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Ortho 2.2 Flashcards

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1
Q

OA Pts are more likely to report ? issue during a flare up

What would an OA joint effusion result look like?

What are the MC OA findings in the hand

A

Stiffness > Pain

Mild pleocytosis
Elevated protein
Normal viscosity

PIP- Bouchard
DIP- Heberden
First CMC

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2
Q

What are three common locations for OA to develop, especially in the foot?

What is the MC form of OA in the knee

If these Pts develop a Baker’s Cyst, it is due to the joint cavity communicating between ? two structures

A

First MTP joint
Calc/Talus/Navi articulation
Valgus/rigidus
Subtalar joint

Varus- bow legged

Gastroc/Semi-membrane

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3
Q

What will be seen on x-rays of OA

The severity of these findings are based on ? scale

What are the 4 grades

A

Lost joint space
Osterophytes
Sclerosis
Subchondral cysts

Kellgren Lawrence

0: none
1: doubt
2: minimal
3: moderate
4: severe

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4
Q

Non-pharm Tx of OA

Pharm Tx of OA

What opioids can be used for short-term relief w/ NSAIDs

A

Avoidance Reassure Education Weight-loss

NSAIDs, then Acetaminophen

Codeine Hydrocodone Oxy Tramadol

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5
Q

? COX-2 selective NSAID has s/e similar to Tylenol and used in Pts w/ no cardiac risk but are not achieving pain relief w/ Acetaminophen

What therapy can PTs utilize who are unable to tolerate weight bearing exercises

What are the indications surgical repair is needed for joints w/ OA

A

Celecoxib

Isometric exercises

Lost function
Pain at night
Non-surg failure

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6
Q

Define RA

What are common Sxs of RA

What joints are more commonly involved symmetrically

A

Chronic synovium inflammation causing erosion

2+ swollen joints in AM >1hr x 6wks or,
+RF/anti-CCPs

Feet Hands Ankle Wrist Knee

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7
Q

To receive an official Dx of RA, Pts need 6 out of 10 points based on ?

If they present w/ ? finding, they meet the definition

What joints are affected first and which ones are spared

A

Joint involvement
Acute phase reactants
Pt self report
Serology results

Characteristic erosive changes

First: hand/feet
Spared: DIP

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8
Q

Extra-articular Sxs of RA are more common in Pts w/ ?

These rarely occur in the absence of ?

? tendons can be ruptured by the Dz process

A

+RF

Clinical arthritis

EPL= no thumb extension

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9
Q

What are the predominant early PE findings of RA

What two findings are not predominant findings

? is an early result and what is a late result of the Dz process

A

Pain w/ pressure
Swelling
Dec ROM

Warmth, Erythema

Early: PIP
Late: joint deformity

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10
Q

? is the MC site for subcutaneous RA nodule

What is Rheumatoid Factor

What lab result is as sensitive and more specific

A

Elbow

IgM against Fc of IgG

Anti-CCP Abs

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11
Q

What lab result correlates to the degree of RA joint inflammation

? will CBC results look like

Which one correlates to Dz activity

A

ESR/CRP

Dec serum albumin
Inc ESR/CRP
Platelets

Albumin

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12
Q

What part of the body does Ankylosing Spondylitis affect?

What other conditions are associated with this Dx?

What is the Tx plan?

A

SI joint

Iritis Aoritis Carditis Enthesitis Uveitis

NSAIDs, Exercise

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13
Q

What parts of the body are affected by arthritis associated w/ IBS

What other conditions can be present w/ this Dx

What is the Tx

A

Asymmetric/oligoarticular
SI Ankle Knee

Crohns Enthesitis UColitis

NSAIDs

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14
Q

What parts of the body are involved w/ Psoriatic arthritis

What other conditions can also exist

What is the Tx

A

Wrist Ankle SI Hands

Dactylitis Iritis Nails Enthesitis Skin lesions

NSAIDs Biologics Methotrexate

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15
Q

What imaging results are seen in PTs w/ Ankylosing Spondylitis

What finding correlates to severity of Dz

What is different about this type of arthritis compared to other seronegative arthritis’?

A

Sacroiliitis, Kyphosis

Hip Ankle Shoulder

Less severe

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16
Q

What microbe pathogens can cause Retiers?

What are the 5 patterns of psoriatic arthritis

What differentiates one of these manifestations from RA

A

Clostridium Campylobacter Chlamydia Shigella Salmonella Yersinia

DIP
Arthritic mutilans
Asymmetric oligo
Symmetric poly
Sacroilitis

Symm Poly: DIP involvement w/ absent RA nodules

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17
Q

? form of IBDz is more likely to develop arthritis

? is the presenting Sx in all seronegative arthropathies

What do Pts w/ Reiters present w/

A

Crohns

Back pain

Conjunctivitis
Asymmetric oligoarthritis of LE large joints
Dactylitis
Urethritis
Enthesitis: Achilles, Plantar
Sacroilitis
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18
Q

What is the ‘usual’ clinical presentation of Psoriatic Arthritis

Pts w/ joint problems commonly have ? d/o

Pts w/ IBDz arthritis commonly have ? -itis’?

A

DIP pain
Scaly cutaneous lesions

Nail- Pits Oncolysis Ridging

Sacroillitis
Spondylitis
Knee/Ankle arthritis

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19
Q

IBDz associated arthritis has ? worsen during flare ups

What type of back measurement needs to be done for Pts w/ Ankylosing Sine?

What is the AKA name for this measurement’s starting point

A

Peripheral Sxs
Spondylitis Sxs remain same

Post Iliac Spine midline to upper lumbar

Dimples of Venus

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20
Q

? is a common x-ray finding of Psoriatic Arthritis in the hands

What causes the ‘bamboo/poker’ appearance on x-ray of ankylosing spondylitis

Which NSAID is particularly successful at controlling the Sxs from seronegative spondyloarthropathies

A

Proliferative bone reaction
Terminal phalanges resorption

Bamboo: anulus fibrosus enthesitis
Poker: ALL ossification, Facet autofusion

Indomethacin

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21
Q

What drugs are used for Sxs of AnkSpond not controlled by NSAIDs

What drug may be used for chronic reactive arthritis?

What is best for the Tx of Psoriatic Arthritis

A

TNF-a: Etanercept, Infliximab, Adalimumab

Sulfasalazine

DMARDs
Skin lesions: photo therapy

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22
Q

? type of gunshot wounds are particularly susceptible for compartment syndrome?

? are the MC compartments to be affected by

What are the 4 compartments of the leg

A

Prox tibia

Leg/Forearm

Ant/Lat/Sup-Deep posterior

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23
Q

What are the 3 compartments of the forearm

What are the 3 compartments of the thigh?

How long can muscles withstand compartmental pressure before beginning necrotic break down and what happens if relief is not achieved in that time?

A

Volar: flexor, pronator, supinator
Dorsal: extensors
Wad: radialis, extensors

Medial Ant Post

4hrs
6hrs- possible reversal
8hrs: irreversible necrosis

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24
Q

What are the seven Ps of Compartment Syndrome

? Sx is present at the onset of this condition

What is the most specific test to rule in Compartment syndrome and what are two are extremely late findings

A 
Pain Pallor Paresthesia Paresis Poikilothermia Pulselessness
#7: pressure

Altered sensation in effected compartments

PooP w/ passive stretch-
Pulseless
Paresis

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25
CRPS is a clinical Dx composed of ? What are the two types ? types of injuries can precipitate this Dx
Functional impairement Autonomic dysfunction Trophic changes Pain 1: RSD/Algo- no lesion 2: causalgia- + nerve lesion Distal radius Fx Injury to infrapatellar branch
26
? is the most important step for CRPS prognosis outcomes What is the exception to this rule What happens after this exception
Early, appropriate Tx Distal radius Fx w/ poor finger function 3mon after Fx Algodystrophy after 10yrs
27
? prophylaxis Rx can be used after distal radius Fx to reduce chances of developing CRPS What is first line Tx for Complex Regional Pain Syndrome What off-label meds are used for pain control
Vitamin C 500 IU/d Parenterals Counseling Sympatholytics Therapy CCB (a-2 agonists) Anti-HTN/convulsants TCA Steroids
28
CRPS Tx therapy program utilizes PROM but ? is stressed more ? adaptive modalities are used for CRPS Tx ? medication is used for stellate blocks
AROM w/ stress loading TENS Iontophoresis Contrast bath Bupivacaine
29
Continue intrathecal administration of ? drugs are used for refractory CRPS Sxs ? are the possible sequelaes of CRPS What are the possible s/e of stellate ganglion blocks for these Pts
Clonidine (a-2 agonsit) and Ziconotide (snail venom creates CCB) Deformity Neuromas Contractures Compression neuropathy ``` Seizures Hoarseness Arm numbness Weakness PTHx ```
30
How is gout Tx How is CPDD Tx What are the 3 stages of urate crystal deposition
Indometha/Naproxin (Sx<48hrs) Colchicine/Glucocorticoids Allopurinol/Probenecid Aspiration- Dx and Thx Steroid injection- 1-2joints NSAID/Colchicine if multiple joints during acute attack 3 or > attacks/year= Colchicine prophylaxis Acute Interval Chronic
31
Gout affecting 1st MTP is AKA ? What other areas can be affected If Pt has gout in the back they have ? type
Podagra Ankle Tarsal Knee Tophaceous
32
After initial gout attack, Pts can expect to remain ASx for ? long Where can tophi development occur Define Chondrocalcinosis
2yrs Hand tendon sheath Olecranon Forearm extensor Achilles MC in women >80y/o: CPPD X-ray findings of punctate/linear calcifications of articular cartilage/internal joints
33
? joint is affected by CPPD more than half the time What joint involvement come after this MC site How can CPDD be differentiated from OA/RA
Knee Wrist MCP Hip Shoulder Elbow SPine OA: synovial fluid, x-ray RA: no bony erosion or tenosynovitis
34
CPDD Pts w/ severe neuropathic joint Dz usually have ? two underlying conditions What 4 metabolic d/os are associated w/ CPDD What is a rare adverse outcome of the CPDD Dz process
DM Tabes Dorsalis Hyperparathyroid Hemochromatosis Hypophosphatasia Hypothyroidism End stage arthritis
35
? is the most preventable cause of death for in-hospital PTs and 3rd MC cause of death in PolyTrauma Define Virchows Triad ? surgical positions increase DVT risk
PE DVT identification: Stasis Damage Hypercoagulable Supine Abduction Internal rotation Flexion
36
How does general anesthesia increase DVT risk ? bioactive chemicals are released during this time and can increase the risk further Post-hip arthroplasty Pts have been noted to have decreased levels of ? putting them at DVT risk
Dilation, Stasis Histamines Leukotrienes Anti-thrombin 3
37
? are classified as high risk surgeries for DVT development Clinically, what two sings are indicative of DVTs What post-op findings are indicative
Total joint arthroplasty Internal fixation of hip fx Polytrauma Spinal cord injury + Homan Edematous Painful Fever/Leukocytosis
38
Pts that die of PE do so w/in ? time frame What are the current mainstays of prophylaxis What is the FDA approved drug for VTE prevention
<30min Fondaparinux LMWH ASA Warfarin Desirudin- hirudin derivative
39
Indirect inhibition of ? factors can help reduce DVT formation What is the MC used DVT prophylaxis for hip/knee arthroplasty What is this drugs s/e
2a 9a 10a Enoxaparin Renally cleared- swithc to heparin if dec renal clearance
40
? is the MC used anticoagulation w/ INR goal of ? This MC is better at preventing ? clots for Pts having total hip arthroplasty Mechanical prophylaxis reduces VTE Dzs secondary to ? and ?
PO Warfarin: INR 2-2.5 Proximal Increased fibrinolysis Decreases stasis
41
How long is DVT prophylaxis continued after hip/knee/plasty surgery continued Spinal trauma Pts may need a IVC filter placed if ? 3 criteria are met Why is Warfarin bridged w/ Heparin
7-10 days Hx of VTE w/ prophylaxis Prolonged immobilizaiton Chemical anti-coag is c/i Warfarin reduced Protein C/S causing Pt to be hypercoagulable
42
How long is Warfarin used for? Therapeutic heparin is monitored w/ ? lab results How is Enoxaparin monitoring achieved
3mon Activated partial thromboplastin Anti-factor 10a levels
43
What is the Tx for acute PEs Oral anticoagulation is then recommended for ? long after first PE What is an adverse outcome of Tx
Admit w/ heparin, O2 and then Warfarin 6mon HIT Type 2 (AKA White Clot Syndrome)
44
DISH is predominant in ? Pt population How do these Pts present Since this condition can also lead to spinal fusion, how is this differentiated from Ankylosing
White male >60y/o Spine stiffness in AM/PM Red hip ROM Knee arthritis Normal posterior apophyseal/SI joints
45
What landmark does dish follow in the in the cervical region What are the two MC causes of cervical myelopathy What may be seen on x-rays of the pelvis and ribs
PLL 1st: cervical spondylosis 2nd: cervical DISH Whiskering- shaggy hyperostotic bone
46
What are the two MC Dxs encountered by Rheumatologists What are the two suspected etiologies for Fibromyalgia What type of cardiac murmur may develop fibromyalgia
1st: RA 2nd: Fibromyalgia Genetics Environmental MVP- mid-systolic click w/ late systolic murmur
47
How is FMS Tx per FDA recommendation Why do these Pts need to be started at the lowest dose possible ? meds need to be avoided
Pregabalin Duloxetine Milnacipran Usually have hypersensitivity to Rxs Steroids
48
What two meds can be used at bedtime for fibromyalgia What is recommened for use if Pt develops/has depression What meds are good for sleep maintenance
Amytriptyline Cyclobenzaprine Fluoxetine Initiatiion: Trazadone Maintain: Gabapentin, Tiagabine
49
? meds are added for Fibromyalgia PTs w/ Restless Leg Syndrome or MVP? What are the most beneficial injections for pain relief? ? type of fitness program is recommended for these pts
Clonazepam Pramipexole Lidocaine Saline if allergic Aerobic 20-30min/day x 5 days/wk
50
What is an adverse effect Pts w/ fibromyalgia can develop in response to long term Amytriptyline or Cyclobenzaprine usage Where/how does osteomyelitis usually affect Peds/Adults How can neonates present w/ this
Tachyphylaxis- decreased responses Peds: Hematogenous to metaphysis of long bones (can lead to septic arthritis) Adult: open Fx/post-ORIF Pseudoparalysis
51
How does osteomyelitis present in adolscents/adults What images can be used for Dx of osteomyelitis but what is the best method for Dx What do lab results look like in cases of osteomyleitis
Post-op: drainage, failed/delayed healing MRI Open biopsy/aspiration Acute- elevated leukocyte, ESR/CRP Chronic/ImmSupp- normal ESR/CRP- Dz process marker
52
What are the MC organism to cause osteomyelitis in Peds and adults What is an indication of surgical site infection in Pt w/ AIDS What is a rare adverse outcome if chronic osteomyelitis develops
Peds: Staph A > GBS > HInflu Adults: Staph A, Pseudomonas CD4 <200 Malnutrition (albumin <2.5g) Marjolin Ulcer- SCC metaplasia
53
Since surgical debridment is required for osteomyelitis Tx, what type of ABX usage is recommended What are the 3 methods of septic arthritis development What microbe is the MC cause of septic arthritis in PTs >2y/o
Parenteral/impregnated methyl methacrylate beads after surgery Direct Hematogenous Extension Staph A
54
IV drug users can develop septic arthritis in ? unusual locations ? microbe is their culprit Septic arthritis in kids is MC spread by ? route
Sternoclavicular Sacroiliac Pseudomonas Hematogenous
55
? Pt populations are at increased risk for developing septic arthritis ? is a common scenario for Peds to present w/ that have a septic arthritis Dx What will older children present w/
Systemic Lupus ImmComp RA Previously ambulatory, no refusing to bear weight Anorexia Fever Irritable Tachy
56
What are the hallmark PE findings of septic arthritis If the hip is affected, it will usually be held in ? position ? lab marker is used for monitoring response to therapy
Tenderness/Effusion/Erythema w/ painful PROM Flexed, Abducted CRP
57
What lab result of a native joint indicates Dx of septic arthritis What if it's a prosthetic joint What will glucose/protein results look like
WBC >50K >1,100 w/ neutrophils >64% Low glucose High protein
58
When assessing septic arthritis, if ? 3 microbes are suspected, the lab needs pre-notification ? form of imaging is useful to identify the location of infection What are the next best steps after Dx of septic joint has been made
H Influenza Gonorrhoeae Kingella Tc-99 Synovial/blood culture IV ABX Surgical decompression/lavage
59
? is the cornerstone of successful Tx of septic joint Once transitioned to PO AB, how long is the regiment continued What microbe and type of microbe causes Lyme Dz
Emergent surgical decompression 4-6wks Spirochete: Borrelia burgdorferi
60
Lyme Dz is the most ? What types are endemic to Europe and Asia? What are the 3 phases of Lyme Dz
Prevalent vector-borne illness in US B afzelli B garinii Local: viral Sxs Disseminated: cardiac/neuro- Meningitis Rediculopathy Cranial neuropathy Late: arthritis/neuro- paresthesia encephalopathy radiculopathy joint pain
61
? is the most important non-op Tx for Lyme Dz Lyme Dz risk remains low if tick is removed w/in ? time frame How are these PTs Tx w/ ABX
Skin/Clothing checked for ticks <36hrs Doxy 100mg BID x 28days Amox 500mg TID x 28 days <8y/o: Amox 20mgg/kg
62
What are the 3 types of osteoporosis What types of Fxs can Pts present w/ that indicate the type they have Osteoporosis is usually unnoticed until Pts present complaining of ? four issues
Primary 1: post-menopausal (6x F>M) Primary 2: senile (2x F>M) Secondary: M>F steroid Hx, MM, OM, OI, hyperpara/thyroid Type 1: compression vertebral, distal radial Type 2: hip, pelvis Type 3: men w/ low energy Fx Back pain Fx Lost height >2" Spine deformity
63
? is the 10yr Fx risk assessment for Osteoporosis and what two factors are as important as low bone density What is the name of the thoracic kyphosis these PTs can develop What are the two DEXA scores provided and what are the ranges
FRAX: bone density + RFs Old age + prior low energy Fx Dowagers Hump Z: peers T: healthy, young PTs 0- -1: normal - 1 - -2.5: osteopenia - 2.5 or more: osteoporosis
64
Where does DEXA scan measure density at What is DEXA best used for ? Who needs to have DEXA scans d/t RFs
Spine FemNeck Trochanter Femur Monitoring osteoporosis Tx Female >65y/o Post-menopause <65y/o Men w/ Hx low-trauma Fx/prostate Ca Primary Hyperparathyroid
65
What are the two sub-types of osteoporosis When does bone mass density reach peak levels during life What recommendations are given to reduce risk for osteoporosis development
High-turnover: high NTx score Low formatoin: low NTx score <28y/o Ca/Vit D Avoid alcohol/tobacco Impact loading- walk, strength, Tai Chi
66
How much Ca intake is recommended for osteoporosis prevention What are the two main forms of Ca for ingestion What is the difference in these two method of breaking down during metabolism
750-1000mg/day (range 25-45) Carbonate Citrate Carbonate reqs acid Citrate dissolves at all pH levels w/ dec risk for stone development
67
How much Vitamin D is needed for proper Ca absorption How much Vitamin D intake is recommended Fx from fall can be avoided w/ as little as ? Vit D intake/day
>15ng to avoid insufficiency >30 recommended 800-1200 IU/day 2-4K if Vit D deficient 800
68
What is the 3rd MC cause of delayed Fx healing How is Osteoporosis Tx w/ Rx
Low Vit D High NTx= antiresoptives (disphosphonates, -ate) SERM: Denosumab Low NTx: Anabolic (intermittent PTH)
69
? medication is used to increase spinal bone mass but doesn't dec risk for hip Fxs but w/ ? s/e ? is used in Pts w/ dec renal function ? medication has mild spinal Fx protection and possible pain relief but w/ 2 s/e
Raloxifene- inc DVT risk and hot flash occurance Denosumab- inhibits osteoclast formation Calcitonin No non-vertebral Fx protection Inc Ca risk
70
When are anabolic agents recommended for use against osteoporosis When is their use c/i Prolonged diphosphonate usage is associated w/ ? 2 adverse outcomes
Pre-menopause Impaired Fx healing Diphosphonate failure Low turnover Radiation Hx Paget Dz Children Atypical femur Fx Jaw necrosis
71
What are the three parts assessed for overuse syndromes during PE + Phalen test means ? Dx How are overuse syndromes Tx and what type of rehab program is useful in Tx
Inspect: Atrophy Pallor Erythema Swelling Palpate: Point of max tenderness Strength for pain w/ resistance De Quervains (APL, EPL) Protection Rest Ice NSAID Cream Eccentric
72
Sprains are uncommon in ? population Instead of sprains, these Pts usually end up w/ ? Dx What are the 3 degrees of Sprains What are the 4 grades of Strains
Open growth plates SALTR Harris Fx 1: partial w/ no instability 2: partial w/ laxity 3: complete w/ laxity 1: <10% muscle, intact fascia 2: 10-50% muscle, intact fascia 3: 50-100% muscle, intact fascia 4: 100% tear w/ disrupted fascia
73
What is assessed in strains or sprains during PE and what imaging modality is best All sprain/strain need x-rays if pain is still present after ? days How are Sp/trains Tx
Point of max tenderness Sprain: joint stability Strain: stretch injured muscle for defect MRI: confirm/grade/rupture 7-10 PRICE- mainstay Cryotherapy NSAIDs Minor sprain- compression, immobilize Minor strain- immobilize w/ muscle stretched
74
When do sprain/strains need to be referred to Ortho What are the 3 stages of benign tumors What are 3 terms used for benign growths
Grade 4 strain, all Grade 3, Sev Grade 2 Latent Active Aggressive Well-defined Non-aggressive W/out cortical destruction W/out periosteal reaction
75
? Sx indicates a bone tumor has weakened the structural integrity What is a critical part about evaluating bone tumors on x-ray? Most benign tumors don't weaken the underlying bone w/ ? exceptions
Sxs exacerbated w/ activity Pattern recognition Osteoid osteoma Osteochondroma
76
What Sxs are absent in Pts w/ benign bone tumors If these Sxs are present, ? Dx should be suspected ? is the MC scenario for bone tumors to be found
Constitutional Sxs Mets Infection Lymphoma Incidental finding
77
What is the best imaging modality for suspected bone tumor assessment What other imaging modalities are used and what are the pros What do bone scans use for imaging
Radiograph MRI better: soft tissue/marrow CT better: bone detail Tc-99m: isotope bound to ligand methylene-diphosphonate
78
PTs >40y/o w/ aggressive bone lesions will probably have ? types of Ca If a primary site can't be located after detailed Hx/PE, what is the next step What blood tests may be done to help w/ Dx in Pts >40y/o
Metastases Myeloma CT- chest abdomen pelvis Light Immunoglobin Microglobulin Electrophoresis Quant immunoglobin Protein electrophoresis Free light chain assay B-2 microglobulin factor
79
What are the two MC methods for obtaining bone biopsies for suspected neoplasms What type of benign tumors can cause pathological Fx and loss of function These Pts are at risk for ? two things if they become immobile
Closed needle, Open bone Active/Aggressive HyperCa Pneumonia
80
How are benign bone tumors Tx ? drug plays a vital role in managing established bone mets What is the theorized etiology of growing pains in ? population MC
Active/Aggressive: surgery Primary tumor, Peds: Chemo, Surgery Mets: Rad/Chemo/Surgery Disphosphonates Over activity- muscle strain/fatigue Boys 2-5y/o w/ ligamentous laxity
81
What may be found on PE in suspected growing pains What part of the body is MC affected what is done for management/Tx
Pain w/ deep pressure Flexible flatfeet Calves Stretching Education Analgesics
82
Pt w/ suspected growing pains may need metabolic work up if ? two Dxs are possible What is more common about CRPS in Peds Where do these Pts MC have skin color changes
Leukemia Endocrinopathy Type 1: MC extremeties in Peds 9-15y/o Ankle/Feet
83
What are the S/Sxs of long term CRPS in Peds What two meds are used for Ped Pts that don't respond to rehab Most cases of child abuse occur in PTs ? old w/ ? populations at higher risk
Muscle wasting/contracture Coarse hair, extremity Thick nails Amitriptyline Gabapentin <3y/o First Handicapped Stepchildren Premature
84
Toddlers commonly have bruises located ? What is the next step in evaluation if a child's mental status is abnormal What is the name and age criteria for the series of x-rays done for these suspected abuse cases
Brow Elbow Chin Knee Shin Subdural hematoma Retinal hemorrhage Skeletal survey: <2y/o
85
Fx highly suspicious for abuse Fx moderately suspicious for abuse Bone scans can be used to assess for rib fxs in suspected abuse, what would be seen in healed Fxs
``` Post ribs Corner long bone metaphysis Scapular Process, spinal Chip long bone metaphysis Sternum ``` ``` Multiple/Bilateral/Aged/ Fxs Fingers Epiphyseal separation Vertebral body Skull, complex ``` Fusiform thickening
86
How is the age of a Peds Fx assessed by imaging How are Fxs older than 6wks best assessed ? type of wrist Fx is not associated w/ Fx
7-14d: new periosteal/callus 14-21d: lost Fx line, mature callus/trabecula 21-42d: dense callus >42d: sublte fusiform sclerotic thickening Eval for thickening by comparing to contralateral side Buckle
87
What system is used to describe Peds Fxs involving the physis ? type of x-ray increases the ability to view these Fxs What are the adverse outcomes from these types of Fxs
Salter-harris Oblique Premature growth arrest Dec bone length
88
What are the Tx goals of Peds Salter-harris Fxs How are these Fxs Tx Mild displacement is allowed in ? gender that are ? age
Reduction/Avoiding arrest x 6wks Type 1-2: closed reduction, cast immobilization 3-4: reduction w/ ORIF Boys 15 and > Girls 13 and >
89
Kids younger than 13y/o should not have any Fx older than ? reduced Salter Fx Types 3-4 require surgery d/t ? structures involved These require reduction to ensure congruent surfaces to prevent ? formation
>7 days Cartilage of growth plate and articular surface Physeal bars
90
How long do Peds w/ Salter-harris Fxs need f/u ? types of Fxs require longer f/u process How is JIA named differently in the US and Europe
12mon, less if they reach skeletal maturity before f/u appointment Femur, Tibia JRA: USA JCA: Europe
91
There are at least seven types of JIA, but they all have ? two things in common What are the types of facts of each
Chronic arthritis x 6wks Pt is <16y/o Systemic: Fever Arthritis Rash Adenopathy Hepa/Spleno-megaly Pericarditis Oligoarticular: 4 or < joints, high risk ASx uveitis RF neg-poly: RF-,, 5 or > joints RF pos-poly: RF+, 5 or > joints Psoritatic: first degree relative Enthesitis: SI, enthesitis, HLA-B27 Udifferentiated: doesn't fit elsewhere
92
What joint needs to be palpated when assessing suspected JIA in ASx Pts What are adverse outcomes from this Dz How is this Tx
TMJ Joint arthritis/destruction Blindness from un-Tx uveitis NSAID- first line Few joints: intra-articular CCS Unless arthritis is mild, DMARD (Methotrexate) or a-TNF (Etanercept, A/I-umab)
93
What two meds are used for Ped PTs w/ refractory JIA uveitis When would splinting be recommended What is an adverse outcome to Tx for these Pts that are on a-TNF meds
Inflixiamab Adalimumab At night for contractures Fungal/TB infection
94
# Define Osteochondritis Dissecans Where does this d/o MC occur and where can it occur Where does it rarely develop
Osteonecrosis of subchondral bone MC- posterolateral medial femoral condyle Talus Humerus Elbow Femur Patella
95
What do Pts w/ OCD in the knee report as a pain relieving maneuver What test may be positive on PE for this condition What is the goal of Tx and how are these Tx
Walking toe out Wilson Test Let lesion heal Non-op: Peds w/ lesion <1cm, LLD, crutches, refractory due to noncompliance= immobilization Surgery: mature/cartilage has separated or lesion >2cm
96
Why is hematogenous spread of microbes in Peds most likely to infect metaphysis of long bones What is the sequence of infection progression What is the difference between osteomyelitis sequestrate and involucrum
Circulation creates u-turn, slowing flow down Canal, Cortex, Abscess formation Seq: abscess inc pressure= bone fragment Persistence leads to chronic osteomyelitis Involucrum: periosteum remains, new bone growth
97
How does subacute osteomyeltits present in Peds and d/t ? microbes X-rays of these Pts can show ? finding that can mimic ? How do these Pts appear in clinic
Indolent- bacteria/TB Lytic- aggressive appearance like a tumor Pain Malaise Warmth Erythema Swelling Tenderness
98
What is an early Sx of Ped osteomyelitis if the infection is in the pelvis or spine What is seen if the upper extremity is involved How does chronic osteomyelitis present
Refusal to walk/limp Pseudoparalysis Sepsis Sinuses w/ chronic drainage
99
? is typical PE finding for Peds w/ Acute Hematogenous Osteomyelitis What lab results will be elevated earliest during the Dz process What are the MC joints involved
Fever >100.4 Tenderness over bone Effusions CRP, <8hrs of infection onset Intra-articular: Prox- Femur Humerus Radius Distal-Fibula
100
How does subacute osteomyelitis appear on x-ray How does AHO appear differently on x-ray ? is the imaging modality of choice for Dx AHO
Lytic lesions w/ thin sclerotic rim and crosses physis Physis sparing MRI
101
What are the next steps of Tx once a case of Peds osteomyelitis is suspected ? microbe is MC the cause ? other microbes need to be covered when considering ABX coverage
Culture/biopsy IV ABX Staph A GBS Neonate: enteric rods 6-48mon: H influenza
102
What special step is needed if Kingella kingae is the suspected culprit of Peds osteomyelitis When are these Pts switched from IV to PO ABX How long are ABX recommended
PCR and special culture media 7 days 6wks
103
What is almost always needed to Dx subacute osteomyelitis ? Tx step provides the best likelihood for Dz eradication Why is immobilization recommended and for ? long
Biopsy from surgical debridment Removal of all infected material 3-6wks Dec pain Reduces chance of pathological Fx
104
Septic arthritis in kids is usually d/t ? route and microbes Septic joints will have ? lab results What joints are most likely to be affected
Hematogenous seeding of synovium from: Skin infections Impetigo Pneumonia ESR >30 WBC >15K Synovial WBC >50K Knee Hip
105
Septic arthritis needs to be ID'd early in Peds and can be done so by ? What signs may be present when this Pt arrives If the hip/elbow/knee is involved, Pts hold it in ? position
Hyaline cartilage damage from lymphocytic enzymes <72hrs from inoculation Guarding Fever Anorexia Malaise Hip: Flex Abducted External rotation Knee/Elbow: slight flexion
106
When assessing Peds Pt for septic arthritis, how is their presentation different if the underlying Dx is Transient Synovitis or Legg-Calves Dz ? lab marker is best for monitoring Ped Septic Arthritis Septic joints will have ? lab results
TS/LC: discomfort instead of pain CRP ESR >30 WBC >15K Synovial WBC >50K
107
How is Ped Septic Arthritis Tx Pediatric Seronegative Spondyloarthropathies have ? 4 characteristics in common ? c/c presentation suggests a case of anklyosing spondylitis
Joint aspiration/drainage IV ABX HLA-B27 Inflammation of tendon/fascia/enthesitis Pauciarticular arthritis in LE Extra-articular inflammation Asymmetric peri-articular arthritis of the lower extremeties in kids 9 or >
108
Peds Reiters Syndrome is a triad of ? three Dx This conditions can be triggered by diarrhea caused by ? microbes What can cause the non-gonorrhea urethritis in adolescents
Conjunctivitis Enthesitis Urethritis Yersinia Campylobacter Salmonella Shigella Trachoma Chlamydia
109
Peds w/ Reiters in what two locations are particularly painful How does Peds w/ Psoriatic arthritis tend to present Peds IBDz arthritis usually presents prior to ? and ? prevelance is twice as common
Achilles or Plantar Fascia Female <15y/o w/ skin problems before arthritis <21y/o w/ arthralgia w/out effusion
110
What PE finding is a distinguishing feature of juvenile spondyloarthropathies Peds w/ Ankylosing Spondylitis may have enthesitis in ? locations What extra-articular Sxs do Peds w/ Reiters present w/
Purple discoloration around joint Patellar Achilles Plantar Conjunctivitis Anterior uveitis Photophobia
111
What is the most common manifestation for Peds w/ Psoriatic arthritis Involvement of ? three locations is more common w/ Psoriatic than other Spondylonegatives What lab result supports a Dx of juvenile Reiters Syndrome
Monoarticular knee Digit tenosynovitis UExtremity involvement Nail pitting Sterile pyuria
112
How are Peds w/ Spondyloarthropathies Tx What is the name of the distal end of the spinal cord that ends at ? level Anything below is AKA and if compressed presents as ?
Muscle strengthening Orthoses Activity modification NSAIDs Conus medullaris ending at L1-2 Cauda equina: L2-S4 Paralysis w/out spasticity
113
How does Cuada Equina present on PE What special tests are done for suspected Cauda Equina Syndrome How can Pts seen in the ER for back pain be mis-Dx w/ Cauda Equina
Bilateral radiculopathy Incontinence Foot drop Stumbling gait Inability to rise from chair (quad/extensor test) Inability to walk on heels (ankle dorsiflexion, plantar flexion) If given narcotic injection, causes acute urinary retention
114
How is Dx of Cauda Equina confirmed w/ imaging What is a possible error that could be an adverse outcome to this Dz What is the usual cause of cervical radiculopathy in young/older PTs
Compressed thecal sac on CT/Myelogram Blame bladder Sxs as Cystocele/Prostatism w/out considering sphincter paralysis Young: herniation traps root in foramen Older: stenosis/arthritis
115
What will usually be seen on PE of cervical radiculopathy Stenosis of the cervical spine commonly present w/ ? Sxs Pts will report ability to relieve Sxs w/ ? maneuver
Radicular pain w/ UE numbness/paresthesia (deltoid to thumb) Changed grip/handwriting Trunk/leg dysfunction Gait disturbance Incontinence Place hands on top of head
116
What type of neck malformation may be present and restrict movement in cervical radiculopathy ? motor/sensory tests need to be done for these PT How is this Dx confirmed w/ imaging
Reduced cervical lordosis C5-T1 UE reflexes CT/Myelogram w/ contrast
117
How is Cervical Radiculopathy Tx What two Txs are avoided in this population Define Cervical Spondylosis
Most spontaneous x 8wks NSAIDs + traction Opioids Manipulation Degenerative disc dz of the cervical spine
118
What causes the Cervical Spondylosis dz process What are the MC Sxs of Cervical Spondylosis What Pt is morelikely to have spinal stenosis and myelopathy w/ this condition
Herniation Osteophyte growth Thick ligamentum flavum Limited mobility Pain worse w/ upright Older men
119
What are 3 Sxs of early cervical mylopathy from cervical spondylosis What PE findings will be abnormal This type of abnormality suggests ? structure is involved
Palmar paresthesis Altered gait (heel-toe) Difficult dexterity Lost vibration/proprioception in the feet Posterior column
120
? sensory and motor function tests are needed for PTs w/ Cervical Spondylosis What two special neuro tests may be positive in cervical spondylosis PTs X-rays may reveal osteophytes originating from ? landmark
C5-T1 and L1-S1 ``` Lhermitte sign Hoffmann Clonus Hyper-reflexia Babinksi ``` Zygoapophyseal joints
121
Where are cervical spondylosis/age-related degenerative findings MC seen How is this Tx What two meds can be used for sleep aids
C5-7 Cervical pillow NSAIDs Surgical decompression Doxepin Amitriptyline
122
What is the classic mechanism for whip-lash injury What is the MC findings on PE How are these Pts Tx
Stopped car that is rear ended= flexion/extension Non-focal/radicular neck pain ``` NSAIDs Soft collar Muscle relaxants Cervical pillows Doxepin/Amitriptyline ```
123
What 3 x-rays are ordered for cervical strains and what is a normal measurement obtained What is the next step and measurement if severe pain is present What image should not be ordered until after eval by specialist
AP/Lat/Odontoid- pre-vertebral tissue width at C3 should be <1/3 width of C3 Vertebral body translation 3.5mm or more and/or 11* of angulation Flex/Extension images
124
What type of rehab is recommended post-cervical strains What is the most important x-ray obtained for multiple injury trauma Pt What are the MC missed injuries
Walking early Isometric exercises when tolerated Cross-table lateral view of C1-T1 Injury to upper/lower C-spine
125
What type of x-ray is needed for trauma Pt to evaluate the cervical-thoracic junction How are neck injured Pts Tx if cleared by imaging but pain persists Flexion-distraction injuries of the T/L spine usually alos have ? injuries too
Swimmer view Cervical collar x 7-10 days Abdominal- bowel lac
126
What secondary issue can develop in Pts w/ lumbar spine Fxs What are the hallmark PE findings of an unstable T/L flex-distract or burst Fx Burst Fxs tend to involve ? column of the spine and best seen w/ ? image
Ileus- dec bowel motility Hematoma w/ step off Middle, CT
127
Any vertebral Fx other than ? requires additional imaging Isolated transverse process Fxs need to be inspected for injury to ? and can be Tx w/ ? to dec Sxs Compression Fxs w/ ? measurements are also tx the same method x 8wks
Single compression Kidney, thoracolumbar corest Wedging <20* No posterior involvement
128
? is the MC cause of disability and lost time at work for Pts <45y/o What causes the irritation process for this condition What is used to monitor progress
Acute low back pain Injury to anulus fibrosus= nucleus pulposus leak= irritation Lumbar flexion Ease of extension
129
Acute LBP that need x-rays need to have ? landmark in the picture What are the two phases of Tx for acute lower back pain When does this type of back pain become reclassified to chronic lower back pain
T10 Initial: Sx relief Secondary: return to activity Pain >3mon
130
All Pts w/ chronic lower back pain need to be evaluated by ? providers Identifying ? underlying issue w/ Chronic LBP can help Sx resolution Often there is ? sign seen on x-rays
GYN Internist FamMed Spine Depression Vacuum- Nitrogen in air space
131
What type of material is found in the nucleus pulposus What are the 3 parts of the intervertebral disc What two movements increase pressure on the nucleus pulposus
Collagen Type 2 Nucleus pulposus Anulus fibrosus Sup/Inferior end plates Twisting Lifting
132
Where do lumbar herniations MC occur What nerve root is irritated Herniations located in ? areas tend to NOT have radiculopathy below the knee and have ? Sx
L4-S1 L5-S1 L1-4, pain in anterior thigh
133
? PE test has high correlation to lumbar herniation What test is even more specific though When performing the supine straight leg raise, this maneuver pressures ? area
Seated leg raise Crossed straight leg raise L5-S1 is stretched
134
What will be seen in L3-4 herniation onto L4 What will be seen on L4-5 herniation onto L5 What will be seen on L5-S1 herniation onto S1
Weak anterior tibialis, asymmetric knee reflex Great toe extensor weakness, numb dorsal foot/lateral calf Unable to toe walk, lateral foot pain, asymmetric ankle relfex
135
When is an MRI ordered for suspected lumbar herniations How many epidural injections can these PTs receive When should the injections be avoided
Sxs >4wks 3 in 6mon Substantial neuro deficit
136
Motor, Reflex and Sensation for L4 nerve root Motor, Reflex and Sensation for L5 nerve root Motor, Reflex and Sensation for S1 nerve root
Anterior tibialis / Patellar / Medial foot Extensor hallucis longus / NONE / Dorsal foot Gastroc soleus (toe raise) / Achilles / Lateral foot
137
Why would a PT younger than 60y/o experience lumbar stenosis Where does stenosis typically develop ? type of movement tends to narrow the lumbar region
Achondroplasia L2-5 Spine extension
138
What special tests should be done for suspected lumbar stenosis? What is uncommon and ? area is rarely affected by this condition Lateral x-ray views need to have ? landmark included
Proprioception/Romberg/Neurovascular Leg muscle weakness Uncommon sphincter tone decrease T10
139
How is lumbar stenosis Tx non-op When do these Pts become surgical candidates What is the goal of Tx
Water exercise Epidural injections Non-ambulatory/Dec quality of life Prevent progression
140
What type of malignant tumors of the spine are considered rare/common Highest incidence of spinal carcinoma is d/t ? and via ? How are Cas to the spinal column spread via hematogenous
Primary- rare Metastatic- common BLT KPC by hematogenous spread Batson's plexus- connects w/ inferior vena cava
141
Malignant tumors of the spine can present in ? ways ? is the MC presenting issue for these Pts What is the first manifestation these appear as on x-ray
Pain as presenting c/c Incidental Neuro findings Known primary tumor Pain, usually from minor vertebral Fxs Lost pedicle integrity (winking owl)
142
What is the best screening study for widespread mets after suspected spinal neoplasm This test will usually be negative in Pts w/ ? Dx What are the most severe sequelae of pathological Fxs induced by these mets
Tc-99m bone scan Multiple myeloma Quad/Paraplegia
143
How are ASx spinal neoplasms found during the search for mets Tx non-op How are painful metastasis Tx When is surgery indicated
Chemo/Rad/Hormones Radiation if no deformity/neural compression Pain w/ neurodeficit- decompression and stabilization w/ post-op radiation
144
What is a common adverse outcome after surgical decompression of spinal neoplasms? Define Scoliosis What is the MC presenting Sx
Wound complication if surgery is post-radiation/steroid Coronal curvature of spine >10* using Cobb method Pain in region of deformity
145
What is the MC overlapping condition seen w/ scoliosis If these PTs have radiculopathy it's because of ? compression Neurological findings are rare but ? is the MC
Degenerative spondylosis L4-5 Hallucis Longus
146
How is decompression in scoliosis assessed How is adult scoliosis Tx What are the red flags for referral in these Pts
Plum line- C7 to gluteal cleft NSAIDs Water/swimming therapy Neuro deterioration Can't walk 2 blocks d/t pain Respiratory dysfunction Trunk exercise
147
# Define Degenerative Spondylolisthesis What is the opposite direction of slippage called What nerve roots need to be evaluated
Female >40 L4-5 body slips fwd d/t deteriorated facets/disc leaving lamina/pars interarticularis intact Retrolisthesis- posterior slippage L1-S4
148
What neuro findings are seen in Pts w/ Degenerative Spondylolisthesis Narrowing of ? two spaced in degenerative spondylolistesis causes ? types of pain Where does pediatric isthmic spondylolisthesis usually develop
Dec knee reflexes, also seen in geriatrics Weak toe/heel walking Weak toe dorsiflexion Lateral recess= radiculopathy Central canal= claudication L5-S1
149
Isthmic Spondylolisthesis develops at ? junction This form of the condition is more likely to represent ? event If only the defect is present, and no slippage has occurred? the PT has ? Dx
Lamina w/ pedicle (pars interarticularis) Cyclic loading AKA- fatigue Fx that fails to heal Spondylosis
150
? activities put Pts at higher risk for developing Isthmic Spondylolisthesis How do Pts w/ isthmic spondylolisthesis present to clinic What may be seen on PE
Gymnastic/Football Posterior pain radiation below knees, worse w/ standing Dec lordosis/flat buttocks Vertebral step off Hamstring spasm w/ forward extension/leg raise
151
What area of the lumbar spine can become compressed during Isthmic Spondylolisthesis What is the x-ray finding name for this condition Since Peds are considered skeletally immature, what imaging test is ordered to assess metabolic activity at site of defect
L5 Collar on scotty dog Single Photon Emission Test- SPECT CT
152
How are cases of Isthmic Spondylolisthesis Tx ? is the MC cause of thoracic and lumbar pain in kids? Spinal hyperextension loads posterior spine to test for ? while flexion loads anterior spine to test for ?
Metabolically active and skeletal immature= rigid brace Surgery: refractory, high grade slip Skeletal mature: no fixation, NSAID, exercise Muscle strains Extend: posterior- spondylolysis Flex: ant- discitis, compression Fx
153
Abnormal abdominal reflexes may be the only sign Peds Pt has ? Dx What is the initial imaging method of choice for Peds w/ back pain Discitis and vertebral osteomyelitis in Peds are issues involving ? d/t ?
Syringomyella Weight bearing PA/Lat x-ray Discitis: MC Staph A in anterior spine in kids <5y/o Osteo: Staph A in vertebral column in Pts >5y/o
154
Where is discitis MC seen in Peds Other the MC microbe causing discitis, what other 3 microbes can cause this Dx What special tests are performed and what is the imaging modality of choice
Low thoracic/Lumbar Kingella E coli GAS Percussion- localizes Passive flex- pain due to anterior element compression MRI
155
What provacative test can be done for Peds Pts w/ suspected discitis ? other Dx test should be considered in these populations ? abnormal lab results may be seen in Peds w/ discitis/vertebral osteomyelitis
Pick up- will avoid bending back to retrieve item TB skin test Normal WBC w/ inc ESR/CRP
156
What are common adverse outcomes in Peds w/ discitis/vertebral osteomyelitis How are these PTs Tx by non-op methods When is surgery/biopsy indicated
ASx persistent disk narrowing and spontaneous vertebral fusion Empiric bed rest, LLD, analgesics IV ABX x 2wks then PO x 4wks Orthosis worn x 6wks Non-responsive to empiric Txs
157
# Define Kyphosis What is the normal range for thoracic kyphosis and how is this measured What are the two MC causes of hyperkyphosis and in seen in ? populations
Greek- humpback Curve on saggital plane w/ apex more posterior 20-50* w/ Cobb angle between T3-T12 >50*= hyperkyphotic Postural- female Scheuermann dz- male
158
How is Sheuermann Dz Dx on imaging What are the names of the nodes seen in this Dz Neuro findings are rare in these Pts except for ?
Wedgine >5* in three vertebraes Schmorl- disc herniations through end plates Congenital kyphosis
159
How is hyperkyphosis assessed in clinic How do the two different etiologies appear What is a common neuro finding seen in pathlogical forms of hyperkyphosis
View from side w/ Adam fwd bend test Scheuermann/pathologic- sharp apex angulation Postural- gradual curvature Hamstring spasm/contracture
160
How is the magnitude of a hyperkyphosis angle measured What are the adverse outcomes of this dz What can complicate surgical Tx of this
Cobb angle: T5-12 w/ >50* being abnormal Dec pulm function- >90-100* Back pain Neuro Sxs= congenital Proximal junction kyphosis
161
# Define Scoliosis What is the MC Dx How is this MC scoliosis classified
Lateral curvature >10* w/ Cobb angle Idiopathic Age of onset: Birth-3yrs: infantile 3-11yrs: juvenile >11y/o: adolescent
162
What is neuromuscular scoliosis associated w/ causing to be seen on PE What is the predominant effect of Peds scoliosis What is usually seen in PTs w/ neuromuscluar scoliosis
Flaccid weakness/spasticity Loss of sitting balance Impaired respiratory function Long thora/lumbar curves
163
Idiopathic neurological progression presents as ? What findings on PE can solidify Dx of idiopathic scoliosis in Peds What is the most sensitive test for screening and quantifying scoliosis in Peds
Lost sitting balance Cafe au lait spots Axillary freckles- neurofibromatosis Lesions over spine= spinal d/o Cavus feet- neuromuscular dz/cord anaomaly Adam's forward bend test Cobb angle
164
What are the indications for ordering MRI for Pt w/ Idiopathic Scoliosis Pts w/ congenital spinal dyformities need ? additional images ordered What is an adverse outcome for Pts w/ scoliosis
Age (infantile/juvenile) Abnormal Hx/PE findings Radiographic- (KREWL) Kyphosis Rib abnormals Erosive vertebrae Wide spinal canal Left sided thoracic curve Renal US Spine MRI Echo Curvatures >80*= dyspnea from restrictive pulm dz
165
What/why does idipathic scoliosis have a reduced life expectancy How are idiopathic scoliosis PTs Tx non-op How are idiopathic scoliosis Pts Tx op
Cor pulmonale, MC infantile/juvenile and congenital cases Skeletal immature w/ curve 25-45*- bracing Neuromuscular scoliosis- 1) observation if sitting/function are normal 2) soft orthosis if progressive/Sxs Immature >45* Mature >50-60*
166
How is neuromuscluar scoliosis Tx What is the downside for the future in these Pts How is congenital scoliosis Tx
No function/sitting impairement- observe Progressive/Sx- soft orthosis Post-op complication risk is higher Premptive spinal fusion
167
# Define Spondylolysis What causes this What level is this MC seen
Defected pars interticularis Stress Fx progresses into pseudoarthrosis L5
168
What can cause a higher grade slip to occur in spolylolisthesis What is the MC Sx and what is the land mark it stops at What may be the first sign of a stress reaction of spondylosis/listhesis and how is it reproduced on PE
lumbar kyphosis Activity related radicluopathy stopping above knee Hyperextension of spine
169
How are Peds w/ stress reaction/early cases of spondylolysis Tx When are these Tx w/ fusion/decompression surgery
LLD NSAIDs TLSO x 3-4mon Immature Pts w/ slippage >50% Chronic Sxs
170
What are the 6 types of AC injuries
1- AC ligament sprain 2- AC ligaments torn, widening <100%, unstable in ant/post direction 3- 100% displace, CC disrupted here 4-6: periosteum, deltoid, traps are disrupted 4- Sup & Posterior displace 5- sup displaced clavicle 6- distal clavicle is in sub-acromial/coracoid space
171
How are AC joint injuries confirmed w/ imaging What is a type of weakness this type of injury can make PTs adopt How are these injuries Tx
AP films- Type 2-6 Weight bilateral- Type 1-2 Weak pushing/benching Type 1-2: sling Most Type 3- Tx non-op Surg: young/labor/Type 4-6
172
What is the goal of rehab after AC injuries How do Pts w/ shoulder arthritis present to clinic Pts w/ shoulder arthirits and long standing rotator cuff tears may also develop ? issue
Reduce pain Protect joint Function Diffuse/deep pain worse to posterior shoulder High riding humeral head
173
What will be seen on PE of shoulder arthritis What x-ray findings help support a dx of shoulder arthritis What would be seen if the actual underlying issue was RA?
Equally decreased A/PROM Flattened humeral head Inferior osteophyte Posterior erosion of glenoid Periarticular erosions Osteopenia Central wear of glenoid
174
? is an adverse outcome for Pts w/ shoulder arthritis How are these Tx non-op What procedure is done for mil/mod cases w/ preserved ROM
Severe loss motor/strength even w/ -plasty Heat/Ice NSAIDs Stretching exercises Arthroscopy debridement and capsular release
175
How does Transient Brachial Plexopathy develop What is the corner stone of an accurate Dx of burner/stinger How is a preganglionic burner to C8-T1 confirmed on exam
- C5-7 stretch injury while neck tilts in opposite direction - Upper plexus between shoulder pad and scapula - C8-T1 stretched w/ arm abduction (usually pre) Neuro Exam Horner's Syndrome: Myosis Ptosis Enophthalmos Anhidrosis
176
Dorsal scapular and long thoracic nerve may be injured during burners/stingers because of their origin ? ? muscles are assessed to see if these nerves have been injured If these muscles are intact, the location of the burner/stinger is then ?
C5-7 Rhomboid Serratus anterior Post-ganglionic
177
Recurrent episodes of burner Sxs may suggest ? What findings on exam are required for an athlete to return to playing after a burner What is the MC and associated RFs for developing idiopathic Frozen Shoulder
Cervical stenosis Inc risk cord injury Resolution of pain/neuro Sxs Normal neuro exam Full cervical ROM DMT-1
178
What PE finding is pathognemonic for frozen shoulder Where is the most point tenderness elicited on exam What imaging finding helps solidify the Dx of Frozen Shoulder
Contracted coracohumeral ligament Deltoid insertion site Subscapularis Contracted capsule Loss of inferior pouch
179
What is the functional goal of rehab for frozen shoulders ? movement tends to be the most restricted for these Pts During rehab Pts shouldn't perform this restricted movement past ?
Inc ROM in scapula/glenohumeral joint External rotation w/ arms in adduction 30-45* of abduction
180
Frozen shoulder rehab that is too aggressive can result in ? When do they need to be referred for further eval What are the 4 muscles of the rotator cuff
Fx humerus 3mon w/out improvement of pain/motion Supraspinatus Infraspinatus Teres minor Subscapularis
181
What part of the rotator cuff is susceptible to impingement syndrome under the coracoacromial arch and how is weakness here tested What structures make up the corachromial arch What is the characteristic presentation
Supraspinatus- 90 elevated and internal rotation Coracoid process Coracoacromial ligament Acromion Acromioclavicular joint Gradual ant/lat pain worse w/ overhead activity from supraspinatus trauma from coracoacromial arch
182
What two special tests are usually positive on impingement exam Where will Pt have pain on PE Once suspected, how is the Dx confirmed
Neers Hawkins W/ 90-120* abduction W/ lowering arm Suacromial injection- pain relief is Dx
183
How are impingments/rotator tendonopathy Tx non-op What is the goal of rehab What can happen if more than 3 CCS injections are performed
Exercise x 3-4/day x 6wks Then subacromial injection Then stretching Overhead activities w/out pain Proximal bicep head tear
184
What type of x-rays are used to assess rotator cuff isues ? is the Dx/pre-op image of choice How are rotator cuff tears Tx non-op and op
30* caudal tilt- psurs from inferior acromion Coracoacromial- outlet, hooked acromion MRI Non: CCS Avoidance NSAIDs Strength/stretch rehab Op: 6mon non-op failure, acute= <6wks of injury
185
What are the goals of rotator cuff rehab What is an adverse outcome of rotator cuff surgical Tx What PT population usually have proximal bicep tendon ruptures
Pain ROM Strength Function Large tears= high failure Debridement may relive pain Older adults w/ chronic shoulder pain d/t rotator cuff
186
What are the landmarks that the long bicep tendon head is found in What special test is done for assessing possible proximal bicep tendon ruptures What is an adverse outcome for 10% of these Pts
Intertubercular groove, intrarticular for proximal 3cm Ludington- put hand behind head and flex Loss of elbow flexion/forearm supination (screw driver)
187
When are proximal bicep tendon ruptures repaired w/ surgery Instability is MC found in ? joint Pts w/ this MC instability have recurrent episodes of ?
Young athletes Adults <40y/o as laborers Shoulder Subluxation- humeral head slips out of socket MC in Anterior/Multi-directional
188
# Define TUBS Define AMBRI What type of forces cause a ant/posterior dislocation
Traumatic Unidirectional instability w/ Bankhart lesion best Tx w/ Surgery Atraumatic, Multidiretional Bilateral signs of laxity, REhab as preferred Tx, and Inferior capsule shift Post: Adduct w/ internal Ant: Abduct, external
189
What is a common but poor prognostic presentation in Pts w/ multidirectional instability Pts w/ posterior dislocation present holding arm in ? position w/ ? movement impossible What are 3 special tests performed for shoulder instability to isolate the direction of instability
Voluntary dislocation d/t psychological disturbance Add, internal External= impossible Apprehension- anterior Sulcus- inferior Jerk- posterior
190
What x-ray finding is clear evidence of an anterior dislocation Posterior dislocations are missed on AP radiographs and axillary are impossible to obtain, ? image is needed How are shoulder dislocations Tx non-op
Hill-Sachs lesion: compression Fx of posterior humeral head from pressing on anterior edge of glenoid Trans-scapular First anterior= immobilize 3wks Rehab- subscapularis strength
191
What types of shoudler instability are Tx non-op When do these Pts need to be referred TUBS also have a tear in the labrum located ?
Atraumatic/voluntary (AMBRI) instability Failed reduction 2 or > dislocations/3mon w/ rehab Multidirection instability Anterior glenoid labrum
192
SLAP tears are injuries to what 2 structures What are the two mechanisms that cause tears What special tests are done for suspected SLAP tears
Superior glenoid labrum Bicep anchor complex Fraying- natural degeneration Frank tear- trauma Crank test Resisted supination/external rotation Active compression (Obrien) Clunk
193
What image is needed for Dx of SLAP tear How are SLAP lesions Tx non-op What is the next step if non-op fails and Sxs persist
MRA= gold standard NSAIDs Rehab towards stabilization, stretch, strength x 6wks Dx arthroscopy
194
What is the goal of rehab for SLAP tears What 3 exercises need to be avoided ? is the MC adverse outcome of SLAP lesions
Goal: reduce pain, protect joint Bench press Over head press Bicep curls Shoulder stiffness
195
What causes Thoracic Outlet Syndrome What three underlying congenital issues can cause Thoracic Outlet Syndrome These Pts can present w/ Sxs mimicking ? d/t ?
Compressed brachial plexus/subclavian vessels between superior shoulder girdle and 1st rib Fibrosed scalene muscle Long C7 processes Anomalous fibromuscular band Cervical rib Brachial plexus= ulnar entrapment
196
When evaluating Thoracic Outlet Syndrome, evaluate ? area for masses What is the simplest and most reproducible PE test What x-rays are ordered for TOS and why are they ordered
Supraclavicular fossa Raised arm stress test- shoulders abducted to 90*, open and close fist x 3min AP: r/o cervical rib/C7 process PA/Lat: r/o apical lung tumor/infection
197
What are four adverse outcomes from thoracic outlet syndrome What are two rare but possible outcomes ? is the MC cause of elbow joint destruction
Weakness HAs Inability to do overhead work Coordination decrease Raynauds Ulcerations RA
198
Non-rheumatoid inflammatory arthritis of the elbow usually presents as ? condition Elbow OA is usually seen in ? populations How are elbows tested for the presence of osteophytes
Pseudo/gout Manual laborers Weight lifters Jogging- Extension= posterior Flexion= anterior
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How is elbow arthritis Tx Why are elbow arthroplasty's avoided as much as possible What muscle originates at the lateral/medial epicondyle of the humerus and inflamed during epicondylitis
RA: plasty Non-Rheum: CCS, gout control Post-trauma/OA: Stretch Analgesic Debridement Prosthesis loosens/breaks Lat: Extensor carpi radialis brevis Med: flexor/pronator muscles
200
What form of epicondylitis is more common What makes pain of lateral/medial epicondylitis worse What is the most consistent PE finding for lateral epidcondyltitis
Medial > Lateral Lat: Wrist extension and grip Med: Wrist flexion and pronation Tenderness over extensor 1cm distal and anterior to lateral condyle
201
What in office test can differ lateral/medial elbow Dxs ? is the MC adverse outcome from this condition What is the most important non-op Tx step for elbow tendonitis
Lifting- pain w/ palm up= medial condyle Pain Avoidance Persistent Sxs= CCS Debridement
202
What are the 4 stages of Tx of humeral epicondylitis What criteria can be used to determine if Pt is ready for early exercises Surgical failure of these Pts can result in ? mids-Dx
Reduce pain/inflammation Promote arm strength Return pain free activity Maintenance Pain free hand shake PIN w/ lateral epidcondylitis Ulnar w/ medial epicondylitis
203
Pts w/ pulmonary/breathing difficulty may present w/ ? abnormal c/c What is done that is therapeutic and Dx
Olecranon bursitis Aspiration
204
How is olecranon bursitis Tx non-op If septic olecranon bursitis is Dx by lab, IV ABX use needs to be broad enough to cover ? microbe followed by ? When can PO ABX be used?
Small, mild= NSAIDs, LLD Non-septic= compression bandage, Reassess 2-7days Negative cultures, fluid re-accumulation= aspiration and CCS injection PCN resistant Staph A Surgical decompression Daily aspiration Septic bursitis Tx early and Pt not ImmComp
205
Why are chronically inflamed olecranon bursitis' rarely ever InD'd? When do Pts need to be red flagged and referred? Where can the ulnar nerve experience entrapment
Risk for chronically draining/infected sinus development Septic/recurrent w/ 3 or > aspirations 10cm prox to elbow 5cm distal
206
What are the two MC nerve entrapment in the upper extremity and what causes the compression Define Cubitus Valgus What can cause ulnar palsy
1st: carpal 2nd: ulnar, cubital tunnel or between humeral/ulnar heads and flexor carpi ulnaris muscle Carrying angle >10* stretches nerve Repetitive subluxation/dislocation w/ flexion
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# Define Radial Tunnel Syndrome What is the commonly mis-Dx as How is it differentiated
Compressed PIN between supinator heads causing lateral elbow pain Lateral epicondylitis No sensory, innervates thumb/finger, carpi ulnaris extensors
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# Define Pronator Syndrome Why is this entrapment condition hard to find or is found late What are early and late signs of ulnar compression
Muscular compression of median nerve in proximal forearm Vague, few PE findings, high relation w/ worker's comp Early: aching elbow/numb fingers Late: weak intrinsic muscles
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How is the location of Radial Tunnel Syndrome differ What to Pts w/ Pronator Syndrome present w/ ? c/c What activity can aggravate Sxs of pronator syndrome
Pain 4-5cm distal from lateral epicondylitis Forearm aches w/ proximal radiation Driving
210
? is a provocative maneuver to test for ulnar compression What are the first abnormals seen when assessing sensation/motor function If two point discrimination is abnormal this means ?
Elbow flexion test Light touch/vibration Compression has progressed to degeneration
211
? provocative test is done for radial tunnel syndrome ? is the most reliable PE test for pronator syndrome Nerve conduction studies w/ a decrease of ? indicate ulnar nerve compression
Middle finger test- resisted extension causes forearm pain Pain w/ direct pressure to pronator teres 4cm distal to antebrachial crease 30% or more
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What is the most important step in ulnar nerve compression Tx to prevent ? adverse outcome When is surgical Tx considered What is the adverse outcome of distal bicep tendon ruptures if not Tx in timely manner
Preventing flexion/pressure Prevents permanent loss of strength/sensation Ulnar: Sxs/weak x 3-4mon Radial: discomfort after 3-6mon of rehab/non-op Pronator: no relief after 3-6mon of rehab/non-op Lost supination x 50% Lost flexion strength x 15% (initial, but improves)
213
W/ complete tears of distal bicep tendon, ? structure may remain intact Resisted flexion, the muscle belly will migrate in ? direction MRI is used to confirm Dx and distinguish between ? two things
Aponeurosis Proximally Tendon avulsion from radial tuberosity Ruptured muscle-tendon junction (poor prognosis)
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What nerve can be damaged during surgical correction of distal bicep tendon repair These need to be corrected w/in ? time frame ? structure is the primary valgus resistor in the arm and a tearing of this structure can present as ?
Radial <2wks of injury Ulnar collateral ligament Medial paresthesia
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? maneuver is used to provoke valgus stress to UCL What may be seen on x-rays in chronic UCL injuries ? imaging modality is used for Dx
Milking Loos bodies Ossification Osteophytes Marginal spurs MRI w/ contrast
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What is the MC adverse outcomes of UCL injury ? is an indicator that non-op Tx will be successful for the Pt When do ulnar collateral ligament tears need to be referred for surgical repair via ? procedure
Persistent pain w/ throwing Main goal is pain relief Competitive throwers >3mon of non-op Txs Tommy John surgery
217
Arthritis of the wrist are MC from ? etiologies How does wrist arthritis appear on exam depending on the cause Define Caput ulnae
Trauma RA ``` RA: Wrist: radial deviation Finger: ulnar deviation Dec grip w/ pain OA: Swelling Pain Dec ROM ``` Prominent ulna seen on PE
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When assessing wrist arthritis on x-rays, ? finding is indicative of early pseudogout ? random lab test may be needed during an abnormal work up ? is the MC compression neuropathy of the upper extremity
Calcificaiton of fibrocartilage complex Lyme Dz Carpal tunnel from compressed median nerve
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What are common precipitating conditions that can lead to Carpal Tunnel ? is the most useful PE test and what other test can be done What abnormal PE finding may also be noted
``` RA tenosynovitis Tumor Pregnancy DM Thyroid ``` Nerve compression test Phalen Failed two point discrimination <5mm
220
? is the most useful confirmatory test for carpal tunnel What is the purpose of non-op Tx De quervain tenosynovitis is swelling/stenosis around sheath of ? tendons
Electrophysiologic Dec pressure on median nerve Abductor pollicis longus Extensor pollicis brevis
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When is De quervain tenosynovitis commonly developed How is it Dx How is de quevains Tx
Post-partum w/ ulnar deviation during picking up child Finklestein test 2 wks NSAIDs w/ spica splint Persistent= CCS sheath injection CCS failure= surgery
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? is an adverse outcome of surgical Tx for De Quervains ? are the MC soft tissue tumors of the hand in Pts 15-40y/o What are the two types and how does their presentation tell the type
Injury to radial sensory nerve Ganglion: cyst from joint capsule/synovial sheath deterioration Sheath- tender w/ grasping, bump at base of finger (proximal flexion crease) Mucus- dorsum finger swelling distal and lateral to DIP
223
Where do wrist ganglions tend to develop What are these called if they are located at base of a finger in a tendon sheath Where do mucuous cysts develop and what effect do the exert
Wrist dorsum Volar radial wrist Base of finger at A1 Volar retinacular ganglia Distal to DIP Arthritic interphlangeal joint- press on germinal matrix causing nail pitting
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Dorsal ganglions of the wrist usually develop over ? joint A volar radial ganglion is usually between ? structures The volar growths may adhere to ? structure
Scapholunate joint Flexor carpi radialis Radial styloid Radial artery
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Volar retinacular ganglions of the flexor tendon sheath MC develop on ? fingers Mucus cysts tend to develop along ? Mucus cysts are the only growths that can cause ? x-rays changes
Long/Ring One side of extensor tendon of DIP Degeneration Spurs from dorsum of DIP
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Why is aspiration/rupture of a mucous cyst not recommended If this adverse outcome does occur, how it it Tx Define Kienbock Dz and these PTs present to clinic
Infecting DIP joint 1s generation Cephalosporin Osteonecrosis of carpal lunate in men 20-40y/o unable to grasp heavy objects
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As the Kienbock Dz progresses, what is the final result How does Kienbock Dz appear on x-rays and how is Dz staging accomplished w/ imaging Radiographic classification uses ? method
End stage arthritis of wrist Early: inc density Later: fragment/collapse MRI Lichtman/Weiss and Assoc.
228
How is Kienbock Dz Tx non-op X-rays are obtained w/ arm in ? position Why is this positioning needed
Normal/sclerotic- splint, NSAIDs x 3wks Shoulder abducted to 90 Elbow flexed to 90 Eval ulnar variance- difference between ulnar and radius
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Ganglias are the MC benign soft tissue tumors ? are the MC benign and malignant neoplasms of hand bones ? is the MC malignant neoplasm of hand Most hand tumors are painless w/ ? exception
2nd: Giant cell tumor 3rd: EIC B: enchondromas M: chondrosarcomas SCC Glomus- pressure/cold sensitive
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How are hand/wrist tumors evaluated and what does their location indicated
EIC- digit/amputated stump end, non-transillumination w/ light Giant: multi-nodular, firm and non-tender at thumb/index/long finger's interphalangeal joint Lipoma- thenar emminence
231
Recurrent paronychia infections and chronic nail deformities can be caused by underlying ? AIDs Pts w/ skin nodules w/ red/brown plaques have ? Symptomatic enchondroma is usually tender along ?
SCC Kaposi sarcoma Proximal phalanx
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# Define Carpal Boss These are sometimes associated w/ ? What color d/c come from mucous/EICs?
Dorsal prominence at base of 2nd/3rd carpal Ganglions EIC: white/cream Mucous: clear
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Hand tumors usually need ? imaging for max info ? can cause Pts to develop ulnar tunnel syndrome What are the 3 zones of ulnar tunnel syndrome
MRI ``` Wrist entrapment (mass/lesion) Trauma- jack hammer, base of hammer hammering ``` 1: motor and sensory Sxs (pisiform) 2: motor deficits 3: sensory (hook of hamate)
234
Pts w/ ulnar tunnel syndrome originating at the elbow will almost all have ? Sx What can happen if this condition goes untreated Animal bites to the hand MC occur in ?
Sensory and Motor changes Sensory loss Atrophy Clawed ring/little finger Dominant hand of kids
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What are the two MC animal bites and which one is more likely to become infected What are the MC microbes infected after animal bites Outside of the US, ? is the MC vector for rabies
Dog, Cat Cat > Dog Dog/Cat- Pasteurella multocida Dog- AHStrep, Bacteroides, Fusobacterium Staph A Dogs In US= bat skunk fox raccoon
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Animal bite w/ purulent drainage suggests wound is at least ? old What ABX are used for Tx What are the two MC causes of arthritis in the hand/wrist
>10hrs PO Augmentin 875mg IV Amp-Sulbactam PCN Allergy= Tetracycline OA Secondary degenerative joint dz
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All deformities and destruction in hand/wrist arthritis from RA are due to ? pathological What joints are MC involved in OA/RA of the hand processes What is the difference between the two when assessing pain
Synovial hypertrophy Inflammation OA: DIP PIP, thumb CMC RA: wrist, MCP, tenosynovitis RA: pain w/ acivity OA: pain w/ palpation
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What two deformities can develop in RA of the hands OA involving the DIP forms ? nodules and can have ? other growth on them Involvement of ? joint is more rare w/ OA so it's presence usually indicates ?
PIP contracture- boutoniierre Hyper-extended PIP, DIP flexed- swan neck Heberden w/ mucous cysts MCP, Hx of trauma
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How is RA of the hands Tx ? tendons can rupture in these Pts Idiopathic degenerative arthritis of the thumb's CMC MC affects ? Pt populations and caused by ?
NSAIDs Etanercept/Infliximab Little Ring Thumb Female 40-70y/o Joint configuration/laxicity
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What is the MC Sx and hallmark of arthritis of the thumb CMC joint ? tunnel syndrome may co-exist or be mimicked What test is performed on PE to Dx thumb CMC arthritis
MC: Pain w/ grip/pinch Hallmark: Tenderness over palmar/radial aspects of joint region Carpal Grind test
241
How is thumb CMC arthritis managed non-op Define Boutonniere Deformity What PE test is done for Dx confirmation
Thumb spica splint w/ NSAIDs Splint failure= injections Extensor tendon ruputres from insertion on middle phalanx, PIP is flexed unopposed Joint in flexion, extend PIP Lack of 15-20* PIP extension= rupture
242
What will be seen on x-rays of Pseudo-Boutonniere deformities How are Boutonniere's Tx non-op Define Dupuytren Contracture and who is more likely to develop this condition
PIP flexion= calcification on lateral view of PIP Splint in extension x 6wks (young Pt) or 3wks (old Pt) Thick/contracted palmar fascia in Pts w/ dominant genetics of Northern European men >50y/o
243
What are the associated RFs for Dupuytren's development ? finger is MC affected during Dupuvtren Contractures in descending order What non-Tx step can be done to help slow the Dz progression
Pulmonary Dz, Alcohol/smoking, Vibration trauma, Epilepsy, DM Ring Little Long Thumb Index ``` Night splinting Collagen injection (+FDA) ```
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? procedure may be done to Tx Dupuytrens w/ isolated cord involvement When does Dupuytren's become surgical candidates What are the two types of finger tip infections and what is the MC microbe to cause both types
Aponeurotomy 30* fixed flexion of MCP 10* deformity at PIP Felon- thumb/index tip from puncture Paronychia- tissue around nail; post-manicure/deformity Staph A
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Why do Herpetic Whitlows and Felons need to be carefully differentiated What happens if felons are left untreated How are paronychias Tx non-op
HL- clear fluid vesicle around finger tip; don't I&D Felon- I&d for Tx; tender, red Distal phalynx osteomyelitis Septic flexor tenosynovitis Warm/moist soak x 10min Q6h w/ PO ABX x 5days (1st Gen- Cephalexin/Dicloxacillin) MRSA risk- Sulfameth/Trimeth/Clinda Sev infection= nail removal
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What are the two types of incisions that include the puncture site for felon Tx What is the most important part of Tx What type of closure is used
Central volar longitude (visible pus) Dorsal mid-axial (no pus visible) Using curved hemostat to break up septae Secondary, never suture
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When suturing finger tips back in place on Peds, what type of materials are used When is this replantation method an option Complete laceration of what two structures will result in immediate loss of flexion at PIP and DIP
Absorbable: 4O/5O chromic or plain gut Thumb: at/prox to IP Finger: prox to middle of middle phalanx or multiple amputations Flexor Digit Sublimis- mid Flexor Digit Profundus- distal
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? finger tendon is most likely to be injured during sporting activities What type of neuro examination needs to be done to finger trauma When testing fingers after traumatic lacerations, what is tested during flexion ROM
Profundus of ring finger Two-point discrimination 1st: active 2nd: strength
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Most Pts can't move pinky finger independently d/t joint connectivity preventing independent movement of ? muscle How are these tendonous injuries initially treated
Sublimis Clean/splint Surgery <7days
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What are the 4 Kanavels Signs of finger tendon/sheath infection Flexor tendon sheaths extend from ? to ? and have ? plates How do tendon/sheath infections present and once ID'd are Tx w/ ?
Sausage digit Passive flexion/extension pain Percussion/palpation pain Distal palm to DIP A1-5 C1-4 Puncture w/ swelling <48hrs Anti-Staph/Strep IV ABX PO ABX x 7-14days Non-responsive- surgical drainage
251
What kind of microbe can infect hand wounds from human bites These injuries can be Tx out[Pt if Tx is sought out w/in ? time frame How are these Tx non-op
AHS/Staph A- MC Eikenella corrodens <8hrs Arthrotomy wash out w/ PCN/1st Gen Cephalosporin PCN Allergy- Tetracylcine
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What is the f/u instructions after medical Tx for human fist bite What causes a mallet finger to develop These may present w/out pain if they are older than ?
F/u 24hrs then, Daily whirpool or dressing change Q12hrs Extensor tendon avulsion from distal phalanx 14days
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How long are mallet fingers splinted for Tx How long after splinting do skin checks need to be done What is the next step if Pt is unable to fully extend finger by second f/u appointment
Acute: 6-8wks >3mon old: 8wks 4-5 days Refer for surgical pinning
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? type of mallet finger may need further evaluation What do fingernail avulsions in infants need to be assessed for? How are painful subungual hematomas decompressed
Volar subluxation of distal phalanx Bony fragment >1/3 of joint surface Physeal injury= referral Battery-operated microcautery or 18g needle
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? type of suture material is used to keep nail in place on nail bed Any injury to the nail fold should be repaired w/ ? material Post-nail avulsions need to be wrapped in ? 5 things
6.0-7.0 bioabsorbable gut 5.0 gut/nylon or monofilament Kids- absorbable ``` Anti-bacterial ointment Non-adherent gauze Sterile gauze Outer wrap Splint ```
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What structures keep flexor tendons from bow stringing Define Trigger Finger ? fingers are MC affected by trigger finger
4 annular 3 cruciform Thick flexor tendon or first annular pulley Long and Ring Kids= thumb, other finger involved suspect metabolic d/o
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Trigger finger is commonly seen in Pts w/ ? other comorbidity Higher prevalence is seen in PTs w/ ? two comorbidity Where do PTs point pain located to ? but the issue lies at the ?
RA DM Hypothyroid Carpal tunnel De Quervains Pain at PIP Source at MCP
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How are Trigger Fingers Tx non-op Peds elbow pain is usually d/t overuse activity placing ? stress on the elbow When imaging Pediatric elbows, the head of the radius should be pointing in ? direction
CCS injection x 2 Failure= surgical release Valgus Towards capitellum
259
Posterior fat pad in Peds means high likely hood of occult Fx and need repeat images in ? What kind of cast are the placed in for in between appointments What is the next step if at f/u appointment no tenderness is appreciated on exam
2-3wks Posterior long arm Immobilization not needed
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If peds dislocate their elbow, it's usually in ? direction Why are elbow sprains rare/unlikely in Peds How are elbow sprains Tx
Posterior Bones are the weak link Short term immobilization
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? is the MC elbow injury in kids <5y/o What are the only two PE findings consistent w/ this MC injury How can Nursemaid Elbows be reduced
Pulled/Nursemaid elbow- subluxation of radial head d/t elbow extension w/ forearm pronated Tenderness on radial head Resisted supination Thumb over radial head Fully supinate forearm No reduction= flex elbow Alt: forearm pronation w/ elbow extended/flexed
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When reducing Nurse Maid's elbow, what structure moves and makes a noise Kids will immediately be able to resume activity w/ arm except for ? ? is the compression and tension side of Peds humerus
Annular ligament moves Presentation 1-2 days after injury ``` Medial= tension (avulsion Fx, LLE) Lateral= compression (capitellum osteonecrosis) ```
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Osteonecrosis of lateral elbow in Peds is AKA ? depending on their age What are the 4 MC congenital deficiencies of the Peds Upper Arm Any type of surgical correction for these are not considered until ? age
<10y/o- Panner Dz >10y/o- osteochondritis dissecans Thumb Radial Ulnar Transverse deficiencies 6-18mon
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? other d/os are commonly seen w/ Hypoplasia of the Thumb They can have ? type of anemia When is surgery an option and by ? procedure
Holt-Oram Syndrome (congenital heart dz) Craniofaical abnormals VATER Fanconi Adequate size of thumb CMC joint is stable Index Pollicization- index finger transfered to thumb
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What blood d/o is seen in Peds w/ Radial Deficiency Why is this dificiency abnormal Ulnar deficiency may present w/ ? abnormal coalition
Thrombocytopenia w/ absent radius Normal thumb is present Radiohumeral synostosis
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How is ulnar deficiency unlike radial and thumb deficiencies Instead these Pts are more likely to have ? issues Transverse deficiency maintain ? function but are more likely to have ? issues
Not associated w/ abnormalities of other organ systems Tibial deficiency Proximal femoral deficiency Elbow flexion Congenital constriction band sydrome
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# Define Syndactyly What other syndromes are these PTs more likely to have Define Polydactyly
Lack of separation between finger/toes Apert/Poland syndrome ``` Extra digit in hand/foot (thumb/great toe- preaxial) Little finger (post-axial) ```
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# Define Congenital Radioulnar Synostosis Define Congenital dislocaiton of radial head ? PE finding suggests prognosis predictor for surgical Tx
Ulnar/radial proximal ends don't separate= no pronation/supination Presenting issue of elbow deformity d/t posterior dislocation Concavity- traumatic dislocation, surgical candidate Convex- congenital, poor surgical outcome
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LLE includes terms that are different by side of elbow, what are the lateral/medial Dxs What two subsequent issues can develop from LLE depending on the Pts age What is a more common sequelae of untreated LLE
Traction/Tension: apophysitis of medial epicondyle, UCL strain, olecranaon avulsion Compression: OCD, Panners Fragment: 8-12y/o Avulsion: 12-14y/o Delayed/failed olecranon fusion
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LLE OCD usually occurs in Pts older than ? after ? structure has ossified ? is the Dx if the Pt is under this age ? is the MC PE finding of LLE
>12 y/o after capitellum ossifies <12y/o= Panners TTP Flexion contracture
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How is LLE Tx non-op How is OCD Tx non-op
Rest x 3-6mon Rest x 12mon
272
What is the MC type of Obstretric Palsy What is the two other types of Obstetric Palsy
Erbs- motor and sensory deficit of C5-6 causing Waiter's Tip (weak elbow flexion, weak should Abd, Flex and External rotation) Klumpke- lesion to C8-T1 affecting hand/wrist Panplexus palsy- entire plexus involvement
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If Peds Pt recovers atigravity strength in under ? months, prognosis is good What is a poor prognostic factor What are 3 other poor prognostic factors
2mon Return of bicep function after 3mon Entire plexus Horner Syndrome Nerve root avulsion
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? is the MC observed clinical Sx of Obstetric Palsy ? reflexes may be impaired These Pts may exhibit tenderness located ? for first few weeks after birth
Reduced spontaneous movement- pseudoparalysis Moro A/Symmetric tonic neck reflex Supraclavicular triangle
275
What is the position of Waiter's tip in words What PE findings are consistent w/ a preganglionic avulsion injury of sympathetic chain
Forearm pronated Elbow extended Wrist flexed Shoulder adduct, internal rotated Horners Syndrome Phrenic nerve palsy Nerve involvement- long thoracic, dorsal scapular, suprascapular, thoracodorsal
276
Erb's Pts w/ progressive internal shoulder rotation are at risk for ? for the first two years What is considered the best non-op Tx for Obstetric Palsy What is the cornerstone of Tx
Shoulder subluxation/dislocation Supervised at home exercise program Assessment and monitoring neuro function/recovery
277
What two Dx are suspected in infants w/ sudden loss of function in part that was mobile at birth What causes Congenital Muscular Torticollis and what does it look like How is Congenital Muscle Torticollis differentiated from AARD
Sepsis, Abuse Unilateral contracture of SCM= head to affected, rotate to unaffected Contracture of left SCM= tilt to left, rotate to right, left side facial/mandibular flattening, right side occipital flattening AARD- SCM spasm occurs on opposite side of tilt
278
Infantile Torticollis can present mimicking ? syndrome CMT is commonly associated w/ ? two PE findings What lower extremity issues may also be noted
Klippel-Feil Syndrom- congenital fusion of two or more cervical sections causing dec ROM/head tilts Plagiocephaly Facial assymetry Metatarsus adductus Calcaneovalgus Hip dysplasia
279
Pts w/ CMT hold their head in ? termed position What does an optic exam need to be conducted for acquired torticollis How can these findings be resolved on PE
Cock-robin Superior oblique palsy= nystagmus causing torticolis Close eyes/block vision
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? are the neuro causes of Torticollis AARD affects ? part of the spine AARD can also develop after ? inflammatory d/o causing ? syndrome
Posterior fossa tumor Cervical spine tumor Syringomyelia C1-2 Grisel- inflammation of pharynx
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? image is needed when assessing suspected AARD torticollis ? are the adverse outcomes of this Dz process How is CMT Tx non-op
Odontoid Malaligned atlantoaxial joint Klippel-Feil syndrome are at risk for spinal cord injuries Rehab stretching exercise Position beds/table to make baby look away from affected side
282
If CTM has to be Tx w/ surgery, what are the time frames How is AARD initially Tx non-op ? is the MC bony Fx and MC/LC location
Problems lasting >12mon= SCM release after 4y/o Soft collar w/ analgesics and Benzos Persistent >7d= cervical traction w/ analgesia and relaxers Persistent= halo traction Persistent >1mon= cervical fusion Clavicle MC- middle LC: proximal
283
What types of images are needed for clavicle Fxs When are clavicular Fxs referred to Ortho When is surgical correction indicated
AP w/ 10* cephalic lift CT if high suspicion for Fx/dislocation of medial end Painful nonunion after 4mon ``` Ipsilateral rib Fx/flailing Open Neurovascular compromise Shortened Fx of distal 1/3 medial to coracoclavicular ligament, imedial part of clavicle superiorly displaced ```
284
How are mid-clavicle Fxs Tx non-op by age Regardless of age, when is gentle shoulder exercises supposed to begin ? type of clavicle Fxs are more likely to result in nonunion
Figure 8 <12y/o- support x 3-4wks Adult- support x 6-8wks 2-3wks Displaced lateral or midshaft lateral to coracoclaviculr ligament Segmental Fxs
285
? type of neuro injury usually accompanies humeral shaft Fxs Most humerus shaft Fxs are Tx non-op w/ how much acceptance What type of Tx is used for humeral shaft Fxs w/ <2cm of shortening
Radial x6mon- dec wrist/finger extension w/ lost sensation to dorsal web space 20* apex ant/lateral U-shaped coaptation x 2wks
286
Humeral Fxs w/ radial nerve dysfunction need EMG/NCV studies after ? long What are the 4 segments that proximal humeral Fxs can be classified as w/ ? method What muscles attach to the different humeral tuberosity
6wks Neer Greater/Lesser tuberosity Humeral head Shaft Greater- Supra Infra TM Lesser- Subscap
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What is the MC two-part humerus Fx What image is obtained if an axillary view is impossible What is the most common error that occurs when assessing proximal humeral Fxs
Surgical neck Transcapular- scapular y-view Shoulder dislocation- AP images alone are not enough
288
How are proximal humerus Fxs w/ <1cm displacement Tx When can the sling be removed and worn PRN Why are two part Fxs of the greater tuberosity w/ >0.5cm displacement Tx w/ surgery
Sling w/ pendulums after 3wks Deltoid/rotator isometrics after 6wks 3wks Restore rotator cuff muscles
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What types of displaced humeral Fxs need to have surgical Tx What types of humeral Fx usually has disrupted blood flow requiring prosthetic replacement Two part proximal humerus shaft Fxs where lesser tuberosity is also Fx'd may also have ? abnormal injury
Two part humeral neck All 3/4 part Fxs Displaced 4 part Posterior shoulder dislocation
290
What is the MC associated injury to accompany scapular Fxs If Pt is able to sit for images, ? is the best for Dx Axillary view is better for revealing Fxs in ? two locations
Rib Fxs Transcapular lateral/oblique Acromial/Coracoid
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Any scapular Fx where the glenoid is poorly viewed needs ? next step image ? is a common adverse outcome from these injuries ? is are two rare outcome
CT ASx malunion Suprascap nerve injury Impingement syndrome
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How are scapular Fxs Tx non-op What are the operative red flags for these Fxs ? is the MC dislocated joint in kids and in ? direction
Sling w/ motion as tolerated after 1wk Glenoid displace >2mm Acromion w/ impingement Scapular neck >30* deformity Elbow; posteriolateral w/ damage to UCL being universal
293
What is a 'perched' elbow dislocation What is the terrible triad in adults What is the terrible triad in kids
Subluxated w/ trochlea resting on coronoid Elbow dislocation, Radial head fx, Coronoid fx Elbow dislocation, Radial head fx, medial epicondyle Fx
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What imaging is needed after reducing elbow dislocation Define a simple dislocation While under conscious sedation for elbow reduction, if Pt develops muscle spasms or marked swelling, ? is the next step
CT No associated Fx General anesthesia
295
How are elbows positioned for max stability after reduction How are these splinted post-reduction How long after elbow Fx/Reduction should motion be restarted
Elbow flexed, forearm pronated Elbow flexed at 90* w/ extension block x 4wks 5-7 days and progress over 3-6wks
296
How are distal humerus Fxs Tx non-op How is a Fx olecranon Tx non-op When is protected ROM recommended to return
Splint x 10 days w/ protected ROM Posterior splint w/ eblow at 45* flexion F/u x-ray at day 7-10 Rubber ball squeeze daily 2-3wks
297
Since most olecranon Fxs need to be surgically Tx, what is a common adverse outcome of Tx What is the classification methods of radial head Fxs What types of radial head Fxs can have mechanical blocks with them
Implant irritation requiring implant removal Modified Mason: 1- non/minimal displacement 2- >2mm displacement, angulated neck/mechanical block 3- severely comminuted Types 2 and 3
298
# Define Essex-Lopresti Fx What type of imaging is needed for radial head Fx What is a common adverse outcome of radial head Fxs
Radial head Fx w/ injury to forearm Greenspan Loss of last 10* of extension
299
How are radial Fxs Tx What types are red flags Define Bennett Fx Define Rolando Fx
Type 1- move as tolerated Type 2/3- surgical ORIF Type 2 w/ rotation block Type 3 Fx w/ elbow dislocation/instability Oblique thumb base Fx enters CMC joint Less common than Bennett, y-shaped intra-articular Fx
300
What is the goal of Tx for Fxs at base of thumbs How are Fxs at the base of thumb Tx non-op and w/ surgery What types of x-rays are needed to view a hook of hamate Fx
Restore axial length, put metacarpal fragment against smaller volar fragment Thumb spica-cast x 4wks Bennett- ORIF Semi-supinated Carpal tunnel view
301
What happens if Hook Of Hamate Fxs are left un-Tx How are these Tx non-op
Non-union Tendon rupture, little finger Wrist immobilization in neutral position
302
MC type of distal radius Fx seen in adults ? is the name of the Fx that is opposite of the MC Define Barton Fx
Colles- Fx tilts dorsal w/ Fx of ulnar styloid Smith- Fx fragment tilts volar Intra-articular carpus Fx w/ subluxation of carpus and displaced radius fragment
303
# Define Chauffeurs Fx What is an adverse outcome from wrist Fxs How are these Tx non-op
Oblique radial styloid Fx Compartment syndrome Sugar tong x 3 wks Short arm cast x 3wks
304
What PE finding of distal radius Fxs suggests open Fx Most of these Fx's are Tx non-op w/ ? How much angulation is acceptable for wrist Fxs
Fat droplets in blood Sugar tong splint x 2-3 wks Lateral- <5* of dorsal angulation AP- no less than 15* radial inclination >2mm step off = reduce
305
Distal radius Fxs that have low levels of Vit D can have ? much supplemented What is used during distal radial Fxs to decrease risk of CRPS development ? is the MC Fx of the hand and when is surgical Tx needed
1-2K IU/day Vit C 500mg/day Boxer Fx- distal > proximal > middle >40* angulation + extensor lag
306
? is the MC phalangeal Fx in adults Phalangeal Fxs are more common in ? expecially ? phalanx Most Fxs of the phalanx are non-op Tx by?
Distal, Proximal then Middle Peds, little Splint x 3-4wks Rpt x-rays at 1wks Resume activity at 3wks
307
MC adverse outcome after hand Fxs MC carpal bone Fx in men Why are these Fxs associated w/ so much osteonecrosis
Joint stiffness Mid-pole scaphoid Blood supply enters at distal third at dorsal side
308
What are the Snuff Box landmarks ? x-ray view may be needed to view Fx + Sunff Box tenderness and normal x-rays are Tx w/ ?
Top: EPL Bottom: EPB Oblique Forearm base thumb spica Cast w/ thumb IP free x 6wks F/u 7-14 days, pain= MRI
309
How long do scaphoid Fxs in different areas take to heal ? type of x-ray is used to show scaphoid-lunate disassociation Finger sprains are characterized by injury to ? structures
Distal: 6-8wks Middle: 8-12wks Prox: 12-24wks Clenched fist Torn collateral ligament and/or volar capsule ligament
310
Almost all sprains of the finger can be Tx non-op w/ ? type as the exception Most dislocations of the hand are MC in ? and due to ? injuries A complex dislocation of the MCP joint can cause ? structure to become entrapped to the dorsal carpal head
Unstable, complete UCL rupture in thumb MCP PIP Hyperextension tearing the volar capsule FDP
311
DIP dislocations usually are in ? direction PIP splints allow ? movement and block ? movement What type of Peds elbow Fx has a high incidence of neurovascular problems
Dorsal Flexion Block last 20-30* of extension of volar plate Supracondylar- AIN palsy
312
What are the MC elbow Fx in kids 2-12y/o What is the 2nd MC type of Fx What is the 3rd MC type of Fx What type of Fx is uncommon
Supracondylar Fxs of distal humerus Lateral condole Fx of distal humerus Medial epicondyle Fx Lateral epicondyle
313
Why are Peds w/ condylar Fxs serious Transphyseal Fx across distal humerus are uncommon and MC seen where? ? is the weak point of the radius in kids
Growth plate of distal humerus and articular surface of elbow are involved Infants from abuse Metaphysis of radial neck
314
The valgus force that causes an adult radial head Fx will cause ? Fx in kids PE tests for radial, median and ulnar nerve Supracondylar Fx causing brachial artery to be injured in Peds that is not ID'd can result in ? type of contracture
Radial neck R: thumb up M: ok sign U: criss-cross finger Volar forearm compartment syndrome= Volkman ischemic contracture
315
How are Peds condylar Fxs Tx Radial neck Fx's w/ ? angles can be Tx w/ cast immobilization Metaphysical Fx of proximal humerus typically occur in ? age groups while physeal Fxs tend to occur in ?
Rpt x-ray day 3-5 30-45* in Pts < 10y/o Meta: 5-12y/o Phys: 13-16y/o
316
Newborns w/ Fx of clavicle or proximal humerus may present w/ ? ? are the MC physeal Fx How are proximal humerus Fxs in Peds Tx
Pseudoparalysis Salter Type 2 Non-surg, best w/ sling: 70* <5y/o 40-70 5-12y/o <40 in >12y/o
317
Clavicle Fx w/ shortening more than ?needs surgery ? is the MC location for Fxs in kids Kids younger than 4y/o are more likely to have ? types of Fx
2cm >30-40* angluation Fragment >50% apposition Distal 1/3 of forearm Torus- buckled cortex, least complex forearm Fx Greenstick- disrupted cortex on tension side, buckled on compression side
318
? is the MC torus Fx in Peds Define Galeazzi Fx Define Monteggia Fx To minimize physeal damage, reduction attempts shouldn't be made after ? days
Dorsal surface of distal radius Displaced distal radius w/ dislocation of ulna Radial head dislocation (anterior) w/ Fx of ulna 5
319
How are prox/middle forearm Fx in Peds Tx
Surgery: >10* All Monteggia: closed reduction w/ 6-10wk immobile
320
C5 M/R/S C6 M/R/S C7 M/R/S C8 M/R/S
Deltoid/Bicep flexion Bicep Lateral upper arm Wrist extension Brachioradialis Lateral lower arm Wrist flexion, Finger extend Tricep tendon Middle finger, thenar Finger flexion None Medial lower arm
321
T1 M/R/S L4 M/R/S L5 M/R/S S1 M/R/S
Interosseous None Medial elbow Anterior tibialis/patellar/medial foot Extensor digit longus/non/dorsal foot Peroneus longus/brevis/achilles/lateral foot
322
Intra-articular hip pathology is classically associated w/ ? c/c What 'sign' may be used by Pts to pin point pain and what movement makes pain worse What provocative PE test is positive for hip impingement
Groin pain C-sign, worse w/ rotational movement FADDIR- Fixed Adduction Internal Rotation
323
# Define Pure Femoral Cam Impingement Define Pincer Impingement A normal acetebulum has ? morphology
Femoral neck loses concave anatomy tears anterosuperior labrum w/ flexion Focal-over: focal retroversion Global-over: coxa profunda/protrusio Anteverted- posterior rim more lateral than anterior rim
324
What is the adverse outcome of hip impingement? How are these Tx non-op How does Tx change if there is a long Hx of Dx or tendinitis
Etiology of 80% of hip OA NSAID LLD ROM/Strength Deep massage Active release
325
? is Dx and Therapeutic for hip impingements and is the most accurate test to determine ? issues ? do hip impingement PTs need for post-op rehab Systemic d/os may first present w/ ? c/c and what two are the MC causes
Fluoroscopical intra-articular injection Intra-articular etiology for hip pain CPM device Stationary bike Hip pain/Sxs Lupus/AS
326
? types of gait do inflammatory arthritis of the hip have depending on the length of Dz What are the early/late signs seen on x-rays How is non-infectious fnflammatory hip arthritis Tx
Antalgic- early in Dz Trendelenburg- lost cartilage Early: osteopenia/effusion Late: symmetric narrowing/periarticular erosions ``` NSAID DMARD Tylenol Cane on contra-lateral side TxOC: arthroplasy ```
327
Where is the lateral femoral cutaneous nerve most susceptible to compression and what ? type of innervation does it provide What is a rare cause of this nerve compression what can Pts present w/ if condition is uncommon or acute?
Exiting pelvis, medial to ASIS Sensory only Cecal tumor Uncommon: Groin ache Acute= pain radiating to SI joint
328
What is the MC spot to reproduce hypo/dysesthesia Sxs of lateral femoral cutaneous nerve entrapment If Pt is a jogger, what do they describe pain as ? Rarely is surgical release needed for Tx unless ?
Superior and Lateral knee- MC w/ burning Electric jab w/ hip extension Persistent burning dysethesia
329
When obtaining Hx for hip OA, what early life issues can indicate secondary issues may be present What part of the OA Dz process causes Pts to alter gait How are young/active Pts w/ this condition Tx w/ surgery
Infant/toddler= dysplasia Small child- Legg Calve Dz Adolescent- SCFE Flexion contracture= increased lumbar extension Realignment osteotomy Arthroplasty metal-on-metal Hip fusion: young labor/vigorous lifestyle
330
What risk factors can lead to osteonecrosis of the hip? How will these PT present and ? type of gait will they have depending on the duratino of Dz
Steroid Lupus Alcohol Trauma RA Sickle 30-50y/o w/ bilateral Pain, Dec ROM, + straight leg Early: atalgic Late: trendelenburg
331
What is seen on x-ray of hip osteonecrosis what is a beneficial next step if unilateral findings are noted How is osteonecrosis Tx if femoral collapse has/not occurred
White crescent sign= subchondral Fx MRI contralateral hip to eval ASx condition ``` Not: Core decompression Vascular/Osteochondral grafts to relieve pressure Has: Core decompression= short term relief Arthroplasty ```
332
What is an unique adverse outcome of core decompression Tx for osteonecrosis What are the three etiologies of Snapping Hip Where do Pts w/ trochanter bursitis induced from ITB snapping hip describe their pain as?
Femur shaft fx if core biopsy is placed below lesser trochanter MC: ITB over greater trochanter Iliopsoas over pectineal eminence of pelvis Intra-articular labrum tears Pain in AM/PM, or laying on affected side
333
Snapping from subluxation of iliopsoas tendon is described and located as ? ? type of snapping is more debilitating and causes Pt to reach for support What two etiolgoies of snapping may benefit from CCS injection to bursa
Groin pain w/ hip extension from flexed (rising from chair) Intrarticular origin ITB into trochanteric bursa Psoas tendon ITB: rotate hip w/ leg in adduction Ilio: hip extension from flexed position
334
Hip strains can encompass what 5 muscles? What is the usual mechanism of injury for hip strains? ? is a common etiology in general for all hip strains
Abdominals Flexors- Sartorius Iliopsoas Rectus Adductors Contraction w/ muscle stretched- kicking ball but leg blocked causes iliopsoas strain Over use
335
? type of MRI image is used for hip strain Dx How is a strained adductor isolated on PE? How is a rectus, iliopsoas or sartorius strains isolated on exam?
Short Tae Inversion Recovery Groin pain w/ passive abduction/resisted strength test RF: Inc pain w/ muscle stretch Ill: deep groin/inner thigh pain Sar: superficial, lateral pain
336
What are the 5 phases of hip strain rehab What are the typical MRI findings for transient osteoporosis of the hip Stretching ? two muscles in particular may help w/ greater trochnater bursitis rehab
48-72hrs; RICE, protected weight w/ crutches 2: 72hrs-7d; PROM, heat, stimulation 3: 7d+: isometric exercises, inc strength/flexibility Femoral neck edema= T1 decreased/T2 increased Piriformis Tensor fascia latae
337
What non-leg sourced issues can lead to trochanteric bursitis? Where can this pain radiate to? How do Pts describe pain
Lumbar spine dz Leg, butt, or knee, NOT to foot Worse when rising, improves, worse <30min Unable to lie on affected side
338
? is the essential finding on PE for Dx trochanteric bursitis and what movement makes pain worse How is this Dx different from gluteus medius tendonitis and what movement makes pain worse What mechanisms usually cause ACL tears and what will Pt report for activity after event
Pain to palpation on lateral greater trochanter- worse w/ hip abduction GMT- tenderness above greater trochanter, worse w/ ab/adduction and rotation Twist/hyperextension force during non-contact event Pt unable to continue game
339
? other 3 structures are possibly torn along w/ an ACL tear in descending order Multiple ligamentous injuries need to have ? life threatening issue r/o? Lateral Capsular Sign seen on lateral tibia is AKA ?
Meniscal > MCL > L/PCL Popliteal disruption Segond Fx
340
ACL injuries w/ tibial eminence Fxs are more common in ? Pts Chronic ACL insufficiency leaves ? structure prone to injury and why? ? muscle rehab is used for stability improvement
Open physes Posterior horn of medial maniscus; secondary stabilizer to anterior tibial translation Hamstring* curl Isometric quad flex Leg raise
341
? ranges of motion need to be avoided during ACL rehab due to excessive stress on damaged area ? anatomical deviations can make Pts susceptible to ACL damage ? adverse outcome can occur post-op if full ROM was not restored prior to surgery
Extension 30-10* and varus/valgus stress Foot pronation Large Q-angle Anteverted hip Genu recurvatum/valgum Arthrofibrosis w/ loss of motion
342
Isolated patellofemoral OA can exist in ? 3 populations If RA is the cause of the knee OA, what compartment is affected OA knee w/ effusion can extend past joint line into ? structure
MC- Tibiofemoral OA Patellar subluxation Patellar baja Valgum d/t ligamentous laxicity (more dec ROM) Pes anserinus
343
What is the characteristic x-ray results for Pts w/ degenerative arthritis from OA What is the hallmark x-ray finding of inflammatory arthritis What types of images may be obtained after weight bearing x-rays
Sclerosis Osteophytes Asymmetric joint narrowing Periarticlar cysts Symmetric joint narrowing Osteopenia Bony erosion at margins Lateral: Merchant Axial: Sunrise
344
Why would weight bearing AP x-rays w/ OA knee in 40* flexion be used preferably What non-surg Tx is used for knee OA PTs that have Varus Gonarthrosis ? type of management is not recommended for Pts w/ advanced knee OA cases
More sensitive for early arthritis, expecially when posterior femoral condyle is involved Lateral heel wedge- unloads medial compartment Arthroscopic
345
What procedures may be effective for correcting alignment and reducing pain in mild-mod knee OA w/ deformity cases? This may have expected relief for ?yrs until ? definitive step is warranted Pes anserinus is the insertion site for ? 3 muscles and commonly develops in PTs w/ ? Dx
Unloading tibial/femoral osteotomy 5-10yrs, Knee replacement Sartorious Gracillus Semi-tendon Early OA in medial compartment
346
? nerve can become compressed during pes anserinus bursitis Septic bursitis presents w/ ? 3 Sxs Non-infectious traumatic bursitis presents w/ ? and w/out ?
Saphenous and infrapatellar branch Pain Erythema Warm + Warm, - pain/erythematous
347
How are bursitis and septic arthritis of the knee differentiated on x-ray What therapeutic modality may help bursitis here Early onset, mild septic bursitis of the knee can be managed by ? exception
Burs: diffuse pre-patellar swelling SA: suprapatellar pouch swelling US/phonophoresis PO ABX
348
What causes and what are the S/Sxs of neurological claudication What are the causes and what are the S/Sxs of vascular claudication
Spinal stenosis= ischemia of cauda equina: Pain in butt, spreads to legs Walking downhill inc pain Prox to distal Slowly improves w/ sit/supine/stationary bike over time Secondary to peripheral vascular dz, screen w/ ABI: Immediate relief w/ cessation of movement Worse w/ stationary bike distal to proximal
349
? type of injury causes MCL/LCL tears What injury can occur to the lateral knee at the same time a MCL injury is sustained and how How are MCL and LCL best palpated
MCL: Valgus/abudction- football clipping LCL: Varus/adduction Lateral femoral condyle presses against lateral tibial plateau= lateral meniscus tears MCL: slight knee flexion PCL: figure-4
350
Laxity measurements of ? much can indicate the grade of sprain Why are varus/valgus stresses to test for MCL/LCL integrity best done w/ 30* of knee flexion What is suspected if valgus/varus laxity is noted w/ full extension and how are these then classified prompting ? to be assessed
<5mm- Grade 1, insterstitial 5-10mm- Grade 2, partial >10mm- Grade 3, complete Ligaments/posterior capsule are relaxed ACL/PCL injury w/ disrupted posterior capsule Knee dislocation w/ spont reduction; neurovasc w/ ABI
351
How are MCL/LCL sprains managed What types need surgical correction What types need surgical correction
<5mm- Grade 1, insterstitial 5-10mm- Grade 2, partial >10mm- Grade 3, complete Grade 1-2: RICE, NSAID, Crutches Begin playing at 1mon in hinged brace, w/ Sx resolution Grade 3 MCL proximal and in midsubstance: non-op w/ hinged brace, inc weight bearing 4-6wks, brace x 3-4mon Grade 3 LCL d/t capsule/tendon/ Tibial MCL avulsions, repair <7days
352
? PROM ca also help identify what compartment is involved in acute compartment syndromes Chronic/exertional compartment syndrome may have ? c/c and MC involves ? compartment What compartments of the lower leg are involved by compartment syndrome it Pt reports numbness in dorsal/plantar regions?
EHL by moving great toe- anterior Peroneus brevis/longus by foot inversion- lateral Extending great toe- deep posterior Dorsiflex ankle- superficial posterior First web dorsum paresthesia Weak dorsiflexion MC anterior compartment Dorsal foot- ant/lat compartment Plantar aspect- deep posterior compartment
353
# Define Myositis Ossificans Traumatics and ? is this a sub-category of ? ? type of strengthening therapy is recommended for thigh contusions and ? therapeutic step can be taken for severe quad contusions to speed up time to returning to game What are 3 anatomic RFs placing PTs at risk for developing ITB inflammation
MC thigh contusion causing calcified mass via heterotropic ossification Heel raises Elastic wrap w/ knee in hyperflexion RICE/ROM Rum, genu Internal tibial rotation Pronation of foot
354
? functional test on PE confirms present of ITB syndrome How are cases of Tennis Leg Tx non-op What is the goal of this non-op Tx
One legged hop w/ flexed knee= pain NSAID RICE Cam w/ .5" lift Crutches until pain free ambulation Control inflamm/pain w/ RICE
355
When can medial Gastroc tears begin early movement exercises ? is the MC PE finding of meniscal tears Young Pts w/ meniscal tears that cause large effusions/hemarthrosis indicates tear is located ?
7-21 days later w/ PROM Tenderness on joint lines <5mm of meniscal attachment sites
356
Meniscal tears located ? tend to have small/no effusions associated with them Peripheral meniscal tears that are near ? location may be able to self-heal ? PE test is used for meniscus test and what type of force does this test cause
Degenerative/near central body of meniscus Meniscocapsular junction McMurray= Appley + Thessaly Forced flexion circumduction
357
When is arthroscopic debridment preferred for meniscal Tx Initial Tx consists of ? and early ? is done to improve mobility and reduce pain ? is the MC site of the femur to develop osteonecrosis
Younger PT w/ substantial tear Locked knee Older Pt non-op failure RICE Controlled movement Weight bearing medial condyle
358
What can cause femur osteonecrosis Chronic osteonecrosis will present w/ ? c/c ? are early and late radiographic signs that femoral osteonecrosis is occurring
``` MC: female +60y/o Renal transplant Sickle cell Gaucher Dz Steroids ``` ASx Early: Sclerosis, Flat condyle Late: Narrowed spacing, Osteophytes
359
? imaging is used to Dx femoral osteonecrosis How are these Tx surgicall ? is the hallmark Sx Extensor Mechanism Tendinitis
MRI, Bone scan Debridement Osteotomy Replacement Anterior Knee pain
360
Long standing Jumper's knee can cause ? muscle to atrophy What images are needed How long should these PTs be LLD
Vastus medialis obliquus Oblique x-ray= enthesophytes: calcification of tendinous insertions 3days-6wks
361
What are the 3 phases of Tx for Patella/Quad tendonitis What is the MC adverse outcome of Tx Tears need to be repaired w/in ? days
1: NSAID Immobilizer LLD (rest, pain control) 2: Strength Flexibility ROM PRP (pain free motion) Debridement 3: Resume activities (resume: heat prior, ice after) Persistent functional impairment, even w/ surgery <7days
362
What type of force causes a quad/patellar tendon rupture If simultaneous, bilateral Quad/Patellar ruptures occur and the demographic criteria are not met, what two issues need to be r/o What will usually be absent in their Hx
Fall on knee that is partially flexed Endocrinopathy FQN usage Quad/Patella tendinitis
363
? PE finding is pathgnemonic for leg extensor disruption? What is the hallmark of clinically substantial extensor tear Why are knee tendon ruptures assessed w/ lateral views w/ 30* of knee flexion?
Large effusion w/ palpable defect Inability to extend knee against gravity/perofrom straight leg raise Inferior patella in line w/ Blumensaat line
364
? triad presentation suggests Quad/patella tendon rupture and need surgical correction w/in ? days What RFs place Pts at risk for patella dislocaiton/maltracking Knee dislocations mimic ? other Dx
Palpable defect Unable to extend knee Patella alta/baja <7 days ``` Patella alta Shallow trochlear groove Flat patella under surface Excessive anterior femoral neck anterior version Externally rotated tibia Ligament laxity ``` ACL tear
365
What is the c/c of Symptomatic Malalignment present What two PE findings can contribute to lateral patellar instability What are the two axial patellofemoral views used to assess knee alignment
Retropatellar pain d/t Genu Valgum alignment Patella alta Pos J sign Merchant/Laurin
366
What is the initial Tx for acute patellar subluxation/dislocation Total time of immobilization shouldn't exceed ? long ? is the initial Tx for chronic, recurrent maltracking/instability
Brace/immobile in extension x 4wks Modified weight bearing Pain meds Ice >4wks Quad strength/flexible Lateral butress brace Electrical stim/K-tape
367
? term shouldn't be used for describing patellofemoral syndrome What key item is usually missing from their Hx of presentation Gait is assessed for ? finding
Chondromalacia No swelling Patellar winking- inc femoral anteversion/weak glut medias
368
When assesing patellofemoral syndrome, w/ knee at 30* flexion, how much meidal/lateral movment should be seen w/ patella manipualtion What is the hallmark of Tx Of the five plicas, what 3 are most palpable
1 quad medially 2 quad lateral Pain free PT without full-arc and open chain quad exercises Supra: under quad tendon to medial/lat capsule Medial: medial capsule to medial anterior fat pad Infra: Ligamentum Mucosa; anterior covering of ACL
369
Why do plica structures become bothersome when inflamed ? plica is most likely to become symptomatic and what is found on PE if this plica is inflamed Baker Cysts are associated w/ ? knee issues
Bowstring over femoral condyles Medial- knee at 90* flexion w/ pop at 60* of flexion Degenerative meniscal tear RA
370
In whom do Baker's Cysts rupture in more often Most cysts are located between ? Rarely this will become large enough to impinge on ? nerve, but if they ruputre it can mimic ?
>40 w/ degenerative arthritis Gastroc/Semi-tendon Tibial nerve: plantar surface numbness DVT
371
How are ruputres Baker's Cysts Tx non-op ? four injury mechanisms can suggest issues w/ PCL ? is most sensitive test for PCL damage
Analgesic Rest Elevation Dashboard injury Fall on flexed knee w/ foot plantar flexed Pure hyperflexion injury Hyperextension after ACL= dislocated knee Posterior drawer
372
How are PCLs Tx non-op What movement needs to be avoided Any suspected PCL tear needs ? test done during assessment
Resolve swelling/Restore motion x 1-5 days, then: Strength w/ emphasis on short arc terminal extension 30-0* of flexion Hamstring curls ABI
373
Shin splint pain is localized to the distal third of tibia which is the origin of ? muscle and presents w/ ? foot shape ? is the hallmark PE finding for shin splints and What movement may also ellicit pain
Tibialis posterior Pes planus Tenderness along posterior medial crest Pain w/ plantar flexion
374
Pts w/ shin splints should research ? type of orthotic Congenital deficiencies of the lower leg Tx are based off of ? two things Surgical Txs won't be offered until ? age
Anti-pronation Foot functional? Anticipated limb length discrepancy? 9-12mon
375
# Define Longitudinal Deficiency of Fibula All of these PTs need ? Tx What is the classification method
MC long bone deficiency, absence of fibula Limg length discrepancy Kalamchi: 1A- minimal shortening 1B- partially present 2- absent
376
What other d/os are assoicated w/ Tibial Deficiency 1/3 of these PTs will also have ? What position does leg adopt if there is deficient femur present
``` Congenital Heart Dz Cleft palate Imperforate anus Hypospadias Hernia Gonad malformation ``` Hand anomalies Flexed thigh, Abducted, Externally rotated FABER'd
377
What is better about a deficient femur Dx compared to deficient tibia Dx ? is MC cause of anterior knee pain in kids What is an uncommon cause and where in the structure is the deformity located and associated w/ the same located pain
Less organ anomaly involvement Patellar mal-tracking Bipartite patella- superolateral corner
378
Peds PFS can be improved w/ ? rehab What two RFs are strongest w/ developmental dysplasia of the hip What are the two maneuvers done to r/o this Dx
Strengthening medial head of quad FamHx Female gender Barlow- provocative; attempt to displace femur head posterior Ortolani- relocates dislocation
379
? PE finding indicates femoral shortening in Peds Degrees of varus allowed in Peds When are x-rays of Varum needed if Ped is <2y/o
Galeazzi sign ``` 10-15 at birth Straight/Neutral at 18mon Valugs after 2y/o 10-15 valgus at 3-4 5-7 by 11 ``` Below 25th percentile
380
? Dz process can cause Peds leg Varus and needs Tx If Surgical Tx is needed, surgical realignment via osteotomy is best if done by ? age
Blount Dz- abnormal growth between posterior and medial tibial physes 4y/o
381
AC injection
PT seated Neviaser portal (posterior clavicle, anterior scapula) Supralateral to inferomedial direction
382
Posterior Shoulder Injection/Aspiration
Pt seated Palpate coracoid 2cm medial, cm inferior to posterior acromion corner Thumb on posterior soft spot Aim for coracoid tip
383
Subacromial Bursa Injection
Pt seated w/ arm in lap Posterior- lateral corner of acromion 1cm inferior, 1cm medial Needle angle 20-30*
384
Elbow Joint Injection/Aspiration
Pt supine Arm against chest w/ 90* flexion Soft-spot portal: Lateral epicondyle Radial head Olecranon tip Over anconeus muscle
385
Tennis Elbow Injection
Arm against chest w/ elbow flexed at 90* Inject at point of max tenderness Inject through Extensor Carpi Radialis Brevis muscle
386
MCP/PIP injection site Thumb CMC injectio site Wrist aspiration/injection site
Dorsolateral Between CMC and Trapezium 1cm distal to Lister's, 1cm distal to radius Divot= radiocarpal joint Needle angle 10-11* distal to prox
387
Carpal Tunnel Injection De Quervains injection
Volar insertion 1cm proximal to flexor crease in line w/ ring finger Needle 30-45* 45* to skin Thumb paresthesia= sensory branch of radial nerve has been depolarized; reposition 2-3mm dorsal/volar
388
Hook removal technique for Right Hand Trigger Finger Injection site Trochanteric Bursitis Injection
Press and retrace entrance path Incision w/ 15blade Distal palmar crease Pt on unaffected side w/ pillow between legs Insert until hit bone, withdraw 2mm
389
Knee Injection/Aspiration Pes Anserine Bursa Injection
Pt supine Lateral knee entry- 1cm lateral, 1cm superior to superiolateral patella Bursa: between Gracili/Semi-tendon and MCL Hit bone, withdraw 1-2mm
390
Ankle Joint Injection Where do the sensory nerves travel in the foot
1cm prox to medial malleolus Plantar side of tarsal
391
Mortin Neuroma injection Plantar Fasciitis injection site Chronic Stress Fx of foot are more likely to develop ?
1-2cm proximal to toe web Medial calcaneus, 2cm from plantar surface Jones Navicular

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