Kingston Exam Review Orthopedics Tom Green MD. MSc. FRCPC, Dip Sports Med (CASEM) Emergency Medicine and Sports Medicine Royal Columbian Hospital Allan McGavin Sports Medicine Clinic University of British Columbia

What will we cover Not a comprehensive review of everything!!! Prioritizing your biggest resource: TIME!!! Some General exam tips from someone not too too far out. What ortho to expect on exam day. The Ortho Chapters Representative written questions and Visual Stim 2

My General Exam Tips: There is a lot to cover – Don’t get bogged down in the details – Don’t over think it. High vs. Low Yield – Discuss in study group Where are the lists?? – Each page of Rosen’s – review till your eyes hurt On exam day – Don’t get hung up on low yield effort. – Taking a hit on a few questions is ok. – Questions have multiple parts.

Orthopedics in the study year 239 pages out of 2511 pages of Rosen’s Thats 9.5% 2 weeks in our study schedule early in the year!!! Strategies to re-review X-ray visual stim Quick snappers

Resources = Rosen’s Rosen’s and Tint are where the money is. Ortho is well covered. – Good for fractures and major complications – So so for soft tissue, rehab, common complications of minor injury Not the most realistic in the real “Canadian” world. – Lots of consults and MRIs. Lags behind evidence. – Not much new in ortho, but things evolve – Open Fractures, Clavicle, Achilles, Scaphoid, AC separation Other Texts which are pretty good – Harris and Harris: Radiology of Emergency Medicine – Simon and Sherman: Emergency Orthopedics

Orthopedics on Exam Day On the exam: 4-6 Questions?? Where are you going to see ortho: – Visual Stim / Written / Parts of oral Anatomy: common injuries in commonly injured bones – ie: Label the x-ray or Rosen’s diagram Indications for surgical consult Complications of common injuries Associated injuries: ie: ongoing pain in ankle sprain

LOOK CAREFULLY Is this a non accidental pattern. Is this a pathologic injury. Patterns associated with significant injury Potential big miss. Ortho question on an oral exam!!! Don’t trip over the lifeline Exam Day Strategy Am I Missing Something?? Each section has potential subtle findings lipohemarthrosis / talar dome / hand and foot bones......

Highest Yield chapter Questions likely to have portion from this chapter Lots of lists in boxes and text. Fracture descriptions and Eponyms (CAREFUL HERE) Complications Associated Injuries Salter Harris Open Fractures Splinting Basics Chapter 49: General Principles General Principles

The Hand Chapter 50: hand Information overload. – Acceptable angles etc..... – +++ text Higher Yield Flexor and extensor tendon anatomy Zones of extensor tendons Ligamentous injuries: ie: Skiers thumb Tenosynovitis (Kanavel’s signs) Also High Yield Amputations and Avulsions

Wrist and Forearm Chapter 51: Wrist and Forearm Common on exams (and in practice) Types of fractures Normal Anatomy and Acceptable reductions Criteria for distal radius reduction Pediatric radius fractures Carpal ligamentous instability DISI / VISI

Ligamentous Wrist Injury Mayfield’s stages of injury. Lunate Angulation depends on primary force of ligament. Triquetral force: Dorsal Scaphoid force: Volar Scapholunate dissociation / DISI Scapholunate ligament rupture Perilunate dislocation Capitolunate space disruption “space of porrier” Luno-triquetral rupture / VISI Lunotriquetral ligament Lunate dislocation Dorsal Radiolunate ligament Chapter 51: Wrist Carpal dislocations D.S. Melsom, I.J. Leslie: Current Orthopaedics (2007) 21, 288–297

When the wrist x-ray looks normal Common missed or subtle injuries Scaphoid fracture Dorsal Triquetral Ligamentous injury – Ligamentous carpal instability: stages 1-4 – VISI, DISI In real life and maybe on the exam: – Can always splint and get follow-up or CT. Chapter 51: Wrist

Elbow Neurovascular anatomy and risk with fractures and dislocations. Supracondylar fractures: highest yield Midshaft Humerus fractures Radial Head fractures Pulled Elbow Most other elbow fractures require ortho consult – Less you can ask about on exam. Chapter 52: Humerus and Elbow

Shoulder Chapter 53: Shoulder Dislocation – Types – Reduction method (tough question to ask) AC separation grades and management. Clavicle fractures. – Surgical indications Good practical info on soft tissue injuries. – Lower yield on exam, but high yield at work Rehab!!!!

Back Pain Low Yield Chapter for Exam Prep This edition is well written decent summary of approach. Chapter 54: MSK Back Pain Key Points Indications for plain films in low back pain Plain films vs. Advanced imaging? RED FLAGS

Pelvis High Yield Lots of lists in this chapter Oral Exam!!! – More likely ortho for oral exam?? – Decisions in trauma management. ie: angio vs OR Label the Anatomy!!! Classification of Pelvic Fractures – Tile / Young & Burgess Trauma management Chapter 55: Pelvis

Tile Classification 17 A Stable pelvic ring injury B Partially stable ring rotationally unstable vertically stable C Unstable ring (vertical shear) rotationally and vertically A1 Avulsion fractures of the innominate bone A2 Stable iliac wing or stable minimally displaced ring fractures A3 Transverse fractures of the coccyx and sacrum B1 Open book injury—unilateral B2 Lateral compression injury B3 Bilateral type B injuries C1 Unilateral C2 Bilateral, one side type B, one side type C C3 Bilateral type C lesions Tile: Stable / Rotational / Rotation + Vertical Stresses Biomechanical Stability Chapter 55: Pelvis

Young and Burgess 18 Lateral / AP / Vertical shear Combined Severity within each category defined by posterior injury Describes pelvic ring fractures based on mechanism of injury Is predictive of injury severity and resuscitative needs Chapter 55: Pelvis

When the x-ray looks normal Hard to see – Acetabular fractures. Chapter 55: Pelvis Displaced ramus fractures. Sacral foramina asymmetry. Sacral lateral lip avulsion. Ischial spine avulsions. L5 transverse process. Markers of posterior arch fractures

Femur and Hip High Yield Child with a limp!!!!! Hip fracture – Anatomy and blood supply – Femoral nerve block Femur Fractures Differential Diagnosis of Hip Pain without fracture. – Big and common sense list – Low Yield Dislocation – Techniques – management and complications. Chapter 56: Femur and Hip

Knee and Lower Leg Knee dislocation – Management – Risks / Investigations Soft Tissue Injuries and sports medicine injuries. When the x-ray looks normal – Effusion – Lipohemarthrosis – Tibial spine avulsion – Osteochondral lesion – Segond fracture – Arcuate sign Chapter 57: Knee and Lower Leg

Ankle and Foot Lots of Good Questions Chapter 58: Ankle and Foot Classification and mechanism of ankle fractures Management of ankle fractures (ie: surgery / cast) Ankle sprain and Differential diagnosis of sprain Foot: Lisfranc Calcaneus fractures: x-ray visual stim

Ankle and Foot When the x-ray looks normal Chapter 55: Ankle and Foot Talar Dome 5th MT avulsion Joint spaces Mortise Syndesmosis Talar tilt Calcaneus Lisfranc

Summary Lists, lists, lists, lists, lists Don’t over think and over resource. Questions are multipart and there are lots of them Visual stim: keep your good x-rays. Anatomy of commonly injured joints Common soft tissue complications Is this a non accidental injury pattern When the x-ray looks normal

Thank You If you have any questions about ortho Tom Green