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What are the 5 aims of tmt in spinal injury?
- 1. Dx injury
- 2. prevent further neuro damage
- 3. maximize recovery
- 4. mobilise patient early
- 5. prevent late instability
A routine C spine trauma series is which views? (3)
- transoral C1, C2
What is the ligament that most often gets stretched out in shoulder dislocation
anterior glenoid labrum
What are the 4 rotator cuff muscles. Why does physio help these prevent shoulder dislocations?
- Teres Minor
Because they are dynamic stabalizers
What is the most common associated injury in a dislocated shoulder?
damage to the axillary nerve
How do you put a shoulder back in?
What arm position typically results in an anterior shoulder dislocation when taken to extreme?
Abduction and external rotation
How would you treat a displaced midshaft clavicle fracture?
Describe the tests you do to test for a rotator cuff tear (just supra and infraspinatus)
- 1) Supraspinatus: empty can test
- 2) Infraspinatus: resist external rotation
How do you treat lateral epicondylitis (tennis elbow)? (4)
- -activity modification
What is Phalen's maneuver and how does it test for Carpal tunnel syndrome?
- -elbows out and the dorsum of your hands back to back, flexing your wrists
- -pinches off the median nerve and mimic their symptoms
Which causes of shoulder pain do you often see in the 5th to 6th decade of life? (3)
- Rotator cuff (impingement and tear)
- adhesive capsulitis
- glenohumeral arthritis
Hypotension following trauma must be assumed to be THIS until proven otherwise
How do you treat hypovolemic shock? How do you NOT treat it?
Do NOT treat using vasopressors, steroids, or sodium bicarbonate
What components are included in a SAMPLE trauma Hx?
- Signs and Symptoms
- Last Meal
- Events related to injury
What are the signs of comparment syndrome? (6)
- Polar (Cold)
- Paresthesias (numbness)
- Pain out of proportion
- Pulseless (late finding)
Describe the 3 phases of callus bone healing. Describe primary bone healing
- 1) Inflammatory phase
- 2) Reparative phase
- 3) Remodelling phase
Primary bone union: Two pieces are held tightly together so that there is no movement (e.g. with pins)
When should a fracture be splinted?
As soon as possible!
What are the two stages of definitive care in fractures?
- 1) reduction
- 2) immobilization (maintenance of reduction)
Why are knee dislocations a surgical emergency?
There can be compression of the popliteal artery. may lead to an above the knee amputation, compartment syndrome
What are the red flags for back pain? (6)
- 1) Certain ages (>50 or children)
- 2) Neurodeficiency that is large and progressive
- 3) Past cancer Hx
- 4) Immunosuppressed
- 5) Constitutional symptoms
- 6) fails to improve with tmt
If you think that the vascular supply is compromised after a break, what is the first thing you should do? (2)
Reduction and splinting
What is the most serious complication of a displaced supracondylar fracture of the humerus?
Compartment syndrome of the forearm. There is a major artery by this.
What are the indications for an open fracture reduction?
- NO CAST mnemonic
- Open Fracture
- Neurovasc Compromise
- Intra-Articular fracture
- Salter-Harris 3,4,5
What should you NOT do with a patient with idiopathic LBP? What should you do?
Treat with NSAIDS and muscle relaxants. Continue normal activites
What is the only cause of back pain that need emergency sugery?
Cauda Equina compression
3 common reasons for bone lesions on X ray
- multiple myeloma
- malignant lymphoma
What investigations should you do if you see a bone lesion? (4)
- -blood test (ESR, CRP, M-protein)
- -Chest X-ray (looking for source of mets)
- -bone scan (shows amount of bone turnover)
What are the red flags that should make you think of a bone tumor? (4)
- 1) persistent bone pain
- 2) localized tenderness
- 3) Spontaneous fracture
- 4) Enlarging mass/soft tissue swelling
What is one way that you can differentiate malignant from benign bone tumors?
benign: no periosteal reaction
Malignant: Periosteal reaction (Codman's triange, sunburst, Onion skin)
Describe the age for 3 primary bone tumors (in order of prevalence)
- 1) Osteosarcoma: usually in 2nd decade of life
- 2) Chondrosarcoma: Usually over 40
- 3) Ewing's Sarcoma: Usually 5-20
What are the 5 most common tumors to be meastatic to bone?
- BLT with Kosher Pickle
What are the 5 major risk factors for DDH?
- the 5 F's
- Feet first (breech birth)
- Family Hx
- First Born
- leFt hip
What are the two clinical test you can do to look for DDH?
- Ortolani (for dislocated hip): abduct hip and press down on the top of the leg to try and reduce it (+ve if you feel a clunk)
- Barlow test (for dislocatable hip): flex hips and knees to 90 deg with hips fully adducted and try to push the femoral heads out posteriorly
How do you treat DDH (birth to 6 mo, 6-18 months, 2+ years)
- birth to 6: Pavlik harness
- 6-18 month: traction and hip spica
- 2+ years: femoral shortening and open reduction
Describe the natural course of Perthe's (3 stages)
- 1) idiopathic ischemic event leads to avascular necrosis
- 2) revascularizarion causes dead bone to be woven into new, weaker bone
- 3) Sx occur when subchondral fractures and femoral head deformation inevitably happen
What do kids with Perthe's usually present with? (3)
- -tender anterior thigh
- -limited abduction and internal rotation
What is the main ideal behind tmt in Perthes?
Brace in abduction and flexion to keep the femoral head in the acetabulum
Who gets slipped capital femoral epiphysis (SCFE)? what is the difference between stable and unstable?
Fat teenagers with an endocrine problem
unstable is non-weight bearing
how do you treat SCFE?
bed rest and surgery to screw the epiphysis back to the underlying bone.
With regards to Cobb's angle, what is the definition for scoliosis, when do you brace, when do you do surgery (2)
- Scoliosis: >10 deg
- Brace: 25-45 degrees
- Sugery: curves that progress despite bracing, curves that are 50-60 degrees
What does bracing do in scoliosis?
prevents further progression, only surgery can correct
If you see a congenital spin deformity, what else should you check for?
heart and kidney deformities (form at the same time)
In what condition do you see the Scotty dog with it's neck broken off?
What is the unhappy triad in knee injuries?
What are the 2 clinical tests you can do to test for an ACL tear?
- Anterior drawer (90 degrees flexed)
- lachmann (most sensitive) (10 degrees flexed)
For both try to sublux the tibia anteriorly
What is the definitive tmt in ACL repair (only in active patients)?
Surgical graft from the hamstrings
What are the mechanical Sx you see in meniscal tears? (3)
Clicking, catching, locking (true lock is a leg stuck in flexion)
What is the most sensitive test for meniscal tears? Another common test. How do you treat meniscal tears?
joint line tenderness. Another test is McMurray's treat with surgery (removal of problem portion)
What is the common mechanism of injury for a PCL tear?
flexed knee pushed backwards "dashboard injury"
What are the dynamic stabilizers of the patella? Which direction are knee dislocations? How would you treat the first dislocation?
Quads, lateral, non-operative (brace)
How would you treat extensor mechanism disruption of the knee?
Refer to surgery emergently (1-2 weeks)
How do you treat an open fracture? (3)
- -urgent surgery
- -tetanus prophylaxis
What is the female athlete triad?
Disordered eating, Amenorrhea, osteopenia
What are the three most common overuse injuries in the lower leg?
- -achilles/patellar tendinopathy
- -patellofermoral pain
- -metatarsal stress fractures
How do you treat overuse injuries in the leg? (4)
- 1. relative rest
- 2. address training errors
- 3. Physio
- 4. NSAIDS/Bracing
Largely, how do you treat fractured metacarpals?
ORIF (open reduction, internal fixation (pins))
Can do a closed reduction if it is just the neck
What do you call Ulnar collateral ligament injury?
- acute: ski pole thumb
- Chronic: gamekeepers thumb
Forced abduction of the thumb
What functions do the radial, ulnar, and median nerve have in the hand?
How do you treat hand flexor and extensor tendons problems
- Flexor: surgery
- extension: generally splint
How should you splint a hand injury?
In the safety position, provides the best use and is comfortable
What should you do if you suspect a scaphoid fracture but see nothing on xray?
Cast it on suspicion alone and xray again in 2 weeks. If there is dissociation, you need to do an ORIF
What is the most common cause of carpal instability? In what positions are the involved bones in?
- scapholunate dissociation
- scaphoid is palmarflexed, lunate is dorsiflexed
what usually causes a distal radial fracture (colle's fracture)? how would you treat?
Treat with closed reduction using long arm cast
How can you tell is someone has had a concussion (general)? What is your advice?
There is a big list, if they have any of the symptoms they have a concussion
- -Immediately remove them from play
- -slowly return them to play in stages after a week
When you see a cold white limb what should you do?
it is a surgical emergency
Name and briefly describe the 9 types of children's fractures
- 1) Buckle Fracture: Impaction injury, stable
- 2) Traumatic bowing: no true fraction
- 3) Greenstick fracture: incomplete fracture, one cortex broken, the other isnt
- 4) Complete fracture: rarely communitated (i.e. usually just two large pieces)
- 5) Growth Plate injuries: Salter Harris classification
- 6) Pathologic breaks: fractures through abnormal bones
- 7) Stress fractures: due to a sudden increase in activity
- 8) Open fractures: NEED tetanus, ABX, I&D
- 9) Child abuse: multiple injuries over time, at various stages of healing
Describe the salter harris classification? What special thing should you do with a growth plate injury?
- I: Separated
- II: Above the growth plate
- III: Lower than the growth plate
- IV: Through the growth plate
- V: ERasure of the growth plate (crush injury)
- (VI is the same as V but off to one side)
YOU NEED TO FOLLOW UP in 6 months to a year to look for growth abnormalities
When would you do an open reduction in a kid? (4)
- 1) closed reduction fails
- 2) displaced intraarticular fracture
- 3) possible head injured child with femur fracture
- 4) multiple trauma
Describe Monteggia's fracture and how you treat it
Diaphyseal (shaft) fracture of the proximal ulna with subluxation of the radial head.
ORIF of the shaft fracture and closed reduction of the radial head
Describe Conservative tmt for foot and ankle problems (5)
- -REST IT!
- -If it's pinched, give it some room (cortisone, orthotics)
- -If it's a tendon, rest followed by physio
- -If it's arthritis, immobilize it
- -If it's broke, send it to Ortho
How do you treat achilles tendonitis? (3)
-rest, NSAIDS, heel rise orthotics
TMT options for posterior tib tendonitis
- 1) orthotics, rest
- 2) Surgery: osteotomies to fusions
How do you treat an ankle fracture?
- 1) if the mortice (part where the talus sits in the tib-fib union) is intact, cast it
- 2) if the it isn't intact, surgery
How do you treat ankle arthritis?
fusion or arthroplasty
When do you not need to treat searching great toe and metatarsus adductus?
When they are flexible enough to move by hand.
List 5 benign causes of intoing. How do you treat?
- -searching great toe
- -metatarsus adductus
- -internal tibial torsion
- -medial femoral torsion (W sitting)
- -Combination of the above
Reassure parents that they will likely straighten out on their own
What is blount's disease? Who gets it? How do you treat?
Growth disturbance of posterior medial portion of proximal tibia. Fat black kids who walked early. treat by bracing or surgery
If you see a cavo-varus foot what is the first thing you should do? What usually causes it?
look hard for the muscle imbalance that is causing it. It is usually caused by a neuropathy (e.g. Charcot-Marie-Tooth)
How do you treat a calcaneovalgus foot? What else should you look for?
- -Do nothing it responds on its own
- -look for associate DDH
What is the preferred method of fixing a club foot these days
The Ponsetti method (bracing)
How do we treat syndactyly (webbed feet)?
We dont. No problems arise from them.
What is Kohler's disease?
It is like Perthe's (avascualar necrosis) of the navicular bone.
In general what is the best emergent care of a fracture
reduction (with gentle traction) and splinting
What are the indications for operative treatment in a fracture? (10)
- 1) cannot maintain a closed reduction
- 2) unstable fractures (ankle, forearm)
- 3) fractured femur shaft
- 4) displaced intra acticular fractures
- 5) "floating knee" or "floating elbow"
- 6) open fractures
- 7) multiple traumas
- 8) pathological fractures due to mets
- 9) fractures with vascular complications
- 10) patients where bed confinement is not desireable (e.g. hips)
Read the fracture management document in one note. Most of the questions came out of there.