ortho notes learning objectives

7/28/2019 Ortho Notes learning objectives

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Ortho

Ortho 1Artificial Joint Replacements

Dr. Donald Longjohn, May 15, 2012

1. Know when surgery is indicated for joint problems

Indications for surgery: Pain unrelieved by non-operative means (Meds, injections, therapy), Reducesquality of life, and appropriate surgery available, acceptable risk for surgery

Indications for joint surgery: presence of joint dz, level of pain, interference with sleep, impact of

function (walking distance, ambulatory aids, ability to perform ADLs)

2. Know the surgical options current available for joint problems. Identify the best surgical option for a

patient profileSurgical options for Arthritis:

Osteotomy: correct joint malalignment (abn force distribution) by cutting bone and realigning, force

on involved surface by redistribution, joint spared but shortens bone

Indications: young, active, OA due to malalignment/trauma, cartilage remainingDebridement: remove inflamed synovium and smooth irregular articular surfaces, better if there is a

specific lesions that are addressed (degen meniscal tears, loose bodies in knees), not used much now

Arthrodesis (fusion of joint): eliminates motion at joint, increases stress on adjacent joints, rarely done

Arthroplasty (replacement): resection or total, total is best for pain relief, function and motion,potential for wear, loosening and infection; incidence of THA increasing, most dont require revision

Hip surface replacement: big head so less risk of dislocation, metal/metal articulation, Risk of

femoral neck fracture (esp older, women)Total Knee (TKA): increasing incidence, more difficult rehab than THA, functioning extensor

mechanism is required for good function, not true only lasts 10t (90% chance of 10y, 80% of 20y)

3. Know the contraindications for joint replacement

*Active infection, morbid obesity, progressive neurological dz, young age (


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4. Understand pathoanatomy, clinical findings, and treatment of plantar fasciitisPathogenesis: inflammation/microscopic tearing of plantar fascia, 50% have spur

PE: pain worst in morning, gradually improve, pain upon starting walking after sitting, point tender of

medial calcaneal tubercle, 80% overweight/obese, tight calf muscle, and inability to dorsiflex

Treatment: Address overuse (lose weight, cross train, job modification), calf stretching, NSAID, healorthotic (heel cup, pad), warm soak with/without Epsom salt or contrast bath, PT, night splint

Ortho 3Biomechanics of FracturesDr. Lee, May 17, 2012

1. Understand the factors that contribute to fractures.

Strength of bonemetabolic, structural, modality of force applied, age effects

2. Understand the factors that contribute to fracture healing

Metabolic (nutrition, smoking, NSAIDs) and local biology (blood supply from surrounding soft tissues)

3. Understand principles of fracture treatment.

Restore axial alignment, anatomy, and pre-injury state as quickly as possible

4. Understand complications of fractures.

Non-union: arrest in the healing process, sclerosis at bone ends

Hypertrophic: bones and ends viable, build up of callusAtrophic; vascularity compromised, bone degenerates at break

Other complications: Adult Respiratory Distress Syndrome (ARDS), Fat emboli, PE, compartment

syndrome, nerve injury, vascular injury, injury to soft tissue

SPP #4: Low Back Pain

Dr. Abbott, May 17, 2012

1. Describe at least 3 differences between todays humans and our ancestors, and between humans and other

primates that help explain why humans are predisposed to back pain.

Our ancestors were hunters and gatherers and evolved for this lifestyle. We are sedentary today.We have a lordotic curve of the spine while other primates are arched.

We walk bipedally

2. Describe at least lifestyle 5 factors that lead to back pain in Americans today.

Excessive sitting, poor sitting posture, static posture, way people lift/carry, way people walk/run

3. List and describe the 6 most common etiologies of low back pain.Muscle of ligamentous strain (usually from acute injury)

Disk degeneration or rupture

OsteoarthritisVertebral fracture or collapse (freq in older persons with osteoporosis)

Psychosocial factors (hysteria, malingering, etc.)

Spinal stenosis

4. In addition to #2 above, list 4 serious causes of low back pain that must be ruled out in any case of lowback pain, and describe 2 or 3 signs or symptoms (red flags) for each cause.

Neoplasm, Infection, Metabolic problems, extrinsic diseases (i.e. aortic aneurism)

Red Flags: AGE > 50 y.o. Or < 20 y.o. History of cancer, Constitutional symptoms, IV drug abuse,

Immune suppression, Recent infection, Pain worse at night, Trauma, Progressive neurologic symptoms5. List the specific symptoms and signs of compression/compromise of specific L-S nerve roots.

L4 L5 L6

Screening Exam Squat and Rise Heel Walking Walk on toes

Strength Weak extension of leg at knee Weak dorsiflexion of foot Weak plantar flexion of foot

Sensory Numbness at knee Numbness at web of big toe, lateral calf Numbness along back of calf, lateral foo

Reflexes Loss of knee-jerk reflex No reflexes lost Loss of ankle jerk


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Pain Along front of leg Along side of leg Along back of leg

6. Describe at least 4 psychosocial issues that may be associated with back pain.Depression, Anxiety, Hypochondriasis/Hysteria, Acute remunerative back pain

Ortho 4Clinical Applications of the SpineDr. Smith, May 17, 2012

1. Learn the basics of a neurological examination for acute spinal cord injury (SCI)

Motor exam: diaphragmatic breathing indicates intact C45 Upper and 5 lower extremities groups; Strength tested 0-5 C5- Shoulder abduction/elbow flexion, bicep reflex C6- Elbow flexion/wrist extension. bracioradialis reflex C7- Elbow extension/ wrist flexion. triceps reflex C8- Finger flexion T1- Hand intrinsics

L2 Hip flexion

L3 Knee extensionL4 Ankle dorsiflexion, patellar reflexL5 Great toe extension S1 Ankle PF/ eversion/hip extension, Achilles reflex S2 Knee flexion

2. Understand complete vs. incomplete SCI and the syndromes associated with incomplete injuries

Complete: loss of motor/sensory function below the injury level

Incomplete: preserved motor and sensory function below the injury level Central cord syndrome: central gray matter destroyed, white preserved, extension injury in arthritic C-spine

o Present with quadriplegia with preserve perianal sensationo UE>LE involvementUE flaccid and worse deficito Good prognosis

Brown-Sequard Syndrome: hemisection, penetrating injury (GSW or stab wound)o loss contralateral pain/To Loss of ipsilateral motor and light touch proprioceptiono most recover ambulation, bowel, bladder

Anterior Cord Syndrome: pressure on anterior cord or infarcto loss of motor and pain/T sensationo preserved light touch and proprioception (dorsal column)o poor prognosis if no sacral sensation to pinprick after 24h

Posterior Cord Syndrome: very rareo Loss of light touch, proprioceptiono motor, pain, T intacto Foot slapping gait from loss of proprioception

Cauda Equina Syndrome: space occupying lesion within L/S canalo Disc herniated, tumor, epidural hematoma, epidural abscesso Sx: saddle anesthesia, lower ext. pain, sensorimotor loss, bowel-bladder dysfunctiono Surgical emergencydecompress ASAP

3. Be able to distinguish the clinical and radiographic differences between the basic spinal compressive

pathologiesCervical Myelopathy: disease of spinal cord, symptoms of hand clumsiness or gait instability

Characterized: clumsiness of hand and gait imbalance Etiology: degen spondylitis, congenital stenosis, ossification of posterior longitudinal ligament, tumor, epidural

abscess, trauma, kyphosis Pathophysiology: disc dehydration, annular tears, herniated disk, disc narrowing, posterior spurs Clinical: neck pain, coordination/dexterity loss, balance/gait abn, sensory changes (diffuse numbness, tingling),

bladder/bowel dysfunction

Neuro Exam: tandem gait testing, reflex testing (UE variable, LE hyperreflexic), disinhibition of reflex arc,Hoffmans sign, Babinski+, Ankle clonus

Not dx by radiograph, MRI contraindicated, myelomalacia is bright on T2, signal change on T1 is badprognosis

Cervical Radiculopathy: spinal nerve compression which follows a dermatome and may be associated with weakness

numbness and hyporeflexia

Etiology: cervical spondylosis, disc herniation Clinical: occipital headache, pain in neck, shoulder, arms, parasthesisa, weakness or clumsiness


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Neuro exam: Spurling test, hyporeflexia May have referred pain or other MSK pathology

Lumbar Radiculopathy: dermatomal pain usually radiating below the knee and may be associated with weaknessnumbness and hyporeflexia

Etiology: disc herniations and synovial facet cysts Clinical: axial back pain, radicular pain, neurogenic claudication Neuro Exam: straight-leg raising test (esp L5, S1), Femoral stretch test (L2-4), motor weakness, absent reflexes L4-5 Hern disc: shooting pain with numbness in the great toe, worse sitting/driving

Lumbar Spinal Stenosis: narrowing of spinal canal

Etiology: Spondylolysthesis (slippage of vertebrae), fact osteophytes, disc herniations, synovial cysts,hypertrophy of ligamentum Flavum

Clinical: 50+yo, back and leg pain, +/- radicular distribution, burning/tightness in buttocks (walking) Neuro: induced with exercise, loss of DTR, muscle weakness, SLR rarely+ Consider coexisting Dx

SPP #5: Shoulder Injury and Elbow Injury

Dr. Abbott, May 17, 2012

1. Describe the location and function of the rotator cuff muscles of the

shoulder.See Right2. Describe the 2 most common etiologies, and the basic pathophysiology

of impingement syndrome. List signs and symptoms.

Most common site of pathology: supraspinatus tendonRubbing/compression of the tendon under surface of the arch

(coracoids-coracoacromial ligament-ant. acromion) Onset is insidious or

sudden. Pain in the lateral upper arm, may radiate distally, worse at night

disrupting sleep, worse with reaching overhead. Increasing weakness orstiffness. On exam, tenderness to forceful palpation just inferior to the acromion Pain is at subacromial front

(vague) of the shoulder with radiation to the deltoid insertion.

Epidemiology:40yo: chronic rotator cuff/supraspinatus tendonitis

>60yo: partial and full-thickness tears of the supraspinatus tendon and OA common

3. Describe anatomical site and pathophysiology of lateral epicondylitis.Extensor carpi radialis brevis

4. List signs and symptoms and differential of elbow lateral epicondylitis

Signs and Sx: sharp pain brought on by gripping, carrying brief case, tenderness over lateral epicondyle(no warmth/swelling), normal range of motion,

DDx: Lateral epicondylitis (tennis elbow), Medial epicondylitis (golfers elbow), Other ligamentous injury, Trauma,Arthritic/inflammatory process, Neuropathy

Ortho 5Orthopaedic Soft Tissue Injury and Sports Medicine InjuriesDr. Vangsness, May 17, 2012

1. Understand the structure & function of collagen in soft tissuesCollagen maintains structural integrity of soft tissues

2. Be familiar with three common soft musculoskeletal tissue injuries

3. Appreciate the healing/surgical treatment of these tissues as it pertains to the athlete/high demand pt

4. Know the Treatment Plans for These Common InjuriesMeniscus Ligament Tendon

Function Load-bearing, shock absorption,

joint stability and lubrication

Tensile and viscoelastic properties,

effects of age

Tight collagen bundles and tens

strength,


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Injury/Healing Very painful

Poor healing (periph vascularity)

Arthritis dev w/o intact men.

Failure from load deformation and

stress/strain, L ~10%

Common injury of ACL

Pathology from age-related

changes, function to move

muscles/bones, pain

Rotator cuff (


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6. Describe other knee conditions that may mimic meniscal or ligamentous injuries to the knee.Chondromalacia Patella, Subluxation, Dislocation can present with medial joint pain and giving way of the knee.

An increased Q-angle, + Apprehension test, PF stress with pain and crepitation and X-rays lead to this diagnosis.Loose Bodies in the knee joint can cause "clunks and clicks" and "buckling" of the knee. P.E. and X-rays, and, if

necessary, arthroscopy will aid in the diagnosis.Bursitis - both pes anserinus and medial collateral ligament bursitis present with medial joint pain. But the pain is

very localized to these structures and a diagnostic injection of local anesthetic will confirm the diagnosis by complete,

temporary, relief of pain.

Tendonitis - Patella and Popliteal tendonitis and Iliotibial "Band" Friction Syndrome are seen in runners and aredifferentiated by their locality and relation to specific sports activity.

7. Describe the MRI findings of meniscal and ligamentous tears of the knee joint.Shows tear (white) in damaged structure

8. Outline the treatment for meniscal and ligamentous tears of the knee joint.Conservative treatment with PT and a brace, arthroscopic meniscal repair/excision followed by PT or

arthroscopic meniscal repair/excision plus ACL reconstruction followed by PT and a brace.

9. Describe rehabilitation after a knee injury.Depends on patients desires for his life. Can be very intense or moderate

Ortho 7Pediatric OrthopaedicsDr. Choi, May 21, 2012

Pre-quiz (Or, important points!)

1. Name three differences between adult and pediatric bones

Children have a physis (growth plate), a thick periosteum and a more porous cortex.

2. Name three fracture patterns unique to children

Bending patternBuckle pattern (torus)

Greenstick fracture (incomplete)

Complete (typical in adults)

Children have GREAT ability to remodel3. What is the most common operative fracture in kids?

Supracondylar humerus fracturesfrom falling with outstretched hand

Lecture Objectives:

1. Understand the basics of fracture disease in children.


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Plastic deformation (or bowing/bending), torus (or buckle) fractures, and greenstick (or incomplete) fractures arefracture patterns unique to growing child/adolescent.

2a. Name the natural history of knee alignment from birth to age 7 years.During normal development, children are bow legged, and then become knock-kneed. Special shoes or

wedges make no difference

b. Most common causes of in toeing (pigeon toes)?Natural history: Out-toed and birth, then in-toed until 10y

Causes:1. Metatarsus adductus: foot deformity in 1styear of life, spontaneous resolutions by 2-4yo, curved foot2. Internal tibial torsion: common 1-3y, expect spontaneous recovery by 4yo3. Femoral anteversion: femur twisted internally (knees internally rotated), present at birth, sit in W position,

resolved to normal adult values by 8-10y

c. Know that rotational problems require surgery in only 0.1% of cases

3. Identify 2+ causes of limping in the growing child/adolescentslipped capital femoral epiphysis (SCFE)

and Legg-Calve-Perthes (LCP) Disease. Understand the disease, epidemiology, natural history, and basictreatment principles for SCFE, LCP, and scoliosis.

SCFE LCP Scoliosis

Disease Physis widens, leads to slippage ofthe femoral head posteriorly

Idiopathic avascular necrosis involving the

femoral head

Abn lateral curvature of the

spine


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Clinical

Presentation

Present w hip, thigh or knee pain

PE: obligate ext rotation

X-ray: slipped off like ice cream

Limp, w groin hip, thigh or knee pain usually

activity related

X-ray: flattened femora head w partial

dislocation

Uneven shoulders, Prominent

shoulder blades, Uneven

waistline, Lumbar prominen

Leaning to one side

Causes Unclear exact causeObesity, Af. Am., delayed bone

age, certain endocrinopathies,

renal osteodystrophy

Unknown.

Temp disruption of blood supply

Unclear, genetics?

Epidemiology Most common adolescent hipproblem

Adolescent boys, 10-16yo

10-15% bilateral

Boys (4:1), 4-8yo (1:2000 kids)

10% bilateral

2-4% adolescent, ages 10-16

NaturalHistory

Early arthritis Good long term prognosis, younger = better

Spontaneous improvement 80-100 may affect heart/lun

Basic

treatment

principles

Prevent further slippage

Surgery: pinning/screwing

Conservative, non-opactivity mod, anti-

inflammatories, PT

Rarely: surgical repair


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7. Describe the electromyographic and nerve conduction findings found in CTS.Can show just how bad the CTS is. Shows increase in the distal median sensory latency time and distal

median motor conduction time at the level of the wrist and early denervation of the thenar muscles.

8. Outline the non-operational and surgical treatment of CTS.

Non-op: splinting to remove pressure, NSAID, steroid injection into carpal canal

Surgical: remove pressure in carpal canal

Ortho 8Overview of Hand SurgeryDr. Stevanovic, May 21, 2012

1. Obtain a general overview of hand surgical problems and an approach to the field of hand surgery.

Donttouch nerves. Make sure there is a collateral circulation.Zones of tendons at right

Infection: 4 signs on Kanavel:

*Slight flexion of finger*Fusiform swelling*Tenderness along flexor sheath*Pain with passive extension

2. Have a basic knowledge of hand anatomy.

Study gross anatomy3. Understand a basic concept of hand evaluation

Determine what structure is maintained in order to determine what can be done.

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