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Flashcards in Midterm 3: Buzzword Bingo Deck (479):
1

Types of bones that use endochondral bone formation

Long bones (humerus, femur, metacarpals, etc); short bones (carpals, tarsals, etc)

2

Cartilage model of bone forms -> starts to ossify from center outward

Endochondral bone formation

3

Types of bones that use intramembranous bone formation

Flat bones - clavicle, scapula, bones of the skull, bones of the pelvis

4

Embryonic mesenchymal cells cluster, differentiate into osteoblasts -> osteoblasts form spicules of bone that coalesce into bone plates

Intramembranous bone formation

5

Defect in this process leads to underdeveloped or absent clavicles, dental anomalies, larger fontanelles at birth, and osteoporosis

Intramembranous bone formation -> the disorder described is clavicocranial dysplasia

6

Autosomal dominant mutation in Cbfa1/Runx2

Claviocranial dysplasia - these are transcription factors in genes needed for osteoblast differentiation, so the mutation has the biggest effect on intramembranous bone formation

7

Impaired cartilage differentiation and growth may impact what kinds of bone development?

Endochondral bone formation, so long and short bones, but not so much flat bones

8

Zone of the epiphyseal plate that is the most common site of fracture

Hypertrophic zone

9

AD (heterozygous) mutation leading to constitutive activation of FGFR3 at the proliferative zone of bone

Slows proliferation of bone -> achondroplasia

10

Part of bone responsible for increasing in length

Epiphyseal plate

11

Dense bone in diaphysis that transmits force efficiently

Cortical bone

12

Type of bone found in metaphysis/epiphysis that provides cushioning

Cancellous/trabecular bone

13

"Butterfly fragment"

The triangular piece of bone that breaks off when a bone is broken under an axial load that is too strong. The side under tension cracks in a direction perpendicular to the axial load, but the side under compression shears, producing the triangular "butterfly fragment"

14

Cell that controls signaling for bone remodeling, mineralizes bone, and produces type 1 collagen

Osteoblast

15

Long-lived cell embedded in bone that maintains calcium homeostasis and plays a role in mechanotransduction within the bone

Osteocyte

16

Cell of hematopoietic origin that looks like a multinucleated giant cell and releases carbonic anhydrase to break down bone

Osteoclast

17

Bone cells of mesenchymal origin

Osteoblast -> osteocyte

18

Bone cells of hematopoietic origin

Osteoclast

19

Functional unit of cortical bone

Osteon/Haversian system

20

A receptor on osteoclasts that activates signaling pathways to result in bone resorption

RANK

21

A molecule secreted by osteoblasts that can activate osteoclasts

RANKL

22

Cellular target of action of activated vitamin D/PTH (what they act on)

Osteoblasts -> induce release of RANKL

23

Consequence of continuous over-secretion of PTH

"Brown tumors" - a vascular, fibrous lesion that occurs when hyperparathyroidism causes too much bone resorption in order to release more calcium

24

Net action of pulses of PTH or synthetic analogue (teriparatide)

Building bone

25

Drug class that mimics the structure of inorganic phosphate and leads to osteoclast apoptosis

Bisphosphonates

26

Tumor releases lots of RANKL -> what happens?

RANKL >> OPG, so there is too much bone resorption -> lytic lesions. Occurs in giant cell tumors, multiple myeloma, metastatic breast cancer

27

Tumor releases lots of OPG -> what happens?

OPG >> RANKL, so there is too much bone formation -> blastic lesions. Occurs in prostate cancer

28

Molecule that binds to RANKL and prevents osteoclast activation

OPG

29

OPG knockout mouse would have bones that looked like...

Osteoporotic bones! Very low bone density, since OPG induces bone formation by inhibiting bone resorption.

30

RANKL or RANK knockout mouse would have bones that looked like...

Hyperdense bones! Not enough RANKL/RANK action would lead to a lack of bone resorption, leading to very dense but probably structurally problematic bones.

31

Denosumab MOA

RANKL Ab that essentially acts like synthetic OPG, preventing RANK/RANKL interactions and inhibiting bone resorption

32

Osteoblasts are responsible for signaling for which aspects of bone remodeling?

Formation and resorption

33

RDA for calcium

1000 mg/day for most adults, more for adolescents, pregnant/lactating women, post-menopause, men over 70

34

Main goal of PTH secretion

Raise calcium levels

35

Blood Ca++ is low -> what does parathyroid do?

Secrete PTH

36

Blood Ca++ is high -> what does parathyroid do?

Prevent secretion of PTH

37

If the calcium sensing receptor in the kidney senses high Ca++, what does the kidney do?

Excrete calcium in urine

38

If the calcium receptor in the kidney senses low Ca++, what does the kidney do?

Reduce excretion of calcium in urine

39

MOA of PTH at kidney

Increase Ca++ resorption, inhibit phosphate resorption (because phosphate binds Ca++ and lowers available calcium), increases activation of vitamin D by 1-a-hydroxylase because that increases gut absorption of Ca++

40

MOA of PTH at bone

Bind to receptors on osteoblasts -> activate osteoclasts -> increased bone turnover -> release of calcium and phosphate into blood

41

High PTH leads to increased secretion of what signaling molecule by osteoblasts?

RANKL

42

If blood Ca++ is high, what should PTH levels be?

Lower

43

If levels of 1,25-D are high, what should PTH levels be?

Lower

44

How do Ca++ and phosphate levels change in response to 1,25-D?

1,25-D leads to both increased Ca++ (in conjunction with PTH) and increased phosphate

45

MOA of 1,25-D at GI tract

Stimulate Ca++ and phosphate absorption

46

MOA of 1,25-D at parathyroid gland

Decrease PTH production and cell proliferation there

47

MOA of 1,25-D at bone

Maintenance of adequate minerality of bone

48

Best marker to measure vitamin D status

25-D -> the formation of this is unregulated so this reflects total vitamin D entering the system

49

Step of vitamin D activation that is most highly regulated

Activity of 1-a-hydroxylase

50

Effect of PTH on 1-a-hydroxylase

Induces its activity in order to raise Ca++ levels by creating more 1,25-D

51

Inducers of 1-a-hydroxylase activity

PTH, low phosphate

52

Inhibitors of 1-a-hydroxylase activity

High Ca++, 1,25-D

53

This protein is structurally similar to PTH, shares a receptor, and if its levels are abnormally high (like in some cancers), it can mimic excess PTH

PTH-related protein

54

Does human calcitonin have an appreciable effect on bone and calcium, as far as we know?

Not really

55

Cells that produce calcitonin

C-cells of the thyroid

56

Key biomarker for determining etiology of hypercalcemia or hypocalcemia

PTH levels - will determine if this is a parathyroid problem or due to an external factor

57

High Ca++, low/normal phosphate, decreased bone density, high or inappropriately normal PTH. Urinary calcium low

Primary hyperparathyroidism - bones, stones, groans, and psychiatric overtones

58

Patient with brown tumors, abdominal pain, kidney stones, and confusion

Uncontrolled primary hyperparathyroidism

59

Treatment for primary hyperparathyroidism

Surgical removal of affected gland - usually curative

60

Patient with a failed parathyroidectomy - what might you suspect?

Familial hypocalciuric hypercalcemia - rare AD disorder due to a LOF mutation of calcium-sensing receptors

61

Patient with malignancy (not of the parathyroid gland) and hypercalcemia - what could be causing the hypercalcemia?

Invasion/destruction of bone by tumor, production of PTHrP by tumor, production of vitamin D by the tumor

62

Patient with a granulomatous disease like TB or sarcoidosis and hypercalcemia - why?

Unregulated 1a-hydroxylase activity

63

Hypercalcemia, renal failure, and metabolic alkalosis

Milk-alkali syndrome

64

Hypercalcemia in a patient who has been immobilized in the ICU - why?

Demineralization and increased bone resorption due to prolonged immobilization

65

Low calcium, low or inappropriately normal PTH

Primary hypoparathyroidism, found in DiGeorge syndrome (22q11 deletion), post-surgical, or autoimmune

66

Low or normal calcium with high PTH

This is normal - this is why we have parathyroid glands. Called secondary hypoparathyroidism, though.

67

Common causes of secondary hypoparathyroidism

Vitamin D deficiency, renal failure

68

Effect of compressive force on bone

Bone growth (electronegative force)

69

Effect of tensile force on bone

Bone resorption (electropositive force)

70

Potential for healing in a kid with an injury to bone but not growth plate

Good! Can heal almost completely because an intact growth plate tends to straighten itself out over time

71

Treatment for an injury involving growth plate

Recognize, reduce the fracture gently but accurately, adequate fixation (don't fixate the physis if possible), monitor for late growth disturbance

72

Bone response to low load

Loss of bone mass via resorption

73

Bone response to a gradual increase in load above physiologic load

Increased bone mass

74

Repetitive microdamage to bone

Stress fracture

75

Acute overload of bone

Traumatic fracture

76

A bone healing that starts with inflammation and a hematoma, followed by formation of a soft callus made of osteoid that surrounds the hematoma, followed by a hard callus forming as fiber bone replaces the osteoid, followed by corticoremodeling

Secondary bone healing

77

Bone healing after internal fixation, where cutting cones are formed by osteoblasts going in both directions to cross the break and heal the cortex

Primary bone healing

78

Older patient with progressive vision loss seen over time, and straight lines do not appear straight in their vision

Macular degeneration - blood in the antral vision/degeneration there. The phenomenon known as metamorphopsia is seeing straight lines as curved. This is urgent but not emergent.

79

Dark visual loss with flashes, followed by floaters, followed by a "curtain"

Retinal detachment - flashes are tugging of the retina due to fluid from a tear in the retina, floaters are RBCs getting behind the retina, and the curtain is retinal detachment

80

If 50% or more of the retina is detached, what sign is visible?

Rapid afferent pupillary defect

81

"Smoky" vision in a diabetic

Vitreous hemorrhage

82

Causes of vitreous hemorrhage

Proliferative diabetic retinopathy, retinal tear, valsalva maneuver, trauma

83

Urgent or emergent: Macular degeneration

Urgent - same day ophtho

84

Urgent or emergent: retinal detachment

Urgent - same day ophtho

85

Urgent or emergent: vitreous hemorrhage

Urgent - same day ophtho

86

Pale or white retina with a cherry red spot and RAPD, profound visual loss

Central retinal artery occlusion

87

Urgent or emergent: central retinal artery occlusion

EMERGENT! Do ocular massage to get the embolus out and page ophtho ASAP

88

History of hypertension; retinal exam shows "blood and thunder" (torturous vessels and multiple areas of blood in retina)

Central retinal vein occlusion

89

Urgent or emergent: central retinal vein occclusion

Not as urgent - next day ophtho

90

Cause of central retinal vein occlusion

vein gets compressed by central retinal ophtho

91

Important management of central retinal vein occlusion, besides sending to ophtho next day

Treat hypertension to prevent this occurring in the other eye!

92

Corneal edema, deep eye pain, sudden decrease in vision, nausea, vomiting, halos in vision, eye is hard to the touch, pupils fixed and mid-dilated

Angle closure glaucoma

93

Urgent or emergent: angle closure glaucoma

EMERGENT! Call ophtho right away

94

Relative afferent pupillary defect, eye pain that is worse with movement, central scotoma, and decreased color vision

Optic neuritis

95

Pathophysiology of angle closure glaucoma

The angle of the anterior chamber gets clogged - this can occur with dilation of the pupils, especially if someone has a positive volcano sign

96

Pathophysiology of optic neuritis

Swollen optic nerve in 1/3 of patients, but the symptoms are caused by optic nerve inflammation leading to demyelination. This is a common early manifestation of multiple sclerosis.

97

MRI findings in optic neuritis

periventricular white matter lesion

98

Urgent or emergent: optic neuritis

Can refer next day - not all that urgent

99

Moderate to severe vision loss, relative afferent pupillary defect, decreased color vision, altitudinal visual field issues

Ischemic optic neuropathy

100

Urgent or emergent: ischemic optic neuropathy

Urgent - same day referral

101

Patient with ischemic optic neuropathy and scalp tenderness or jaw claudication: workup

Suspect giant cell arteritis - this makes it a more urgent situation. Start steroids right away, get labs (ESR, CRP), order temporal artery biopsy

102

Patient with headache, homonymous hemianopia

Occipital lobe stroke

103

Urgent or emergent: occipital lobe stroke

Medical emergency!! Call the stroke team

104

Patient with occipital lobe stroke: results of important CN II tests

Visual acuity may be 20/20... that's because it's not the optic nerve that's affected! Important thing to check is visual fields, to look for deficits in one half of the visual field (homonymous hemianopia)

105

Patient complaining of dark vision lasting for 5-10 minutes, then resolving spontaneously

Transient monocular visual loss (amaurosis fugax)

106

Pathophysiology of transient monocular visual loss

Small embolism in retinal vessels causes transient ischemia, leading to visual loss. It is spontaneously broken down, which is why you get the return of vision after 5-10 minutes.

107

Important management for transient monocular visual loss

Workup for thromboembolic events, clots, friable plaques, heart issues, giant cell arteritis

108

Urgent or emergent: transient monocular visual loss

Usually work up emergently if it occurred within the past few days, to check for underlying causes (do a carotid doppler, echo, labs, etc)

109

Type of cartilage on articular surfaces, the ribs, nasal septum

Hyaline cartilage

110

Type of cartilage on auricle of ear, trachea, auditory tube

Elastic cartilage

111

Type of cartilage at tendon/ligament junction with bone, annulus fibrosus of intervertebral disc, menisci

Fibrocartilage

112

Developmental origin of cartilage in the head

cranial neural crest

113

Developmental origin of cartilage in the limbs

lateral plate mesoderm

114

Developmental origin of cartilage in the axial skeleton

Paraxial mesoderm

115

Biggest molecular component of cartilage (and the other components)

Main component is water, followed by collagen, then proteoglycan, then non-collagenous protein, then cells

116

Major component of extracellular matrix dry weight

Collagen

117

Component of cartilage that provides its framework and tensile strength

Collagen

118

Component of cartilage that provides its compressive strength and attracts water

Proteoglycans

119

Function of anchorin CII

anchors chondrocytes to collagen

120

Function of cartilage oligomeric matrix protein

maintain properties and integrity of collagen network

121

Function of fibronectin in cartilage

Matrix organization and stability

122

Function of tenascin in cartilage

Cell adhesion and cell-matrix interactions

123

How are nutrients transported through cartilage to chondrocytes?

Cartilage is avascular so nutrients are transported via diffusion in the massive amount of water that contributes to cartilage.

124

Describe the structure of proteoglycan

Chondroitin sulfate molecules link onto the core protein, forming a proteoglycan. These then aggregate as attachments on hyaluronic acid through a link protein.

125

Composition of elastic cartilage

Collagen type II and elastic fibers

126

Composition of hyaline cartilage

mostly collagen type II and aggrecan (proteoglycan), some type I collagen

127

Composition of fibrocartilage

Type I and II collagen, basically combined hyaline cartilage with dense connective tissue

128

Which types of cartilage have a perichondrium, and what is it?

Hyaline and elastic cartilage have a perichondrium, which is a fibrous outer layer with fibroblasts that is on top of a chondrogenic region with stem cells.

129

Cartilage that forms in the healing response to injury

Fibrocartilage

130

Cartilage that bests tolerates repetitive deformation

Elastic cartilage

131

Cartilage that is strongest and best for mechanical support

Hyaline cartilage

132

Role of hyaline cartilage in joints

Reduce friction and distribute loads

133

4 zones of articular hyaline cartilage

Superficial zone, middle zone, deep zone, calcified zone. The middle zone is the thickest.

134

Zone of articular cartilage with smaller, flatter cells secreting lubricin

Superficial or tangential zone

135

Orientation of collagen II fibers in superficial zone

parallel to surface (same orientation as the flattened chondrocytes)

136

Zone of articular cartilage with rounded/oval, bigger, metabolically active cells making collagen

Middle/transitional zone

137

Organization of collagen fibers in middle zone

Less organized

138

Zone of articular cartilage with spherical chondrocytes arranged in columns, the most proteoglycan of any layer, and the least water

Deep/radial zone

139

Orientation of collagen fibers in deep zone

perpendicular to surface (vertical)

140

Zone of articular cartilage characterized by hypertrophic chondrocytes expressing collagen X and MMPs to degrade the ECM

Calcified zone

141

Tidemark

Line separating cartilage from subchondral zone

142

Why is collagen X important?

It is a precursor to bone formation

143

Why does the calcified zone produce MMPs?

To degrade ECM and allow for bone formation

144

A constant load on cartilage produces a time-dependent deformation - what is this called?

Creep behavior

145

A constant deformation of cartilage results in time-dependent stress: what is this called?

Stress-relaxation behavior

146

Growth factors important for chondrogenesis

FGF, TGFbeta, BMP, WNT

147

Chondrocytes divide in lacunae of cartilage into chondroblasts, which mature into chondrocytes, leading to increasing cartilage diameter

Interstitial cartilage growth - embryonic process

148

At the edges of the cartilage, stem cells divide into chondroblasts and then into chondrocytes in the perichondrium, leading to increased length

Appositional cartilage growth

149

Changes in collagen with aging

Fewer but bigger chondrocytes, less water, more collagen crosslinking, less proteoglycan -> increased stiffness, more glycosylation end products

150

Favored type of metabolism for chondrocytes

Anaerobic metabolism/glycolysis

151

First step in hip osteoarthritis management

Conservative, non-operative management - PT, weight reduction, anti-inflammation. Surgery is normally elective

152

Joint-sparing hip osteoarthritis surgery

Osteotomy, core decompression, or hip arthroscopy

153

Major limitations of total hip arthroplasty

Obesity, comorbidities (BMI>40 is a huge contraindication). Also poses a risk of osteolysis/bone loss

154

RFs for hip fracture

F>M, smoking, EtOH, decreased VitD, thin, caucasian, post-menopausal

155

Repair for an intertrochanteric hip fracture

Can be fixed via plates or screws depending on the fracture itself

156

Repair for a femoral neck fracture

Since it damages blood supply to the femoral head, a partial or total hip replacement is needed.

157

Morbidity for a hip fracture

High - around 20% within one year since many of these patients are sick or fragile to begin with

158

Groin pain, restricted and painful hip ROM especially on internal rotation, Trendelenberg test, loss of joint space on XR

Hip osteoarthritis

159

Back, hip, or vascular? Groin pain

Hip

160

Back, hip, or vascular? Low back or buttock pain

Back

161

Back, hip, or vascular? Calf pain on exercise

Vascular (although need to rule out neurogenic claudication as well)

162

Back, hip, or vascular? Not a lot of radiation of pain, if it's present it only goes to the knee

Most likely hip, which doesn't tend to have a lot of radiating pain

163

Back, hip, or vascular? Pain radiates down below the knee following a dermatome

Back - radiculopathy

164

Back, hip, or vascular? Patient has a limp and has trouble tying shoes

Hip

165

Back, hip, or vascular? Pain is better with back flexion

Back

166

Back, hip, or vascular? Pain follows a particular pattern, occurs at a specific distance of walking, and gets better with rest

Vascular claudication

167

Back, hip, or vascular? Decreased hip ROM that reproduces pain

Hip

168

Back, hip, or vascular? Positive straight leg test and neuro findings

Back

169

Back, hip, or vascular? Loss of leg hair

Neuro

170

If you suspect that leg pain is due to a vascular cause, what should you do as a test?

Ankle-brachial index

171

Prevention of hip fracture

Maintain bone health with calcium, vitamin D, osteoporosis drugs as needed. Fall prevention as well

172

Goals for obese patients prior to elective hip or knee replacement

Lose weight (BMI below 40 ideally), metabolic control, optimize nutrition

173

First imaging step for hip pain

Plain films - you don't need MRI right away to see osteoarthritis

174

Function of the menisci of the knee

Weight bearing

175

What's a risk of meniscectomy that explains why it's not really done any more?

Taking out the meniscus leads to increased loads on the joint and an increased risk of osteoarthritis at the knee

176

Causes of knee DJD

Obesity, genetics, old trauma, loss of meniscus, chronic instability, malalignment

177

Imaging for diagnosis of meniscal tears

MRI, in addition to exam

178

Pain at the knee joint line

Meniscal tear

179

Repair of meniscal tears

Repair via arthroscopy/joint preservation, observation, or (less commonly) meniscectomy)

180

Initial treatment of knee osteoarthritis

Decrease loads: weight loss, activity modifications, and unloader braces
PT: try to improve strength and ROM

181

Purpose of a tibial osteotomy

Correct a bow-legged deformity

182

Foreign body sensation in eye, swollen eyelids, itching, crusting

Blepharitis - inflammation of melbomian glands

183

Tx for blepharitis

Lid hygiene with diluted baby shampoo, ABX or steroids, lubricants. If it presents with rosacea in a severe form, treat with doxycycline

184

Staph infection of a melbomian gland causing cellulitis

Chalazion

185

Tx for chalazion

hot compresses, massage, topical ABX and steroids, I&D

186

Red, indurated, painful eyelid without proptosis or blurred vision

Preseptal cellulitis - caused by trauma, sinus infection, eyelid margin infection

187

Tx for preseptal cellulitis

oral ABX and monitor for orbital cellulitis

188

Red, indurated, painful eyelid with diplopia, vision loss/RAPD, and/or no improvement with oral ABX

Orbital cellulitis

189

Diagnostic test for orbital cellulitis

orbital CT

190

Tx for orbital cellulitis

IV ABX and surgical drainage

191

Vesicles on unilateral face with involvement of the tip of the nose (pain to palpation)

Shingles of V1 nerve root with Hutchinson's sign

192

Tx of shingles

Oral acyclovir

193

Outturned lid

Ectropion

194

In-turned lid

Entropion/trichiasis

195

Dacryocystitis

Nasolacrimal duct infection

196

Test for corneal pathology

Fluorescein dye - dab it on the anterior fornix and visualize with cobalt blue. It stains corneal epithelium

197

In regard to eye pathology: define injection

Red eye

198

Torn area of corneal epithelium, painful, stains with fluorescein

Corneal abrasion

199

Tx for corneal abrasion

topical ABX, patching, dilating drops

200

Pain and blurry vision with punctate staining of cornea with fluorescein

Dry eye, exposures, or contact lens overuse

201

Fluorescein staining with a linear branching pattern, corneal swelling leading to clouding of cornea

HSV keratitis (could also be caused by VZV but that would have a rash)

202

Most common cause of infectious corneal blindness

HSV keratitis

203

Centrally located punctate staining

Contact lens keratitis - could be viral, bacterial, chemical, amoebic, parasitic

204

Tx for contact lens keratitis

Discontinue use of contacts, use ABX, don't sleep with contacts

205

Tx for HSV keratitis

Oral antivirals

206

Corneal ulcer: causes and management

This is an emergency! Due to pseudomonas infection, anterior chamber infection. Get ophtho consult asap

207

Consider that this might be a vision-threatening cause of vision loss if you have the following symptoms:

S = sudden visual loss
T = trauma (ruptured eyeball?)
O = other signs/symptoms of scary conditions
P = pain

208

Red eye with sudden visual loss: DDx

corneal ulcer, cellulitis, angle closure glaucoma

209

Management of open globe injury

This is an emergency! Need a shield on the eye

210

Management of corneal foreign body

CT or XR to spot the metal, since this is most often from metal flying during activities that involve metal on metal

211

Blunt injury filling the eye with blood

Hyphema - this is an urgent condition

212

Nausea, vomiting, red eye

Angle closure glaucoma

213

Diplopia and red eye

Orbital cellulitis

214

Photophobia and red eye with tiny white dots on inside of cornea

Iritis

215

Sleeps in contacts, has a red and painful eye

Worry about corneal ulcer

216

Deep boring pain and red eye: DDx

Angle closure glaucoma, cellulitis, iritis, scleritis

217

White of eye appears red

Scleritis

218

Pathophys causes of scleritis

Dilation of vessels due to inflammation or increased flow; abnormal vessels; blood outside vessels

219

Edema of conjunctiva

Chemosis

220

Watery or clear eye discharge

Viral etiology or dry eye, viral will often present with palpable preauricular LNs, if viral is very contagious

221

Purulent eye discharge

Bacterial infection - staph, strep, haemophilus. Treat with ABX

222

Mucoid, white-yellow eye discharge

Allergic, Tx with topical antihistamines. Often itchy!

223

Benign causes of subconjunctival hemorrhage

cough, sneeze, meds

224

360 degrees of subconjunctival hemorhage

Globe rupture - protect eye. This is emergent! Really bad if associated with an abnormal pupil

225

Abnormal wing of tissue in an area of eye exposed to UV, and red

Pterygium - often recurs

226

Superficial and mild pain and red sclera that blanches with 2.5% phenylephrine

Episcleritis - caused by dilation of vessels in the vascular plexus between the conjunctiva and the sclera. Can be idiopathic

227

Red sclera with a violaceous hue, with severe boring pain, often associated with autoimmune systemic disease, doesn't blanch with phenylephrine

Scleritis - this can be vision-threatening. Need ophtho consult to prevent vision loss. Treated with steroids and NSAIDS.

228

What is the function of the angle of the anterior chamber?

Drains fluid (aqueous humor) out of the anterior chamber. Usually 45 degrees

229

Pathophysiology of acute angle closure glaucoma

A bigger, more anteriorly positioned lens pushes the iris forward, causing a narrower angle of the anterior chamber. When the pupil dilates, the peripheral iris becomes thicker, and it closes off the angle and gets stuck to the lens, so aqueous humor backs up causing an increase in eye pressure, leading to pain, nausea, and vomiting.

230

Findings in acute angle closure glaucoma

Fixed mid-dilated pupil, dilated vessels, shallow anterior chamber, wrinkled cornea due to corneal edema

231

Anterior chamber filled at least partway with blood

Hyphema, due to blunt trauma compressing eye in AP direction, so it expands in other directions, potentially ripping the iris off its base

232

WBCs forming a hypopia in the eye, along with infection, decreased vision, severe pain

Endophthalmitis - often introduced during surgery

233

Limbal flush, small pupil, photophobic

Iritis

234

Pathophysiology of iritis

Infection and genetic predisposition lead to an autoimmune response causing vasodilation of vessels at the limbus. Also called anterior uveitis

235

Fibrous connective tissue that attaches muscles to bone

Tendon

236

Function of tendons

Move bones or other structures

237

Fibrous connective tissue that attaches bone to bone

Ligament

238

Function of ligaments

Hold structures together, provide stability

239

Composition of tendons

Type I collagen produced by tenocytes, within a proteoglycan matrix

240

How is collagen organized in tendons?

In response to mechanical load

241

Loose connective tissue that allows longitudinal movement of tendons, binds tendon fascicles, and supports vessels and nerves as well

Enotenon

242

Loose connective tissue that allows movement within the tendon sheath

Paratenon

243

Synovial structure that reduces friction within the connective tissue surrounding the tendon

Tendon sheath

244

Tendon blood supply

Longitudinal vessels along the tendon unit with blood supply to enotenon and paratenon; diffuses across sheath to tendon

245

Innervation of tendon

No nerve fibers within tendon. Epi- and paratenon contain nociceptive nerve endings that terminate on the surface of the tendon, and Golgi tendon organs are at the musculotendinous junction to transmit stretch information

246

What can athletes do to improve the viscoelastic relationship of their tendons?

Preconditioning

247

Composition of ligaments

Collagen and matrix produced by fibroblasts

248

Most common type of ligament insertion

Indirect insertion: superficial layer connects to periosteum, and bone is penetrated by Sharpey's fibers

249

Less common type of ligament insertion

Direct fibrocartilagenous insertion: tendons insert deep and superficial through four zones: ligament, fibrocartilage, mineralized fibrocartilage, bone

250

Blood supply to ligaments

Uniform microvascularity from the ligament insertions

251

Innervation of ligaments

Nociceptive fibers and proprioceptive fibers (these are for joint positioning sense, and are important in sprains because these take a long time to come back, so damage to these increases risk of re-injury)

252

Stress-strain relationship of ligaments

Non-linear: non-uniform recruitment of fibers

253

Pathophysiology of Achilles tendinopathy

The area is relatively hypovascular. Repetitive use causses microtrauma to the distal tendon (least vascularity), which probably leads to poor healing and inflammation.

254

Presentation of Achilles tendinopathy

Gradual onset, pain over distal Achilles tendon, thickening or nodularity, bursitis.

255

Painful/reduced active plantarflexion and passive dorsiflexion, but squeezing the gastrocnemius produces a passive plantarflex

Achilles tendinopathy. The Thompson test (squeeze the gastrocnemius) was negative (it produced passive plantarflexion) - if it didn't produce the plantarflexion that would suggest a tendon rupture

256

Do you need imaging for Achilles tendinopathy?

Not needed. May see Haglund's deformity on plain films, ultrasound may help confirm diagnosis, MRI may show thickening of the tendon.

257

MSK consideration with fluoroquinolones

Risk of tendon rupture - this is why we avoid prescribing them whenever possible

258

Initial management of Achilles tendinopathy

Ice, NSAIDs for one week, heel lifts in shoes, avoid aggravating activities, PT

259

Tx for Achilles tendinopathy with most evidence of benefit

Eccentric resistance-based PT, but it may take a long time and requires a lot of buy-in

260

Are injections helpful for Achilles tendinopathy?

Evidence is mixed... steroids are helpful for reactive bursitis but may increase the risk of rupture. Injectables have no long-term outcome differences vs placebo

261

When to do surgery for Achilles tendinopathy

If no improvement after 4-6 mo

262

MOA of Achilles rupture

Sudden maximal plantarflexion with the ankle already fully dorsiflexed

263

Will patients with Achilles rupture have previous S/Sx?

1/3 have Sx of tendinopathy but most probably have tendon degeneration before rupture

264

Squeeze a patient's gastrocnemius and get NO plantarflexion passively

Positive Thompson's test, indicates Achilles rupture

265

Imaging for achilles rupture diagnosis

US is ideal for showing the movement of the tendon in plantarflexion and dorsiflexion. MRI can also work

266

How to manage Achilles tendon rupture

Surgery will lower risk of re-rupture - probably will use surgery for athletes so that they can get back to peak performance.

267

2 main inflammatory causes of tenosynovitis

Systemic inflammation or inflammation due to overuse

268

Gradual onset of reduced active motion of tendons in wrist, may have trigger finger

Presentation of tenosynovitis of wrist

269

Tenosynovitis with acute onset, pain, redness, and decreased passive range of motion

Infectious etiology - need to recognize this

270

Tx for inflammatory tenosynovitis

Ice, splinting, NSAIDs, PT, corticosteroid injections to sheath

271

Tx for infectious tenosynovitis

ABX if identified quickly and non-suppurative, otherwise give broad-spectrum ABX and do surgical debridement

272

Insidious onset of symptoms: sharp pain in heel in the morning like "stepping on a rock" with tenderness at the anteromedial calcaneus and pain with passive dorsiflexion

Plantar fasciitis - overuse at the proximal portion of the plantar fascia

273

Relevance of a calcaneal spur on XR in a patient with plantar fasciitis?

Not really relevant - not the source of the pain

274

Tx for plantar fasciitis

Rest, NSAIDs, PT, orthotics or arch support, sleeping socks that dorsiflex the ankle all night

Second line: immobilization, corticosteroids

275

Grade 1 ligament tear

Partial tear, no laxity

276

Grade 2 ligament tear

Partial tear with laxity but a solid endpoint

277

Grade 3 ligament tear

Complete tear with laxity and no endpoint/soft endpoint

278

Bony avulsion on a ligament tear

This is more common in kids - the ligament is intact but the bone has a piece come off at the ligamentous attachment

279

Ligaments sprained in an inversion ankle injury

Anterior talofibular ligament, calcaneofibular ligament, posterior talofibular ligament - these are the ligaments on the lateral side

280

MOI of a high ankle sprain

Dorsiflexion and external rotation lead to the talus pushing out against the fibula, causing a high ankle sprain and/or fibular fracture

281

When to allow a joint injury patient to sit out of their sport but stay on the sidelines

Fracture (bony tenderness, crepitus, deformity) or instability without prior complications

282

When to allow a joint injury patient to immediately go back in to their game

If joint is stable, no fracture, and they can protect themselves

283

What produces a more severe injury: inversion or eversion?

Eversion

284

Ottawa criteria for when to image ankle

Needs to have malleolar zone pain AND either tenderness over posterior lateral or medial malleolus OR can't bear weight at time of injury/for 4 steps in office

285

Ottawa criteria for imaging foot

Get foot films if there is mid-foot pain AND it is tender over the navicular or base of 5th OR the patient can't bear weight

286

Low-risk ankle rule in pediatric patients:

Don't need radiographs if ankle injury is not a high-risk fracture and it meets these criteria: Acute injury (<3 days), no underlying risk of pathologic fracture (Hx of OI, bone lesion, etc), no congenital ankle or foot malformation, child can express pain or tenderness, and tenderness/swelling is limited to the distal fibula or the ligaments surrounding it below the level of the anterior tibial joint line.

*Injuries which can be managed functionally with splinting and return to activity as tolerated are deemed low-risk: sprains, nondisplaced SH I and SH II, of distal fibula, avulsions of distal fibula or lateral talus

287

Best management of ankle sprains

RICE, walking boot or bracing, PT early and often to improve proprioception

288

How to help prevent ligament injuries

Neuromuscular training programs - high risk reduction

289

Most common direction for a GH dislocation

Anterior inferior direction

290

Where does the long head of the biceps tendon anchor in the shoulder?

Superior labral cartilage

291

Important stabilizers of the shoulder

Superior, middle, and inferior GH ligaments and the ligaments stabilizing the AC joint

292

Dynamic stabilizers of the shoulder

Rotator cuff muscles, especially subscapularis and its tendon in the anterior direction

293

MOI of a GH dislocation

Indirect force with arm abducted and externally rotated, OR direct force - blow from posterior shoulder

294

Patient with a prominent posterior acromion and sulcus sign (skin tight over edge of acromion), in a lot of pain, arm carried in abduction/internal rotation

GH dislocation in anterior direction

295

Ideal immediate management of GH dislocation

Reduce the dislocation acutely, in the ED with sedation if needed

296

Tx of shoulder dislocation after reduction

PT necessary because there's a high recurrence rate. Surgical stabilization is an option.

297

Imaging for GH dislocation

Pre-reduction and post-reduction plain films from at least two views - AP and scapular Y or axillary

298

Other structures that may be injured in a GH dislocation

Axillary nerve... But this usually resolves quickly.

Anterior inferior labrum - if this is injured, there is a particularly high recurrence rate.

299

Grade 1 AC separation

Stretched AC ligament, no deformity, normal XR

300

Grade 2 AC separation

Complete tear of AC ligament, may or may not have deformity or widening on XR, laxity of ligament

301

Grade 3 AC separation

Complete tear of AC and coracoclavicular ligaments - laxity, deformity (distal clavicle elevation), widening of joint on XR, unwilling to use arm

302

MOI of shoulder AC separation

Direct blow to lateral shoulder

303

How to manage axillary neuropraxia after GH dislocation

Watch and wait - this is common and usually resolves in a few days

304

Capsular contracture and inflammation leading to restricted passive ROM, nothing else appears to be wrong, normal MRI

Adhesive capsulitis aka frozen shoulder

305

How to diagnose adhesive capsulitis

Diagnosis of exclusion - MRI will be normal

306

RFs for adhesive capsulitis

F>M, ages 30-60, often bilaterally but usually spaced a few years apart, and never affects same shoulder twice. Can have an insidious onset or can occur if there is trauma w/o significant damage to shoulder joint that leads to inflammation and then stiffness. Diabetes and thyroid disease - may have an autoimmune component. Stroke, burn patients, Parkinson's disease, cardiac disease, etc - again, inflammation. Hx of minor trauma, post-thoracic surgery, hyperlipidemia, drug-related. Dupuytren's contracture is also associated with increased risk. Possible genetic component

307

Pathophysiology of Adhesive Capsulitis

Synovial inflammation -> capsular fibrosis -> passive stiffness -> contractures of rotator interval and GH ligaments

308

Work-up for adhesive capsulitis

Plain films to rule out bone causes, MRI as well... But this is a clinical diagnosis of exclusion

309

Management of adhesive capsulitis

This will resolve on its own over 2-3 years. Tx is pain relief and corticosteroid injections so that the patient can tolerate PT, which is needed to restore mobility

310

MOI of ACL rupture

Usually non-contact: quick direction change, sudden deceleration, hyperextension, valgus, or tibial torsion. Patient will usually feel a pop. Women at greater risk after puberty because it changes the angle from hip to knee.

311

Felt a "pop," pain and swelling, sudden effusion within 10 minutes, decreased range of motion in a knee injury sustained in a non-contact sport

ACL rupture

312

PE maneuvers to test ACL

Lachman's, pivot shift, anterior drawer tests

313

Imaging for suspected ACL rupture

XR to look for bony avulsions - usually normal, but a Segond's fracture is pathognomonic

MRI is gold standard and will show the ACL tear. The ligament will appear black. May also show contusions, indicating a pivot shift, which is also pathognomonic.

Arthrocentesis will show bloody fluid

314

Terrible triad

ACL, MCL, and medial meniscus injuries

315

Management of ACL rupture

Refer to ortho surgery! Most common kind of graft is an autologous bone-patellar tendon-bone autograft. This provides greater stability but may cause some patients more anterior knee pain post-op. Could also do a hamstring tendon autograft but that might cause hamstring weakness.

316

MOI of MCL injury

Valgus force to knee, may or may not have twisted

317

Management of an MCL injury

Normally will heal well without intervention. May place in an immobilizer brace or a more functional brace, and range of motion exercises help as well. If there is laxity, suspect an ACL injury too.

318

Prevention of MCL injuries in football

Bracing

319

MOI of patellar subluxation

Twisting injury

320

Tenderness over medial patellar border, large and sudden knee effusion, and apprehension sign (involuntary quad contraction and dislike of lateral movement of patella)

Presentation of patellar subluxation

321

What not to miss in a high ankle sprain

Fibula fracture - if this fracture has mortise widening it's likely to require surgical repair

322

Avulsion fracture of 5th metatarsal on XR

NO fracture line in the space between 4th and 5th metatarsal

323

Jones fracture

Don't miss diagnosis - fracture line is proximal to 4th and 5th metatarsal joints. Needs to be treated operatively with a fixation screw in athletes. Non-weight bearing for everyone. The challenge here is that it's in a watershed area so there's poor blood flow and therefore a risk of poor healing

324

What is the os coxa and when does it fuse?

Ilium, ischium, and pubis where they come together at the hip. Fuses at age 16, until then it's connected by the triradiate cartilage.

325

Types of cartilage in SI joint

Sacral side is hyaline, iliac side is fibrocartilage

326

Q-angle

Angle of femoral shaft relative to vertical axis. 13 degrees in males, 18 degrees in females

327

If you do arthrocentesis from the patellofemoral joint, are you sampling the tibiofemoral joint as well?

Yes since the synovial cavity is continuous

328

How are knee menisci tethered to the tibia?

Coronary ligaments made of fibrocartilage

329

Where is bone deposited in the growth plate?

Diaphyseal end

330

Which ankle ligaments prevent over-inversion?

Anterior talofibular, posterior talofibular, calcaneofibular

331

Which ankle ligament prevents over-eversion?

Deltoid ligament

332

Nerve roots for hip flexion

L2-3

333

Nerve roots for hip extension

L4-5

334

Nerve roots for knee extension

L3,4

335

Nerve roots for knee flexion

L5-S1

336

Nerve roots for dorsiflex ion

L4-5

337

Nerve roots for plantar flexion

S1-2

338

Major extensors of the hip

Gluteus Maximus, posterior fibers of gluteus medius

339

Major flexors of the hip

Anterior fibers of gluteus medius, gluteus minimus, tensor fascia lata... And also iliopsoas

340

Hip abductors

Superior fibers of gluteus Maximus, gluteus medius, gluteus minimus, tensor fascia lata

341

Adductors (among the butt muscles) of the hip

Gluteus Maximus... But the adductor muscles do most of this

342

Butt muscles that medially rotate the hip

Anterior fibers of gluteus medius, gluteus minimus, tensor fascia lata

343

Butt muscles that laterally rotate the hip

Gluteus Maximus, posterior fibers of gluteus medius

344

Lateral rotation contracting the piriformis could compress what nerve?

Sciatic nerve

345

Nerve fibers in obturator nerve

L2-4

346

Main dorsiflexor of foot

Tibialis anterior

347

Lack of dorsiflexion

Foot drop, steppage gait

348

Blood supply to head and neck of femur

Medial and lateral circumflex femoral arteries

349

Blood supply to posterior compartment of thigh

Perforating branches of deep femoral artery

350

After the femoral artery passes through the adductor hiatus and into the popliteal fossa, the popliteal artery splits into what branches?

Anterior tibial artery and posterior tibial artery (which then gives off the fibular artery)

351

Dorsalis pedis artery comes from which artery?

Anterior tibial -> pierces interosseous membrane -> anterior compartment -> becomes dorsalis pedis

352

Medial and lateral plantar arteries come from which bigger artery?

Posterior tibial artery

353

What provides collaterals circulation around the hip?

Cruciate anastomoses - inferior gluteal artery, lateral and medial femoral circumflex arteries, first penetrating branch of deep femoral artery

354

Pre axial vein of lower limb

Great saphenous vein - drains into femoral at the femoral triangle

355

Post-axial vein of lower limb

Lesser saphenous vein - drains into popliteal vein

356

How do valves function in the deep veins of the leg?

Skeletal muscle pump means that they are closed when muscles relax and open when muscles contract

357

Most powerful dorsiflexor

Tibialis anterior

358

What type of contraction does tibialis anterior do in the swing phase of the gait cycle?

Isometric/concentric contraction to dorsiflex foot and prepare for heel strike

359

What type of contraction does tibialis anterior do in the stance phase of the gait cycle?

Eccentric contraction to slowly lower foot to the ground and prepare for toe-off

360

Damage to which nerve produces a foot drop?

Common fibular

361

A nerve that can't re-establish organized nerve bundles after trauma might produce...

A post-traumatic neuroma

362

If you lose these muscles you can't run or jump

Gastrocnemius and soleus

363

Fibers proliferate around the third common digital nerve of the foot, compressing it and causing pain and paresthesias in someone who wears high heels

Morton's neuroma

364

Describe pain sensation in neonates

Underdeveloped pathways, so have higher risk of hyperalgesia, immature respiratory centers so worse side effects from opioids, develop opioid tolerance more easily

365

Good ways to manage pediatric acute or procedural pain

Comfort position (lap, or sitting up), distraction, sucrose for infants under 6 months, breastfeeding for infants, don't reassure or apologize

366

Overall goals of pain management in kids

Minimize opioids, minimize side effects - might use scheduled NSAIDs, acetaminophen, opioids PRN

367

Analgesics that work via COX inhibition on arachidonic acid pathway

NSAIDs

368

Analgesic that blocks central and peripheral prostaglandin synthesis

Acetaminophen - but avoid combo products like Vicodin or Percocet if possible, and give it IV/PO

369

Which opioid is especially contraindicated in children?

Codeine

370

Is hydromorphone or morphine safer in renal failure?

Hydromorphone

371

Side effects of opioids and their management

Pruritus - nalbuphine, naloxone, ondansetron
Nausea/vomiting - ondansetron, metoclopramide
Respiratory depression - monitor for this, stop the meds, give naloxone

372

Gabapentin MOA

Acts on presynaptic calcium channels

373

IV lidocaine MOA as an analgesic

Anti-inflammatory, sodium channel blockade

374

Ketamine MOA

NMDA antagonist, acts as an analgesic

375

Clonidine MOA as an analgesic

Alpha2 agonist, augments descending modulation

376

Why use regional analgesia?

Putting local anesthesia around a nerve - good pain control, reduced opioids, safer than epidural because there's less risk of ileus (and if it occurs it has a shorter duration)

377

What area of the spinal column do neuraxial blocks go into?

Meds go into the epidural space if they are done as an epidural, but a spinal block goes into the subarachnoid space (CSF) - more numbness for a shorter duration

378

What is the risk of a sympathectomy in a young patient under age 8?

Decreased blood pressure (all patients have a risk of urinary retention)

379

Which problem comes first in opioid use - sedation or respiratory depression?

Sedation always precedes respiratory depression

380

Analgesic ceiling effect

In NSAIDs, etc - beyond a certain dose you don't get improved analgesia

381

A patient on patient-controlled analgesia wants more meds -> how will you alter the dose if you need to?

Up the demand dose, but don't increase the basal dose

382

Are opioids better for acute or chronic pain?

Acute

383

Goals of treatment of chronic pain

Functional improvement at work, school, ADLs

384

Tools for chronic pain management that aren't meds

Patient education, CBT, DBT, mindfulness, coping skills, PT, OT, exercise, activity, treat comorbidities, improve sleep hygiene, diet, diabetes control, etc

385

Considerations for acetaminophen for chronic pain

Lower maximum daily dose

386

Considerations for NSAIDs for chronic pain

Watch for GI bleeds, renal function, cardiac issues

387

Which low-dose antidepressants can be used for chronic pain?

SNRIs (duloxetine, venlafaxine) and TCAs (nortryptiline, amitryptiline)

388

Which anticonvulsants are used for chronic pain?

Topiramate, gabapentin, pregabalin

389

Initial management of back pain without worrisome symptoms

Rest for a few days, ice/heat, NSAIDs, muscle relaxants, PT, acupuncture

390

When are epidural steroid injections beneficial for back pain?

May help with radicular pain or with facet joint or SI joint pain

391

What is a risk of doing spine surgery to resolve back pain?

May continue to have back pain after the surgery

392

Good prognosticators for epidural steroid injections

Education, radiculopathy, pain for <6mo

393

Bad prognosticators for epidural steroid injections

Constant pain, disrupted sleep from pain, unemployed due to pain

394

Presentation of facet joint pain

Mostly axial, often bilaterally, PE shows positive facet loading, paraspinal tenderness

395

Test for SI joint pain

Positive FABER

396

Criteria to diagnose fibromyalgia

Widespread pain index: 19 areas, need pain in 4 or 5 areas over past week, and severity is judged by fatigue/waking up in refreshed/cognitive symptoms, and pain needs to have lasted for over 3 months

397

Management of fibromyalgia

NOT opioids. Anticonvulsants, dopamine agonists, SNRIs, TCAs, non-pharm management are good options

398

Painless mass between the tendon of the medial gastrocnemius and distal tendon of semimembranosus, right behind the medial condyle, driven by transient increase in intraarticular pressure

Baker's cyst

399

Dx of Baker's cyst

Ultrasound - may have internal septations, and is avascular (a vascular mass would suggest it could be sarcoma)

400

Management of Baker's cyst

Only aspirate if it's bothering the patient - treat with steroid injections if symptomatic or painful. 50% will recur.

401

DVT appearance on ultrasound

Common femoral vein has no flow or is full of stuff or doesn't compress well

402

Muscle strain appearance on MR

Bright on T2, focal mass with edema and contusion

403

Differentiate between schwannomas and neurofibromas

A schwannomas is a tumor of the Schwann cell. It is intrinsic to the nerve, better encapsulated, and easier to remove. A neurofibromas is a tumor of the nerve itself, is harder to remove, and has a worse prognosis. Treat both with surgical resection.

404

Benign, slow-growing fatty mesenchymal tumor that presents as a mobile, firm mass

Lipoma

405

PNS repair rules

Regrowth one inch per month
If cut, maximum repair is 70% of function
If patients are older than 40, nerve recovery decreases
2-3 cm nerve gap is the maximum that's feasible for good repair

406

Myelinated neurons in a fascicle are wrapped by ___.

Perineurium

407

Compression of nerves causes what change in signals?

Increased conduction time

408

One nerve injured

Mononeuropathy

409

Mononeuritis multiplex

Multiple nerve injuries in different locations - in vasculitis, DM, lupus, sarcoidosis

410

Changes in central processing after irritation of PNS can cause what?

Chronic regional pain syndrome - pain, hyperalgesia, spasm

411

Nerve is bruised but intact

Neuropraxia

412

Nerve axon is transected

Axonotmesis

413

Endoneurial tube is transected and/or fascicles ruptured

Neurotmesis

414

Sunderland 1 nerve injury

Neuropraxia - localized, axons fine, conduction is preserved above and below injury. Recovery in minutes to 6-8 weeks - injury persists until local myelin repairs itself. Good prognosis

415

Sunderland 2 nerve injury

Axonotmesis - axon transected, Wallerian degeneration dismally, acute recovery may occur but proximal lesions heal better.

416

Sunderland 3 nerve injury

Endoneurial tube transected, Perineurium intact, Wallerian degeneration dismally, may form a neuroma

417

Sunderland 4 nerve injury

Fascicles ruptured -> scarring, axonal misdirection, reinnervation of inappropriate targets. Usually requires resection, repair, or graft. Will form a neuroma in continuity.

418

Sunderland 5 nerve injury

Nerve completely transected. Requires surgical repair. The proximal end forms a neuroma.

419

Cut axons degenerate distally

Wallerian degeneration

420

How long does it take the NMJ to die if a nerve is cut?

About a year

421

Why can't you get back 100% function with nerve repair?

Axons get narrower, so 100% function isn't possible

422

What's a procedure you can do to help prevent neuroma?

Embed the cut end of the nerve in muscle

423

Pain and numbness in lateral 3.5 fingers, worse at night, improved when shaking hands out or with wrist splints

Distal median nerve injury, like in carpal tunnel. There will be a sharp demarcation on the ring finger of the deficit. Positive Phalens test, Tinel sign. EMG will help show it. Tx is conservative.

424

Carpal tunnel with atrophy of thenar muscles

Surgical release of the median nerve

425

Proximal median nerve injury at the elbow presents with...

Benediction hand - weakness of long flexors of fingers, sensor loss in Palm

426

Pain from right elbow to medial two fingers, interossei weakness

Ulnar neuropathy - both palmar and distal surfaces may have pain. If there's dorsal involvement the injury is probably at the elbow, if not it's at the wrist. If long flexion is weak that localizes injury to the elbow.

427

Tx for ulnar neuropathy

Conservative, surgery
Surg - simple decompression or transposition. Transposition is moving the nerve medially, which is used more for recurrences since it has a higher risk of complications

428

Pain and numbness of medial hand and little finger after writing

Hypothenar issue with ulnar neuropathy. Image here with MRI or US for ganglion cyst or Schwannoma. Treat conservatively or with decompression

429

R finger drop, radial deviation with extension (loss of ulnar extension)

Posterior interosseous nerve palsy - a high radial nerve palsy would give wrist drop, but just the PIN would spare the radial extensors.

430

Tx of PIN neuropathy

Have to release the Arcade of Frose to finish PIN decompression

431

L hand numbness with thenar atrophy and atrophy of first dorsal interossei, all one diagnosis

Thoracic outlet syndrome producing Gilliat-Sumner's hand, impinging lower trunk or medial cord of brachial plexus. Fix in surgery - make sure you don't hit the phrenic nerve!

432

Upper extremity weakness and fasciculations bilaterally with no pain or numbness

High suspicion for ALS

433

Shoulder pain, weak abduction and external rotation, prominence of scapular spine, atrophy of supraspinatus and infraspinatus

Supra scapular nerve entrapment in supra scapular notch... But need to rule out brachial plexus neuritis (severe shoulder pain without provocation followed by persistent weakness)

434

Winged scapula

Most likely long thoracic nerve, spinal accessory nerve, or dorsal scapular nerve. Conservative to

435

R foot drop with decreased eversion but intact inversion

L5 radiculopathy or peroneal neuropathy

436

Decreased sensation of dorsal 1st web space

Problem with deep fibular nerve

437

Imaging for R foot drop

US or MRI to look for cysts, tumors, etc.

438

Tx for tarsal tunnel syndrome

Tarsal tunnel release - release each nerve!

439

Neuralgia paresthetica

Nerve trapped against iliac crest (lateral femoral cutaneous nerve) - obese patient or patient in really tight skinny jean, numbness of anterolateral thigh, worse with sitting. Tx with meds, weight loss, injection, surgery (would require snipping inguinal ligament)

440

Carpal tunnel EMG results

Prolonged latency for median nerve compared to ulnar nerve, drop in amplitude indicating axonal loss

441

Diabetic neuropathy EMG

Decreased amplitude

442

Ulnar neuropathy nerve conduction study

Drop in velocity from above elbow to below, may also have decreased amplitude

443

M wave on EMG

Stimulation of muscle fibers

444

H wave on EMG

Stress reflex

445

F wave on EMG

Supra maximal stimulation

446

Ptosis and miosis

Horner syndrome

447

Weak shoulder abduction

Axillary nerve injury

448

Can't make OK sign

Damage to anterior interosseous nerve (branch of median nerve)

449

Can't flex first two fingers

Median neuropathy

450

Can't extend last 3 fingers

Ulnar neuropathy

451

Can't adduct 5th finger (Wartenberg sign)

Ulnar nerve problem

452

Pathophysiology of osteoarthritis

Initial injury to hyaline cartilage caused by its degeneration leads to a cascade of inflammatory response, causing increased breakdown, desiccation, loss of chondrocytes and their repair function, etc until there is no longer a smooth contour. Bone plate gets bony hypertrophy, synovial hypertrophy, inflammation, and osteophytes.

453

Imaging hallmarks of osteoarthritis

Non-uniform joint space narrowing from cartilage loss, subchondral sclerosis, osteophytes, subchondral cysts

454

Tests for nerve damage in little kids

Wrinkle test - skin won't wrinkle in warm water if there's a nerve injury
Sweat test - skin won't demonstrate typical sweat patterns

455

Pre-operative management if you are going to do a tendon transfer or nerve transfer

PT/OT - joint must be passively mobile. Pain management and social support also important.

456

Clinical indications for nerve transfer

Proximal brachial plexus injury, delayed presentation or referral, trauma causing segmental nerve loss, other trauma in that area

457

Principles for choosing a donor nerve

Purely motor, anatomically would be able to be removed without needing its own nerve graft, enough axons for the target muscle, has redundant function, has synergistic function with recipient nerve

458

Neuropathy with orthostatic hypertension

Autonomic dysfunction

459

Neuropathy with skin rash

Vasculitides

460

Neuropathy with skeletal deformities

Hereditary neuropathy

461

Neuropathy with nerve enlargement

Demyelinating neuropathy

462

Neuropathy with abnormal hair and nails

Toxic exposure

463

Diagnostic test for large fiber neuropathy

EMG and nerve conduction study - look at amplitude, affected motor units

464

Diagnostic test for small fiber neuropathy

Autonomic testing, and skin punch biopsy in which you look at the density of intraepidermal nerve fibers to see if it's reduced

465

High A1c, hands and feet have neuropathy, slowly progressive with predominant sensory loss moving distal to proximal

Diabetic neuropathy

466

Prodromal illness followed by tingling in hands and feet, ascending proximal and distal weakness, areflexia, due to Tcell driven response against peripheral myelin

Acute inflammatory demyelinating polyradiculopathy (Guillain-Barre syndrome, etc). LP shows increased CSF without WBCs. Tx with plasma exchange or IVIG

467

Neuropathy with increased IgM, heavy chains, or light chains

Monoclonal gammopathy

468

Length-dependent neuropathy with axonal pathology producing subacute combined degeneration of SC (corticospinal tracts, posterior columns, sensorimotor axonal polyneuropathy)

Vitamin B12 deficiency - test for B12 or methylmalonate

469

Copper deficiency neuropathy - what should you evaluate for?

Excess zinc

470

Low vitamin B1 and neuropathy

Progressive sensorimotor axonal neuropathy in beriberi

471

Other toxins that can cause neuropathy

Alcohol, renal failure, heavy metals, chemo (vincristine, taxanes)

472

Early age of onset of neuropathy,, generalized, skeletal abnormalities, symmetric, slowly progressive

Most common is Charcot-Marie-Tooth - high arches, hammer toes. AD, develops in first 20 yrs of life

473

Sx of compartment syndrome

Decreased sensation in first web space - deep fibular nerve involvement
Pain with passive extension of toes, lower leg firm and tense

474

Pressures diagnostic of compartment syndrome

Delta P <30, or absolute P>30

475

6 Ps

Pain, pallor, pulselessness, poikilothermia, paresthesias, paralysis

476

Pathophysiology of compartment syndrome

Increased pressure -> ischemia -> ATP decreases -> cell death -> release of CK, myoglobin, muscle enzymes, electrolytes

477

CK levels posing greatest risk of rhabdomyolysis and AKI

CK > 15-25000

478

Factors important in muscle differentiation and repair

Myf5, MyoD, Mrf4

479

Stages of muscle repair

proliferation, differentiation, hypertrophy