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Surgery > Delahay rounds 1/9/17 > Flashcards

Delahay rounds 1/9/17 Flashcards

1
Q

tf

the osseus anatomy of the knee provides stability

A

f
little osseus stability
provided by complex soft tissue envelope

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2
Q

pts with patella removed because of arthritis or trauma have what changes in strength

A

30% reduction in quadriceps strength
because the patella (all sesamoid bones) function to increase the line of pull (moment = force x distance to fulcrum ~ torque, per delahay) to decrease the force for quadriceps function

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3
Q

tf

msk pain will commonly be relieved by rest

A

t

if not, start thinking neoplasm

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4
Q

two etiologies of instability in the knee

A

ligamentous - ligaments crossing from femur to tibia

patello-femoral joint - buckling/giving away… sometimes stretch pain causes reflex relaxation and collapse

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5
Q

in what activities is the patello-femoral joint least stable

A

any that require quad contraction WHILE IN FLEXION
walking DOWN stairs
bicycling

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6
Q

normal lateral knee angulation

A

5-7 degrees valgus

(medial condyle is larger as more force through it on way from center of femoral head to center of ankle joint

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7
Q

knee xr’s helpful for

A

fractures (trauma)
joint subluxations (alignment)
articular surface condition (arthritis)

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8
Q

xr views of knee

A

ap
lat
merchant/sunrise
(45deg flex beam pointed inf, parallel w patellar articular surface)

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9
Q

clear space on merchant/sunrise view of knee represents…

A

articular cartilage

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10
Q

study of choice for intraarticular pathology of knee

A

MRI

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11
Q

presentation of ligamentous injury of knee

mgmt

A

instability
pain swelling
sense of knee shifting/giving away
e.g. descending stairs or turning on loaded knee
immobilization – brace and rom – strengthening (progression as pain subsides) – surgical candidate if still unstable after strengthening program

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12
Q

tf

patellofemoral joint is one of the most common areas of pain in the knee

A

t

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13
Q

patello-femoral pathology

etiology
presentation
mgmt

A

degenerative changes or maltracking in trochlear groove - anterior knee pain w loading flexed eg down stairs bicycle, relieved w rest but not one position too long (movie sign) needing to change position to relieve discomfort (degenerative change eg chondromalacia patella is softening of articular surface can be primary or secondary to trauma)
mgmt nonop quad and patellar tracking exercises 6-8 wks, if fail can consider op to improve pt results

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14
Q

movie sign

A

anterior knee pain while in one position for too long (eg at movie) feeling like need to change position to relieve discomfort eg due to chondromalacia (articular softening) of patella aka patellofemoral pathology

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15
Q

approach to osteoarthritis in knee

A

same as arthritis everywhere
5 modalities
-nsaids for pain and swelling
(same mech but diverse pt response so try 2 or 3 before considering failed, watch gastritis and GI intolerance)
-intraartic corticosteroid inj for acute exacerbation back to baseline
(consider surg if inj more than q6-8 wks or 2-3x/y as detriment to articular cartilage)
-pt maintain rom strengthen quads and hamstrings to reinforce soft tissue sleeve, limit to pt ability as can worsen sx in late stages of degenerative arthritis
-cane or crutch assistive devices to limit stretch across knee and increase walking tolerance
-activity mod eg sports work parking weight loss (knee can bear 3-5x body weight)
6 - surg

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16
Q

how much force can be generated at knee joint

A

3-5x body weight (eg jumping)

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17
Q

surg for knee arthritis

A

arthroscopic debridement lb remov (3-6mos relief, if sig oa found may opt for replacement

osteotomy to realign (eg most common varus deformity from medial erosion places greater force on medial), wedge resected from lat tib or wedge placed on med side… 5-10yr relief, not for unstable or stiff knee, replacement when sx return

arthrodesis (fusion) for young active... but stiff straight leg not ideal...
resection arthroplasty (fibrous pseudoarthrosis forms in place) and walk w brace ... these rarely performed only for tka failures

TKR total knee replacement common 1/4 mill /yr US , pts 65-70 typical… 95% successful 10-15 yr survivorship. bone cement, non cement improving. cut articular surfaces, remove acl, some allow keep pcl, must balance lcl mcl +- pcl, resurface patella. immed chair mobi w full weight bearing allowed w stabilizer preventing hyperflexion. d/c 3-4 days, need rom 3-6 wks or else scar invation prevents major gains.functional 2-3 wks but rehab 3-6 mos

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18
Q

complications of TKA total knee arthroplasty

A

aseptic loosening 0.5%/year… 90% 15y survivorship
loose v 5yr, eval for deep infection (young, obese, high demand also risks)

patellofemoral complaints common (poor soft tissue balancing/alignment, arthritic w/o patellar resurfacing and ^60kg 160cm)

thromboembolism most common, 25-50% dvt rate, ppx SCDs warfarin asa lmwh NOACs coming along

deep infection 1% incidence
staph a, staph epi
thin inferior wound dehicence
DM a risk
treat aggressively - remove everything, debride, ivabx 6wks, can reimplant w low expectations s/p extensive debridement
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19
Q

ddx for knee pain in adult

A

arthritis
patellofemoral pathology
meniscal tear
ligamentous injury

per delahay book

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20
Q

knee physical exam

A

INSPECT GAIT PALPATE RANGE SPECIAL TESTS
angulation, swelling bruising ecchymosis, gait 65deg flexion smooth cadence step length equal bilat, no sudden shifts, seated position of patella anterior and symmetric, palpate while flex extend for patellar tracking and crepitus, palpate supine for point tenderness and ant/post same time for displaceable edema, normal flex extend 0-135, var valg stress, lachman ant post drawer recurvatum (backbendknee), mcmurray squat and twist for meniscal tear

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21
Q

mcmurray test

A 
knee
flex
adduct
ext rot ankle
extend knee
pain or snap ~ meniscal tear
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22
Q

delahay dx for hip pain

A 
trochanteric bursitis
it band snapping over trochanteric bursa
iliopsoas snapping
acetabular labral tear
loose bodies
AVN (hip prox hum knee talus)
arthritis
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23
Q

types of hip arthritis

A

osteoarthritis (primary idiopathyic congenital vs secondarymdevelopmental avn post-trauma immunogenic)
inflammatory (RA ank spondy psoriatic sle
infectious (pyogenic - staph a, staph epi, gonococcal)
other (lyme borrelia, nonpyogenic mycobacterium, crystals gout psuedogout, hemophilia hemosiderin dep)

24
Q

referred pain is pain in structures which have the same __ origin

A

mesodermal

25
Q

referred pain vs radicular pain

A

dull deep boring
localized injury does not signify compression of neural elements
pain in structures w same mesodermal origin
(e.g. lumbar back pain to buttocks and thigh)

sharp lancinating
numbness tingling maybe
mechanical compression of inflamed nerve root w pain traveling along anatomic course of nerve
e.g. lumbar back pain to foot

26
Q

define radicular pain

A

radiculopathy
mechanical compression of inflamed nerve root w pain traveling along anatomic course of nerve
e.g. lumbar back pain to foot

27
Q

define referred pain

A

pain in structures which have the same mesodermal origin

28
Q

most common nerve roots in radiculopathy

A

L5
S1
(levels that account for pain below the knee)

29
Q

severe lumbar back pain
urinary retention
urinary incontinence
are major symptoms of…

A

cauda equina syndrome

large midline disc herniation compressing several roots of cauda equina

30
Q

cauda equina compression syndrome
path
pres

A

massive herniation (midline..?) of L3 L4 L5 disk compresses cauda equina
pain buttocks and back of thighs and legs
numbness buttocks, backs of legs, soles of feet
weakness/paralysis legs and feet
atrophy of calves
paralysis of bowel and bladder

31
Q

how does the straight leg raise test work

A

compresses inflamed lumbar root against a herniated disc or bony spur

32
Q

what constitutes a positive straight leg raise

A

leg pain BELOW KNEE reproduced or intensified

back or buttock pain not sufficient

33
Q

physical exam of lumbar pain to include what other than ortho exam

A

peripheral vascular exam
hip exam
abdominal exam

34
Q

at what angles does straight leg raise actually stretch sciatic and potentially yield positive result

A

35-70 degrees
less than that just slack
beyond that not stretching much more

35
Q

when are plain radiographs helpful for spine ortho

A

stenosis
spondylolisthesis
gross segmental instability
fracture

36
Q

xr views to get of lumbosacral spine

A

ap
lat
coned-down lateral view of lower two interspaces

occasionally but not routinely two oblique views to id subtle spondylolysis or pars interarticularis defects

37
Q

what is a lateral cone-down spine xr

A

In a typical non-cone-down image, the pelvis bones are superimposed over the spine. Cone-down views result in clearer pictures and allow better visual of lower lumbar/sacral spine and the joint space. You may see this view called the “L5/S1 spot.”

38
Q

bony lesions may not be visualize on spine plain film until what % of cancellous bone has been destroyed

A

50%

39
Q

tf

MRI is often image of choice for spine

A

tish

but significant false positive (asymptomatic abnorms) so be judicious with it

40
Q

indications for myelography for low back pain pt

A

eval neural compression when MRI cannot be used
-dye injected into dural sac, outlines structures eg herniated discs, extrathecal masses
(invasive and complicated by headaches nausea vomiting even rarely seizures so not taken lightly or often used)

41
Q

use of CT scan for spine ortho

A

as confirmatory diagnostic tool, high false positive if used without clinical correlation…

42
Q

when do signs of denervation with fibrillation in setting of a compressed nerve root become apparent by EMG

A

3 weeks pressure

earlier may only show muscle irritability despite nerve entrapment

43
Q

4 most common ddx for low back pain evaluated by ortho

A

back strain
herniated disc
spinal stenosis
spondylolisthesis

44
Q

back strain aka

A

lumbago

45
Q

lumbago aka

A

back strain

46
Q 
back strain
aka
eti
pres
dx
tx
A

lumbago
trauma or postural inadequacy results in legamentous or muscle strain
nonradiating lumbosacral pain, may refer to posterior thigh or buttock, mild is pain wo objective findings can continue activity, mod is limited spinal motion and paravertebral muscle spasm return to activity 2 wks, sev is tilted forward or side diff ambulation may take 3 wks to function
clx, if persists (eg more than 2 wks) xr to ro spondylolisthesis or tumor
tx w controlled physical activity

47
Q

herniated disk

path/eti

A

herniation of nucleus pulposus thru torn annulus fibrosis
usually 20-40yo 3rd or 4th decade of life when pulpsosus still gelatenous, perf usually lateral to post midline where posterior longitudinal ligament weakest, L4-L5 L5-S1 most common, just above those much less common
pain radiating to leg along root distribution

48
Q

a disc herniation at L4-L5 will most often compress…

A

L5 nerve root

49
Q

a disc herniation at L5-S1 will most often compress…

A

S1 nerve root

50
Q

which nerve root does a lumbar disk herniation most often compress

A

the root that exits just below the herniation
but can get the one two below sometimes
and the one above if an extreme lateral herniation

53
Q

which muscles and tendons attatch to talus

A

none

55
Q

tf

relationship if tibia to fibula is static

A

f

w dorsiflexion fibula moves laterally proximally and externally rotates

56
Q

how much weight does fibula bear

A

1/6 in stance phase

58
Q

what is the mortise of the ankle

A

tibio fibular recess that accepts talus

59
Q

mortise and tenon

A

hole space

thing that fitsl

60
Q

define
forefoot
midfoot
hindfoot

A

phalanges and metatarsals

tarsals

talus calcaneous

Surgery (22 decks)

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