1. Ortho Jeopardy I’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 Q $100 Q $200 Q $300 Q $400 Q $500 Q $100 Q $100 Q $100 Q $100 Q $200 Q $200 Q $200 Q $200 Q $300 Q $300 Q $300 Q $300 Q $400 Q $400 Q $400 Q $400 Q $500 Q $500 Q $500 Q $500 Final Jeopardy

2. 40yo M w/ shoulder pain s/p shoulder reduction following volleyball game.

3. Answer: Hill-Sachs deformity

4. 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

5. 79yo F s/p fall from standing, c/o hip pain. Name fracture, be specific

6. Answer: Intertrochanteric femur fracture

8. 16yo M w/ Rt elbow pain s/p fall onto right arm. Name the fracture and tell-tale sign seen here.

9. Answer: Supracondylar fracture w/ Posterior fat pad sign

10. 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

11. 25yo M w/ hip pain s/p fall from dorm loft. Give fracture and mgmt.

12. Answer: Femoral neck fracture; emergent ortho consult

13. 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)

14. 29 y/o M slipped while playing soccer. Name the bony abnormality. Your Text Here

15. Answer: Perilunate dislocation

16. 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

17. 22yo “profressional skateboarder” w/ wrist pain s/p gnarly ollie. Name the Fx.

18. Answer: Colle’s fracture

19. 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

20. 22yo M w/ Rt hand pain s/p altercation. Lacerations over knucles. Give Fx and mgmt.

21. Answer: Boxer’s fracture w/ fight bite injury; Tx w/ copious irrigation and prophylactic abx

22. 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

23. 25yo F c/o Rt wrist pain s/p drunken fall. Name this injury.

24. Answer:Scaphoid fracture

25. 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

26. 20yo snowboarder c/o L wrist pain s/p fall onto clenched fist.

27. Answer: Smith’s fracture

28. 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.

29. 55yo M w/ wrist pain s/p fall. Name the injury and tell-tale sign

30. Answer: Scapholunate dissociation

31. 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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34. 19yo F w/ ankle pain s/p trip over curb. Name the Fx.

35. Answer: Trimalleolar fracture

36. 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

37. 27yo M w/ lateral foot pain s/p rolling ankle during basketball game. Name the injury.

38. Answer: Jones fracture

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

40. 50yo M w/ lateral knee pain s/p jumping off top rung of ladder.

41. Answer: Tibial plateau fracture

42. 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;

43. 20yo M w/ lateral foot pain s/p twisting ankle.

44. Answer: Pseudo-Jones fracture

45. 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

46. 13yo M w/ knee pain s/p fall off bicycle. SH classification pls.

47. Answer: Salter-Harris II

48. 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

49. Salter-Harris Classification S – I – Slip A – II – Above L – III – Lower T – IV – Through R – V – Rammed

50. 44yo M w/ midfoot pain s/p MVA

51. Answer: Lisfranc Fracture

52. 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

53. 70yo F s/p FOOSH

54. Answer: Monteggia Fracture

55. $200 Answer from H4 Your Text Here

56. 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

57. 22yo M c/o pain at base of Lt thumb after punching wall

58. Answer: Bennet’s fracture

59. 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

60. 70yo F s/p FOOSH

61. Answer: Galeazzi fracture

62. 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)

63. 55yo M w/ RLE pain s/p FFH

64. Answer: Maisonneuve Fracture

65. 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

66. 22yo F w/ foot pain s/p jump from 2 nd floor fire.

67. Answer: Calcaneus fracture

68. 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 -

69. 25yo M unrestrained driver w/ wrist pain s/p MVA

70. Answer: Barton’s fracture

71. 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

72. 32yo M tree cutter, new onset quad s/p tree branch to head.

73. Answer: Jefferson fracture

74. 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

75. 55yo M unrestrained driver w/ wrist pain

76. Answer: Lunate dislocation

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

78. 45yo M high speed MVA w/ low back pain, ankle pain

79. Answer: Pilon fracture

80. 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

81. Final Jeopardy 60yo M w/ wrist pain after trying to start Ford Model T

82. 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