Orthopedics 4

  1. What ligaments hold atlas to axis & keep it stable?
    Alar ligaments
  2. Light touch: Upper Neck:
  3. Light touch: Lower Neck:
  4. Anterior vert column:
    vert bodies, disc spaces, A&P longitudinal ligaments, & annulus fibrosis
  5. Posterior vert column:
    pedicles, facet joints, laminar spinous processes, & posterior ligament complex
  6. If one of the two vert columns is intact, then:
    the injury is stable
  7. If both columns are disrupted, then:
    the injury is unstable
  8. 2 major regions of C spine:
    cranio-cervical junction (occiput to C2); lower cervical spine (C3 - C7)
  9. Cranio-cervical jnct (occiput to C2)
    50% of motion; atl-occ jnt (Yes); atl-axial jnt (No)
  10. Lower C spine (C3 - C7)
    50% of motion divided evenly between segments
  11. Spine Forces:
    flexion (forward & lateral), extension, axial compression, rotation, & distraction
  12. Anterior Marginal Line
    line drawn along the anterior vertebral bodies
  13. Posterior Marginal Line
    line drawn along the posterior vertebral bodies C2 - C7
  14. Spinolaminal Line
    line drawn along the bases of the spinous processes C1 - C7 (marks the posterior margin of the spinal canal)
  15. Posterior Spinous Line
    line drawn along the tips of the spinous processes C2 - C7
  16. Radiology: Trauma:
    order lateral, AP, & odontoid view; all 7 vertebrae must be seen
  17. Radiology: Lateral:
    4 smooth lines
  18. Radiology: AP:
    spinous processes should be in a vertical row
  19. Radiology: Odontoid:
    open mouth: inspect odontoid, distance between axis & dens should be equal bilateral
  20. Tx Jefferson fx: stable
    Rigid collar (cervicothoracic) x 3 mo; regular f/u for radiographs
  21. Tx Jefferson fx: unstable
    Cranial traction; halo x 3 months; > 5mm C1-C2 subluxation = C1-C3 fusion
  22. Odontoid fx types
    type I (rare): avulsion fx of alar ligament; type II & III
  23. Burst Jefferson fx stability: determined by:
    transverse ligament
  24. Burst Jefferson fx stability:
    Usually neuro intact (fragments burst away; wide breadth of C1 canal)
  25. Burst Jefferson fx: 1/3 of fx assoc with:
    an axis fx
  26. Burst Jefferson fx: 50% chance that:
    some other C spine injury is present
  27. Odontoid fx MOA
    Hyper-flexion or hyper-extension
  28. Odontoid fx: Blood supply (watershed area):
  29. Odontoid fx: assoc with:
    C1 neural arch fracture or Jefferson fx
  30. Odontoid fx: 25% incidence of:
    neurologic injury
  31. Odontoid fx: non-displaced fx show:
    callus at 2-3 weeks
  32. Hangmans Fx =
    Traumatic Spondylolisthesis of C2 (bilateral C2 pedicle fx)
  33. Hangmans Fx MOA
    hyperextension & sudden violent distraction; hyperextension & axial loading; or flexion & compression (usu combination of forces)
  34. Hangmans Fx: Types
    4 types (I, II, IIA, III = worst)
  35. Hangmans Fx: Immobilization:
    rigid cervical orthosis or halo vest system
  36. Hangmans Fx: Traction:
    used generally for reductions (Gardner-Wells tongs or halo vest system)
  37. C spine inj prevalence in football
    10-15% of football players
  38. Sp cord injury overall incidence
    4/100,000 per year
  39. Most recent sport SCI:
    football, trampoline (gymnastic), diving
  40. Highest % head injuries
    football; then ice hockey
  41. Acute Cervical Sprain =
    Injury to restraining ligaments of cervical spine
  42. Acute C- Sprain grade I (mild):
    ligaments damaged but not lengthened
  43. Acute C- Sprain grade II (mod):
    some laxity but not total disrupt
  44. Acute C- Sprain grade III (severe):
    ligament completely disrupt
  45. Acute C- Sprain can occur alone or with:
    C-strain (mx), fx/ dislocation, instability
  46. Isolated C-sprain: S/S
    • localized pain, decreased ROM, no neurologic deficits
    • Acute C- Sprain: if no fx/ sublux on films, then get:
    • flex/ext (assess for instability)
  47. Acute C- Sprain: if sig mx spasm, then:
    repeat flex/ext films after spasms subside (protect neck)
  48. Acute C- Sprain: if poss subluxation:
    pt should wear hard collar & flex/ext films repeated in 2-4 wks
  49. Acute C- Sprain: if instability present, may need:
    6-12 wks immobilization in rigid orthosis and/or surgery
  50. Acute C- Sprain: if xray w/u neg:
    RTP only when painless full ROM & normal neck strength
  51. Cervical Stenosis =
    narrowing of sagittal diameter of cervical canal
  52. C-stenosis often asymptomatic until:
    acute hyperflexion/ extension or axial loading of C-spine produces neuro signs
  53. C-stenosis: segments most commonly involved
    C5 and C6 segments
  54. Cervical Stenosis Types
    Congenital; Developmental; Acquired
  55. C-stenosis: Congenital =
    short pedicles, funnel shape of cervical canal
  56. C-stenosis: Developmental =
    bone size due to stress in weight training
  57. C-stenosis: Acquired =
    spondylosis, spurs, disc bulge or space narrowing
  58. Fx & Dislocation: Injury MOA
    axial load w/ slight neck flexion (spearing)
  59. Downed Player: initial x-rays s/b obtained:
    on spine board with helmet on
  60. Cervical Spondylosis =
    Chronic disc degeneration (arthritis)
  61. Cervical Spondylosis: Represents:
    nerve root compression
  62. Cervical Spondylosis S/S:
    neck pain, radicular pain radiating from neck to upper extremity
  63. Cervical Spondylosis Rx:
    supportive, facet injections, operative decompression
  64. Brachial Plexus Neuropraxia include:
    Burners, stingers, hot shots (football, wrestlers, hockey)
  65. Brachial Plexus =
    C5, C6, C7, C8, T1
  66. Brachial Plexus Neuropraxia: Blow to head:
    lateral flexion to contra side of shoulder being depressed results in traction on nerves
  67. Brachial Plexus Neuropraxia S/S
    Sudden burning pain, numbness in lateral arm, thumb, & index finger, lasts 1-2 min
  68. Brachial Plexus Neuropraxia: if S/S persist/ repeated:
    MRI is indicated
  69. Brachial Plexus Neuropraxia RX:
    • ROM, strengthening, protection
    • Atlas: superior surface of lateral masses articulates with:
    • the occipital condyles forming the occipito-atlantal joints
  70. Atlas: inf surface of lateral masses articulate with:
    the superior articular facets of C2 forming the C1 - C2 apophyseal joints
  71. R/O C Spine Fx
    Pt not c/o neck pain; no neck tenderness on palp; no hx LOC; no mental status changes fr trauma, etc; no S/S referable to neck inj (paralysis, sensory changes); no other distracting inj
  72. C Spine injuries
    Occ- atl Dislocn; Occ Condyle Fx; Atlas fx (C1); Odontoid fx; Atl-Axl (C1-C2) instability; C2 Lateral Mass fx; traumatic Spondylolisthesis of C2 (Hangmans fx)
  73. Burst Jefferson fx MOA
    Axial blow to head, force transmitted thru occ condyles; forces C1 lateral masses outward
  74. Burst Jefferson fx Radiology:
    C1 lat masses not line up vertly w/ C2 sup articular facets; distance btw dens & C1 lat masses is asymmetric
  75. Odontoid fx: tx
    Reduce fx & hold in halo immobilization (3 months); C1-C2 fusion if severely displaced or non-union; Few advocate acute ORIF dens
  76. Hangmans Fx: alignment:
    vert body of C2 is normally aligned w/ C1 & dens; post elements of C2 are normally aligned w/ C3
  77. Hangmans Fx: Stability:
    unstable; neuro deficit is surprisingly rare unless C2 - C3 subluxation is severe
  78. Hangmans Fx: Tx
    will usually stabilize with halo fixation; anterior fusion may be needed due to delayed instability
  79. Hangmans Fx: Operative Tx:
    occipitocervical fusion; atl-axial fusion; transarticular screw fixation; ant. screw fixation of dens; internal fixation w/ posterior plating of occiput to C2
  80. Evaluation of cervical instability (White & Punjabi )
    Vert malalignment; >3.5mm translational displacement; 1.7 mm or greater disk widening
  81. C-Cord Neurapraxia & Transient Quadriplegia: S&M recovery usu occurs in:
    10-15 minutes (up to 24-36h in some)
  82. C-Cord Neurapraxia & Transient Quadriplegia may involve:
    both legs, both arms, or ipsilateral arm & leg
  83. C-Cord Neurapraxia & Transient Quadriplegia Initial evaluation:
    routine c-spine films & poss CT scan (flex/ext films if routine films normal); consider MRI
  84. Fx & Dislocation: forces transmitted:
    directly to spinal structures; energy first absorbed by discs with compressive deformation; continued energy: angular deformation & buckling w/ failure of discs, lig structures & bony elements
  85. On Field Eval (Downed Player)
    • 1: Assess ABCs;
    • 2: initial neuro;
    • 3: turning the athlete;
    • 4: immobilization;
    • 5: evacuation
  86. Downed Player: turning athlete
    Doc at head grasp player shoulders & cradle head w/ forearms (if use hands alone, avoid flexing neck). Avoid cervical traction
  87. Downed Player: immobilization
    Leave helmet & shoulder pads on; fasten torso to spine board w/ straps; sandbags/ blankets on either side of head and taped with helmet to board
  88. Downed Player: immobilization: C-collar =
    NOT an alternative to proper head immobilization on the board & may compromise the airway
  89. C Spine injuries: Tx
    Philadelphia collar immobilization (stable); Halo immobilization (stable); Occipito-cervical fusion (unstable)
  90. Trapezial strain:
    localized pain posterior C-Spine; Pain reproducible with palpation of trapezius; Wry neck or torticollis; Rx: Supportive
  91. Stingers & Burners =
    transient shooting/ burning pain or paresthesia in one arm related to neck or shoulder trauma
  92. Stingers & Burners: due to:
    stretch injury on brachial plexus or compression on nerve root (neural foramen)
  93. Stingers & Burners: If S/S longer than 15 min:
    consider w/u (if compression type injuries, image for foraminal stenosis or herniated disk)
  94. Shoulder: 4 joints:
    SC, AC, GH, Scapulothoracic
  95. Acromion process Type I:
    Flat, smooth acromion at clavicular joint; normal subacromial space
  96. Acromion process Type II:
    Hooked acromion; subacromial space mildly decreased
  97. Acromion process Type III:
    Hooked acromion with spur; subacromial space significantly decreased
  98. Shoulder Hx: unusual aspects
    hand dominance; Night pain; Clunks, pops; Neck pathology
  99. Night pain: may indicate
    rotator cuff injury
  100. Scapular winging/trauma =
    Serratus or Trapezius dysfxn
  101. Unable to externally rotate =
    Posterior dislocation
  102. Supra/infraspinatus wasting =
    RCT or suprascapular n. palsy
  103. Dec. cervical ROM, pain below elbow =
    Cervical disc disease
  104. Throwing athletes/ ant. Pain =
  105. Pain or “clunk” w/ motion =
    Labral tear
  106. Night pain =
    Impingement, Frozen
  107. Generalized laxity =
    Multidirectional instability
  108. Shoulder Exam: significant:
    Asymmetry; Atrophy; Apley scratch test
  109. Rotator cuff: tests for impingement
    Neer; Hawkins (both passive)
  110. Test of AC joint
    crossover (passive)
  111. Tests for biceps tendonitis
    Speeds; Yergason (both active)
  112. Tests for anterior shoulder instability
    Sulcus; apprehension & relocation (both passive)
  113. Tests for labral tears
    Obrien; anterior slide; crank
  114. Circulation tests
    Adson; Allen; Roos
  115. Shoulder imaging: Standard views:
    AP and axillary
  116. Imaging: Can get Y view if:
    suspected dislocation or scapular fx (trauma)
  117. On shoulder imaging: may see:
    bony bankhart, Hill-Sachs (uncommonly), or spur; tumor or fx; elevated humeral head (RCT); AC separation or DJD
  118. Best imaging for RCT
    CT arthrogram good, but MRI is better (invasive)
  119. CT is good for:
    bone abnormality; tumors
  120. MRI for RCT
    95% sensitivity & specificity in detecting RCT
  121. MRI good for:
    RCT; SLAP lesions (Arthrogram); Soft tissue
  122. Ultrasound: Positives
    Non-invasive; Cost; Portable
  123. Ultrasound: Negatives
    Quality; User dependent
  124. Shoulder Injections
    Depo medrol w/ lidocaine & bupivacaine HCl (total of 10 mL); 25 gauge 1.25-1.5 needle
  125. Common Injection Solutions
    Depo Medrol, Celestone; Dexamethasone; Kenalog
  126. Depo Medrol, Celestone =
    shorter acting, less irritating
  127. Dexamethasone =
    Medium (duration)
  128. Kenalog =
    Long acting, slightly more painful initially; mix with lidocaine & Marcaine
  129. 5% of all fractures seen by FP =
    Clavicle Fx
  130. Clavicle Fx: MOA
    FOOSH, onto shoulder, direct trauma
  131. Clavicle Imaging
    AP, 45 degree cephalic tilt
  132. Grades of AC Separations:
    6 different grades
  133. AC Separation: MOA
    Usually direct blow to shoulder
  134. AC Separation: PE:
    step deformity, TTP AC joint, (+) crossover sign
  135. AC Separation: Radiographs:
    AP, Zanca (100 cephalic tilt), axillary
  136. AC Separation: Grade 3 & above:
    Refer for poss surgical fixation, otherwise conservative care (sling)
  137. AC Separation: RTP when:
    pain-free with abduction, crossover
  138. Anterior SC Dislocation: MOA
    Anterior usually MVA
  139. Anterior SC Dislocation: PE:
    TTP SC joint, deformity
  140. Anterior SC Dislocation: Radiographs:
    AP, 40 degree cephalic view
  141. Anterior SC Dislocation: Mgmt
    Usually conservative; Sling, ROM
  142. Posterior SC Dislocations: MOA
    Usually fall on flexed and adducted shoulder
  143. Posterior SC Dislocations: Concern
    Can be life-threatening; immediate referral and CT
  144. Posterior SC Dislocations: Mgmt
    Closed reduction or surgical reduction
  145. 95% of dislocations =
    Anterior Shoulder Dislocations
  146. Anterior Shoulder Dislocations: usually held in:
    ext. rotation and abduction
  147. Cf to anterior, posterior shoulder dislocations have:
    limited external rotation
  148. Anterior Shoulder Dislocations: Radiographs:
    AP and axillary or Y
  149. Anterior Shoulder Dislocations: Mgmt
    Acute: reduction (Stimpson or Kocher)
  150. Anterior Shoulder Dislocations: Complications:
    recurrent dislocations, bony injury (Hill Sachs, or Bankhart), RCT , NV injury, arthropathy (later)
  151. Anterior Shoulder Dislocation: Tx
    once reduced, sling w/ mobilization in 2 wks
  152. Rotator cuff disorder: age of most pt
    usually > 40 y.o. unless traumatic
  153. Rotator cuff disorder: S/S
    Insidious onset, worse w/ overhead activity, night pain
  154. Rotator cuff disorder: PE:
    ROM, RC strength, Hawkins/Neer, Jobe
  155. Rotator cuff disorder: Tx & CI
    Injections contraindicated if there is a partial tear
  156. Rotator cuff disorder: Tx (conservative)
    NSAIDs, ice, avoid painful activity, PT, injections
  157. Rotator cuff disorder: Tx (surgical)
    arthroscopy vs open
  158. Biceps Tendonitis: usu assoc with:
    other pathology (RCT, SLAP tear); may rupture if RCT worsens
  159. Biceps Tendonitis: PE:
    TTP Bicipital groove, Speeds, Yergasons
  160. Biceps Tendonitis: Tx
    NSAIDs, corticosteroid injection, PT
  161. Biceps Rupture: age of pt
    Usually > 50 yrs old
  162. Biceps Rupture: usually involves:
    long head of biceps (short head rupture rare)
  163. Biceps Rupture: S/S
    pop, ecchymosis
  164. Adhesive Capsulitis =
    Contraction of capsule (Frozen Shoulder )
  165. Adhesive Capsulitis: Usually secondary to:
    immobilization after injury
  166. Clin dx of Adhesive Capsulitis: what is key?
    ROM (usually lose external rotation first)
  167. Adhesive Capsulitis: mgmt
    PT, NSAIDs, injections; may need surgical lysis of adhesions
  168. 3 Stages of Adhesive Capsulitis
    Painful; Adhesive; Recovery
  169. SLAP Lesions =
    Superior Labral Anterior Posterior
  170. SLAP Lesions S/S
    Painful shoulder with clicks, pops with motion
  171. SLAP Lesions: PE
    Pos clunk test, crank test, OBriens, sometimes instability or biceps tendonitis; MRI
  172. SLAP Lesions: tx
    Conservative tx (NSAIDs, PT, rest); arthroscopy vs open repair
  173. Tests for posterior shoulder instability
    Pt supine, elbow flexed 90, arm abducted to 90; push postly, pos test = pt apprehension & laxity
  174. Posterior shoulder dislocations cf to anterior:
    Posterior will have limited external rotation cf to anterior dislocations
  175. Clavicle Fractures: most common geography
    middle third (followed by distal third); most common place at jnct btw middle & distal 1/3
  176. Clavicle Fx: PE:
    edema & pt tenderness over fx site; assess ROM of neck, shoulder; motor strength, sensation; SC dislocations
  177. Clavicle fx: Tx
    Sling; Figure of 8 (sig displacement, use of arms for ADLs); Periodic ROM; No contact sports for 6 wks
  178. Clavicle Fx: When to Refer?
    NV compromise; open fx; symptomatic non-union at 12 wk; Cosmesis; Distal third (? physeal injury, AC injury); Proximal third (SC joint dislocation)
  179. Rotator cuff disorder: DDX:
    Instability; SLAP; Bursitis; Referred pain ; Calcific tendonitis; Thoracic outlet syndrome; Adhesive capsulitis
  180. Ant Shoulder Dislocation: may need surgical repair
    Thermal capsular shift (subluxations); arthroscopy vs open repair
  181. Biceps Rupture: Mgmt
    Conservative: Proximal (most); MRI if dx uncertain; Tenodesis within 3-4 wks prn (Distal)
  182. Adhesive Capsulitis: epidemiology
    assoc w/ other illnesses (DM, thyroid, recent chemo/ rad); F >> M (increased estrogen receptors around shoulders)
  183. Adhesive Capsulitis: Painful stage
    (0-3 months); pain w/ movement; genl ache; mx spasm; inc noc/ rest pain
  184. Adhesive Capsulitis: Adhesive stage
    (3-6 months); Less pain; inc stiffness & restricted movement; less noc pain; pain at extreme ranges of movement
  185. Adhesive Capsulitis: Recovery stage
    (>6 months); dec pain; restrictn w/ slow, gradual inc ROM; recovery spontaneous, often incomplete
  186. Ulnar n. symptoms
    numbness, paresthesia, thenar wasting
  187. Carrying angle (M/F)
    Men 5 degrees, women 10-15 degrees
  188. Elbow Radiographs: Order:
    AP, lateral, oblique
  189. Elbow Radiographs: Inspect for:
    Cortical defects; Radiocapitellar line; Ant. humeral line; fat pad sign
  190. Anterior fat pad =
    Usually normal (Sail sign)
  191. Posterior fat pad =
    Always pathologic
  192. Posterior fat pad sign in adults may indicate:
    radial head fx
  193. Posterior fat pad sign in kids =
    supracondylar fx
Card Set
Orthopedics 4
Orthopedics flashcards made by previous students