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emmajackielee · 6 years

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Stuff I Learned: Ortho Seminar

October 31, 2017: You Can’t Afford to Wait

Treatment of open fractures

Antibiotics + anti-tetanus toxoid

Soft tissue debridement (second look on Day 2-3)

Bony compartment: external fixation

Life-saving > limb-saving > function-saving

Limb threatening injures: open fractures, compartment syndrome, vascular injury, dislocation of major joints

FAST has largely been replaced by rapid CT

Compartment pressure measurement: digital manometer or syringe + manometer

November 2, 2017: Foot and Ankle Disorders

Arch of foot is maintained by plantar fascia

In plantar fasciitis, the tender spot is the medial aspect of the calcaneal bone

The navicular tubercle is the attachment of the tibialis posterior tendone, the dynamic control factor of the arch

Tibialis posterior dysfunction leads to adult flat foot

Unlike calcaneal fracture, medial/lateral malleolar fractures are low energy

Ankle sprains are most commonly inward, affecting the anterior talofibular ligament (ATFL) and calcaneo-fibular ligament (CFL); usually the posterior talofibular ligament (PTFL) is not affected

November 4, 2017: Peripheral Neuropaties

Cubitus valgus deformity stretches the ulnar nerve

Osteoarthritis causes compressive neuropathy by osteophyte formation or deformity

Surgical management is by anterior transposition; post-operative mortality is worse if symptomatic for > 1.5 years

November 11, 2017: Lower Back Pain

Myotome with exclusive L5 innervation: big toe dorsiflexion and hip abduction

Deformities due to back pain: loss of lumbar lordosis, listing

Prolapsed intervertebral disk causes pain during forward flexion of the spine (unlike spinal stenosis)

Consider for surgery in disk prolapse if there is still pain after conservative treatment for 6 weeks

MRI: TR few hundred = T1, few thousand = T2

Straight leg raising test positive on contralateral side = cross sciatica

November 11, 2017: Arthritis

Ficat classification of AVN

Stage I: normal

Stage II: subchondral sclerosis

Stage III: subchondral collapse, crescent sign

Stage IV: secondary OA

DDx finger drop in RA

Radial nerve palsy (posterior interosseous nerve)

Extensor tendon rupture

Volar subluxation of MCPJ

Ulnar dislocation of extensor at MCPJ

November 21, 2017: Basic Science

T scores are used for post menopausal women and for men more than 50 years old; Z scores for pre menopausal women and for men less than 50 years old + children

DEXA looks at hip and spine

Surgical treatment of axial compression fracture: posterior instrumentation and correction of kyphosis, anterior decompression and fusion

3 column theory: flexion compression affects 1 column, axial compression affects 2

November 21, 2017: Cervical Spine Disorders

Hoffmann: disinhibition of C8

Lhermitte’s sign: a sign of C1/C2 subluxation, paresthesia upon neck flexion

Cervical myelopathy: 75% episodic progression, 20% steady progression, 5% rapid deterioration

Oblique XR to look at neural foramina

Cervical radiculopathy: 80% recover completely with conservative treatment

Causes of cervical myelopathy: spondylosis, PID, instability

OPLL = ossified posterior longitudinal ligament (more common in Asian, obesity)

November 25, 2017: Common Shoulder Problems

Most common bone involved in osteoporosis of shoulder: neck of humerus (surgical)

Ligament will not lead to chronic pain of shoulder but labrum will (anterior, posterior, superior, inferior): apprehension for anterior, superior lead to chronic pain

Frozen shoulder stages: freezing (inflammatory), frozen, thawing

Combing hair (shoulder movement): flexion, abduction (front only), external rotation (back)

Wearing coat: external rotation

November 25, 2017: Common Knee Problems

ACL is intra articular and MCL is extra articular; ACL will swell immediately after trauma; MCL delayed

Immediate swelling of knee DDx

ACL tear (72%)

Osteochondral fracture (14%)

Patellar dislocation (6%)

The meniscus is avascular, aneural, and alymphatic

To prevent DVT, must exercise gastrosoleus

Majority of knee location is after a high energy trauma and majority will reduce, leaving no trace on XR

Knee dislocation = Grade 3 laxity in collateral ligament + cruciate ligament

November 27, 2017: Common Orthopedic Problems

Injection of steroid into tendon sheath = high risk of tendon rupture

Trigger finger is due to inflammation of the flexor tendon leading to narrowing of tendon sheath, therefore stuck at A1 pulley region at the MCPJ of 3rd or 4th digit

Mallet finger: caused by acute forced flexion of extended digit

Wall test: ask patient to lean against wall on back and touch wall on other points of the body to check for ankylosing spondylitis

Why spine fracture in AS patient won’t heal: abnormal curvature, stiff joint

November 27, 2017: Hand Injuries

Principles of fracture management

Reduce if necessary

Immobilize if necessary

Always rehabilitate

Nerve entrapment: if there is muscle atrophy, it is advanced; do not manage conservatively

Tinel sign: tap from distal to proximal

Froment’s sign: adductor pollicis paralysis due to ulnar nerve palsy; patient uses flexion via median nerve to compensate when asked addut thumb

November 30, 2017: Common Hip Disorders

Shenton’s line is broken in any disruption of the normal intracapsular anatomy (e.g. hip location, DDH)

Blood supply to the femoral head is retrograde = distal to proximal

AVN treatment

Ficat I-II: core decompression

Ficat II-III: vascular bone graft

Ficat IV: total hip replacement

Joint aspirate cell count

Normal: < 200

Septic arthritis: 80,000 to 200,000

Joint aspiration: anterior approach to avoid femoral blood supply, causing iatrogenic AVN

XR of AVN vs simple hip OA: unilateral, joint space initially preserved, collapsed femoral head

November 30, 2017: Childhood Injuries

Children’s bones are less dense, more porotic, more vascular with a thicker periosteum: form callus quicker

Capitulum always articulates with the radius

Children: physis not ossified, so a fracture on XR may look like a dislocation

Elbow dislocation is RARE! Consider physeal fracture

Physeal fracture: if germinal zone is damaged there is growth retardation/arrest

Supracondylar fractures occur around 6-7 years old

Type I: undisplaced

Type II: displaced, posterior cortex contact

Type III: displaced, no cortical contact (extension type)

November 30, 2017: They are too important to miss

Fracture stages: hematoma, inflammation, callus formation, lamellar consolidation, bone remodeling

Callus formation happens at around 3-6 weeks

Osteosarcoma: metaphysis most commonly affected

Osteosarcoma radiographic features

Codman’s triangle (due to periosteal elevation, early, not specific)

Sunburst appearnace (specific, late)

In children, hematogenous osteomyelitis occurs in the metaphysis since the blood vessel loops back the avascular cartilage, resulting in slower flow; in adults , who do not have metaphysis, it is septic arthritis

Codman’s triangle DDx: tumor, trauma, infection, hematoma

Acetabular fractures are high energy

December 12, 2017: Common Pediatric Problems

Breech presentation in the 3rd trimester is the single most important risk factor for DDH: increase risk by 10-15x

Ossificaiton of bone occurs at around 5-6 months for boys and 4-5 months for girls

Ultrasound is oversensitive, leading to many false positives

Acetabular index angle > 30 degrees is abnormal

Pavlik harness carries at 1% risk of AVN

Perthes is a self-limiting condition with onset between 4 and 8, but the outcome is variable depending on the extent of the collapse

Gold standard treatment for talipes equinovarus is non-operative

#let the learning begin #stuff i learned #medical log #ortho #lecture notes

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