Orthopedic Pearls

  1. What is spondylolysis?
    • -Spondylolysis is a unilateral or bilateral defect in the pars interarticularis portion of the vertebrae.
    • -It is a stress fracture mostly seen in the lumbar vertebrae, and most commonly L5.
    • -Pain is relieved with rest and worsened by lateral bending or extension (NOTE: most back pain is worsened by flexion).
    • -If neurologic symptoms and/or radiculopathy are present, an alternative diagnosis should be considered, because they are rarely associated with spondylolysis.
    • -Diagnostic imaging should start with plain radiographs with added oblique views.
    • -Classically, oblique views show the Scotty dog sign with a crack on the dog’s neck/collar, the pars.
  2. Acute septic arthritis involving 2 or more joints should raise a suspicion of what condition?
    Acute septic arthritis involving 2 or more joints should raise a suspicion of Infective Endocarditis (Mayo Clin Proc, Vol. 82, pg. 615).
  3. Some common injuries and their board review associated complications
    • Anterior Shoulder Dislocation = Axillary nerve or artery injury
    • Supracondylar Fracture = Brachial Artery injury
    • Posterior Elbow Dislocation = Brachial Artery injury
    • Knee Dislocation = Popiteal Artery Injury and Peroneal and tibial nerve injury
    • Humeral shaft fracture = radial nerve injury
    • Posterior hip dislocation = sciatica nerve injury
    • Anterior hip dislocation = femoral nerve injury
  4. List the Salter Harris Classification System of Pediatric Epiphyseal Fractures:
    Type I: A fracture through the physeal growth plate. Typically can not be seen on x-ray unless they growth plate is widened.

    Type II: A fracture through the physeal growth plate and metaphysis.

    Type III: A fracture through the physeal growth plate and epiphysis.

    Type IV: A fracture through the physis, physeal growth plate and metaphysis.

    Type V: A crush injury of the physeal growth plate.

    A image of the fractures can be found on FP Notebook at http://www.fpnotebook.com/_media/OrthoFractureSalterHarris.jpg
  5. Common exam facts about Salter Harris Fractures:
    The type II fracture is the most common.

    The small metaphyseal fragment in Salter Harris type II and IV fractures is called the Thurston Holland Sign.

    Type III and IV fractures often require open reduction and internal fixation due to the fracture extending into the joint.

    Type V fractures may appear normal, but the epiphyseal plate is crushed and the blood supply is interrupted.
  6. Four muscles make up the rotator cuff (SITS) which control internal and external rotation of the shoulder and abduct the shoulder:
    • -Supraspinatus
    • -Infraspinatus
    • -Teres Minor
    • -Subscapularis
  7. True or False: The majority (>90%) of rotator cuff tears are chronic in nature and due to subacromial impingement and decreased blood supply to the tendons.
    • TRUE
    • Tears can also be due to acute injuries (falls, heavy lifting, forceful abduction).
  8. How do you treat rotator cuff tears/injuries?
    Most patients can be treated with:

    • -Sling immobilization
    • -NSAIDs
    • -Referral to sports medicine or orthopaedic surgeons.
    • -Elderly patients should be referred quickly as prolonged immobilization can lead to a frozen shoulder.
  9. Adhesive Capsulitis -- Frozen Shoulder Pearls
    Characterized by pain and loss of motion or stiffness in the shoulder.

    Normally NOT seen below the age of 40, affects ~2% of the population, and diabetics are at increased risk. ELDERLY DIABETICS.

    Due to thickening and contracture of the capsule surrounding the shoulder joint.

    Can occur after trauma to the shoulder if the shoulder is not moved early enough, but is also know to occur idiopathically.

    X-rays are only helpful to rule out other causes of the shoulder pain and are typically normal in Adhesive capsulitis.

    Typically will get better on its own over 2-3 years.

    Physical Therapy and home exercises aimed at restoring ROM can shorten the duration of pain and stiffness. Surgery can be done if there is no improvement with medical management and physical therapy.

    Prevention strategies include early ROM exercises in those with shoulder injuries especially in the elderly diabetic.
  10. When evaluating an elbow plain film, what is the anterior humeral line and what is it's significance?
    The anterior humeral line: On a true lateral film, this line is drawn along the anterior aspect of the humeral shaft on the lateral radiograph. This line passes through the middle one third of the capitellum in bones that are not injured. It is very useful for detecting subtle fractures.

    Fractures (i.e. supracondylar) usually result in displacement of the capitellum posteriorly, thus, the anterior humeral line passes through the anterior one third or entirely anterior to the capitellum.
  11. When evaluating an elbow plain film, what is the radiocapitallar line, and what is it's significance?
    The Radiocapitellar line: Since the radius articulates with the capitellum, a line is drawn through the middle of the radius shaft and extended proximally through the joint should bisect the capitellum on all views (AP & lateral).

    Improper alignment indicates a radial head dislocation (which may be very subtle).
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Orthopedic Pearls
Orthopedic Pearls