exam 1 Flashcards
1
Q
Subjective
A
includes history, which includes MOI, sounds/sensations @ TOI, location, onset, description, and duration of symptoms, factors that change symptoms, past medical history (congenital/ acquired) bilateral comparison, general med health. (obviously include age, sport, etc.)
2
Q
objective
A
includes observation (referenced for symmetry and color of superficial tissues), palpation (referenced for bilateral symmetry of bones, alignment, tissue temperature and other deformities), special tests (includes ROM, ligamentous/capsular tests, and neurological tests)
3
Q
differential diagnosis
A
the determination of which of two or more injuries/diseases/conditions with similar symptoms is the one from which the patient is suffering from
4
Q
diagnosis by exclusion
A
diagnosis made by excluding those diseases/injuries to which some of the symptoms belong, leaving only one to which all the symptoms point
5
Q
primary goal of orthopedic physical exam is
A
to obtain a clinical diagnosis. Also to obtain sufficient information to determine a plan of care that will improve the patient’s health related quality of life
6
Q
Nagi theoretical framework purpose
A
helps us understand how a patient’s pathology creates abnormalities (“impairments”), how these impairments influence functional ability and finally how these functional limitations influence a person’s life.
7
Q
components of Nagi
A
active pathology, impairment, functional limitation, disability
8
Q
active pathology (def. and ex.’s of assessment techniques)
A
interruption or interference of normal bodily processes or structure. EX of assessm. include diagnostic imaging or blood analysis.
9
Q
impairment (def. and ex.’s of assessment techniques)
A
anatomical, physiological, mental, or emotional abnormalities. EX medical history, pain questionnaires, goniometry, and MMT, special tests
10
Q
functional limitation
A
restriction or lack of ability to perform an action or activity in a manner considered to be normal. EX observation during ADLs
11
Q
disability
A
an inability or limitation in performing socially-defined activities and roles expected of individuals within a social and physical environment. EX question patient regarding the impact of injury/illness on quality of life
12
Q
mechanics
A
the branch of science that deals with the effects of forces and energy on the body
13
Q
microtrauma definition
A
the slow, progressive breakdown of soft tissues or bone over a period of weeks/months; AKA repetitive motion injuries
14
Q
pain assessments
A
needs to be both subjective and objective. Sub (part of history) includes location, duration, type, timing, with activity. obj measures the changes in the level or type of pain, EX visual analog scale, numeric rating scale, McGill pain questionnaire
15
Q
pain scale type?
A
numeric rating scale
16
Q
pain scale type?
A
McGill pain questionnaire
17
Q
pain scale type
A
visual analog scale
18
Q
observation
A
gait, posture, obvious deformity, asymmetry, soft tissue contours (muscle wasting), skin color/texture, scars, inflammation, attitude, crepitus?
19
Q
palpation
A
- start with uninvolved limb
- tell patient what you plan to do next
- always compare bilaterally.
20
Q
range of motion and manual muscle testing order
A
- active ROM: patient moves body part
- passive ROM: clinician moves body part
- resistant ROM:clinician resists movement of specific body part
resisted isometric muscle testing done in an anatomical neutral or resting position.
21
Q
neurological examination
A
- cranial nerves
- peripheral nerves (motor functions AKA myotomes, and sensory functions or dermatomes which is an area of skin)
- deep tendon reflexes
- special tests
ALSO NOTE: when testing myotomes each isometric contraction must be held for > or = 5 seconds in order to allow for any myotomical weakness to become evident.
22
Q
vascular screening
A
- evaluate major pulses in region of affected body part
- check capillary refill
- observe skin color
- note temperature of skin
23
Q
Chapter 1 table references
A
Table 1-2 referral alerts. 1-3 potential medical effects on musculoskeletal healing. 1-4 possible causes of changes in bone density. 1-7&8 normal and pathological end-feels to PROM.
24
Q
Clinical pearl
A
always look at at least one joint proximal when considering the pathogenensis of a particular injury or condition
25
findings that warrant an immediate referral to MD
26
Evidence based practice
is the incorporation of 3 elements into the decision making process of patient care: best available evidence, clinical expertise, and the needs and values of the individual patient.
27
means of deciding whether diagnostic test/medical treatment is effective in order from least to most reliable
1. superstition
2. intuition
3. method of authority
4. method of philosophy
5. empiricism
6. scientific method
28
how to practice EBM
1. Identify and define clinically-relevant questions. AKA: PICO. Patient population? Intervention/treatment? Comparison group? Outcome of interest?
2. Search for best evidence. EX MEDLINE.
3. Critical appraisal of evidence. Types of studies? Trusted source?
4. applying the evidence. REMEMBER each patient handled individually, consider their preferences, cost, and convenienve
5. evaluate the performance of EBM
29
hierarchy of research methods
1. Randomized clinical trial
2. Prospective/Cohort study: used when quantification of risks is of interest, takes longer and more $.
3. Case control studies: two groups, similar in every way except trait/condition being studied, commonly retrospective in nature.
4. Cross-sectional study: "snapshot". describes a particular group of patients/athletes at a given instant of time.
5. single case report
6. expert opinion
30
sensitivity
tests ability to detect those patients who actually have the disorder. True Positive rate, also relative to gold standard test.
31
specificity
ability of a test to correctly detect those patients who do not have the disorder. True negative rate.
also tests ability to detect absence of a lesion.
32
intra-rater reliability
extent to which the same examiner obtains the same results on the same patient.
33
inter-rater reliability
describes the extent to which different examiners obtain the same results for the same patient.
34
optimal sports medicine research study
cohort (injured and non injured studied), conducted with many teams/athletes, prospective (longitudinal data collected), one data-recorder wherever possible (intra-rater reliability), uniformity of injury across sports, specific definitions of injury severity, exposure hours used to express incidence rates, acknowledgement of limitations.
35
accuracy of clinical examination and MRI has been established by comparison to findings in
arthroscopic surgery. It is considered to be the diagnostic gold standard.
36
accuracy
ability of a test to correctly detect the presence or absence of a lesion.
37
PPV
positive predictive value: Frequency of an initial diagnosis being confirmed postoperatively.
38
NPV
negative predictive value: frequency of a negative initial diagnosis being confirmed postoperatively.
39
musculotendinous injuries
muscle strain, tendonitis, heterotropic ossification, compartment syndromes
40
articular surface injuries
osteochondral defects, osteochondritis dessicans, osteoarthritis
41
joint structure injuries
sprains, joint subluxation/dislocation, synovitis, bursitis
42
bony structure injuries
exostosis, apophysitis, fractures
43
Load
external force acting on body that causes internal reactions within the tissues. Measured in Newtons.
44
Deformation
the change in dimension of a tissue, commonly measured in mm
45
mechanical stress
the load per unit of area, commonly measured in Pascals (1 N per meter area)
46
mechanical strain
the change in tissue dimensions, as a result of loading. scalar quantity (%).
47
compressive force
two forces applied toward one another that result in the crushing of tissue. EX intervertebral disc herniation
48
tensile force
two oppositely directed forces that pull apart/stretch tissue. EX ligament rupture.
49
shear force
two oppositely directed forces that occur perpendicularly across the long axis of a structure. EX humerus
50
bending force
two force pairs act at opposite ends of a structure. (one might be compression and one tensile). EX greenstick fracture.
51
torsion force
loads caused by twisting in opposite directions from opposite ends. Shear stress encountered will be perpendicular and parallel to the loads.
52
stress strain curves
describes the amount of tensile load specific tissues can tolerate before damage results. hysteris loop representing heat loss. WE CAN LEARN: _magnitude of load_ structure can withstand before failing, _amount of deformation_ a structure can sustain before failing, and _amount of energy_ the material can store before falling
53
toe region
tissue slack is being taken up and there is relatively little change in strength.
54
elastic region
collagen fibers are being stretched as elastic region begins. Fibers require substantial tension to deform and will return to original shape after stretch.
55
plastic region
beginning, application causes a residual change in tissue structure (fibers will not return to original length, partial tearing). continuation of load may cause tissue to rupture at its ultimate failure point.
56
soft tissue pathology
contusions, strains (muscle/tendon), tendonopothy (tendonitis/tendinosis), heterotropic ossification, bursitis.
57
Strain severity
* 1st degree (mild): no sig tissue damage or loss of muscle function (\<5% of tissue affected).
* 2nd degree (moderate): partial tearing of muscle and/or tendon
* 3rd degree (severe): complete rupture of muscle and/or tendon, no function.
58
heterotropic ossification
AKA myositis ossificans. Formation of bone within a muscle belly's fascia or other soft tissues. Etiology: Trauma (#1 cause), neurological disease, genetic origin. common locations in deltiod and biceps
59
olecranon bursitis
inflammation of a fluid filled sac that serves to buffer muscles, tendons, and/or ligaments from other friction-causing structures. May be due to aseptic (traumatic) or septic (staph infection) causes. IOW, micro or macro. ice and rest
60
sprains
ligaments.
* 1st degree (mild)=no sig damage, no joint instability,
* 2nd (moderate)= partial tearing of ligament, increased joint laxity.
* 3rd (severe)=complete rupture, no end point (end feel)
61
shoulder separation
acromioclavicular ligament and coracoclavicular ligament tear, NOT disclocation subluxation
62
sprain involves ___ which is \_\_\_\_ to \_\_\_\_
ligaments; bone to bone
63
strain involves ____ and/or \_\_\_\_, which is ____ to \_\_\_\_
muscles; muscle to bone
64
OCD's
osteochondral defects. damage to articular cartilage surface can happen gradually/instantly, and can be partial or full thickness OCD's.
65
osteoarthritis
wearing away of hyaline cartilage as a result of normal use. Changes in joint mechanics lead to joint degeneration. commonly affects weight bearing joint but can also impact shoulders and cervical spine. Sx- pain, stiffness, prominent morning pain, localized tenderness, creaking, grating
66
neurovascular pathologies
spinal cord injury, peripheral nerve injury, regional complex pain syndrome (RSD)
67
nerve injury
MOI:
1. laceration via cervical fx/dislocation
2. hemorrhage may lead to spinal cord degeneration/death of nerve
3. contusion may ^ swelling & ^ pressure on nerve
4. shock due to mild contusion of neural tissue
incomplete lesion: partial loss of motor function, full recovery possible.
complete lesion: loss of motor function/sensation, full recovery unlikely.
68
nerve injuries classification
1. neuropraxia: injury to nerve resulting in paralysis w/o degeneration of axon, followed by rapid & complete recovery of function.
2. axonotmesis: damage to nerve cells that destroys axons but that does not destroy the supporting structures of the cells, making regeration possible
3. neurotmesis: partial/complete severance of a nerve with disruption of axon and its myelin sheath and connective tissue elements.
69
name for degeneration that occurs after axonotmesis and neurotmesis.
Wallerian degeneration.
70
radioulnar joint
allows 1 degree of freedom: pronation/supination. Uniaxial pivot joint
71
radiocarpal joint
ellipsoid joing, allows 2 deg freedom (flexion/extension, and radial/ulnar deviation)
72
sexy lovers try positions that they can't handle
73
the carpal tunnel
* roof: transverse carpal ligament
* floor: proximal carpal bones
* contents: MEDIAN NERVE, flexor digitorum profundus, flexor digitorum superficialis, flexor pollicis longus
* compression results in paresthesia in 2nd, 3rd, and 4th fingers and decreased grip strength
74
bordered on radial side by abductor pollicis longus, and extensor pollicis brevis. bordered on ulnar side by extensor pollicis longus. Contains scaphoid. Radial artery runs along floor of snuff box
75
another name for scaphoid bone
navicular
76
triangular fibrocartilage complex
lies between radius and ulna and ulna and proximal carpals. functions similar to knee meniscus: increases stability at distal radioulnar joint, and absorbs and distributes forces. Injured with FOOSH, Lift off test.
77
scaphoid anatomy
bridges proximal and distal rows of carpals. Major blood supply (70-80%) is a _branch of the radial artery_, entering at or distal to the "waist" of the bone. Fx of proximal 1/3rd can disrupt the blood supply to the proximal pole, which enters at or distal to the middle third. MOI of scaphoid is hyperextension load to the radial side of the palm.
78
scaphoid fractures
are the most commonly fractured carpal bone. fractures to distal 3rd is 5-10% incidence, to middle third is 65-75% incidence, and proximal 3rd is 15-30%. Complications include delayed union fx, non-union fx, and Preisser's disease (avascular necrosis)
79
Lunate dislocation
most common carpal dislocation. Very subtle/not easily recognized. Special test: Murphy's sign. Kienbock's disease (avasc. necrosis)
80
hamate fracture
Hook of the hamate. check for ulnar nerve involvement!
81
metacarpophalaneal joints
larger head of metacarpals articulates with smaller base of proximal phalange, "knuckles". CONDYLOID joints, which allow 2 degrees of freedom. (flexion/extension, and abduction/adduction). \*\*\*thumb can be abducted at any point, fingers can only when extended.
82
phalanges
14 long bones. collateral ligaments- 1. restrain valgus/varus motion, 2. when fingers are in flexion, they tighten and limit abd/adduction. Volar plate: thick fibrocartilage plate on palmer surface of the joint that helps prevent hyperextension.
83
interphalangeal joints
uniaxial hinge joints. Proximal and distal interphalangeal j. ONE degree of movement. flexion/extension. Collateral lig resist valgus/varus. \*\*\* Grip of fingers in flexion is tighter ulnarly than radially.
84
volar plate injury
thick fibrocartilage plate on the palmar surface of the joint that helps prevent hyperextension of PIP and DIP joints. (so due to hyperextension)
85
Lister's tubercle
AKA radial tubercle, in line with lunate (which is in line with capitate and 3rd metac.
86
movements at the wrist in sagittal plane
flexion/extension
87
movements at the wrist in the frontal plane
radial flexion/deviation or ulnar flexion/deviation
88
primary wrist flexors (3)
flexor carpi radialis, flexor carpi ulnaris, palmaris longus.
\*\*\*\* PALMARIS LONGUS absent in 10-15% of population
89
primary wrist extensors (3)
extensor carpi radialis longus, extensor carpi radialis brevis, extensor carpi ulnaris
90
primary radial flexors
extensor carpi radialis longus and brevis, flexor carpi radialis
91
primary ulnar flexors
extensor carpi ulnaris, flexor carpir ulnaris
92
primary finger extensors
extensor digitorum communis (longus) (extends MCP and IP joints); extensor indicis (extends the index finger); extensor digiti minimi (extends little finger)
93
primary finger flexors
1. _flexor digitorum superficialis_: origin- common flexor tendon at medial epicondyle, medial aspect of coronoid process and oblique line of radius. insertion- at sides of middle phalanges of 2nd-5th digits. action- **flexes the PIP** joints and assists flexion of MCP and wrist joints. innervation- median nerve
2. _flexor digitorum profundus_: origin- anteromedial proximal ulna. insertion- bases of distal phalanges (anteriorly) of 2nd-5th digits. actions-**flexes the DIP joints **and assists in flexion of PIP and MCP jts. innervation=median and ulnar nerves
94
Dupuytren's contracturea: idiopathic flexion contracture of finger flexor tendon. Tx: surgical debridement/release
95
Swan neck deformity
96
major muscles of the thumb
**extensor pollicis longus, extensor pollicis brevis. **actions= EPL extends distal phalanx of thumb at carpometacarpal and interphalangeal joints. EPB- extends proximal phalanx of thumb at carpometacarpal joint. Innervation=radial nerve
97
thenar eminence
abductor pollicis brevis and flexor pollicis brevis. innervation= median nerve
98
hypothenar eminence
abductor digiti minimi, flexor digiti minimi, flexor digiti minimi brevis. Ulnar nerve inn.
99
paresthesia in median nerve dermatome
median nerve is compressed at wrist, resulting in numbness or pain. (symptoms are associated with Carpal Tunnel Syndrome)
100
common injuries of hand
* carpal bone fx account for 18% hand fractures
* of carpal elements, bones in proximal row are more frequently fractured (think FOOSH)
* scaphoid most common fx, 70% of fx in carpal group and 10% all hand fx's.
* triquetrum is second most comm carpal fx, 14% of all wrist injuries
* incidence of isolated fx of any remaining carpal bones is very low
101
scaphoid fx
* 70% of all carpal fx's.
* Clinical course: 4-6 months in cast,
* tends towards delayed/nonunion fx, especially in \>40 yr patients.
* commonly requires ORIF/vascularized bone graft to heal
* Preisser's disease=avascular necrosis of scaphoid
* distal/middle/proximal pole (prox most sensitive bc of blood flow
102
triquetral fx
* 2nd most comm carpal fx,
* most frequently in dorsal corticle.
* MOI: forced hyperflexion (compression)/avulsion.
* if not displaced, can be treated successfully w/ cast for 4-6 wks.
* displaced might require ORIF.
103
lunate fx
3rd most common carp fx. Kienbock's disease is a common complication=AVN of lunate. Macro/Micro, with multiple microfractures possible. Tenderness with direct dorsal palpation. Patient might report central dorsal wrist pain, loss of motion @ wrist, and diminished grip strength.
104
hook of hamate fx
common in baseball/softball. possible complication= damage to terminal branch of ulnar nerve
105
boxer's fx
fx of neck of 5th metacarpal
106
Bennet's fx/dislocation
* involves an intra-articular fx at base of 1st carpometacarpal joint of thumb.
* most frequent of all thumb fxs
* involves an oblique intra-articular metacarpal fx (known as palmar beak fragment) which remains attached to the palmar beak ligament.
107
extensor tendon injuries
* mallet finger: rupture of extensor tendon at distal phalanx. DIP is splinted at 0 deg. May produce a swan neck def.
* boutenniere deformity: rupture of central slip of extensor tendon. results in MCP hyperextension, PIP flexion, DIP hyperextension. PIP IS SPLINTED A 0 deg.
108
contusions
radius most commonly effected
109
wrist tenosynovitis
AKA deQuervain's disease. typically involves abductor pollicis longus and extensor pollicis brevis. Finkelstein's test is not particularly sensitive/specific to deQuervain's.
110
wrist sprains
ulnar collateral lig and radial collateral lig.
111
ganglion
herniation of the synovial sheath. not typically removed unless symptomatic. surgery not 100% effective
112
Colles fx
distal radius displaced posteriorly.
113
smith's fx
reverse of Colles' fx. (radius displaced anteriorly) "flexion fx of radius"
114
scapholunate dissociation
* scapholunate lig is most imp lig @ wrist.
* Etiology: Hx of a fall or direct blow to hyperextended wrist
* x-rays taken in a clenched fist position
* SLD is when gap is 2-3 mm between scap. and lun.
115
carpal tunnel syndrome
* most common repetitive motion injury.
* involves 10 structures that reside in the CT: median nerve, flexor pollicis longus, flexor digitorum superficialis (4 tendons), and flexor digitorum profundus (4 tendons).
* ST: median nerve dermatomal/myotomal tests, Phalen's/Tinel's test, nerve conduction velocity test
116
cyclist/handlebar palsy and cyclist palsy.
handlebar palsy is compression of ulnar nerve. cyclist palsy is compression of median nerve
117
epidemiology of wrist injuries
* abnormally high intensity stress (tennis)
* direct blow in contact sports (football/hockey)
* wrist used as a weight bearing joint (gymnastics)
* repetitive heavy loading
118
radial sided wrist pain
scapholunate interrosseous lig injury is most common of radial-sided injuries.
* coordinates normal wrist motion, and bridges proximal and distal rows of carpals to control position of lunate.
MOI: typically hyperextension loading.
119
ulnar sided wrist pain
typically involves the lunotriquetral ligament or TFCC or both. TFCC plays role in stabalizing the distal radioulnar joint.
120
wrist injury/pain treatment options.
NSAIDS, Immobilization, steroid injections, rehab, surgery.
121
Herbert screw
used in internal fixation of scaphoid fxs.
122
gamekeepers/skiers thumb
* valgus stress (abduction while MCP joint is extended), pain arising from ulnar side of 1st MCP joint.
* MCP joint swelling and ecchymosis
* decreased grip strength
* valgus stress test reveals pain + instability
* grade 1 +2= ulnar gutter or thumb spica splint.
* 3- surgical repair/reconstruction
123
treatment of metacarpal fx
* observation: deformity, swelling, ecchymosis maybe, knuckle asymmetry. fingernail malalignment may be noted.
* decreased ROM/grip strength
* metacarp palpation may reveal crepitus and deformity, pain also radiates through affected finger.
* short arm cast (difficult to immobilize these fxs)
* ORIF for intra-articular + severely angulated fxs.
* percutaneous pinning with K-wires.
124
extensor tendon avulsion treatment
mallet finger treatment.
* popping sensation in fingertip may be reported from forced flexion
* distal phalanx swelling, and DIP remains flexed
* unable to extend
* little/no force produced during resisted ROM testing of DIP joint
* finger splinted CONTINUOUSLY for 8-9 wks. surgery indicated for patient who cannot/will not wear splint.
125
distal phalanx fx
mallet finger w/ and avulsion fx... mallet finger splint
126
finger sprains/dislocation treatment.
* unreduced dislocation, deformity is obvious. sprain results in swelling + possible ecchymosis.
* joint palpation and ROM produce pain. varus/valgus tests may reveal instability.
* Splinting with PIP joint in 30 deg flexion for 2 wks.
* buddy taping for an additional 2-4 wks
* ORIF for unreducable dislocations (volar plate tear?)
127
delayed union fx?
suspect avascular necrosis.
128
changes in tissue feels to spongy
synovitis
129
possible change in tissue feel to hard/warm
blood accumulation
130
possible changes in tissue feels to dense, thickening
scar tissue formation
131
possible change in tissue feels to dense/viscous
pitting edema
132
increased muscle tone
muscle spasm/ muscle hypertrophy
133
change in tissue feel to hard
exostosis (bone or bony outgrowth)
