MSK-1 Flashcards

Question

What is the specificity and sensitivity of straight leg raise?

Answer 1

* Specificity 40% * Sensitivity 95% ## Footnote Both specificity and sensitivity don’t have anything to do with test just being positive or negative. They deal with probability of TRUEness of the negative or positive result.

Answer 2

* The probability that the test will be truly negative among patients who do not have the disease. * Negative test/all patients without the disease, including false positives * A large specificity means the test can rule-in a disease * A positive result signifies a high probability of the presence of disease. A test with 100% specificity will recognize all patients without the disease by testing negative, so a positive test result would definitely rule in the presence of the disease.

Answer 3

40% with negative test don’t have the disease

Answer 4

* Probability of a true positive test in patients with the disease * Positive tests/ all patients who have the disease, including false negatives * A large sensitivity can rule-out the disease

Answer 5

95% with the disease test positive

Answer 6

* A person with a negative straight leg raise probably does not have radiculopathy. (Good sensitivity) * A person with a positive straight leg raise is not so certain to have radiculopathy (poor specificity)

Answer 7

We mean it has a great specificity. specificity. The sign or symptom is very specific to the disease.

Answer 8

* Lumbar Sprain/ strain * Degenerative processes of disks and facets * Spondilolisthesis * Spondylolysis * Scoliosis

Answer 9

* Sprain/strain * Degenerative discs * Spondylolysis, Spondylolisthesis * Herniated disc * Spinal stenosis * Fractures * Kyphosis

Answer 10

* **Cancer** – MM (Multiple Myeloma), Metastatic, Lymphoma, Leukemia, Spinal tumor, Retroperitoneal tumor * **Infection** – Osteomyelitis, Septic disc, Abscess * **Inflammation** - Ankylosing Spondylitis, Psoriatic spondylitis, Reiter’s, IBS (inflammatory Bowel Syndrome), Paget’s

Answer 11

* Extremely common, especially in roofers, pregnancy, obesity, and inactive people. Very common in those with weak core muscles. * Caused by many factors, including osteoporosis with small fractures, herniated discs, muscle spasms, degenerative joint disorders like osteoarthritis, kyphosis and scoliosis, fibromyalgia and depression.

Answer 12

* S/S: Pain originated in the back and radiating down leg suggests nerve root irritation. * Pain from musculoskeletal causes=point tenderness * Unilateral low back and buttock pain that gets worse with standing in one position=sacroiliac joint involvement * Pain in the elderly that is increased by walking and relieved by leaning forward =spinal stenosis

Answer 13

* The most common cause of low back pain is muscle strain * Can be secondary to prolapsed intervertebral disk and low back strain * Signs and symptoms: Pain may be dull, achy, or sharp with movement * Tests: Good H&P, * PE: palpate, assess muscle tone, neuro exam distally, straight-leg raise * **Imaging is not helpful unless Red Flag or you have clinical suspicion in absence of red flags**

Answer 14

* Trauma * Hx CA, Osteoporosis, weight loss * Hx HIV, steroids, IV drugs * Hx of constitutional symptoms like fever, weight loss * Age >70 * Disabling symptoms * Focal neuro deficit on exam (like sensory or motor deficit, change in reflexes, loss of rectal tone) * Symptoms for more than 4-6 weeks | GET IMAGING

Answer 15

* Xray is sufficient in minimally traumatic events or persistent pain * CT useful for bony stenosis and lateral nerve root entrapment * MRI useful in cord pathology, tumors, stenosis, herniated disks, and infections.

Answer 16

* Acetaminophen is considered first-line, NSAIDS better than placebo * Muscle relaxants and opioids are short-term only * Chronically: anticonvulsants, tricyclic antidepressants

Answer 17

* Gentle slow movements increasing ROM * Bedrest is not recommended: use MICE (Motion + ICE) instead of RICE * Prevention: Lifting technique, physical therapy, increased regular exercise like walking, core muscle exercise. * Physical Therapy very beneficial in repeated episodes * Reassurance is helpful, avoid “degenerative”

Answer 18

* Inflammation of SI joint * Stems from improper lifting * On exam patients will have reproducible point tenderness over SI joint, pain reproduced by hip flexion (climbing stairs) OR in Left lateral decubitus position (LLDP) apply pressure to pelvis * Pain can be referred to buttock * SLR is typically negative * Tx with NSAIDs and steroids for severe pain | Pain usually stays local

Answer 19

* Inflammation of the sciatic nerve * Pain, burning tingling that may start in low back or buttock, passing down posterior thigh, sometimes below knee. * Point tenderness is usually between PSIS and greater trochanter

Answer 20

* Herniated Nucleus Pulposus * Can occur in the central, posterolateral foraminal and extraforaminal zones * The more central the herniation, the higher chance of compression of the traversing nerve root. * The more lateral the herniation, the more likely a compression of the exiting nerve root

Answer 21

based upon where the herniation occurs

Answer 22

* Mechanism: Nuclear material displaced into the spinal cord causing pain * Compression of motor nerve causes weakness * Compression of sensory nerve causes numbness * Radicular pain results from inflammation of nerve

Answer 23

* L4/5 , L5/S1 most common * With age, the levels move up in predominance (can happen at any spine level) * Risk factor – genetic inheritance, occupational and recreational injury, smoking, obesity

Answer 24

* Prodrome of low back pain that acutely changes to radiating leg pain (sciatica) * Less than half have an precipitating event * Numbness or weakness in dermatome *** Pain and symptoms worse in forward flexion, better in extension** * Prefer standing or lying to sitting

Answer 25

herniated disc

Answer 26

Not all pain is a herniation, not all herniations cause pain! * Be careful to correlate clinical findings with MRI findings – most patients develop asymptomatic herniations with age * A “disc protrusion” on MRI does not necessary justify surgical intervention.

Answer 27

Positive Straight leg raise (SLR), X-ray (negative usually), MRI is necessary for evaluation of soft tissue and is a gold-standard

Answer 28

Physical therapy, NSAIDs, muscle relaxants, narcotics, for chronic pain: send the patient to a pain specialist—narcotic medications on a regular basis, intrathecal midazolam (versed), and epidural steroid injections * Short course of steroids are beneficial initially

Answer 29

* Persistent treatment in spite of a reasonable course of nonoperative treatment * Profound or progressive motor deficit * Cauda Equina Syndrome * Intractable pain * Patient preference

Answer 30

Determines further imaging

Answer 31

* **Superficial tenderness**: Tenderness over a wide area of lumbar skin to light touch or pinch. * **Non-anatomic tenderness:** Deep tenderness over a wide area that crosses the over non-anatomic boundaries. * **Axial loading**: In axial loading patient stands and the examiner presses downwards vertically on the patient’s head, eliciting lumbar pain.

Answer 32

* **Acetabular rotation**: The examiner rotates the shoulder and the pelvis passively in the same plane while the patient is standing. It is a positive sign if pain is elicited in the first 30 degrees of rotation. * **Distracted straight** leg raise * **Regional sensory disturbance:** The patient’s reports pain that follows a stocking-like disturbance and doesn’t follow a dermatomal pattern

Answer 33

Weakness or cogwheel “giving away” that can’t be explained on neuroanatomical basis.

Answer 34

D. Symptomatic management and follow-up as needed

Answer 35

* Mechanism: Chronic inflammatory disease of the axial skeletal joints, progressively ascending * Presents as intermittent diffuse low back pain and **morning stiffness**, with decreased ROM * Also may involve the aorta, lung and uvea (multi-system disease with hereditary component) * 1 in 1,000 incidence * Disease presents between ages 20-30 * Male to Female ratio 3>1

Answer 36

Acutely —pain and stiffness, worst in the morning, improves throughout the day (similar to RA) * **SI joints are earliest involved** * Should be considered in young adult male with morning joint stiffness Chronically—fusion and fibrosis of vertebrae with decreased ROM and progressive worsening if natural spinal curves, osteopenia starts to develop

Answer 37

* Associated with thoracic hyperkyphosis, painless joint effusions and restricted thoracic expansion * Hyperkyphotic curve, plantar fasciitis, inflamed costosternal joints – typical triad, though not all will be present in all patients

Answer 38

* Tests: X-ray “Bamboo Spine” secondary to a fusion and generalized osteopenia, * Labs--elevated ESR, HLA B27+, (although specificity is low so it is not a screening test) * It is thought that the combo of this antigen and an exogenic component (Klebsiella or Chlamydia) trigger disease process * Treatment: Anti-inflammatories, physical therapy and exercise, oral or injected steroids, and surgery

Answer 39

Ankylosing spondylitis

Answer 40

* Nothing prevents progression * Bracing helps with comfort early * NSAIDs, PT with emphasis on posture, extension exercises, and breathing exercises. Swimming is great! * May develop spinal cord compression requiring surgical intervention * Bony growth may necessitate surgical intervention

Answer 41

* Mechanism: nerve compression caused by narrowing of the spinal canal, nerve root canal and intervertebral foramina * More common in men and women >50yr (most common in 60s) * Aging with secondary changes is most common cause of spinal stenosis * Inherited or degenerative * Can occur at single or multiple spinal levels * May or may not be associated with sciatica

Answer 42

* "Central” stenosis – bilat non-dermatomal pain * “lateral” - dermatomal

Answer 43

Signs and Symptoms: Persistent pain in arms and legs (exacerbated with walking or prolonged standing), pain relieved by leaning forward, decreased sensation, numbness, decreased ROM, and weakness

Answer 44

“Pseudoclaudication” or neurogenic claudication- pain, even paresthesias in ambulation from compression of cord or nerves. * Relieved by leaning forward

Answer 45

* Tests: H&P, X-ray (degenerative changes), CT, MRI, myelogram, Bone Scan * CT and MRI can rule OUT spinal stenosis but can not assure the visualized stenosis is causing patient symptoms

Answer 46

Treatment: Stretching and strengthening exercises, NSAIDs, analgesics, steroid injections, nerve blocks, braces, surgery (decompression and fusion) * Percutaneous image-guided lumbar decompression(PILD) – “band-aid” surgery specifically for lumbar spinal stenosis caused by a thickening of a ligamentum flavum * Surgical decompression in setting of neurogenic compromise

Answer 47

* Laminectomy – most common, removal of lamina, bone spurs * Laminoplasty – lamina removed, plates and screws replace * Foraminotomy - decompression allowing room for nerve root exit * Interspinous Process Spacers – spacers placed between spinous processes to create room, also involves a partial laminectomy * Spinal fusion – reserved for patients with radicular pain, or unstable spine and if other options have not been effective. Long recovery.

Answer 48

* Early recognition * Early immobilization * 85% of c-spine injuries are due to MVAs, many multi-trauma * Stabilize neck, identify life-threatening injuries * PRESUME a spinal cord injury with multi-trauma * Suspect a spinal cord injury with head/brain trauma * Perform impeccable neurologic exam to include sensory * CT or MRI – whichever is available fast * Immediate neuro consult

Answer 49

* MVA 41% * Falls 13% * Firearms 9% * Recreation 5% * Tintinalli, EM 4th Ed., P. 1147

Answer 50

Prognosis cannot be made until spinal shock has resolved , about 24 hours

Answer 51

* Complete cord injury results in paralysis distal to the lesion * Partial cord injuries will have “some degree of recovery”- Tintinalli

Answer 52

Motor paralysis below the lesion, loss of pain and temperature, preservation of sensation, proprioception and vibratory sense

Answer 53

Central Cord (usually from hyperextension, spondylolisthesis, or stenosis) * Weakness, loss of pain in the upper extremities worse than in lower (Good prognosis)

Answer 54

Posterior Cord – aka posterior spinal artery syndrome damaging dorsal columns * Loss of vibration, proprioception and fine touch

Answer 55

Contralateral symptoms explained by decussating fibers at nerve roots and medulla * Ipsilateral weakness, loss of proprioception and vibratory; Contra-lateral loss of pain and temperature

Answer 56

Cauda Equina (not a true cord syndrome) * motor and sensory loss in legs, sciatica, bowel/bladder dysfunction and “saddle anesthesia”

Answer 57

1. Immediate surgical consult

Answer 58

* Composed of lumbar, sacral and coccygeal nerve roots * Mechanism: Rare condition involving large midline disc herniation that compresses several nerve roots, usually at L4-L5 level * Causes: trauma, lumbar disc disease, abscess, spinal anesthesia, tumor, metastatic disease, late stage ankylosing spondylitis, and idiopathic

Answer 59

* Signs and Symptoms: low back pain, unilateral and more likely **bilateral** sciatica, saddle anesthesia with poor rectal tone, bowel/bladder incontinence or **urinary retention**, lower extremity motor and sensory loss * Back pain, Always ask about bowel and bladder incontinence! Do a rectal and note tone. * Clinical PEARL – Look for risk factors for epidural hematoma or abscess

Answer 60

* Saddle anesthesia * MRI

Answer 61

* **Tests**: X-ray (usually normal), MRI of the thecal sac is preferred, lumbar myelogram, post-void residual (urinary retention=neurogenic bladder) * **Treatment**: Emergent ortho referral. Pain control, high dose corticosteroids is standard, laminectomy to decompress the posterior spine has variable support * Admission with immediate consults to neurosurgeon, neurologist and orthopedist

Answer 62

* An abnormal development of the rib cage, in which the breastbone caves in, causing the chest to “sink” inward. * This developmental abnormality often presents at birth, and can be mild or severe. * Although the sunken chest wall deformity is most common in the middle of the chest, it may move to one side of the chest, usually the right.

Answer 63

1.Fatigue 2.Shortness of breath/decreased exercise tolerance * Creates restrictive lung disease 3.Chest pain 4.Fast heart rate (tachycardia)

Answer 64

**Marfan Syndrome** * A connective tissue disorder, which causes skeletal defects. * Is typically recognized by long limbs and ‘spider-like’ fingers, chest abnormalities and spine curvature. High risk of mortality from aortic rupture. **Rickets** * Due to a lack of vitamin D or calcium and from inadequate sunlight exposure, which destroys normal bone growth. * This primarily occurs in children **Scoliosis**: This is the curvature of the spine **Asthma** dt use of accessory muscles

Answer 65

Marfan syndrome

Answer 66

1.Complete Physical Exam 2.Comprehensive Blood Tests, such as chromosome studies or enzyme in assays 3.Physical (stress) Tests 4.Chest x-ray 5.CT scan of the chest 6.Electrocardiogram (EKG) 7.Echocardiogram (picture of the heart)

Answer 67

The primary goal of pectus excavatum repair surgery is to correct the chest deformity to improve a patient’s breathing, posture and cardiac function. Removing a portion of the deformed cartilage and re-positioning the breastbone typically accomplishes this. Repair of pectus excavatum is not recommended unless the patient has symptoms. 1.Risks of Surgical Repair Pneumothorax (accumulation of air or gas in the pleural space) 2.Bleeding 3.Pleural effusion (fluid around the lungs) 4.Infection 5.Pectus excavatum recurrence

Answer 68

* Can be referred by cervical spondylosis * Encompasses many etiologies including MSK, malignancy, inflammatory, endocrine, infectious etc.

Answer 69

* Injury of the glenohumeral joint * Displacement of the head of humerus outside glenoid fossa of the scapula * Mechanism: Combination of abduction, extension, and a posteriorly directed force to the arm

Answer 70

* Signs and Symptoms: Pain, Prominent acromion due to lack of humeral head in glenoid fossa, the deltoid muscles do not look rounded * **PE Check shoulder patch sensation and deltoid strength for axillary nerve dysfunction (40%, resolves)** * X-ray: sometimes pre and post reduction, AP, Y and axillary view * NV testing pre and post reduction as well

Answer 71

* Most are anterior. * Most posterior are due to electrocution or seizures.

Answer 72

* Evidence does not favor one reduction technique. Patients tolerate scapular manipulation well. * Sedation may be necessary, encourage patient to relax shoulder * Immobilization 3 weeks for the <30yo, less for >30yo (to prevent frozen shoulder)

Answer 73

* Apprehension test- patient is supine, arm is abducted to 90 degree and externally rotated. If the patient expresses apprehension, it is positive * Jobe’s relocation test is with apprehension test. If the patient expresses apprehension, apply pressure to anterior humeral head. + If it relieves apprehension, (the patient feels shoulder is supported and it will not dislocate).

Answer 74

* Most common is recurrent dislocation, probably from a loosened Labrum. * Bankart lesion is a loosened/fractured glenoid labrum, sometimes with boney detachment * Hill-Sachs lesion is a break in anterior humeral head cortex from contact with the inferior labrum * Nerve dysfunction usually resolves after reduction

Answer 75

Hill sachs lesion

Answer 76

Bankart lesion

Answer 77

* Injury of the acromioclavicular joint (AC and/or coracoclavicular ligaments) * Mechanism: Falling on the Shoulder, or exclusively trauma to shoulder

Answer 78

* PE: Tender AC joint * “Crossover test” causes AC compression, pain * Tests: X-ray comparing 2 sides with internal rotation, sometimes with weightbearing

Answer 79

* Type 1 sprain * Type 2 AC disruption * Type 3 25-100%increase in space compared to contralateral side * Type 4 posterior displacement of clavicle into trapezius * Type 5 Partial tear of deltoid and trapezius, acromioclavicular space >2X * Type 6 decreased acromioclavicular space with clavicle inferiorly displaced

Answer 80

* Type I: RICE, ROM exercises * Type II, III: Sling use for 1 week, RICE, ROM exercises * All others: likely surgical

Answer 81

* Compression of tissues through the exiting area on the shoulder. * Risk – overuse, overhead activity (mechanic, construction, volleyball, tennis, swimmer) * Sxs – pain with overhead activity, pain waking you up at night, atrophy of muscles affected. * Neer impingement test or Hawkings test are positive. * Tx: RICE, NSAIDs, PT, up to 3 injections to shoulder if no improvement.

Answer 82

* supraspinatus most commonly injured, an abductor * Infraspinatus and teres minor, external rotators * Subscapularis, reinforces anterior capsule * Teres minor

Answer 83

Injury to SITS muscles typically occurring from eccentric overload (Throwing objects), underlying glenohumeral instability, poor muscle strength and training errors * impingement of the supraspinatus tendon as it passed beneath the subacromial arch is the most likely presentation of symptoms

Answer 84

* Mechanism: poor vascularity, trauma, overuse, overhead activity * Signs and Symptoms: Deep pain, often at night, pain with ROM * Tests: Physical exam techniques??? US, X-ray, MRI is the best test * Treatment: Analgesics, sling, referral, surgery with decompression

Answer 85

* Start with the patient's arm abducted 90 degrees. * Ask the patient to slowly lower the arm. * With a rotator cuff tear, the patient will be unable to lower the arm slowly and smoothly.

Answer 86

* Chronic extension force against flexed elbow * Signs and Symptoms: bicipital tendon tenderness and sometimes rupture (POPEYE) maybe seen of both tendons are involved * Dx: Xray to r/o other pathology or an US to evaluate the tendons * Tx: Surgery in case of rupture, RICE/Sling and later PT in case of tendinitis

Answer 87

* S/S: Swelling in that region with mild pain; ROM is good. * Imaging: Nothing unless fracture is suspected * Treatment: activity modification, ACE wrap for compression. Aspiration of the bursa not recommended unless infection is suspected. * NSAIDs and warm compresses * Surgery to remove bursa not common * Leave asymptomatic masses alone unless they restrict movement | Usually from fall

Answer 88

* Subluxation of head of radius from the annular ligament * Mechanism: Caused by traction along the long axis of the arm * Child usually being pulled by the hand and will not move the elbow * Can occur from birth to 6 y/o, most common 1-4 yrs.

Answer 89

Supinate, flex and extand arm super fast

Answer 90

* Child won’t use affected arm and may or may not have tenderness over radial head, but tenderness is elicited upon pronation/supination * On exam, child will be holding arm in slight flexion and pronation * Tests: X-rays are normal * Treatment: Reduction by flexion and supination of the forearm * Child will immediately use arm * Watch child for 15-30 minutes before discharge home

Answer 91

Volkmann contracture

Answer 92

* Typically develops as a result of ischemia from missed compartment syndrome or vascular injury. * Clinically see: permanent shortening of forearm muscles, that gives rise to a clawlike deformity of the hand, fingers, and wrist. * Supracondylar, ulnar or radial fractures are typical causes

Answer 93

Dx: Imaging to visualize shortening Tx: * **Mild** - Dynamic splinting, physical therapy, tendon lengthening, and slide procedures * **Moderate** - Tendon slide, neurolysis, and extensor transfer procedures * **Severe** - More extensive and radical intervention is required, often involving extensive debridement of damaged muscle with multiple releases of scar tissue and salvaging procedures

Answer 94

* Compression of ulnar nerve at elbow leading to paresthesias, wasting, weakness. * Dx with combined elbow flexion and pressure, electromyography. * Tx symptomatically. * Decompression surgery if severe symptoms.

Answer 95

* Mechanism: Inflammation of the carpal canal, resulting in compression of median nerve * Repetitive wrist flexion (computer use, assembly line worker) * Common in women, pregnancy, diabetes * Signs and Symptoms: Paresthesias in median nerve distribution, Pain may radiate from anterior flexor retinaculum to entire arm.

Answer 96

* Positive Phalen’s and Tinel’s sign * Positive Flick signal= patient flicks hand as if shaking down a thermometer to relieve symptoms * Thumb abduction test=the abductor pollicis brevis is innervated by the median nerve only. Weakness is associated with CTS

Answer 97

* Apply pressure over transverse carpal ligament for 30 seconds. * + if pain/ paresthesias * 64% sensitivity * 83% specificity

Answer 98

Nerve Conduction Velocity Test

Answer 99

* Conservative at first: volar or cock-up wrist splinting at night or all day, NSAIDs, rest from repetitive movements * Corticosteroid injections if conservative therapy fails * Surgical: “Release” has 15-20% failure rate. Now available endoscopically. For intractable cases only.

Answer 100

* Stenosing Tenosynovitis in which the synovial lining of the tunnel becomes inflamed and hurts with movement. * Mechanism: Excessive use of the thumb * Involves the tendons of 2 muscles—extensor pollicis brevis and abductor pollicis longus | Usually seen in golfers and tennis players

Answer 101

* **Signs and Symptoms**: Pain, tenderness, redness, swelling at side of wrist beneath base of thumb * **Positive Finkelstein test**—pain when thumb is folded across palm and fingers are flexed over thumb as hand is pulled away from wrist * **Tests**: Excellent history and physical exam (common postpartum when lifting a child) * **Treatment**: Thumb and wrist splinting (thumb spica splint), NSAIDs, steroid injections, surgery to decompress first dorsal compartment if severe

Answer 102

* Is inflammation of the crossover point of the abductor pollicis longus and extensor pollicis brevis with the extensor carpi radialis longus and brevis. * Patients have a history of overuse (rowing/pulling/weight lifting). Pain is worse with wrist motion. * Pain, edema and crepitus 4 to 8 cm proximal to radial styloid is pathognomonic * Splint wrist in 15 degrees extension, rest, Rx NSAIDs for 2 to 3 weeks. PT extensor strengthening

Answer 103

* Valgus Injury of Ulnar collateral ligament of thumb at medial proximal phalanx/MCP joint. * The injury occurred as the gamekeepers sacrificed game such as rabbits by breaking the animals' necks between the thumb and index finger of the gamekeeper and the ground. * Nowadays, MCC is from ski poles injuries. (dt hyperext.) * Important because it affect pincer function and opposition function. * Dx: MRI * Tx: Thumb Spica, RICE, NSAIDs

Answer 104

* Some refer to it as Bible Bump * Most develop spontaneously and are idiopathic * Cyst are almost always filled with pure hyaluronic acid * Treat only if they are troublesome

Answer 105

* Ball of the femur and acetabular socket of the pelvis * Irony – neither a fracture of the ball of the femur (femoral head) or the acetabular socket is considered a “hip fracture” * Hip is a joint, not bony landmark

Answer 106

* Pain over superficial greater trochanter which may radiate over to lateral thigh. Hip joint is not involved. * Caused by repetitive trauma. * Differentiate from ischiogluteal bursitis (from sitting). * May aspirate for analysis, but usually Tx is symptomatic with NSAIDs

Answer 107

* Due to entrapment of lateral femoral cutaneous nerve. * Common in DM/obese and pregnant pt’s – see pain, paresthesia and numbness in the LATERAL portion of thigh * Exam of the leg will be normal. Can be caused by wearing low cut jeans. Can be bilateral in 20% of cases. * Sitting tends to relieve Sxs. Walking/Standing aggravates Sxs. Hyperextension of thigh or deep palpation may aggravate Sxs also. * Tx – Wt loss and neuro meds for nerve pain

Answer 108

* SCFE is a displacement of the capital femoral epiphysis from the femoral neck through the physeal plate (SH1). * Most Common adolescent hip disorder * Prevalence: 10 cases/100,000 persons * The mean age of presentation is 12yo in females and 13.yo in males, near the time of peak linear growth. The male-to-female ratio is approximately 1.5:1. Obesity is a significant risk factor. African- American and athletes are a risk factor.

Answer 109

Clinically see pain and altered gait (limp). The classic presentation is that of an obese adolescent with a complaint of non-radiating, dull, aching pain * hip, groin, thigh, knee or groin * Increased with physical activity * no history of preceding trauma. * It is important to remember that knee pain in the child can be secondary to hip disease.

Answer 110

On physical examination, there is frequently limitation of motion, especially internal rotation and abduction. As the examiner flexes the hip, it moves into external rotation and the patient often holds the leg externally rotated when standing.

Answer 111

slipped capital femoral epiphysis

Answer 112

Trendelenburg gait is an abnormal gait resulting from a defective hip abductor mechanism. The primary musculature involved is the gluteal musculature, including the gluteus medius and gluteus minimus muscles. The weakness of these muscles causes drooping of the pelvis to the contralateral side while walking.

Answer 113

**Children** with SCFE, regardless of classification, should be referred promptly or admitted to an orthopedic surgeon; they must avoid bearing weight until they have undergone orthopedic evaluation.

Answer 114

* Klein Line = "Arbitrary line along superior edge of femoral neck" * Determine whether Klein Line is present—on A/P view, a line drawn along superior border of femoral neck should pass through a portion of the femoral head; if not, SCFE is diagnosed

Answer 115

* Most commonly involves the femoral head. It is usually caused by trauma, typically occurring after a displaced femoral neck fracture and less frequently after a fracture-dislocation of the hip. * Necrosis results when the vascular supply to the femoral head is disrupted at the time of injury. * Non-traumatic AVN occurs in a younger population and is commonly bilateral.

Answer 116

Acetabular branch of the femoral (foveolar)

Answer 117

1.Groin pain is most common in patients with femoral head disease, followed by thigh and buttock pain. 2.Weightbearing or motion-induced pain is found in most cases. 3.Pain in the absence of activity (ie, rest pain) occurs in approximately two-thirds of patients, and nocturnal pain occurs in one-third. When an extremity is affected, the position of the limb (eg, elevated, dependent) does not alter the pain. 4.Although rare, pain in multiple joints suggests a multifocal process.

Answer 118

* The Gold Standard is MRI w/o contrast, bone scan. * The X-ray in early stage is normal, late stage may show changes.

Answer 119

* A slow Unilateral osteochondrosis of femoral head (i.e. avascular necrosis) * Etiology idiopathic. 10% Familial (delayed bone age) * Most commonly see in kids * Incidence at 5-10yo, more common in boys * Gradual onset pain that progresses and worsens to severe pain.

Answer 120

* MRI is Gold standard with Bone SCAN. * Biphosphonates have been found effective with splinting and immobilization, but eventual surgery will likely be required

Answer 121

Developmental dysplasia = Congenital Hip Dislocation

Answer 122

In all cases of DDH, the socket (acetabulum) is shallow, meaning that the ball of the thighbone (femur) cannot firmly fit into the socket. Sometimes, the ligaments that help to hold the joint in place are stretched. The degree of hip looseness, or instability, varies among children with DDH.

Answer 123

1.Dislocated. In the most severe cases of DDH, the head of the femur is completely out of the socket. 2.Dislocatable. In these cases, the head of the femur lies within the acetabulum, but can easily be pushed out of the socket during a physical examination. 3.Subluxatable. In mild cases of DDH, the head of the femur is simply loose in the socket. During a physical examination, the bone can be moved within the socket, but it will not dislocate.

Answer 124

* Some babies born with a dislocated hip will show no outward signs. * Contact your pediatrician if your baby has: * **Legs of different lengths** * **Uneven skin folds on the thigh** * Less mobility or flexibility on one side * Limping, toe walking, or a waddling gait

Answer 125

* X-rays cannot diagnose this until 3 months of age * Ortalani and Barlow maneuvers must be done on all infants and documented as +or- * If it is not diagnosed and treated before the child begins to walk, it is not corrected by conservative means, and may result in permanent disability

Answer 126

Congenital hip dislocation

Answer 127

* Newborns are placed in a soft positioning device, a Pavlik harness, for 1 to 2 months to keep the thighbone in the socket. This special brace is designed to hold the hip in the proper position while allowing free movement of the legs and easy diaper care. The Pavlik harness helps tighten the ligaments around the hip joint and promotes normal hip socket formation. * It is usually worn full-time for at least 6 weeks, and then part-time for an additional 6 weeks.

Answer 128

* Similar to newborn treatment, a baby's thighbone is repositioned in the socket using a harness or similar device. This method is usually successful, even with hips that are initially dislocated. * If the hip will not stay in position using a harness, you may try an abduction brace made of firmer material that will keep baby's legs in position. * In some cases, a closed reduction procedure is required, followed by a body cast (spica cast-pic) to hold the bones in place. This procedure is done while the baby is under anesthesia.

Answer 129

* Most are managed by spica casting. * Open Surgical Treatment is necessary if closed reduction is not successful. In some cases, the thighbone will be shortened in order to properly fit the bone into the socket. Spica cast is then again applied.

Answer 130

* “Water on the knee” is increased synovial fluid in the joint. * Several tests help evaluate this: * Balloon * Ballottement * Bulge * Baker's Cyst * DDx of someone with knee effusion includes internal derangement, inflammation, infection

Answer 131

Gently press just medial of the patella, then move the hand in an ascending motion. Then press firmly on the lateral aspect of the knee. Commonly, no fluid will be appreciated. A medial aspect that 'bulges' out after lateral pressure (positive "bulge sign") is consistent with a moderate amount of fluid. The presence of bulge sign identifies individuals at increased risk of frequent knee pain, progression of ROA and TKR.

Answer 132

Patella tap test or ballottement test is used to examine the knee swelling or knee effusion. This test is also know as dancing knee sign. Place patient in supine position and knee extended. Clinician's one hand is push down front of the leg to the top of the patella this moves any fluid in the thigh to the knee. Then you need to keep pressure on with other hand gently tap over the patella. Positive sign when floating or bouncing of patella occurs and indicates knee joint effusion. Always compare with normal side or opposite side.

Answer 133

* "Popliteal cyst" * Results from knee effusions – path of least resistance

Answer 134

* AKA Patellofemoral Pain or Runner’s knee mm * 60% are women due to pelvis widening * The softening and breakdown of the tissue (cartilage) on the underside of the patella * Pain may refer locally or to posterior knee. Crepitus maybe presen

Answer 135

* Risk = aggressive physical training, obesity, weak Quadriceps * Dx by apprehension test – at 30 degree bend push patella laterally and look for patient apprehension signs. * Non-linear patellar tracking. * Tx with RICE NSAIDs for pain and PT = Quadriceps strengthening

Answer 136

* Excessive rotational force of the femur on the tibia * Medial most commonly affected * Usually with other ligamental injuries

Answer 137

* Signs and symptoms: pain on joint line on the side of injury, “clicking”, “locking”-inability to extend knee, effusion, and joint line tenderness * Pain and effusion are often delayed a day after injury * Tests: MRI, positive McMurray/Apley sign * Treatment: analgesics, knee immobilization, conservative vs. surgical intervention

Answer 138

* Provides anterior/posterior stability * May see partial or complete tear (grade 3 sprain) from pivoting motion during running, jumping, or other sports * Injury is considered a sprain * ACL is more common than PCL * MOI = abrupt stopping/twisting of knee

Answer 139

* Signs and Symptoms include pain, swelling, hemarthrosis and instability * Dx: MRI, Drawer test, Lachman test * Treatment: RICE, knee immobilizer, analgesics, surgery

Answer 140

* Popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pedal pulses. * Alternatively, CTA with Runoff can be performed in ER

Answer 141

* Rare (1.67 per 100,000) * Usually involve quadriceps contraction against a flexed knee, such as when a patient is attempting to regain balance after a fall, jumping, or missing a step on the stairs * Patellar ligament is often involved * Highest risk factors: CTD disease (Ehlers-Danlos, lupus, RA & Marfans) * Clinically see lateral dislocation (most common) or inferior patellar displacement (patella baja)

Answer 142

* Dx: clinical, but get a sunrise view knee xray or an US. * CT is some cases when other injuries are suspected * Tx: preserve extensor function (Splint) and consult surgeon

Answer 143

* Osgood-Schlatter’s Disease = Osteochondritis of tibial tuberosity = Tibial tuberosity avulsion * OS disease is an overuse injury caused by repetitive strain and chronic avulsion of the secondary ossification center of the tibial tubercle, which then heals and repeatedly reavulses. * Osgood-Schlatter occurs most frequently in participants of sports that involve running, cutting, and jumping and who have recently undergone a rapid growth spurt. * The most common presenting complaint is anterior knee pain that increases gradually over time; the pain is exacerbated by direct trauma, kneeling, running, jumping, squatting, climbing stairs, or walking uphill, and is relieved by rest.

Answer 144

Osgood-Schlatter’s Disease

Answer 145

* The diagnosis is made clinically. The characteristic findings are tenderness and soft tissue or bony prominence of the tibial tubercle * Pain is exacerbated by knee extension and squatting. * Initial imaging may be normal * Bone fragmentation maybe evident 3-4 weeks following onset

Answer 146

* Osgood-Schlatter disease usually is a benign and self-limited condition. Symptoms generally resolve once the growth plate is ossified. * Conservative measures are the mainstay of therapy. RICE, NSAIDs, stretching * **Continued** sports participation, provided that the pain can be tolerated and resolves within 24 hours. * Physical therapy to strengthen the quadriceps and stretch the quadriceps and hamstrings. * Surgery is not common. * Prognosis is great and resolves when epiphyseal plates close.

Answer 147

Knee pain that is exacerbated by descending stairs

Answer 148

Can be acute or chronic inflammatory reaction as a result to most commonly pressure to the area * Suprapatellar Bursitis (Carpeter’s knee) * Prepatellar bursitis (Housemaid’s knee) * Infrapatellar bursitis (Plumber’s knee) * Pes Anserine Bursitis

Answer 149

* US may help differentiate abscess vs bursa vs mass; XR not necessary * Aspiration is generally only diagnostic, NOT therapeutic * Tx: NSAIDs, steroids injection and pressure avoidance

Answer 150

* Articular cartilage breakdown * Most common in knee, but can occur anywhere there is cartilage * May lead to aseptic necrosis and recalcification which may cause loose bodies in the knee, furthering the damage * XR may help with OA but MRI diagnostic * OA is inevitable * Tx: surgery for Grade 4, all others get immobilization for 2-4 months

Answer 151

* Abnormal intraarticular band of fibrotic tissue (abnormal Plica) * Causes anterior knee pain. * Risk factors are knock knees or genu valgum. Pain worse with activity, have clicking and locking with knee flexion. Can feel palpable fibrotic cord over medial femoral condyle. * Differentiate from pes anserine bursitis * Misdiagnosed d/t similarities of other knee pain etiologies – common dx on arthroscopy * Tx with activity modification, Ice, NSAIDs

Answer 152

* Ask a patient if his legs are swollen, or if rings are tight. * Be sure to determine Onset, duration, Aggravating factors. * If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema. * It is measured, and therefore documented as 1+, 2+, 3+ and 4+.

Answer 153

* The skin does not result in a persistent indentation. * Non-pitting edema can occur in certain disorders of the lymphatic system such as lymphedema, that may occur after a mastectomy, lymph node surgery, or congenitally. * Pretibial myxedema is a swelling over the shin that occurs in some patients with hyperthyroidism.

Answer 154

Recent inactivity (plane, injury)

Answer 155

* Mechanism: Typically Inversion forces (most common) * Most common injury of the ankle * Patient will hear pop with bruising and tenderness to specific area * Xray imaging based on Ottawa Ankle Rules * Tx: Immobilization with splint (boot, ankle stirrup or posterior short leg), RICE, analgesia OTC * Recovery can take 3-4 months

Answer 156

* Inversion ankle injury = Anterior Talo-Fibular ligament mc involvement * Eversion = less common – Deltoid ligament mc involvement

Answer 157

* Sprain: involves collagenous tissue such as ligaments and tendons * Mechanism by twist or stretch * Strain: injury to the bone-tendon unit at the myotendinous junction (muscle overuse) or the muscle itself * Mechanism by muscle contraction

Answer 158

* Common cause of foot/heel pain * Inflammation of the plantar fascia as it inserts into anterior calcaneus * Origin at the medial plantar calcaneal tubercle * **Pain is worse upon getting out of bed in the morning** is almost pathongnomonic. * Pain gets better with increased ambulation throughout the day * Often associated with a bony exostoses on calcaneus i.e. a “spur”. | Plantar flexion causes pain

Answer 159

* Tx: Ice, NSAIDS, Stretching, arch supports, night brace * Responds very well to local steroids.

Answer 160

* Sxs: Stiffness and pain along the tendon, worse with activity, pain getting worse as the day goes * Imaging: X-rays may show soft-tissue shadowing and calcifications along tendon (bone-spurring) * MRI is useful * Treatment: NSAIDs, PT, stretching, no steroid injections. * Surgery is last resort

Answer 161

* Fibrosis and nerve degeneration of common digital nerve causing neuropathic pain between the 3rd and 4th metatarsals * Dx by squeeze test of the affected nerve. Dorsiflexion aggravates the pain. No imaging necessary * Surgery if no relief with 1 year of conservative treatment (appropriate footwear and steroid injections)

Answer 162

Plantar Fasciitis

Answer 163

* proximal phalanx deviating laterally and the first metatarsal head deviating medially and due to the adduction of the first metatarsus, * More common in females, typically arise due to footwear. * Clinical Dx assisted with XR. * Treatment is directed towards pressure reduction and eventual surgery

Answer 164

* Most common deformity of toes. * See flexion of PIP and hyperextension of MTP/DIP joints. * Complain of pain on dorsal aspect of PIP joint. Callus maybe present. * Tx by stretching and night splinting. Surgery if severe

Answer 165

* 1 in 1,000 will have it; Male to Female 2>1 * Dx by PE with newborn/well child visit * Typically found on prenatal US * Generally managed by stretching, casting and bracing * Surgery maybe necessary if noninvasive treatment is not successful

Answer 166

The six P's include: (1) Pain, (2) Poikilothermia, (3) Paresthesia, (4) Paralysis, (5) Pulselessness, and (6) Pallor