Ortho JeopardyI’ve fallen and I can’t get up

Those crazy kids

Stupid Canadians and their rules

“I don’t know Lloyd, the French are assholes”

Code brown, I mean yellow

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Final Jeopardy

40yo M w/ shoulder pain s/p shoulder reduction following volleyball game.

Answer: Hill-Sachs deformity

Hill Sachs deformity-compression fx of posterolateral humeral head from anterior rim of glenoid-50% of anterior dislocations-may infer damage to cartilagenous and/or osseous portions of the glenoid but does not change mgmt-associated with recurrent dislocations-only requires repair when associated with significant shoulder instability

79yo F s/p fall from standing, c/o hip pain. Name fracture, be specific

Answer: Intertrochanteric femur fracture

Intertrochanteric hip fracture

-results from falls, generally in elderly-Most common hip fx-leg will be shortened, externally rotated (dislocation will be shortened internally rotated)-Bucks traction-admit for ORIF/hemiarthroplasty

16yo M w/ Rt elbow pain s/p fall onto right arm. Name the fracture and tell-tale

sign seen here.

Answer: Supracondylar fracture w/ Posterior fat pad sign

Supracondylar fracture-make up 60% of fx of elbow-Type I: non displaced (posterior fat pad, sail sign, radiocapitellar line) - splint, ortho f/u Type II: partial displacement but retains cortical contact; III: posteromedial or posterolateral displacement w/o cortical contact-II and III admit for closed reduction, pin fixation, possible ORIF; -Volkmann's contracture: swelling incr’d forearm pressure muscle necrosis, fibrosis, contracture

25yo M w/ hip pain s/p fall from dorm loft. Give fracture and mgmt.

Answer: Femoral neck fracture; emergent ortho consult

Femoral neck fracture-intracapsular meaning higher risk for vascular compromise due to tearing of vessels or compression by hemarthrosis-admit all for ORIF but need emergent orthopedic consultation if young 2/2 high risk of AVN (w/ older pt they'll just do hemiarthroplasty)

29 y/o M slipped while playing soccer. Name the bony abnormality.

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Answer: Perilunate dislocation

Perilunate dislocation

-Results from forceful dorsiflexion (FOOSH)-Midcarpal ligament disruption-With enough force the ligaments are stripped away and the capitate is displaced posterior to the lunate producing posterior dislocation-Lunate maintains contact with the radius-Emergent orthopedic consultation

22yo “profressional skateboarder” w/ wrist pain s/p gnarly ollie. Name the Fx.

Answer: Colle’s fracture

Colle’s Fracture-FOOSH distal radius metaphyseal fracture just proximal to radiocarpal joint with dorsal angulation of fracture fragment "dinner fork deformity” -may include fracture of ulnar styloid, disruption of DRUJ  - check median nerve on exam-if non-displaced - sugartong w/ palmar flexion/ulnar deviation-if more than moderate angulation/displacement - reduce in ED w/ finger traps - may require OR but can d/c w/ ortho f/u

22yo M w/ Rt hand pain s/p altercation. Lacerations over knucles. Give Fx and mgmt.

Answer: Boxer’s fracture w/ fight bite injury;

Tx w/ copious irrigation and prophylactic abx

Boxer’s fracture

-Fracture through neck of 5th metacarpal 2/2 closed fist hitting solid object; -if >40degrees of angulation, should attempt reduction in ED-ulnar gutter splint w/ wrist at 30 degree extension and MCP at 90-early hand sx f/u-beware the fight bite – ppx antibiotics

25yo F c/o Rt wrist pain s/p drunken fall. Name this injury.

Answer:Scaphoid fracture

Scaphoid fracture-Scaphoid transmits force from hand to forearm making it most common carpal bone fx (triquetrum=2, lunate=3)-Result from FOOSH or axial load on thumb-TTP over snuffbox - examine with wrist in ulnar deviation, and check for pain w/ axial loading of thumb-negative plain films in 10% - repeat in 2 weeks and splint if high degree of suspicion-non-displaced fx = thumb spica splint and non-emergent ortho referral, if displaced may need ORIF-risk of AVN and non-union if not treated appropriately

20yo snowboarder c/o L wrist pain s/p fall onto clenched fist.

Answer: Smith’s fracture

Smith’s fracture

-aka "reverse Colle’s = fracture of distal radius with VOLAR angulation of distal fragment "garden spade deformity"-result of fall on flexed wrist-tx same as colles, although volar angulation makes reduction difficult, if angulation not severe/tenting skin, just splint.

55yo M w/ wrist pain s/p fall. Name the injury and tell-tale sign

Answer: Scapholunate dissociation

Scapholunate dissociation-Pt c/o pain on radial side of wrist and clicking sensation-PE - scaphoid shift test w/ radial deviation and examiner pressing over volar aspect of scaphoid-widening of scapholunate joint space >3mm-may also get rotation of scaphoid "signet ring sign”-usually require surgical repair-radial gutter or short arm splint w/ early ortho f/u-complications: early severe degenerative arthritis

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19yo F w/ ankle pain s/p trip over curb. Name the Fx.

Answer: Trimalleolar fracture

Trimalleolar ankle fracture

-Fracture involves lateral malleolus, medial malleolus and posterior aspect of distal tibia (posterior malleolus – misnomer)-If there is asymmetry in gap between the talar dome and 2 malleoli on mortise view, the injury is presumed to be unstable-Emergent ortho consult – may d/c w/ early o/p f/u if able to tolerate crutches

27yo M w/ lateral foot pain s/p rolling ankle during basketball game. Name the injury.

Answer: Jones fracture

Jones Fracture-transverse fx through base of 5th MT 2/2 inversion injury-several definitions:

-fx of 5th MT distal to JCT of metaphysis and diaphysis

-10-20mm distal to proximal part of MT-fx distal to distal edge of neighboring

cuboid -complicated by nonunion/malunion-conservative mgmt: ortho surgical boot, NWB for 6 weeks

50yo M w/ lateral knee pain s/p jumping off top rung of ladder.

Answer: Tibial plateau fracture

Tibial plateau fracture

-MOA: strong varus/valgus force w/ axial loading, ie fall from height-lateral = 55-70%-commonly associated with ligamentous injury-non-displaced fx of one plateau - knee immobilizer, NWB, crutches, f/u ortho w/in a few days, possible o/p MRI-if depressed articular surface - early ortho consult and ORIF;

20yo M w/ lateral foot pain s/p twisting ankle.

Answer: Pseudo-Jones fracture

Pseudo-Jones fracture

-2/2 inversion injury-avulsion fx of tuberosity of base of 5th MT -proximal to articulation of 4th and 5th MT -treat w/ cast shoe - WBAT

13yo M w/ knee pain s/p fall off bicycle. SH classification pls.

Answer: Salter-Harris II

Salter-Harris II fracture-SH classication used to classify fractures involving epiphyseal (growth) plate in children -SH II is most common type (75%) w/ good prognosis-fracture involves physis and metaphysis-generally conservative management is appropriate-ORIF is often required for type III and IV

Salter-Harris Classification

S – I – SlipA – II – AboveL – III – LowerT – IV – ThroughR – V – Rammed

44yo M w/ midfoot pain s/p MVA

Answer: Lisfranc Fracture

Lisfranc injury-6 bone tarsometatarsal complex = Lisfranc joint, separates midfoot from forefoot-20 percent of injuries are missed in ED-Fx of base of 2nd MT is pathognomonic for disruption of Lisfranc ligamentous complex-look for loss of alignment of 2nd through 4th MT w/ associated tarsal bones; -MOA ranges from minor rotational force to high speed MVA-frequently require ORIF-May be complicated by DP damage and severe DJD

70yo F s/p FOOSH

Answer: Monteggia Fracture

$200 Answer from H4

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Monteggia Fracture

-ulnar shaft fracture w/ proximal radial head dislocation-easy to miss radial head dislocation so be sure to image the elbow-be sure to check posterior interosseous nerve (finger/wrist extension) fxn b/c it wraps around proximal radius; -requires ORIF - call ortho

22yo M c/o pain at base of Lt thumb after punching wall

Answer: Bennet’s fracture

Bennet’s fracture

-intraarticular fx at base of thumb-MOA: axial load to flexed/adducted thumb as in punch with closed fist-unstable fx - requires thumb spica and hand sx referral-complications include malunion, severe DJD

70yo F s/p FOOSH

Answer: Galeazzi fracture

Galeazzi fracture

-distal radial fracture w/ DRUJ dislocation-emergent ortho referral for ORIF-be sure to check distal neurovascular status-MUGR (Monteggia=Ulna, Galeazzi=Radius)

55yo M w/ RLE pain s/p FFH

Answer: Maisonneuve Fracture

Maisonneuve Fracture-proximal fibular fracture assoc w/ rupture of deltoid ligament or fracture of medial malleolus (disruption of tibiofibular syndesmosis)-when you get ankle fracture, especially isolated medial malleolus fx, be sure to examine knee-requires immediate ortho consultation in ED-most require surgical repair of ankle fx/syndesmotic injury but may also be tx'ed conservatively w/ cast immobilization for 6-8 wks

22yo F w/ foot pain s/p jump from 2nd floor fire.

Answer: Calcaneus fracture

Calcaneus fracture

-MOA:fall from height onto foot-if high degree of suspicion but no obvious cortical disruption, check Boehler angle: <20 suggests depressed fracture-emergent ortho consult - tx varies: orthopods usually use CT to determine plan but most non-displaced fx can be managed conservatively-high incidence of compartment syndrome w/ comminuted fractures-check lumbar spine -

25yo M unrestrained driver w/ wrist pain s/p MVA

Answer: Barton’s fracture

Barton’s fracture-Fx of distal radial metaphysis w/ either volar or dorsal angulation (Colles/Smith) and intra-articular involvement and some carpal displacement – high force mech. -minimally displaced fx tx w/ splint and o/p ortho-unstable fx involving 50% of articular surface or associated carpal subluxation require ORIF - talk to ortho prior to d/c

32yo M tree cutter, new onset quad s/p tree branch to head.

Answer: Jefferson fracture

Jefferson fracture-fracture of C1 resulting from significant axial load to top of the head-4 part fracture involving both anterior and posterior arches-associated SCI common-treatment depends on integrity of transverse ligament intact ligament: tx w/ hard collar; disrupted ligament halo or surgery

55yo M unrestrained driver w/ wrist pain

Answer: Lunate dislocation

Lunate dislocation-similar to perilunate dislocation radiographically-triangular shape of lunate on AP view = "piece of pie" sign, lateral view shows lunate displaced volarly from radius = "spilled teacup" sign -unstable emergent ortho consultation, most require OR-complications = early DJD, malunion/nonunion, AVN, median nerve compression

45yo M high speed MVA w/ low back pain, ankle pain

Answer: Pilon fracture

Pilon Fracture-aka Tibial Plafond Fracture-combination of & distal tibial metaphyseal frx, usually w/ tibiotalar articular involvement -vertical loading drives talus into distal tibia -commonly associated with other high force mechanism injuries, ie VB compression fracture

Final Jeopardy60yo M w/ wrist pain after trying

to start Ford Model T

Final Jeopardy Answer

Hutchinson fracture-fracture of radial styloid w/ intra-articular involvement-aka Chauffeur’s fracture – back-firing of hand crank on old cars-requires ORIF