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Orthopedics Board Review. Satjiv Kohli Mt Sinai School of Medicine Department of Emergency Medicine.

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orthopedics board review

Orthopedics Board Review

Satjiv Kohli

Mt Sinai School of Medicine

Department of Emergency Medicine

slide2
1. 45 yo female presents c/o pain, tingling, numbness, and intermittent weakness in her L hand that has been present for the past several months. She is concerned because the symptoms, which initially occurred only at night, are now occuring during the day and are interfering with her profession as a classical violinist. What is the most likely diagnosis?A. BursitisB. Carpal tunnel syndromeC. de Quervain tenosynovitisD. Medial epicondylitisE. Thoracic outlet syndrome
slide3
A. Carpal Tunnel Syndrome

- Most commonly encountered entrapment neuropathy

- Pain, parasthesias, and weakness in distribution of median nerve

  • Middle aged women, symptoms are often bilateral, insidious in onset and progressive
  • Repetitive motion, trauma, pregnancy, obesity, gout and hyperTH

- Tinel’s sign, Phalen maneuver, and carpal compression

- Wrist immobilization, rest, NSAIDs

slide4
C. De Quervain tenosynovitis

- Inflammation of tendons (EPB & APL) on the side of the wrist at base of thumb

- + Finkelstein’s test

D. Medial epicondylitis

- “golfer’s elbow”

- inflammatory and degenerative process of the medial epicondyle

- discomfort of medial elbow

- associated symptoms of ulnar neuropathy

E. Thoracic Outlet Syndrome

- compression of neurovascular structures in thorax

- pain and paresthesia in ulnar nerve distribution

- trauma, repetitive activities, anatomic

slide5
2. Avascular necrosis is commonly associated with:

A. Colles fx

B. Lunate fx

C. Mallet finger

D. Smith fx

E. Triquetral fx

slide6
B. Lunate fracture

- rare to have isolated lunate injury

- usually result of a fall on outstretched hand

- avascular necrosis (Kienbock disease) can lead to lunate collapse, OA, weakness of grip strength

slide7
3. Which of the following immobilization methods is indicated for a nondisplaced scaphoid fx?

A. Long arm volar splint

B. Short arm thumb spica splint

C. Sling alone, no splint required

D. Ulnar gutter splint

slide8
B. Short arm thumb spica splint

- Scaphoid fx

- most commonly fx carpal bone

- fall onto an outstretched hand

- up to 15% not seen on initial Xrays

- risk of avascular necrosis

- 2/3 of surface is articular

- unstable fx require long arm thumb spica

slide9
4. Middle aged man presents with 3 days of increasing discomfort to his R distal foot. He denies trauma. PMHx significant for OA, CRI, HTN treated with Hctz. On exam, affected joint is warm to touch, slightly swollen with mild overlying erythema. ROM is mildly limited secondary to discomfort. What is the most likely diagnosis?

A. Gout

B. Osteoarthritis

C. Pseudogout

D. Rheumatoid Arthritis

E. Septic Arthritis

slide10
Gout
    • crystal induced arthropathy most commonly seen in men (9:1) 30-50 years old
    • Monoarticular arthritis (90%)
    • Acute inflammation of great toe is the initial joint manifestation
    • PE - tender, warm, erythematous, and swollen
    • Dx - NEGATIVELY birefringent urate crystals
    • Tx- NSAIDs
  • Pseudogout
    • Monoarticular arthritis
    • CaPyrophosphate crystals (POSITIVELY birefringent crystals)
    • Knee, wrist, ankle or elbow
    • Tx - NSAIDs
slide11
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C. Septic Arthritis

- usually found in patients with underlying joint disease or recent trauma

- impaired ROM, fever, localized discomfort

- Synovial fluid analysis - WBC>100,000, + bacteria

slide12
5. A 75 year old woman slips and falls in her bathrub and injures her L hip. She is helped out of the bathtub by her daughter but she is unable to ambulate secondary to pain. In the ED, initial radiographs of the hip and pelvis are negative. The patient continues to have pain in her L leg and is unable to ambulate. What is the most appropriate management step?

A. Admit to rehab facility for PT

B. Order inlet and outlet views of pelvis

C. Order MRI of the L hip

D. Order nuclear bone scan

E. Rx narcotic pain meds and walker and arrange for outpt ortho eval

slide13
C. Order MRI of the L hip

- Senile osteoporosis is leading cause of femoral neck fractures with minor trauma

- Female > men

- Inability to ambulate increases probability of occult fx

- MRI within 24hrs of injury often reveals a fx

- Bone scans lack adequate sensitivity but are most sensitive when delayed 72hrs after the injury

slide14
6. Which of the following statements regarding the dislocation shown below is TRUE?

A. Associated femoral head and acetabular fx’s are rare, so pre-reduction xrays unnecessarily delay fxn

B. Associated sciatic nerve injury is rare

C. Femoral artery disruption can occur in 20% of cases

D. Femoral nerve injury is common and requires reduction under general anesthesia

E. Relocation in fewer than 6 hrs reduces the incidence of avascular necrosis

slide15
E. Relocation in fewer than 6 hours reduces the incidence of avascular necrosis

- posterior hip dislocation most common type (80-90%)

- MVC when knee hits dashboard and the hip is flexed and adducted

- patient presents with adducted, shortened, and internally rotated leg

- delays lead to avascular necrosis

- up to 50% of patient have associated femoral head and acetabular fx

- femoral artery and nerve injuries are uncommon

- sciatic nerve injury is fairly common (10%)

slide16
7. Which of the following statements regarding pediatric knee injuries is correct?

A. Adolescent boys with Osgood-Schlatter disease have pain with motion but not while at rest

B. Limping after a fall from a height of more than 3 ft is an indication for obtaining knee radiographs

C. Ottawa Knee Rules should not be used for children because of the potential for physeal injuries

D. Patellar fractures are the most common type of knee fx seen in preschool-aged children

E. Salter-Harris type I fx of the distal femoral physis cannot be seen on a radiograph

slide17
A. Osgood-Schlatter patients have pain with motion but not while with rest
  • Repetitive injury to the tibial tuberosity such that pulling on it by the patellar ligament results in chronic inflammation
  • Young adolescent boys
  • Pain in the area of anterior proximal tibia during running, climbing stairs, jumping, and kneeling

B. Ottawa knee rules (validated for use in children >2)

- Age>55 years

- Tenderness at head of fibula

- Isolated tenderness of patella

- Inability to flex knees >90

- Inability to take 4 weight bearing steps

slide18
C. Salter Harris fractures

- nondisplaced Salter Harris type I fractures might not be appreciable on an initial set of radiographs but they often have a widened physis

slide19
8. 14 yo boy presents c/o injury to his R knee. He had been walking when his foot got stuck in a hole. He twisted his R knee and felt an immediate sense of his knee “popping out of place.” He reports experiencing moderate pain and holds his R knee in modest flexion. Which of the following is the most appropriate next step in evaluation and management?

A. Check compartment pressures to R leg and thigh

B. Grasp his R lower extremity and extend his knee

C. Obtain plain knee radiographs followed by prompt angiography

D. Perform knee arthrocentesis to relieve the hemarthrosis

E. Splint his RLE in its current position

slide20
B. Grasp his RLE and extend his knee

- patellar dislocations are one of the most common causes of knee hemarthroses

- most commonly dislocate laterally

- knee should be immobilized after reduction

- f/u with orthopedist within 1-2 weeks is suggested

slide21
9. 34 yo male comes in with supervisor after sustaining an injury to his right hand. He was working with with a paint spray gun 30 minutes earlier when the stream of paint contacted his hand, penetrating the skin. He has minimal pain that is localized to R index finger. PE reveals a small entrance wound on palmar surface. Neurovascular intact. Patient is impatient. Wants pain meds and to go back to work.

A. Arrange urgent outpatient hand surgery evaluation within 24hrs, do not allow patient to return to work, rx with tylenol and discharge.

B. Obtain emergent hand surgery consultation immediately, and do not let patient to leave

C. Rx with tylenol, and obtain Xrays; if no fx, d/c with appropriate f/u thru employer

D. Tylenol, perform digital nerve block, prophylactic abx, d/c with f/u thru employer or hand surgery

E. Prophylactic abx, tylenol, and obtain xrays; if no fx, d/c with f/u thru employer or hand surgery

slide22
B. Emergent hand surgery consultation

- the high pressures associated with industrial equipment generate force to penetrate skin and fascial planes

- paint and paint thinner produce a large, early inflammatory response and lead to the largest % of amputations

- other materials that can be injected are grease, oil, hydraulic fluid, plastic wax, H2O, and semifluid cement

- grease causes a smaller inflammatory response but causes formation of granulomas, fistulas, scarring, and loss of function

- patients who present early might have minimal physical findings

- Tx - aggressive pain management with IV opiods, IV abx, tetanus

- early surgical debridement is required to prevent amputation and disability

slide23
10. 58 yo man presents with finger amputation that he sustained while cleaning out lawnmower. R index finger is completely amputated at level of middle phalanx. PE reveals nl vitals and active arterial bleeding from amputation site. The amputated finger is placed in a plastic bag in a cooler filled with ice. Gross dirt and organic debris are on both the proximal amputation site and the amputated part. The patient is R handed with no PMHx. What is the next step to improve the chance for successful replantation?

A. Gently wash both the amputated digit and the proximal site with hydrogen peroxide, then replace digit in the ice

B. Leave the amputated digit in the cooler

C. Remove amputated part from the cooler, wrap it in NS soaked gauze, then refrigerate it in a plastic bag.

D. Send amputated part to pathology

E. Warm amputated part to RT, then rinse it with saline and wrap it in gauze.

slide24
C. Remove amputated part from cooler, wrap it in NS soaked gauze, then refrigerate it in a plastic bag

- more proximal the amputation, the less ischemia time the digit can tolerate

- Xrays of amputated tissue and stump

- prophylactic abx

- cooling amputated part to 4 C lengthens ischemic time from 6-8 hrs to 12-24hrs

- local antiseptics should not be used because they can be toxic to viable tissues

- ice should not come into direct contact with tissue because this can cause local tissue damage

slide25
11. 40 yo male is being boarded in the ED due to lack of inpatient beds. He was involved in motorcycle crash and has a closed proximal tibial fx dislocation and soft tissue swelling. The ortho surgeon applied a splint, scheduled surgery for next day, wrote meds for pain control, and left the hospital. The patient says that his pain is worse, despite narcotics, and that his foot his numb. The splint is removed; PE reveals parasthesia and numbness in the foot and edema. DP and PT pulses are strong; anterior compartment pressure is 35m Hg. What is the best course of action?

A. Higher dose opoids, but do not replace splint

B. Cont to measure compartment pressures over the next 12 hrs; if the level risess to 60mm Hg, inform attending ortho surgeon

C. Obtain repeat Xrays with the splint in place and provide analgesia

D. Prepare the patient for emergency fasciotomy

E. Replace the splint and administer higher dose opoids

slide26
D. Prepare for emergency fasciotomy

- Most commonly following a fx of a long bone (tibia)

- Increased pressure in nonexpandable compartment --> tissue hypoxia --> cap leak, increased edema ->increased pressure

- 5 P’s - pain w/passive stretch, pallor, paresthesia, poikolethermia, pulselessness

- Compartment pressures > 30mmHg are indication for fasciotomy

slide27
12. Which of the following statements is TRUE regarding compartment syndrome of the hand?

A. Patients may complain of intense pain but have little if any physical findings

B. Paresthesias occur as a prominent feature

C. Pain is not a prominent feature

D. Patients prefer to maintain their hand in 45-degree flexion at the MCP and PIP joints, “the cupping position.”

slide28
Patients may complain of intense pain but have little if any physical findings
    • may lack typical paresthesias
    • “pain with passive stretch” is difficult to assess due to the difficulty of isolating muscles in each compartment
    • Tight swollen hand in “minus” position
    • Pressure >15-20 is relative indication for fasciotomy
slide29
13. 35 yo male was playing basketball when he heard a pop in his L ankle. Presents c/o pain and is unable to bear weight on the affected ankle. PE reveals finding shown below. Which of the following statements regarding this patient’s injury is correct?

A. An air filled ankle brace will provide stability and prevent the patient from repeating the injury

B. Early surgical repair will result in better outcome

C. Placement of circular cast is required

D. Ankle should be splinted in dorsiflexion using a posterior splint

E. Patient should be given crutches and analgesia and instructed to bear weight as tolerated

slide30
B. Early surgical repair will result in better outcome

- middle aged men doing sporting activities

- patient will describe pop and be unable to bear weight

- tendonitis and steroid injections are risk factors

- positive Thompson test

- splint affected extremity with a posterior splint, with the ankle in plantar flexion

- non-weight bearing

- early surgical repair results in better outcomes because delay allows for the ends of tendon to contract

slide31
14. Which of the following fractures is most commonly associated with a dislocation of Lisfranc joint?

A. Base of the 5th metatarsal

B. Base of the 2nd metatarsal

C. Diaphysis of the 5th metatarsal

D. Navicular

E. Talus

slide32
B. Base of 2nd metatarsal

- injuries to joint commonly missed

- occur with rotational force or axial loading

- signs include the plantar ecchymosis sign and tenderness about the joint on palpation

-fx of base of 2nd metatarsal is pathognomonic

- require immediate ortho consultation

slide33
Base of 5th metatarsal
    • pseudo-Jones fx (dancers fracture)
    • Occurs after inversion of the ankle with plantar flexion
    • Short leg weight bearing cast for 4-6 weeks

C. Diaphysis of 5th metatarsal

- Jones fx

- high incidence of malunion

- non weight bearing cast for 6-8 weeks

slide34
15. 68 yo male presents with 1 week h/o low back pain after doing some yard work. He denies specific injury, falls, and fever. PMHx significant for HTN. On PE, he has tenderness to palpation in the Rt lumbar region. On ipsilateral SLR, he has pain into hamstring region. DTRs and MS ar nl. Which of the following statements concerning the evaluation and management of this presentation is correct?

A.+ SLR will be of little value in determining whether he has a herniated disc

B. Abnl findings on CT or MRI are highly specific and will correlate well with his symptoms

C. Early radiographic imaging is indicated because of his age

D. Requires MRI of the L spine within 24hrs

E. Should be treated with NSAIDs and muscle relaxants, bed rest for 48-72hrs, and PT within 3-4 days

slide35
C. Early radiographic imaging is indicated because of his age

- Indications for imaging:

- specific neuro deficits

- acute trauma

- age>50

- findings of systemic disease

E. PT should be delayed for several weeks after the initial injury