Transcript 1. Talipes Equinovarus is the proper name for :-

LMCC Orthopedic Review Lecture
April, 2004
“Back to Basics”
Dr. P.R. Thurston
1
Syllabus
1. Diagnosis, Treatment & Complications of Fractures /Dislocations.
2. Diagnosis & Treatment of Arthritis.
3. Assessment and Management of Low Back Pain.
2
Fractures
&
Dislocations
3
Fractures
Definition :-
A discontinuity in the structural
integrity of a bone.
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.
4
Fractures
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.
5
Fractures
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.
6
Definitions
Fracture:-
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.
7
Fractures
Mechanical Properties of Bone
Bone is a two-phase material :Calcium HydroxyApatite
Osteoid
Ca10(PO4)6(OH)2
Collagen type I and III
= mineral
= fibrous
Calcium is strong in compression, but weak in tension.
Osteoid is strong in tension, but weak in compression.
8
Fractures
BUT :-
(for adult bone)
Calcium is stronger in compression
than Osteoid is in tension
And therefore :Bone always fails first in tension
9
Fractures
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.
10
Fractures
A bone consists of three
areas :-
the Diaphysis
Each region has its own
fracture characteristics.
the Metaphysis
the Epiphysis.
11
Fractures
Diaphyseal
Metaphyseal
Epiphyseal
Bending
Torque
Direct
Traction
Compression
Intra-articular
Pediatric
Oblique
Spiral
Transverse
Mixed
12
Fractures
Bending
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.
13
14
Fractures
Torque
- 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’
15
Fractures
Torque
$piral
The butterfly segment is
different from the
oblique bending
fracture.
$
16
Fractures
If no butterfly, then the
ends are Bayonet in
appearance.
17
Fractures
Direct Blow
“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.
18
Fractures
Direct Blow
Transverse Fractures
Comminution on the
opposite side to a bending
fracture, ie. at the point of
impact.
“The Nightstick Fracture”.
19
Fractures
Metaphyseal
Traction – Avulsion.
The Metaphysis is subject to
all of the diaphyseal
patterns plus:-
1) Traction – Avulsion.
2) Compression.
20
Fractures
Metaphyseal
Traction-Avulsion
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.
21
Fractures
Traction – Avulsion.
22
Fractures
Compression
Crush fractures
Impacted fractures
Usually comminuted
Usually axial skeleton
- Vertebrae
- Calcanei
23
Fractures
Epiphyseal
The Epiphysis is subject to all of
the diaphyseal and
metaphyseal patterns plus:-
1) Intra-articular Fractures.
2) Pediatric Fractures about the
Epiphyseal plate.
24
Fractures
Epiphyseal
Intra-articular Fractures
-
Always require accurate
reduction.
-
Usually require surgical
treatment.
-
Are often comminuted.
-
Frequently threaten Posttraumatic Osteoarthritis.
25
Fractures
Epiphyseal
Pediatric Epiphyseal Fractures
-
Produce fracture patterns
specific to children.
-
Always require accurate
reduction.
-
Can produce growth
abnormalities.
-
Salter-Harris Classification.
26
Fractures
I
IV
Salter-Harris Classification
II
III
V
27
Fractures
Salter-Harris Classification
1)
Fractures interfering with growing bones.
2)
Worse prognosis with increasing number.
3)
Probability of surgery increases with
number.
28
Fractures
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.
29
Fractures
Description
1)
2)
3)
4)
5)
6)
Displacement - Angulation
Closed or Open.
Simple or Comminuted.
Fracture Pattern eg. Spiral, Transverse etc.
Anatomical Area.
Mechanism.
30
Fracture Description
This fracture is angulated
laterally, since it points
laterally.
The distal fragment is tilted
medially
31
Description
Medially Displaced
Closed
Comminuted
Short Oblique
Fracture of the
Proximal Humerus
Caused by a direct fall
32
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.
33
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.
34
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
35
Treatment
Closed or Open ( Surgical ).
- Both require an understanding of fracture healing.
- Closed requires reversal of mechanism of injury.
36
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.
37
Indications for Open Reduction
1)
2)
3)
4)
5)
6)
7)
8)
There is a significant Displacement.
Open Fractures.
Intra-articular Fractures.
Un-reducible Fractures
Reductions that cannot be maintained in a cast.
Comminuted or Segmental Fractures.
Floating Joints.
Fractures with Neurovascular damage.
38
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.
39
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.
40
Type 1. Open Fracture = 6 mm, extend & debride
41
Degloving Mechanism
Degloving Mechanism
42
Type III C Injuries – Vascular Injury
Note pallor of the ankle
No pulses
43
Fracture Complications
1.
2.
3.
4.
5.
Pulmonary Fat Emboli
Compartment Syndromes
‘Cast Disease’
Stress Fractures
Pathologic Fractures
44
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.
45
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.
46
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 %
47
Rx Compartment Syndrome
Release all compressive
dressings / plaster.
Elevate extremity to
heart level.
Fasciotomies.
48
Rx Compartment Syndrome
Increased girth.
Pallor of the foot.
Recent surgery.
49
4 compartment
fasciotomy
50
Compartment Syndrome
Careful monitoring.
Recognise it - 5 P’s
Call Orthopaedic Surgeon
Pressure measurements
51
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.
52
Pathologic Fractures
Failure through abnormally
weakened bone
Minimal trauma – BEWARE
Osteoporosis
Metastasis
Tumour:- Benign,
Malignant
(Myeloma).
Metabolic Bone Disease
53
Pathologic Fractures
54
Fractures Ultimately, the treatment of fractures
requires
an understanding of
the mechanism that
produces them,
55
Fractures
An understanding
of the diagnostic
tools available,
56
Fractures
And the current
technologies used in
their treatment
57
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
58
Shoulder Dislocations
95 % anterior
1 % posterior
Luxatio erecta
Medial
Axillary nerve injury
Rapid reduction
59
Shoulder Dislocations
Conscious sedation.
Traction reduction.
Immobilization.
Recurrent.
Voluntary
Habitual.
Multiaxial instability.
60
Elbow Dislocation
Posterolateral.
Median nerve injury.
Ulnar nerve injury.
Rapid reduction.
Early mobilization.
61
Back Pain
62
Classification: Mechanical
(MacKenzie)

Postural syndrome


Dysfunction syndrome


normal tissues become painful by the application of
prolonged stresses (sitting, bending etc)
soft tissues are shortened and stiff. Usually >30 year
old, poor posture, under exercised, reduced mobility
Derangement syndrome

Disc derangement (tears and herniation)
63
Causes and Classification of
Back Pain: McNab
Spondylogenic





Viscerogenic
Vasculogenic
Neurogenic
Psychogenic
Spondylogenic
Osseus:






Trauma
Infection
Neoplasms
Inflammatory
Metabolic (eg.Pagets)
Deformities
– Soft tissues:




Muscles
SI joints
Disc
Facets
64
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
65
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?”
66
Congenital Anomalies

Congenital scoliosis
Arthrogryposis
67
Congenital anomalies

Spina bifida
68
Anatomy
Extension
Flexion
69
Three joint complex
(Kirkaldy Willis, Farfan)
Recurrent rotational strain
Synovial reaction facet joint
Disc circumferencial tears
Cartilage destruction
Osteophyte formation
Capsular laxity
Subluxation
Enlargement of articular process
radial tear
Disc herniation
Instability
Lateral n. ent
Central stenosis
Internal disc disruption
decrease disc height
osteophytes
70
Disc herniation
Ms J.H. 25 y.o. female presented with cauda equina syndrome
71
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
72
Spinal stenosis
AP
lateral
myelogram
Post myelogram CT
73
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%
74
Isthmic spondylolisthesis
75
Severe spondylolisthesis
76
Time for a 10 minute break!
77
Pediatric Orthopedics
1.
2.
3.
4.
5.
6.
Developmental Dysplasia of the Hip.
Legg-Perthes Disease.
Slipped Capital Femoral Epiphysis.
Club Feet.
Osteomyelitis.
Septic Hip.
78
1.
a.
b.
c.
d.
e.
Talipes Equinovarus is the proper
name for :-
Flat feet
In-toeing
Club feet
Knock knees
Wry neck
79
1.
Talipes Equinovarus is the proper
name for :-
c. Club feet
80
1.
Talipes Equinovarus is the proper name
for :a.
b.
c.
d.
e.
Flat feet
In-toeing
Club feet
Knock knees
Wry neck
Pes Planus
Metatarsus Adductus
Genu Valgus
Torticolis
81
Talipes Equinovarus
congenital deformity of the foot
Equinus, Inversion, Adduction, Supination
2 per 1000 live births
50% bilateral
M >F 2:1
Serial corrective casts at birth
Surgery if resistant
EARLY TREATMENT IS ESSENTIAL
82
2. Trendelenburg refers to :a.
b.
c.
d.
e.
Leg length discrepancy
Gait abnormality
Knee recurvatum
Scoliosis
Hip Contracture
83
2. Trendelenburg refers to :-
b. Gait abnormality
84
2. Trendelenburg refers to :a.
b.
c.
d.
e.
Leg length discrepancy – Apparent vs Real
Gait abnormality
Knee recurvatum – straightens past 1800
Scoliosis – lateral curvature, lordosis, kyphosis
Hip Contracture – Thomas test
85
3. All of these are signs of D.D.H.
except :a.
b.
c.
d.
e.
Limited Abduction
Ortolani Sign
Asymmetric Skin Folds
Galeazzi’s Sign
McMurray Sign
86
3. All of these are signs of D.D.H.
except :-
e. McMurray Sign
87
3. All of these are signs of D.D.H.
except :a.
b.
c.
d.
e.
Limited Abduction
Ortolani Sign
Asymmetric Skin Folds
Galeazzi’s Sign
McMurray Sign
Dislocated
Reducible
Dislocated
Knee height
Torn Meniscus
88
89
90
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
91
4. The most common congenital
Spinal abnormality is :a.
b.
c.
d.
e.
Scoliosis
Spina Bifida
Torticolis
Klippel – Feil Syndrome
Multiple Hereditary Osteochondroma
92
4. The most common congenital
Spinal abnormality is :-
b. Spina Bifida
93
4. The most common congenital
Spinal abnormality is :a.
b.
c.
d.
e.
Scoliosis
Spina Bifida
Torticolis – ‘Wry Neck’
Klippel – Feil Syndrome – Congenital Fusion
Multiple Hereditary Osteochondroma
94
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
95
96
97
5.
Polydactyly
98
6.
Syndactyly
99
7.
100
Sprengel’s Deformity
Omovertebral Bone
101
8.
A 6 year old boy with delayed physical
development, convulsions, tetany,
weakness, blue sclera and bony deformities is
most likely suffering from :a.
b.
c.
d.
e.
Physical Abuse
Ehlers – Danlos Syndrome
Osteogenesis Imperfecta
Multiple Hereditary Exostoses
Myositis Ossificans
102
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
103
8.
A 6 year old boy with delayed physical
development, convulsions, tetany,
weakness, blue sclera and bony deformities is
most likely suffering from :a.
b.
c.
d.
e.
Physical Abuse
Ehlers – Danlos Syndrome
Osteogenesis Imperfecta
Multiple Hereditary Exostoses
Myositis Ossificans
104
9.
A 6 year old boy with delayed physical
development, a rachitic rosary, weakness and
bony deformities is most likely suffering from :a.
b.
c.
d.
e.
Physical Abuse
Rickets
Scurvy
Osteitis Deformans
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 :-
b. Rickets
106
9.
107
9.
108
Etiology
Alkaline
Phosphatase
Calcium
Phosphate
Normal
Urea
Vitamin D
Deficiency
Rickets
Up
Down
Normal
Renal
Insufficiency
(Renal Rickets)
Up
Down
Up
Up
Renal
Tubular
Insufficiency
(HypoPhosphatemia)
Up
Down
Down
Normal
109
10. This is :-
a.
b.
c.
d.
e.
Osteomyelitis
Osteomalacia
Osteoporosis
Osteitis Deformans
Leprosy
110
10. This is :-
d. Osteitis Deformans
111
10. This is :-
a.
b.
c.
d.
e.
Osteomyelitis
Osteomalacia
Osteoporosis
Osteitis Deformans
Leprosy
112
Osteitis Deformans
Paget’s Disease
4% of pop. Over 40 yrs.
accelerated bone turnover
often assymptomatic
monostotic > polyostotic
loss of stature
AV shunting
pathologic bone
113
11. A child with knee pain has a ____
problem until proven otherwise.
a.
b.
c.
d.
e.
Knee
Femoral
Tibial
Hip
Patella
114
11. A child with knee pain has a ____
problem until proven otherwise.
d.
Hip
Obdurator Nerve
115
11. All of the following are part of the
differential of hip pain in a 6 year old,
except :a.
b.
c.
d.
e.
Femoral Osteomyelitis
Septic Hip
Transient Synovitis
Legg-Perthes Osteochondritis
Slipped Capital Femoral
Epiphysis
116
11. All of the following are part of the
differential of hip pain in a 6 year old,
except :-
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 :a.
b.
c.
d.
e.
Femoral Osteomyelitis
Septic Hip
Transient Synovitis
Legg-Perthes Osteochondritis
Slipped Capital Femoral
Epiphysis
118
Ages for Hip Disease
D.D.H.
Septic Hip
Legg-Perthes
Transient Synovitis
S.C.F.E.
Birth
Birth – 11
3 – 11
3 – 11
11 - 16
119
12. Osteomyelitis in children is
produced by what route of infection?
a.
b.
c.
d.
e.
Direct extension from another focus
Hematogenous spread
Perforating wounds
Lymphatic spread
Septic hip
120
12. Osteomyelitis in children is
produced by what route of infection?
b.
Hematogenous spread
121
Osteomyelitis
Acute infection,metaphyseal
90% Staph.,20% mortality
100% growth abnormality
Periosteal elevation, osteolysis
Sequestrum, Involucrum
122
13.
123
13.
Paronychia
124
14.
125
14.
Felon
126
15. All of these are findings of a
Herniated L5-S1 disc, except :a.
b.
c.
d.
e.
Absent Achilles reflex
Lateral foot numbness
Sciatica
Low back pain
Extensor Hallucis Longus weakness
127
15. All of these are findings of a
Herniated L5-S1 disc, except :-
e.
Extensor Hallucis Longus weakness
128
15. All of these are findings of a
Herniated L5-S1 disc, except :a.
b.
c.
d.
e.
f.
Absent Achilles reflex
Lateral foot numbness
Sciatica
Low back pain
Extensor Hallucis Longus weakness
Knee jerk
S1
S1
S1
L5
L4
129
16. Avascular necrosis of the femoral
head is associated with all of the
following except :a.
b.
c.
d.
e.
Steroid use
Alcohol
Deep sea diving
Lipid storage disease
Diabetes
130
16. Avascular necrosis of the femoral
head is associated with all of the
following except :-
e.
Diabetes
131
16. Avascular necrosis of the femoral
head is associated with all of the
following except :a.
b.
c.
d.
e.
Steroid use
Alcohol
Deep sea diving
Lipid storage disease
Diabetes
132
17.
8 year old boy
What is the
Diagnosis?
133
17.
8 year old boy
Legg – Perthes
Osteochondosis
134
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.
135
18.
Osteochondroses
Freiberg’s Disease
Osgoode-Sclatter’s
Scheuermann’s
Kienbock’s
Osteochondritis Disecans
2nd Metatarsal Head
Tibial Tubercle
Spine
Carpal Lunate
Lateral Femoral
Condyle
136
19. Diagnosis?
137
19. Gout
138
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
139
20.
L4
L5
Spondylolytic
Spondylolisthesis
140
Spondylolisthesis
Lumbosacral junction defect
Spondylolysis of Pars Interarticularis
Traumatic or congenital
Acute – immobilize
Chronic - surgery
141
21. The Salter- Harris Classification
is used to assess the severity of :a.
b.
c.
d.
e.
Epiphyseal Fractures
Developmental Dysplasia of the Hip
Legg – Perthe’s Disease
Club Foot
Osteomyelitis
142
21. The Salter- Harris Classification
is used to assess the severity of :a. Epiphyseal Fractures
143
I
IV
II
III
V
144
22. What is this deformity?
145
22. A Diner Fork Deformity
Probable Diagnosis?
146
22. Colles
Fracture
147
22. Colle’s Fracture
distal radial fracture
FOOSH
occurs at all ages
commonly 60 yrs. +
osteoporosis
intra-articular
148
CR & K-Wires
149
External vs Internal Fixation
150
23. The common complication
of this fracture is :-
151
23. Proximal pole Avascular Necrosis
152
153
24. This is a :-
a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line
154
24. This is a :-
a. Buckle Fracture
155
24.
This is a :a. Buckle Fracture
b. Greenstick Fracture
c. Stress Fracture
d. Pathologic Fracture
e. Growth Arrest line
156
24.
Greenstick
Fractures
157
25. Is this fracture treated by Closed or
Open Reduction?
158
25.
ORIF
159
25. Fractures of Necessity
160
26. What is the Diagnosis?
161
26. Posterolateral Dislocation of the Elbow
162
26. Reduction by traction.
TRACTION
163
27. What is the Diagnosis?
164
27. Anterior Dislocation of the Shoulder
165
27. Reduction by traction
166
28.
This is a :a. Supracondylar #
b. Olecranon #
c. Dislocation
d. Forearm #
e. Radial Head #
167
28.
This is a :a. Supracondylar #
168
28. Supracondylar Fracture
169
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
170
29. The complications of a Supracondylar
fracture in children include all of the
following except :-
f. Pulmonary Fat Embolus
171
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
172
30. The only sign of a Compartment
Syndrome that is always present
is :a. Pain
b. Pallor
c. Pulselessness
d. Paresthesias
e. Paralysis
173
30. The only sign of a Compartment
Syndrome that is always present
is :a. Pain
174
30. The only sign of a Compartment
Syndrome that is always present
is :a. Pain
b. Pallor
c. Pulselessness
d. Paresthesias
e. Paralysis
175
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
176
31. Compartment pressures
indicating the need for
fasciotomy :-
c. > 25 mms. Hg
177
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
178
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
179
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
180
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
181
33. Name the Fracture :-
182
33. Monteggia Fracture
183
33. Monteggia Fracture
184
33. Monteggia Fracture
185
34. Name this
fracture :-
186
34. Name the
fracture :Galeazzi
Fracture
187
34.
Galeazzi
Fracture
188
35. The commonest complication
of this fracture is :-
189
35. A Radial Nerve Palsy
190
36. Does this fracture
require surgery?
191
36. Does this fracture
require surgery?
Yes
192
37. Does this fracture require surgery?
193
37. Does this fracture require surgery?
No
194
38. This patient
most likely
has a fracture
of the --------.
195
38. This patient
most likely
has a fracture
of the --------.
Hip
196
38. This patient
most likely
has a fracture
of the hip.
External Rotation
Shortening
Hip Flexion
197
38.
198
39. What’s the Diagnosis?
199
39. Sub-Capital Hip Fracture.
200
40. All of the following are
complications of this fracture except :a. Malunion
b. Avascular necrosis
c. Fat emboli
d. Non-union
e. Thrombophlebitis
201
40. All of the following are
complications of this fracture except :-
c. Fat emboli
202
40. Blood Supply of Femoral Head
203
40. Save Head versus Replacement
204
40. Subcapital Hip Fractures
Garden Classification
1. Abduction
2. Minimally displaced
3. 50% Displaced
4. Completely Displaced
205
40. Subcapital Hip Fractures
Properties
1. Avascular Necrosis - 30%
2. Malunion - 30%
3. Non-union - 30%
4. Surgery required
5. Older population
6. Pathologic - Osteoporotic
206
41. What’s the Diagnosis?
207
41.
Intertrochanteric Hip Fracture
208
41. Intertrochanteric Fractures
209
41. Intertrochanteric Fractures
Properties
1. Varus deformity
2. Well - Healing
3. Traumatic + Osteoporosis
4. Surgery required
5. Mid-range Age population
210
42. What is the Diagnosis?
211
42. What is the Diagnosis?
Subtrochanteric
Hip Fracture
212
42. Subtrochanteric Fractures
Properties
1. Non-union
2. Traumatic
3. Surgery required
213
43.
Surgery
or not?
214
43.
Surgery
or not?
Yes
215
44. Surgery or not?
216
44. Surgery or not?
Yes
217
44. Ankle Fractures
Eversion Injuries
218
44. Ankle Fractures
Inversion
Injuries
219
45. What is the approach to this fracture?
23 y.o. male
Basketball injury
Open fracture
Numbness dorsum
toes
220
45.
Reduce dislocation
Sterile dressing
Splint extremity
Re-check NV status
IV Antibiotics
Tetanus
Surgery
221
46.
Surgery or not?
222
46.
Surgery or not?
Yes
223
47. Surgery or not?
224
47. Surgery or not?
Yes
225
47. Surgery or not?
Yes
226
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.
b.
c.
d.
e.
Lumbar Muscular Strain.
Herniated Lumbar Disc.
Herniated Lumbosacral Disc.
Cauda Equina Syndrome.
Spinal Stenosis.
227
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.
228
49.
Your initial approach to this problem would
include some or all of the following:-
a.
b.
c.
d.
e.
f.
g.
h.
Bedrest.
Anti-inflammatories.
Muscle Relaxants.
Spinal X-rays.
Physiotherapy.
Orthopedic/Neurosurgical referral.
CT-Myelogram or MRI
Discectomy
229
49.
Your initial approach to this problem would
include some or all of the following:-
a.
?
b.
c.
d.
e.
f.
g.
h.
Bedrest.
Anti-inflammatories.
Muscle Relaxants.
Spinal X-rays.
Physiotherapy.
Orthopedic/Neurosurgical referral.
CT-Myelogram or MRI
Discectomy
230
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.
b.
c.
d.
Reassure the patient that this is not serious
Order an urgent MRI
Get an urgent referral to Neuro/Orthopedics
Place the patient on immediate bedrest.
231
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
232
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.
b.
c.
d.
Reassure the patient that this is not serious
Order an urgent MRI
Get an urgent referral to Neuro/Orthopedics
Place the patient on immediate bedrest.
233
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.
b.
c.
d.
e.
Fracture of the Hip.
Fracture of the Femur.
Anterior Hip Dislocation.
Posterior Hip Dislocation.
Fracture of Pelvis.
234
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.
235
52. Which of the following signs and
symptoms are consistent with a torn
medial meniscus of the knee:a.
b.
c.
d.
e.
Inability to squat
Pain on descending stairs
Locking
Recurrent effusions
All of the above.
236
52. Which of the following signs and
symptoms are consistent with a torn
medial meniscus of the knee:a.
b.
c.
d.
e.
Inability to squat
Pain on descending stairs
Locking
Recurrent effusions
All of the above.
237
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.
b.
c.
d.
Re-X-ray the ankle.
Remove the cast.
Measure the compartment pressures.
Instruct the patient to elevate the
limb and prescribe an anti-inflamatory.
238
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.
239
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.
b.
c.
d.
Re-X-ray the ankle.
Remove the cast.
Measure the compartment pressures.
Instruct the patient to elevate the
limb and prescribe an anti-inflamatory.
240
54. The most common dislocations of the
shoulder are:-
a.
b.
c.
d.
Medial.
Posterior.
Luxatio Erecta.
Anterior.
241
54. The most common dislocations of the
shoulder are:-
d.
Anterior.
242
55.
Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except:a.
b.
c.
d.
e.
Thyroid.
Pancreas.
Prostate.
Kidney.
Lung.
243
55.
Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except:-
c.
Prostate.
244
55.
Metastatic lesions to bone, of the
following tumours, usually produce lytic
defects except:a.
b.
c.
d.
e.
Thyroid.
Pancreas.
Prostate.
Kidney.
Lung.
245
Th - Tha – That’s all folks!
246