Exam III Flashcards
Peptic ulcer referral pattern
right shoulder, lateral border, right scapula
Myocardial ischemia referral pattern
left or right shoulder and down arm (L>R)
Thoracic aorta aneurysm referral pattern
left shoulder or between shoulder blades
Hepatic /biliary: Acute cholecystitis referral pattern
right shoulder, in between scapula, right subscapular area
Gallbladder referral pattern
right upper trap, right shoulder
liver disease (hepatitis, cirrhosis, metastatic tumor, abscess) referral pattern
right shoulder, right subscapular
Pulmonary (pleurisy, pneumothorax, Pancoast tumor, pneumonia) referral pattern
Ipsilateral shoulder, upper trap
Kidney referral pattern
Ipsilateral shoulder
Gynecologic: Endometriosis referral pattern
Reported in right shoulder, possible in either shoulder depending on location of cysts
Internal bleeding: spleen rupture or trauma, post-op laparoscopy referral pattern
Left shoulder (Kehr’s sign)
Pancreas referral pattern
Left shoulder
infectious mononucleosis (hepatomegaly, splenomegaly) referral pattern
left shoulder/left upper trap
Gynecologic: Ectopic pregnancy
ipsilateral shoulder
Diaphragmatic Irritation
Irritation of the peritoneal (outside) or pleural (inside) surface of the diaphragm refers sharp pain
Central portion—upper trapezius, neck, supraclavicular fossa
Peripheral portion—costal margins and lumbar region
Pain is ipsilateral to area of irritation
Septic arthritis
Sudden/severe, warm with swelling and limited ROM, constitutional signs and symptoms
Polymyalgia rheumatica
Proximal MUSCLE pain, weight loss, elevated Erythrocyte Sedimentation Rate and C-Reactive Protein
Screening for Scaphoid Fracture
Clinical signs
Snuff box tenderness
Scaphoid tubercle tenderness
Longitudinal compression
All 3 present = 100% SN and 74% SP
Cervical ligamentous instabilities with possible cord compromise
Can be due to major trauma, history of RA or ankylosing spondylitis, or oral contraceptive use. Symptoms can include long tract neurological signs especially present in more than one extremity. Also can include dizziness, nystagmus, vertigo, clonus, or positive babinski’s sign.
Cervical and shoulder girdle peripheral entrapment neuropathies
Can present as paresthesias and pain present at rest and possibly with retrograde distribution. Muscles innervated can be tender to palpate and muscles and sensory distribution follow specific nerve patterns.
Spinal accessory nerve pathology
can be due to history of penetrating injury, direct blow, or stretching of nerve during fall or MVA. Present as asymmetry of the neck line and drooping of the shoulder. Also unable to shrug shoulders.
Axillary nerve pathology
Can be in patients >40yo with shoulder dislocation, history of traction or blunt force to shoulder, history of brachial neuritis or quadrilateral space syndrome. Presents with weakness in shoulder abd and flexion and lack of sensation on lateral aspect of upper arm
Long thoracic nerve pathology
Identified in players of many sports, serratus anterior weakness with scapular winging and demonstrates loss of scapulohumeral rhythm
Suprascapular nerve pathology
Deep and poor localized pain. Can be due to history of fracture of scap, traction injury, or direct compression on nerve by other pathology. Presentation is similar to RCT with wasting of supraspinatus and infraspinatus. Loss of abduction and ext rotation of shoulder
Pancoast’s Tumor
Can be in men >50yo with history of smoking. Presents as nagging type pain in the shoulder and along vertebral border of the scapula
Hill-Sachs lesions
posterolateral humeral head compression fracture, typically secondary to recurrentanterior shoulder dislocations, as the humeral head comes to rest against the anteroinferior part of the glenoid.
bankart lesion
- A Bankart lesion is an injury to the anterior-inferior part of the glenoid labrum, the cartilage surrounding the socket of the shoulder joint (glenoid).
- It occurs when the shoulder dislocates anteriorly (forward), tearing this part of the labrum and sometimes involving the ligaments.
What does the fist view do on x-rays?
widening of the scapholunate interval
What does the scaphoid view look like?
Ulnar deviation for best view
Gilula 3 Carpal Arcs
- Proximal curves of the scaphoid, lunate, triquetrum
- Distal surfaces of the same bones
- Proximal curves of the capitate and hamate
What is the Terry Thomas sign?
separation of scaphoid and lunate bones, >5mm seperation
What is a potential risk factor with scaphoid fractures?
Because no blood vessels enter the proximal pole of the scaphoid, a higher incidence of aseptic necrosis and nonunion is noted with fractures on this side of the scaphoid
Screening for Scaphoid Fracture
Clinical signs
-Snuff box tenderness
-Scaphoid tubercle tenderness
-Longitudinal compression
All 3 present = 100% SN and 74% SP
Radial inclination and ulnar variance
refers to the angle formed by the slope of the distal end of the radius as it tilts toward the ulna. Ulnar variance refers to the relative length of the ulna compared to the radius. Normal is considered 21-25 degrees.
Neutral ulnar variance: when both bones are of similar length.
Positive ulnar variance: when the ulna is slightly longer than the radius.
Negative ulnar variance: when the ulna is shorter than the radius.
Gamekeeper’s fracture
also known as askier’s thumb, is a specific injury to theulnar collateral ligament (UCL)of the thumb, often associated with an avulsion fracture at the base of the proximal phalanx (thumb bone). It typically occurs when the thumb is forcefully abducted, such as when falling on an outstretched hand while gripping a ski pole (hence the name “skier’s thumb”).
Bennett Fracture
fracture of thebase of the first metacarpal, typically occurs by blunt trauma or forceful axial load through the thumb
Rolando Fracture
is a three-part or comminuted intra-articular fracture-dislocation of the base of the thumb (proximal first metacarpal). It can be thought of as a comminutedBennett fracture.
Keinbock’s disease
avascular necrosis of the lunate. usually found in the dominant wrist of males 20-40 yo. It can be due to repetitive microtrauma of the lunate and also linked to negative ulnar variance. MRI is most sensitive to see these changes.
Children ossification centers for wrist
Capitate: 1-3 months
Hamate: 2-4 months
Triquetral: 2-3 years
Lunate: 2-4 years
Scaphoid: 4-6 years
Trapezium: 4-6 years
Trapezoid: 4-6 years
Pisiform: 8-12 years
2ndary ossification centers:
Metacarpal heads fuse at 14-19
Phalangeal bases fuse at 14-19
Radial head fracture
Can be due to fall onto outsretched arm that is supinated. Presents as anterolateral pain and tenderness at the elbow, inability to supinate or pronate forearm.
Distal radius (colles) fracture
Can be due to fall on outstretched arm with forceful wrist extension, age >40 (women>men), history of osteoporosis. Wrist swelling and wrist extension is painful
Scaphoid fracture
Fall onto outstretched arm, wrist swelling, pain in anatomical snuff box
Lunate fracture or dislocation
fall onto outstretched arm, generalized wrist swelling and pain, decreased motion, and decreased grip strength (can be used to rule out capitate fracture)
TFCC tear
Traumatic fall on outstretched arm with forearm pronated, commonly associated with colles fracture, ulnar sided wrist pain, tenderness, and clicking. grip strength weakness
Long flexor tendon rupture
Histroy of RA, corticosteroid use, or trauma. Grade 1 and 2 presents with local tenderness, swelling, pain with motion. Grade 3 presents with total loss of motion and palpable defect in muscle
Space infection of the hand
Recent puncture of skin or insect bite. Presents as inflammation, swelling in palm, dorsum of hand, or finger tips
Raynaud’s phenomenon
PMH of RA, occulsive vascular disease, smoking or betablockers. Presents as hands or feet that blanch, go cyanotic and then red when exposed to cold or emotional stress. Also can have pain or tingling
CRPS
Can be result of trauma or surgery, pain does not respond to typical analgesics. Presents as severe aching, stinging, cutting, or boring pain that is not typical of injury, hypersensitivity. Area swollen and warm and red
CRITOE of elbow
Capitulum: 1-3yo
Radial head 5-7yo
Internal (medial) Epicondyle: 5-7 yo
Trochlea 9-11 yo
Olecranon 9-11 yo
External epicondyle 10-12yo
What is the T sign
indicative of a UCL tear, trauma to elbow should be screened with valgus stress test
Monteggia’s fracture
fracture of the proximal third of the ulna with dislocation of the radial head, caused by foosh injury with forearm in hyperpronation
Osteochondritis Dissecans (OCD) of the capitulum
Injury to the joint surface, a seperation of a piece of cartilage and subchondral bone from the articular surface. Presents in adolescent athletes with open grwoth plates. Presents as dull pain, joint swelling, perhaps locking. Due to repetitive valgus compressive forces on the medial side of the joint.
Nightstick fracture
fracture to midportion of the ulna, usually from a direct blow
Galeazzi Fracture
fracture of distal radius and corresponding dislocation of the ulnar head from wrist
Colles fracture
Fracture of the distal radius, consists of fracture of the distal radial metaphyseal region with dorsal angulation and impaction (dinner fork), but without involvement of the articular surface. FOOSH injury
Smith’s fracture
Also referred to ask reverse colles fracture, tends to be more unstable than colles fracture. Tends to displace towards palm
Coxa valga
Increased risk for hip dislocation
Coxa vara
increased risk for femoral neck fracture and SCFE
False-positive view
Anterior coverage of the femoral head can be assessed. It can diagnose CAM deformitity.
Dunn View
evaluates relationship of the femoral head and acetablum
FAI with labral tear
Mechanical pathology because of the abutment of the femoral neck with the acetablum. labrum is vulnerable due to altered joint arthrokinematics. Presents as snapping, clicking, limited hip ROM, and pain at end ranges of flexion or extension. Hip locking is associated with labral tears
The radiographic hallmarks of degenerative joint disease at the hip joint include the following
-Joint space narrowing
-Sclerotic subchondral bone
-Osteophyte formation at the joint margins
-Cyst or pseudocyst formation
-Migration of the femoral head
Avascular/Aseptic Necrosis: Radiographic Findings
Can be distinguished from OA by the normal preservation of the joint space, the crescent sign appears parallel to the superior rim of the femoral head. This represents the collapse of the necrotic subchondral bone of the femoral head
Aseptic Necrosis risk factors
Anemia
Steroids
Ethanol
Pancreatitis
Trauma
Idiopathic
Caisson’s Disease
Legg Calve Perthes Disease
Pediatric impairment. Necrosis of the epiphysis of the femoral head (7y/o), most common between 4-8 y, permanent deformity - OA
Symptoms include limping, pain, stiffness, and decreased hip ROM
Slipped Capital Femoral Epiphysis
Most common adolescent hip disorder, weakening of the epiphyseal plate allows for displacement. Vague pain in hip and knee, limited motion especially in IR, antalgic gait, and limb length shortening. Onset is insidious and can coincide with growth spurts at puberty.
Developmental Dysplasia (DDH)
malformation of the hip in young children beginning to walk, usually affects left hip, more predomiant in girls, genetic and hormonal
Unstable pelvic fracture
Two or more articulation sites on the pelvic ring are disrupted.
In stable/alert trauma patient, a thorough clinical examination will detect pelvic fractures with nearly 100% sensitivity. What is the criteria?
Criteria: All must be present = initial radiograph unnecessary.
Age: > 3 yrs
No impairment of consciousness
No other major distracting injuries
No complaint of pelvic pain
No signs of fracture on inspection
Painless compression of iliac or pubic symphysis
Pain free hip rotation and flexion
