one hand, while pronating the patient's forearm, fully flexing the wrist, and extending the elbow and it reproduces pain in the lateral epicondyle area

Mill test

What 2 physical exam special tests are used to evaluate for lateral epicondylitis (Tennis elbow)?

Cozen & Mills test

What does a fat pad/sail sign indicate in adults?

Subtle radial head fracture

What does a fat pad/sail sign indicate in children?

Supracondylar fracture of humerus

Nursemaid's elbow is common in what patient population?

Preschool aged children (1-4 y/o)

Caused by a sudden pulling force with twisting that causes the immature radial head to sublux outside of the annular ligament

Nursemaid's elbow

2 y/o female presents with pain in the elbow. Pt's mother states that pain began after her father was swinging the patient by the arm. The patient is now refusing to use her arm. Most likely dx?

Nursemaid's elbow

Tx for Nursemaid's elbow

Closed reduction: supination forearm & flexion of elbow to the shoulder

Nursemaid's elbow is caused by a sudden pulling force with twisting that causes the immature radial head to sublux outside of the ___________

Annular ligament

50-60% of elbow dislocations are associated with _______ fractures

Radial head/neck

What is the terrible triad of elbow dislocations?

LCL rupture, Radial head fracture, Coronoid fracture

Tx of a posterior elbow dislocation

Closed reduction performed and stability check with ROM ASAP