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CASEM > High Yield 2 > Flashcards

High Yield 2 Flashcards

1
Q

Hx qs + sx of sciatica

A

Pain radiates from lower back into leg + foot
Can have weakness or sensory impairment
Radicular pain in L4-S3
Burning pain, numbness, tingling
Aggravated by flexion, Valsalva, prolonged standing
R/O RF: fever, weight loss, trauma, IVDU, bladder/ bowel dysfunction, saddle anesthesia

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2
Q

RF sciatica

A

Repetitive lifting, flexion or rotation (labourers, dancers, golfers)

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3
Q

Physical exam sciatica

A

Lumbar + Hip exam
Fasciculations can be present
ROM restricted in flexion + rotation

Sensation can be reduced
L4 - anteromedial leg, medial malleolus
L5 - lateral lower leg, 1st web space
S1 - back of lower leg, lateral aspect heel

Reduced strength
L4 - ankle dorsiflexion
L5 - big toe extension
S1 - ankle plantarflexion

Reduced reflexes
L4 - patella
S1 - achilles

Positive SLR
Positive slump test

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4
Q

DDx sciatica

A

Ankylosing spondylitis
Cauda equina
Facet arthropathy
Compression #
Disc herniation
OA of hip or spine
Sacroilitis
Spinal stenosis
Vascular claudication

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5
Q

Rx sciatica

A

6 wks conservative management - NSAIDs, PT, acupuncture
Can use epidural steroid injection for short term pain relief
Surgery if no improvement after 6 wks + severe pain, neuro deficits or severe dz (lumbar decompression)

Core stability + strengthening
Aerobic activity
Restoring motor function

Yoga
Weight loss

Most improve in 6 wks

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6
Q

Red flags for back pain

A

fracture (trauma, steroid use, menopause), infection (fever, IVDU, immunosuppression), cancer (wt loss, prev cancer), cauda equina (bladder/ bowel, saddle anesthesia, motor weakness)

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7
Q

RF for lumbar strain

A

Age
Activity
Occupation
Obesity
Smoking
Sedentary lifestyle
Psychosocial factors
Poor posture

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8
Q

DDx LBP

A

Herniated disc
OA
Posterior facet syndrome
Spondylolisthesis
Spinal stenosis
OP
AS
Referred pain
Tumor
Fracture

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9
Q

Rx lumbar strain

A

Paracetamol/ NSAIDs x2 wks
Tramadol if more severe
RMT, PT, acupuncture
Consider behavioral therapy

Stretching + strengthening
Yoga
Aqua therapy

Most resolve within 1-3mo

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10
Q

Prevention of LBP

A

Exercise
Posture training
Body mechanics training
Weight loss

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11
Q

Patterns of mechanical LBP

A

Back dominant pattern 1 = intermittent or constant, aggravated w/ flexion, extension can aggravate or relieve, normal neuro exam, discogenic, most common
Back dominant pattern 2 = intermittent, aggravated by extension, relieved by flexion, normal neuro exam, e.g. pars defect in gymnast
Leg dominant pattern 3 = constant, aggravated by flexion, positive SLR, sciatica
Leg dominant pattern 4 = intermittent, aggravated w/ walking + relieved w/ sitting, may have reduced root conduction, e.g. spinal stenosis

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12
Q

Cauda equina signs + sx

A

Severe LBP
Pain, numbness, weakness in legs
Saddle anesthesia
New onset bowel or bladder dysfunction
New onset sexual dysfunction
Absent reflexes
Gait disturbance

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13
Q

Causes of cauda equina

A

Ruptured lumbar disc
Spinal stenosis
Spine lesion/ tumor
Infection
Hemorrhage
#
Complication from MVA, fall
Birth defect

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14
Q

Most common causes of cervical radiculopathy

A

spondylosis > disc herniation > infection > granulomatous > tumor

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15
Q

Hx qs cervical disc dz

A

Unilateral neck, shoulder or arm pain
Paresthesias, numbness, weakness, diminished reflexes
R/O red flags - gait disturbance, bladder/ bowel dysfunction, hand clumsiness, hyperreflexia, clonus, fever, wt loss, bilateral sx, night pain, IVDU

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16
Q

Physical exam findings cervical disc dz

A

C spine exam
Positive Spurling
Sx may improve w/ abduction of upper limb as this decreases stretch on nerve root
Red flags on exam indicating myelopathy (cord compression): hyperreflexia, Babinski sign, ankle clonus, Lhermitte sign, lower extremity weakness, muscle atrophy in bilateral hands, gait disturbance

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17
Q

What is the classic pattern of myelopathy at C5-6?

A

Hyperreflexia at triceps reflex (C7) and diminished bicep + supinator reflexes (C5 + 6)

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18
Q

DDx cervical disc dz

A

Peripheral nerve entrapment
Myelopathy
Brachial plexus lesion, inflammation or injury
Thoracic outlet syndrome
Spinal tumor
Infection
Complex regional pain
Pancoast tumor

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19
Q

Management cervical disc dz

A

PT, NSAIDs, avoidance of provocative activities, cervical traction, heat/ cold
Neck + shoulder muscle strengthening
ROM exercises
Resisted exercises as tolerated
Aerobic activity
Postural education
Ergonomic adjustments

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20
Q

When to refer to surgeon in cervical disc dz

A

Progressive or severe neuro deficit, myelopathy, muscle atrophy
Anterior cervical discectomy + fusion

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21
Q

Sx + hx questions disc herniation

A

Acute onset back pain, can present with multiple episodes
Can be triggered by heavy lifting or twisting motion w/ heavy object
Nerve compression worse when sitting or sleeping on stomach
Pain precipitated by sneezing or straining
R/O cauda equina

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22
Q

Physical exam disc herniation

A

Spinal exam
SLR positive
Decreased sensation, reflexes + weakness
Severe muscle spasm can cause abnormal posture (lateral bend to contralateral side)

Waddell signs
To assess for nonorganic causes of back pain (psychological, socioeconomic)
Superficial tenderness w/ palpation but nonanatomic over large area
Axial loading causing LBP
Rotation of hips + shoulders together causing LBP
Formal SLR positive but distracted SLR not positive
Glove + stocking sensation loss

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23
Q

Sx + physical exam findings of disc herniation at L3 + 4

A

Pain - Lower back, hip, posterolateral thigh, ant leg
Sensation - Anteromedial thigh, knee & calf
Motor weakness - Quads (knee extension), Thigh adductors, Tibialis Anterior (DF)
Atrophy - Quadriceps
Reflexes - Patellar tendon reflex ↓

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24
Q

Sx + physical exam findings of disc herniation at L4 + 5

A

Pain - Above SI joint, hip, lat thigh & leg
Sensation - Lat leg, 1st 3 toes
Motor weakness - DF of great toe (EHL) & ankle, difficulty walking on heels, foot drop may occur
Atrophy - Minor or nonspecific
Reflexes - Post tibial reflex or hamstring reflex ↓

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25
Q

Sx + physical exam findings of disc herniation at L5 + S1

A

Pain - Above SI joint, buttocks, hip, posterolateral thigh, leg, calf, bottom of foot
Sensation - Back of calf, lat heel, foot & baby toe, plantar surface of foot
Motor weakness - PF of foot (Gastrocs/soleus), PF of great toe (abductor hallicus), difficulty walking on toes
Atrophy - Gastrocs & Soleus
Reflexes - Achilles tendon reflex ↓

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26
Q

What are the myotomes of L1-S3?

A

L1 + L2 - hip flexion
L3 + L4 - knee extension
L5-S2 - knee flexion
S1 + S2 - plantar flexion
S2 + S3 - abduction toes

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27
Q

DDx of disc herniation

A

Cauda equina
Hip OA
Knee OA
Meralgia paresthetica
Piriformis syndrome
Sacroilitis
Spinal stenosis

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28
Q

Management + RTP of disc herniation

A

Regular FU 1-2 wks
RMT, acupuncture
Heat or ice after first 2-3 days
Bed rest x2 days max
NSAIDs, muscle relaxants
Lumbar support
Epidural steroid shot for short term relief
Surgery if no improvement in 12 wks or cord compression (discectomy)

RTP when pain free, normal ROM, without neurogenic pain, good core + extremity strength

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29
Q

What are the stages disc herniation?

A

Protrusion
Extrusion
Sequestration

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30
Q

Most common site of herniation + nerve root affected

A

L5-S1 affecting S1 nerve root w/ paracentral herniation + L5 root w/ foraminal herniation

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31
Q

Definition of scoliosis

A

Lateral curvature of spine >10 degrees by Cobb angle

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32
Q

Hx qs in scoliosis

A

Rate of worsening
Pain usually if curve >40
Difficulty breathing
Growth stage - puberty
Hx of lower limb #, joint infection, arthritis - could cause leg length discrepancy
FHx scoliosis

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33
Q

Physical exam in scoliosis

A

Tanner stage
Hypermobility + hyperelasticity
Shoulder asymmetry
Unequal scapular prominence
Elevated hip
Leg length discrepancy
Crankshaft phenomenon: progressive deformity resulting from continued growth of anterior aspect of spine after posterior arthrodesis
Plumb line testing - drop a line from C7 to demonstrate pelvic deviation

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34
Q

XRs for scoliosis

A

XR - standing full length PA + lateral films
Cobb angle

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35
Q

Management of scoliosis

A

Monitor q6mo until skeletal maturity
Bracing for skeletally immature w/ curves 30-50 degrees or if rapid progression
Rigo Cheneau de-rotational brace
Worn 23 hrs/ day until end of growth
PT
Surgery for curves >50
Posterior spinal fusion
If skeletally mature and Cobb angle <40, reassure + discharge

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36
Q

What does risk of curve progression in scoliosis depend on?

A

Pt’s maturity + size of curve

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37
Q

Complications of scoliosis

A

Reduced pulmonary function for pts with thoracic curves >60 degrees

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38
Q

MOI in cervical strain (whiplash)

A

Usually hyperextension of cervical spine causing stretch type injury

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39
Q

Sx of cervical strain

A

Pain - may have minimal pain immediately but develop over hours to days later
Muscle spasm/ tightness

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40
Q

Mechanism of injury anterior shoulder dislocation

A

Anterior - usually from provocative position of abduction + external rotation
Fall on outstretched arm
Tackling

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41
Q

Hx qs + sx for shoulder dislocation

A

Symptoms (r/o neck pain), shoulder pain, decrease ROM, numbness or tingling in fingers
Previous dislocations, fractures
“Dead arm” usually occurs w/ subluxation

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42
Q

Exam for ?shoulder dislocation

A

C spine exam
Shoulder exam
Neurovascular exam upper limb before + after reduction
Deltoid strength
Lateral shoulder sensation
Apprehension test
Relocation test - during apprehension test, posteriorly directed force applied to humerus w/ scapula stabilized - if sx resolve - positive test
Load + shift test - pt is seated, examiner stabilizes scapula and with other hand attempts to sublux humeral head anteriorly + posteriorly
If ?multidirectional instability, assess ligamentous laxity

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43
Q

RF for shoulder dislocation

A

Previous dislocation
Repetitive overhead sports or contact sports
Ligament laxity

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44
Q

XR views for shoulder dislocation

A

XR - AP, axillary lateral, scapular Y, orthogonal views (to r/o bony injuries)
West Point view (good for identifying bony Bankart/ anteroinferior glenoid rim #)
Stryker notch view (good for identifying Hill-Sachs lesion/ posterolateral humeral head compression #)
Post reduction views needed

head of humerus is medially displaced on AP (in anterior shoulder dislocation)

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45
Q

DDx shoulder dislocation

A

AC instability
SLAP lesion
# humeral head, coracoid, acromion
Biceps tendon subluxation
Subscapularis tear

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46
Q

Initial exam of acute shoulder dislocation - sideline

A

Locate greater tuberosity - likely anterior
Assess axillary nerve function (sensation around deltoid, fingers, wrist extension + flexion)
Assess peripheral pulses
Palpate SC joint, clavicle, AC joint, humerus, elbow

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47
Q

CI to closed reduction of shoulder dislocation

A

Humeral head + neck #
Significantly displaced
Severe scapula #

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48
Q

Methods to reduce dislocated shoulder

A

Analgesia, benzos to relax
Can use intra-articular lidocaine
Traction
Stimson - pt lying prone, weight applied to arm hanging down
Counter traction - pt lying supine, traction at 45 degrees of abduction w/ countertraction applied with sheet under axilla

Leverage
Kocher - pt supine, flex elbow to 90 degrees, adduction, externally rotate arm, forward flexion of shoulder

Other methods
Milch - stabilize humeral head, fully abduct arm, apply traction, push humeral head over glenoid rim
Self reduction - pt locks hands in front of ipsilateral knee, relax backwards, allowing gentle traction

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49
Q

Management Post shoulder reduction

A

neural assessment (axillary patch, deltoid function)
Re-examine AC, elbow, wrist
Immobilize w/ sling x1 wk
ROM exercises
Physiotherapy and AROM to begin at 3 weeks, no abduction/ER together for 6 wks
Rotator cuff strengthening - begin in plane of scapula
Scapular stabilization exercises include rowing, modified push ups w/ maximal protraction

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49
Q

When to refer for surgery in shoulder dislocations

A

If rotator cuff tear >50%, Hill-Sachs lesion >25%, glenoid defect >20%, failure of conservative therapy
Consider surgery if 1st time dislocation in young athletes or labourers, >2 dislocations in 1 season, participation in overhead sports, bony Bankart lesion

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50
Q

RTP shoulder dislocation

A

after full ROM and strength returned
Motion control braces can limit abduction + external rotation + decrease risk of future events

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51
Q

What is a Hills Sach lesion, how often does it occur, sx associated, athletes most at risk

A

cortical depression in posterolateral head of humerus
Results from forceful impaction of humeral head against anterior glenoid rim w/ anterior shoulder dislocation
Results in divot
40-90% of anterior shoulder dislocation
Can contribute to ongoing instability - associated w/ painful click, popping, catching
Young, throwing athletes

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52
Q

What is a Bankart + bony bankart lesion?

A

Injury to anterior glenoid labrum d/t anterior shoulder dislocation
Resulting pocket allows recurrent subluxation
Often accompanies Hill-Sachs lesion
“Bony bankart” includes #W

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53
Q

What other conditions are associated with shoulder dislocation?

A

Axillary nerve injury
Humeral head + neck #
Rotator cuff tears (often subscapularis)

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54
Q

Recurrence rate for shoulder dislocations in athletes <25

A

> 85%

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55
Q

MOI for posterior shoulder dislocation

A

trauma (axial load applied to upper extremity in forward flexion, adduction + internal rotation) or from sz or electrocution

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56
Q

RF for posterior shoulder dislocation

A

EDS, Charcot shoulder, at risk sports (football, swimming, golf, racquet sports)

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57
Q

Imaging for posterior shoulder dislocation

A

axillary view, Bedside US is v useful for diagnosis - CT or MRI if XRs neg but high suspicion

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58
Q

Management of posterior shoulder dislocation

A

early reduction
pt supine, apply longitudinal traction while elbow is flexed at 90 degrees, can use countertraction w/ sheet round chest
Apply gentle internal rotation + lateral traction
May need open reduction, especially if >3 wks or w/ associated #
Refer to ortho for long term management

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59
Q

Physical exam findings of posterior shoulder dislocation

A

arm held in internal rotation + adduction, external rotation is blocked, prominence of posterior aspect of shoulder, visible or palpable humeral head posteriorly

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60
Q

What is a burner/ stinger + what is the MOI

A

Brachial Plexus Injury
Traction to plexus when shoulder is depressed + head is forced away from injured side
Compression of cervical roots when head is forced towards side of injury
Direct blow to brachial plexus at supraclavicular fossa

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61
Q

RF for Brachial Plexus Injury

A

Previous burner
Limited ROM of neck or shoulder
Cervical canal + foraminal stenosis
Contact sports

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62
Q

Hx qs + sx Brachial Plexus Injury

A

Acute trauma to neck + shoulder causing burning or stinging in upper shoulder, radiating down
Relation to shoulder + neck mvmt
Usually lasts mins but can persist weeks
r/o concussion, neck injury, unstable shoulder

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63
Q

Physical exam Brachial Plexus Injury

A

Often holds arms close to body or shakes arm
Shoulder exam
Weakness most commonly occurs in deltoid, biceps, rotator cuff
Spurling may be positive
Tinel sign at supraclavicular fossa

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64
Q

When + what to order for ix in Brachial Plexus Injury

A

Not usually needed
C spine XRs if recurrent injury, weakness ongoing few days, neck pain, bilateral arm sx
EMG if sx lasting >3 wks

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65
Q

DDx Brachial Plexus Injury

A

C spine injury (bilateral sx, vertebral tenderness, lower extremity findings)
Shoulder dislocation
AC separation
Clavicle #
Thoracic outlet syndrome

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66
Q

Management + RTP for Brachial Plexus Injury

A

Can RTP once sx resolve
Neck exercises
Stretch tight muscles
Strengthen neck + shoulder

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67
Q

Prevention in future of Brachial Plexus Injury

A

Neck roll, shoulder pad lifter or rigid collar in football
Chest out posture
Ensure correct playing technique

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68
Q

RF for Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis

A

Repetitive overhead activities (throwing, swimming, racquet sports, wt lifting)
Shoulder instability
Prev shoulder surgery
Smoking
Diabetes
<25y/o, impingement usually d/t laxity caused by instability
>25y/o, impingement usually d/t rotator cuff overuse

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69
Q

Sx + hx qs for Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis

A

Insidious onset
Pain w/ overhead activities
Weakness, numbness
Worse in evening + night
No trauma
R/o C spine disease

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70
Q

Physical for Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis

A

Shoulder exam
Painful arc 70-120 degrees
Reduced internal rotation d/t posterior capsular tightness
Neuro exam
suprascapular nerve (supraspinatus & infraspinatus), long thoracic nerve (serratus anterior), thoracodorsal nerve (latissimus dorsi), subscapular nerve (teres major & subscapular), axillary nerve/C5 (deltoid & sensation to lateral surface of the shoulder)

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71
Q

DDx for Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis

A

Rotator cuff tear
Biceps tendinopathy
GH instability
Labral tear
Referred pain from neck
AC joint sprain/ OA
GH OA
Pancoast tumor
Suprascapular nerve palsy
Brachial plexus injury
Axillary nerve entrapment
Adhesive capsulitis
Thoracic outlet syndrome

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72
Q

Management of Rotator cuff tendinitis/ Impingement/ Subacromial Bursitis

A

NSAIDs
Ice
Subacromial bursa steroid inj
Relative rest
PT
Shock wave therapy if calcific
Correction of training errors in racquet/throwing sports ( Poor kinetic chain movement, improper body positioning, improper hip movement)
Consider surgical referral for anterior acromioplasty if conservative rx fails
PRP, prolotherapy, acupuncture

Stretch posterior capsule
Address muscle imbalance & instability
Posture
ROM: Dangling arm circles, finger wall-walking, broom handle exercises
Sword from sheath, posterior dumbbell raises, scapular stabilization

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73
Q

RF for acute rotator cuff tear

A

Age, smoking, fam hx
Repetitive overhead use
Fall risk sports like skiing, surfing, horse riding

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74
Q

MOI for acute rotator cuff tear

A

Many involve acute-on-chronic injuries
For acute complete tears - fall, direct blow, forceful punch
Traumatic hyperextension, internal or external rotation of abducted arm o
Or, in those >40 years old, look for a complete rotator cuff tear with shoulder dislocation
Can develop insidiously

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75
Q

Sx of acute rotator cuff tear

A

Pain and weakness
Night pain
Pain sleeping on affected side
May radiate to elbow
Aggravated w/ reaching motion

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76
Q

Physical for acute rotator cuff tear

A

Reduced ROM
Pain w/ arm abduction from 80-120 degrees
Atrophy of muscles if chronic
Positive drop arm test
Positive lag sign (inability to maintain position of full external rotation)
Positive gerber’s (subscapularis)
Positive empty can test (supraspinatus)
Positive resisted external rotation (infraspinatus + teres minor)
Weakness and pain with rotator cuff strength testing

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77
Q

DDx for acute rotator cuff tear

A

Rotator cuff strain
Labrum tear
Unstable shoulder
Subacromial impingement
AC disorder
GH OA
Adhesive capsulitis

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78
Q

Ix for acute rotator cuff tear

A

XR - can show calcification, superior or anterior migration of humeral head (full thickness tear)
MRI or US

Diagnostic injection into subacromial bursa w/ 10ml 1% lidocaine - if no pain relief or improvement in strength

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79
Q

Management for acute rotator cuff tear

A

NSAIDs
Sling - limited to 2-3 wks
Subacromial steroid injection
ROM + strengthening
Prolotherapy, PRP

80
Q

When to refer to surgeon for acute rotator cuff tear

A

An acute, complete tear of a rotator cuff tendon in a young, heathy individual
Partial tears after failed conservative therapy

81
Q

RTP for acute rotator cuff tear

A

6mo if overhead athlete

82
Q

RF for multidirectional GH instability

A

hyperlaxity, repetitive microtrauma (overhead motion): butterfly/ backstroke swimmers, pitchers, wt lifters, racquet sports

83
Q

Hx + sx for multidirectional GH instability

A

Pain w/ overhead activities
Episodes of “dead arm”
Prev injuries + dislocations
Vague pain radiating to deltoid insertion, occurring after activity, better w/ rest
Inferior instability: pain, numbness while carrying suitcase (d/t traction on brachial plexus)
Posterior instability: pain while arm is forward flexed + internally rotated (pushing open heavy door, push ups, pull-through phase of rowing, blocking in football)

84
Q

Physical for multidirectional GH instability

A

Shoulder exam
positive sulcus test indicates inferior instability
Load + shift test
Test for hypermobility

85
Q

Management for multidirectional GH instability

A

typically these reduce spontaneously, can use short term sling (especially if recurrent)
Ice
PT
Emphasis on strengthening anterior deltoid + rotator cuff muscles (6 wks) then adding scapular stabilizers + improving proprioception (Watson program)
Correction of training errors in racquet/throwing/swimming sports (Poor kinetic chain movement, improper body positioning, improper hip movement)
Consider surgical referral for stabilization if fails conservative therapy
Consider referral to rheumatology if concern of collagen disorder & ophthalmologist

86
Q

RTP for multidirectional GH instability

A

if pain free w/ normal strength at 6mo can RTP

87
Q

Beighton score

A

(4/9 warrants further investigation)
Passively dorsiflex 5th MCP to >90 (Gorling’s sign) (1 point for L+R)
Passively touch forearm w/ thumb when flexing wrist (1 point for L+R)
Hyperextend elbow >10 degrees (1 point for L+R)
Hyperextend knee >10 degrees (1 point for L+R)
Place palms flat on floor without bending knees (1 point)

88
Q

MOI AC separation

A

Direct impact over superolateral shoulder, forcing AC joint inferiorly
Injury occurs from depression of scapula

89
Q

Physical for AC separation

A

Shoulder exam
Deformity (step off) of AC joint with type 3 + higher
Piano key sign (type 3 + 4 may have instability of lateral clavicle when depressed manually)
Pain w/ adduction
Cross body adduction test (pain = positive)

90
Q

Ix for AC separation

A

XRs - true AP, scapular Y, lateral, axillary view (needed to assess posterior displacement of distal clavicle)
Zanca view good for assess AC joint

91
Q

DDx for AC separation

A

Fractures of coracoid, acromion, clavicle
Rotator cuff injuries
SLAP lesion
Labral tear
GH dislocation
Brachial plexus injury

92
Q

Management of AC separation

A

Type 1 + 2 = conservative (sling x1 wk, activity modification, ice, NSAIDs, PT w ROM exercises)
Type 3 = conservative first but may need surgery
Type 4, 5 + 6 = surgery

93
Q

RTP for AC separation

A

When full, painless ROM + normal strength
Usually 6wks-6mo

94
Q

What is a SLAP tear?

A

Superior labral tear from anterior to posterior (shoulder)

95
Q

MOI for SLAP tear

A

Can be acute or chronic
Acute: compression d/t fall on outstretched arm or onto adducted shoulder, traction from swift pull, humeral head shearing (seatbelt)
Chronic: throwing/ overhead activity

96
Q

What are the 4 most common types of SLAP lesion?

A

Type 1 = degenerative fraying of labrum
2 = detached labral/ biceps complex
3 = bucket handle tear
4 = bucket handle tear w/ extension into biceps tendon

97
Q

RF for SLAP tear

A

Repetitive overhead motion
Shoulder instability or trauma
Underlying laxity

98
Q

Hx + sx for SLAP tear

A

Non specific shoulder pain
Commonly anterior/ superior
Catching, clicking, popping
Decreased performance (reduced strength, accuracy)
Sense of instability

99
Q

Physical for SLAP tear

A

Shoulder exam
Compression rotation test positive
O’Brien test positive
Speed test positive
Yergasons positive

100
Q

Ix for SLAP tear

A

MRA best, then MRI
GH arthroscopy is gold standard

101
Q

DDx for SLAP tear

A

GH OA
Rotator cuff impingement, tendinopathy, tear
Biceps tendinopathy, tear
Shoulder instability
AC joint OA
Cervical radiculopathy

102
Q

Management of SLAP tear

A

Conservative but may need surgery if no improvement in 3-6mo
Relative rest, PT, NSAIDs

Surgery - debridement, SLAP repair, subacromial decompression
Post op care: sling x4 wks, ROM exercises, PT

Rotator cuff strengthening
Scapular stabilizer strengthening
Posterior capsule strengthening

103
Q

RTP SLAP tear

A

2-6mo

104
Q

Prevention of SLAP tear

A

Monitoring pitch counts in youth
Ensure proper overhead mechanics

105
Q

Cause of adhesive capsulitis

A

Thickening, fibrosis + contraction of GH joint capsule

106
Q

RF for adhesive capsulitis

A

Shoulder immobilization
Diabetes
Thyroid dz
Stroke
Females
Age 40-70

107
Q

Types of adhesive capsulitis

A

Primary
Secondary (following trauma, immobilisation, systemic illness)

108
Q

Hx + sx adhesive capsulitis

A

Progressive shoulder pain
Worse w/ any movement (passive + active)
Pain worse at night
Functional impairment

109
Q

Physical of adhesive capsulitis

A

Decreased ROM + pain

110
Q

Phases of adhesive capsulitis

A

1 = painful, insidious onset nocturnal pain, no ROM impairment - lasts 2-9mo
2 = progressive limitation of ROM in all directions - lasts 4-12mo
3 = thawing, sx gradually improve over 5-24mo

111
Q

DDx of adhesive capsulitis

A

Rotator cuff pathology
Impingement syndrome
Biceps tendinopathy
OA
Cervical radiculopathy
PMR

112
Q

Management of adhesive capsulitis

A

Spontaneously recover
Treatment focused on sx control - NSAIDs, saline + steroid inj, PT, suprascapular nerve blocks
Surgery: manipulation under anesthesia or capsular release
Time frame for recovery
18-30mo

113
Q

RF for Suprascapular nerve palsy

A

Volleyball - particularly “floating serve”
Overhead throwing

114
Q

MOI for Suprascapular nerve palsy

A

Traction injury
Compression from cyst, tumor, ligament
Direct trauma (scapular #)
Iatrogenic (eg during repair of rotator cuff tear or SLAP tear)

115
Q

What is the suprascapular nerve and what does it supply?

A

Arises from trunk of brachial plexus at Erb point
Carries fibers from C5 + 6
Innervates supraspinatus + AC + GH joints

116
Q

Hx + sx Suprascapular nerve palsy

A

Distal vs proximal
Distal - painless, infraspinatus atrophy, weakness of external rotation
Proximal - pain in posterior/ lateral shoulder, weakness + atrophy of supraspinatus + infraspinatus

117
Q

Physical for Suprascapular nerve palsy

A

Shoulder exam
Infra + supraspinatus atrophy
Resisted external rotation weakness
Positive Jobe (empty can) test for supraspinatus
Tenderness on palpation of scapular notch

118
Q

Ix for Suprascapular nerve palsy

A

XR neck + shoulder
Magnetic resonance neurography is gold standard
EMG nerve studies - wait min 3-4 wks after onset of sx

119
Q

DDx for Suprascapular nerve palsy

A

Cervical radiculopathy
Brachial plexus injury
Rotator cuff pathology
Labral pathology
Parsonage-Turner syndrome (Brachial neuritis - sudden severe pain then weakness)

120
Q

Management of Suprascapular nerve palsy

A

Conservative management unless there is a lesion causing nerve ocmpression
Rest from overhead activity
PT for strengthening external rotation and stabilize scapula
NSAIDs

121
Q

Origin of Axillary Nerve

A

C5-6 rami, branch of posterior cord of brachial plexus

122
Q

MOI of Axillary Nerve Injury

A

Traction injury during anterior dislocation or fracture
Compression injury d/t direct blow to anterolateral deltoid
Quadrilateral space syndrome
Iatrogenic during shoulder surgery

123
Q

RF for Axillary Nerve Injury

A

Anterior shoulder dislocation
Humeral head #
Hockey, football, rugby
Repetitive overhead sports

124
Q

Hx + sx of Axillary Nerve Injury

A

Easy fatigability w/ overhead activities
Decreased strength w/ shoulder abduction
Paresthesia or numbness in lateral upper arm

125
Q

Physical for Axillary Nerve Injury

A

Shoulder exam
Deltoid or teres minor atrophy
Weakness in shoulder abduction (deltoid)
Weakness in external rotation (teres minor)
Tenderness to palpate posterior shoulder in quadrilateral space

126
Q

Ix for Axillary Nerve Injury

A

XRs - shoulder + C spine
MRI
EMG studies - min 3 wk after onset

127
Q

DDx for Axillary Nerve Injury

A

Brachial plexus syndrome
Cervical radiculopathy

128
Q

Management of Axillary Nerve Injury

A

Non operative initially
ROM
Relative rest
Strengthening
Avoidance of triggering activity
Electrical stimulation of deltoid to prevent atropy
Surgery if no improvement in 3-6mo

129
Q

RF for Biceps Tendinopathy

A

Males
50-60 y/o
Repetitive use of upper limb

130
Q

Hx / sx for Biceps Tendinopathy

A

Anterior shoulder pain localized over bicipital groove, may radiate distally
Pain aggravated by overhead activities

131
Q

Physical for Biceps Tendinopathy

A

Point tenderness over bicipital groove w/ arm in 10 degrees internal rotation
Speed test positive
Yergason test positive
Upper cut test positive

132
Q

Ix for Biceps Tendinopathy

A

MRI (best) or US

133
Q

DDx of Biceps Tendinopathy

A

Rotator cuff tendinopathy
Impingement
Labral tear
Subacromial bursitis
AC separation
GH OA
Thoracic outlet syndrome
Pancoast tumor
Tumor at apex of lung causing arm weakness + shoulder pain

134
Q

Management of Biceps Tendinopathy

A

Rest, ice, NSAIDs
ROM exercises
PT - scapular stabilization, rotator cuff + biceps strengthening, US waves
Surgery for refractory cases

135
Q

MOI of clavicle #

A

Direct trauma, fall onto shoulder
Football, lacrosse, hockey

136
Q

Physical for clavicle #

A

Ecchymosis or tenting over skin over #
Tenderness to palpate
Fracture motion or crepitus w/ palpation
Pulmonary + neurovascular exam

137
Q

Ix for clavicle #

A

XR - AP, Zanca, axillary views
CT may be required

138
Q

DDx for clavicle #

A

AC joint injury
GH dislocation
Rotator cuff tear
Humeral head #

139
Q

Management of clavicle #

A

Non operative
Sling
ROM + active shoulder flexion to 40 degrees once pain improves
Avoid ROM >45 degrees of forward flexion until healed

Operative
Indications: displaced or shortened, comminuted middle-third #, distal clavicle #, neurovascular compromise, open #, tenting over skin
May be considered in young healthy athletes with goal of expediting RTP

1 wk after injury then every 2-4 wks until union occurs
XRs q4wks

140
Q

Timeframe for recovery of clavicle #

A

Clinically within 6-8 wks
Radiographically 8-12 wks
RTP when radiographically healed for contact sports

141
Q

Prevention of future clavicle #

A

Can use donut pads to protect clavicle from re-injury

142
Q

MOI of humerus #

A

Humeral head: fall onto outstretched hand, high energy trauma in young or low energy trauma in old, excessive rotation of arm in abducted position, electric shock or seizure, pathologic # from mets

143
Q

RF for humerus #

A

Elderly
Females
OP
Falls
Smoking
Steroids
RA

144
Q

Sx of humerus #

A

Pain around greater tuberosity
Difficulty initiating active motion

145
Q

Physical for humerus #

A

Shoulder exam inc neurovascular exam before and after immobilization
Arm adducted + held closely to chest
Shoulder effusion

146
Q

Ix for humerus #

A

AP, scapular Y, axillary
May need CT

147
Q

DDx for humerus #

A

Shoulder dislocation
Acute hemorrhagic bursitis
AC separation
Traumatic rotator cuff tear

148
Q

Management of humerus #

A

Non operative vs surgical - refer to ortho

Surgery

Non operative
Sling x2 wks
PT
Closed reduction w/ ortho

149
Q

RF for non union of humerus #

A

displacement, inadequate immobilization, aggressive rehab, pt non compliance, OP, alcohol use, smoking, steroids

150
Q

Sx of Little League Shoulder

A

Months of progressive pain w/ throwing

151
Q

Physical for Little League Shoulder

A

Tenderness over anterolateral proximal humerus
Weakness w/ resisted shoulder abduction, internal + external rotation

152
Q

Ix for Little League Shoulder

A

XR - widening of proximal humerus growth plate

153
Q

Management of Little League Shoulder

A

Rest from throwing x3-12mo
PT focused on rotator cuff strengthening

154
Q

What is Thoracic Outlet Syndrome?

A

Neurogenic or vascular sx in upper extremity d/t compression of brachial plexus + subclavian vessels by skeletal or muscular structures above 1st rib and behind clavicle
Can be neurogenic (most commonly), arterial or venous

155
Q

RF for Thoracic Outlet Syndrome

A

Repetitive overhead activity
Poor posture
Middle aged females
Cervical rib
Trauma
Obesity

156
Q

Hx + sx of Thoracic Outlet Syndrome

A

Neurogenic or vascular sx associated w/ certain positions
Arm, shoulder, neck pain
Numbness or tingling (commonly in ulnar distribution)
Cramping
Motor weakness (late finding)
Gilliatt-Sumner hand (severe wasting of abductor pollicis brevis + hypothenar muscles)
Venous: edema, cyanosis, heaviness in hand, venous distension
Arterial: often asymptomatic until embolization occurs. Pallor, pain, paresthesias, coolness, decreased pulses
Worse w/ lifting heavy objects, overhead activities, shoulder abduction, external rotation

157
Q

Physical for Thoracic Outlet Syndrome

A

Neurovascular exam of upper limb
Bruit in supraclavicular space

Provocative tests:
Elevated arm stress test (arms abducted above head, pt opens + closes fists for 3 mins, positive if pt experiences pain or paresthesias)
Wright test - affected arm progressively hyperabducted + externally rotated - positive test if radial pulse lost

158
Q

Ix for Thoracic Outlet Syndrome

A

Clinical diagnosis
If vascular, consider hypercoagulable workup
XRs of C spine + shoulder
MRI
EMG studies

159
Q

DDx for Thoracic Outlet Syndrome

A

Cervical disc disorders
Rotator cuff pathology
Brachial plexus neuritis
Carpal tunnel
Ulnar nerve entrapment
MS

160
Q

Management of Thoracic Outlet Syndrome

A

Conservative therapy except if acute vascular compromise or progressive neuro deficits or refractory sx despite treatment
NSAIDs
Muscle relaxants
Wt loss
PT - exercises + trigger point injection
Botox into scalene muscles

Postural retraining
Strengthening of muscles that elevate shoulder girdle
Pectoral + scalene strengthening + stretching

161
Q

What is Lateral epicondylitis?

A

Tennis elbow
Overuse injury involving the extensor/supinator muscles that originate on the lateral epicondylar region of the distal humerus
More common than medial epicondylitis
Extensor carpi radialis brevis usually involved

162
Q

MOI of Lateral epicondylitis

A

Repetitive strain or direct blow to epicondyle or sudden forceful pull or forceful extension or incorrect tennis play

163
Q

Hx + sx of Lateral epicondylitis

A

Pain at lateral elbow, insidious onset
Acute pain w/ shaking hands, gripping objects, turning doorknob, pouring tear, sweeping
Triggers - new racquet, new backswing, new string tension, increased playing

164
Q

Physical for Lateral epicondylitis

A

Point tenderness over lateral epicondyle
Pain w/ Cozen’s test (pain w/ passive wrist flexion and resisted extension)
Tenderness w/ resisted middle finger extension
Tender w/ resisted supination

165
Q

DDx for Lateral epicondylitis

A

PIN entrapment
Radial tunnel syndrome
C7 radiculopathy
Humeral #
Radial head #
Posterior pinch syndrome/ plica of elbow
OA elbow
Loose body
OCD of capitellum

166
Q

Management of Lateral epicondylitis

A

NSAIDs, ice, relative rest
Steroid inj
Counterforce elbow brace
Wrist splints (use at night)
Taping during activity
PRP, prolotherapy, topical nitrates
Refer for surgery if no improvement in 6mo

PT - laser therapy, dry needling
Ortho for decompression/ release surgery

167
Q

Prevention of Lateral epicondylitis

A

Reduce playing time
Learn proper technique
Strengthen muscles
Proper equipment (racquet size, string tension, dry tennis balls)

168
Q

RF for Lateral epicondylitis

A

More common in women
>40 y/o
Smoking
Obesity
Poor technique
Playing tennis >2hrs daily
Backhanded hitting style
Common in carpenters, labourers that swing a hammer/ tool

169
Q

Hx + sx of medial epicondylitis

A

Gradual onset
Pain + tenderness along medial elbow
Difficulty gripping
Decreased wrist strength

170
Q

Physical for medial epicondylitis

A

Tender over medial epicondyle
Resisted wrist flexion + pronation causes pain

171
Q

DDx for medial epicondylitis

A

Ulnar neuritis
Cubital tunnel syndrome
Inflammatory arthritis
Cervical radiculopathy
Thoracic outlet syndrome

172
Q

Management of medial epicondylitis

A

NSAIDs, ice
Elbow strap or counter-force brace
Wrist splint if pain on wakening
Nitro patch
OT, PT
Can consider steroid injection

Stretching + strengthening
Wrist extension + flexion curls, forearm pronation + supination, gripping, finger extension (using rubber band around fingers)

173
Q

RF for medial epicondylitis

A

More common in non-overlapping grip (baseball), rock climbers
Racquet sports, tennis, golf, throwing

174
Q

RF for biceps tendon rupture

A

Males
Age >30
Anabolic steroid use
Smoking
Pre-existing biceps or rotator cuff tendinopathy

175
Q

Commonly associated conditions w/ biceps tendon rupture

A

Supraspinatus + subscapularis tears
SLAP lesions

176
Q

Types of biceps tendon rupture

A

Distal bicep tendon ruptures are only about 10% of all bicep tendon ruptures
The vast majority are proximal ruptures of the long head of the biceps tendon, which do very well without surgical intervention and result in minimal strength loss.

177
Q

MOI for biceps tendon rupture

A

Happens when elbow is eccentrically loaded suddenly. Ex: unloading an item from the back of a truck that falls into your arms, causing your bent elbow to suddenly straighten.

178
Q

Sx of biceps tendon rupture

A

Patients may feel a painful “pop” at the time of injury
Pain - usually more proximal
Weakness is most noted with supination (can’t turn doorknob)
Patients often notice the change in appearance of their bicep contour

179
Q

Physical for biceps tendon rupture

A

Distal
Bruising, often medial elbow
Loss of strength in resisted elbow flexion + supination
Reverse Popeye sign
Hook test: With an intact distal biceps, you can hook your finger under the bicep tendon from the lateral side when their elbow is flexed 90 degrees and they are actively supinating. There is nothing to “hook” in a distal bicep rupture.
Biceps squeeze test positive

Proximal
Popeye sign (visible lump deformity in midupper arm)
Motor function usually preserved
Positive Speed + Yergason tests

180
Q

Management of biceps tendon rupture

A

Proximal
Immobilization in posterior elbow splint w/ elbow at 90 degrees + forearm in full supination
Passive ROM exercises
Strengthening at 4 wks
RTP 2-3mo
May warrant surgery in young athletes

Distal
Immobilization in posterior elbow splint w/ elbow at 90 degrees + forearm in full supination
Refer to ortho for surgery

181
Q

Complications of biceps tendon rupture

A

Loss of elbow flexion + forearm supination strength

182
Q

Causes of olecranon bursitis

A

Direct injury
Prolonged pressure (elbow leaning on table)
Overuse - repetitive flexion of elbow
RA

183
Q

Sx of olecranon bursitis + hx qs

A

Pain
R/O systemic infection

184
Q

Physical for olecranon bursitis

A

Elbow exam
Normal ROM
Bursal swelling

185
Q

Ix for olecranon bursitis

A

US
If systemic sx, do joint aspirate for gram stain, C+S

186
Q

Management of olecranon bursitis

A

Non septic - stiff elbow pad, NSAIDs
If ?septic - aspiration, abx

187
Q

RF for ganglion cyst

A

Females
Repetitive strain of hand + wrist

188
Q

Sx of ganglion cyst

A

Painless cyst over joint or tendon sheath
Can be painful if causing compression

189
Q

Physical for ganglion cyst

A

Firm smooth mass
Usually fixed to deeper structures
Readily transilluminates

190
Q

DDx for ganglion cyst

A

Epidermal inclusion cyst
Lipoma
Rheumatoid nodule
Tophus

191
Q

Management of ganglion cyst

A

Often spontaneously resolve
Aspiration but high risk of recurrence
Surgery but higher risk of complications

192
Q

What is De Quervain Tenosynovitis?

A

Stenosing tenosynovitis of 1st dorsal compartment of wrist

193
Q

RF for De Quervain Tenosynovitis

A

30-50 y/o
Females
Pregnancy
Golfing, wrestling, racquet sports, javelin
Excessive cell phone use

194
Q

MOI for De Quervain Tenosynovitis

A

Overuse
Direct trauma

195
Q

Sx of De Quervain Tenosynovitis

A

Pain along radial styloid
Aggravated by moving wrist or thumb

196
Q

Physical for De Quervain Tenosynovitis

A

Tenderness on palpation of APL + EPB tendons
Positive Finkelstein test

197
Q

DDx of De Quervain Tenosynovitis

A

Thumb carpometacarpal OA
Radial styloid #
Scaphoid #
Radial neuritis

198
Q

Management of De Quervain Tenosynovitis

A

Rest, ice, splinting, NSAIDs
Steroid shot into 1st dorsal compartment - works well
Refer for surgery if conservative therapy fails >3mo

CASEM (13 decks)

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