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CASEM > High Yield 7 > Flashcards

High Yield 7 Flashcards

1
Q

Describe the decision based RTP model

A

Evaluation of health status (medical factors)
Pt demographics
S+S
PMH
Functional tests
Psychological state
Potential seriousness

Evaluation of participation risk
Type of sport
Position played
Limb dominance
Competition level
Ability to protect

Decision modification
Timing + season
Pressure from athlete
External pressure
Injury masking
Conflict of interest
Fear of litigation

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2
Q

Eligible impairment types in the Paralympics

A

Hypertonia, ataxia, Athetosis, impaired muscle power, impaired passive range of movement, leg length difference, lime deficiency, short stature, vision impairment, intellectual impairment

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3
Q

What is autonomic dysreflexia?

A

Stimuli below level of lesion triggers a reflex of sympathetic overstimulation

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4
Q

Sx of autonomic dysreflexia

A

Usually pts w/ cord injury at or above T6 but as low as T10
Throbbing HA, profuse sweating, flushing, anxiety, blurred vision

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5
Q

Triggers for autonomic dysreflexia

A

ingrown toenail, kidney stones, pressure sores, bowel obstruction, constipation, bladder obstruction (blocked catheter), sitting on a pin, tightening straps, boosting (intentionally causing autonomic dysreflexia to induce bradycardia which increases performance)

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6
Q

Physical for autonomic dysreflexia

A

Bradycardia
HTN >200

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7
Q

Management of autonomic dysreflexia

A

Monitor BP q5 mins
Elevate head + lower legs
Loosen clothing inc removing abdo binders, compression stockings

Check bladder drainage equipment for kinks, clogging, overfull bag
Empty leg bag
If ?blocked, irrigate gently with 10ml NS
If still no urine flow, re-catheterise
Be aware of sudden hypotension if urine does start flowing

Fecal evacuation
Apply lignocaine gel around anal sphincter and into rectum
Leave for 5 mins
Insert finger to digitally evacuate stool
Monitor BP throughout - if BP increases, stop and give med before continuing

Meds - if BP >150 and no cause identified with above measures, start med
GTN spray 1 spray 400mcg (ensure no viagra in last 24hrs)
Captopril 25mg SL
Nifedipine 10mg
Nitropaste 2% 2.5cm - apply above level of lesion
Sodium nitroprusside

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8
Q

Complications of autonomic dysreflexia

A

Szs
MI
Retinal hemorrhage
Pulmonary edema
Cerebral hemorrhage

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9
Q

How does an episode of autonomic dysreflexia affect comp?

A

BP can be checked prior to comp, if >180, athlete removed but not sanctioned

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10
Q

Describe the issues with Thermoregulation in para athletes

A

Sweating is impaired below level of injury - important to hydrate + acclimatize appropriately, cooling + pre-cooling enhance endurance (ice packs, misting, ice baths, slurpees)
Reduced shivering response + lack of sensation causes inability to maintain warmth

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11
Q

Describe the issues with Osteopenia in para athletes

A

Immobility of paralysis promotes lower limb + spine osteoporotic changes
Increased risk of #s with minimal trauma

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12
Q

Describe the issues with Neurogenic bladder in para athletes

A

Increased frequency of UTIs d/t incomplete voiding, increased bladder pressure, catheter use
Often subtle findings of infection (reduced performance, fatigue, reduced appetite)
Prevent UTIs w/ hydration, cranberry juice, aseptic technique w/ catheters
Don’t treat asymptomatic bacteriuria

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13
Q

What are the uses of CT, US vs MRI

A

CT - useful adjunct for intra-articular fracture preoperative planning in larger joints, where the fractured bone is to be repaired rather than replaced, or complex areas, such as the carpal or tarsal regions
US - ideal inexpensive way of assessing superficial soft tissues for both trauma and masses. It has the distinct advantage of being dynamic, imaging the patient in real time as they move, and also being interactive with the patient, assessing their points of pain
MRI - useful method for assessing the soft tissues for injury or mass, the bones for occult injuries, and bone marrow changes

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14
Q

What imaging modality is useful, and what view are needed for fingers

A

XRs useful for trauma, FB, localized mass
Views: PA, oblique, lateral
US for radiolucent FB
MRI or US for mass or tendon lesion/ injury

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15
Q

What imaging modality is useful, and what view are needed for the thumb

A

XRs useful for trauma, FB, localized mass, UCL avulsion
Views: PA, lateral
US for radiolucent FB
MRI or US for mass, UCL injury or tendon lesion/ injury

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16
Q

What imaging modality is useful, and what view are needed for the hand

A

XRs useful for hand pain
Views: PA, oblique, lateral
MRI + US for soft tissue

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17
Q

What imaging modality is useful, and what view are needed for the wrist

A

XR useful for wrist pain
Nontraumatic views: PA, ulnar oblique, lateral
Traumatic views: PA, ulnar oblique, radial oblique, lateral wrist, navicular view, scaphoid views (oblique + ulnar deviation w/ cranial angulation), clenched fist AP (for scapholunate ligament disruption)
US useful for soft tissue + tendon
CT for occult scaphoid # or hook of hamate #
MRI good for AVN lunate or scaphoid, TFCC tears, intercarpal ligament injuries

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18
Q

What imaging modality is useful, and what view are needed for the forearm

A

XR useful for trauma, mass, FB, OM, abscess
Views: AP, lateral
US or MRI for soft tissue

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19
Q

What imaging modality is useful, and what view are needed for the elbow

A

XR good for chronic injuries, arthritis, FB, olecranon bursitis
Views: AP, lateral (good for olecranon bursitis + effusion)
Trauma views: AP, lateral, radial head
US or MRI for soft tissue

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20
Q

What imaging modality is useful, and what view are needed for the humerus

A

XR good for trauma, infection, mass, FB
Views: AP/ external rotation, lateral/ internal rotation
Outlet view for subacromial nerve impingement
Stryker notch view for Hill-Sachs lesions
Westpoint view for bony Bankart lesions
Velpeau view for dislocation
Trauma views: AP scapula, lateral Y view, axillary view
US or MRI for rotator cuff
CT for pre-op planning before shoulder replacement or for Hill-Sachs or bony Bankart lesions

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21
Q

What imaging modality is useful, and what view are needed for the scapula

A

XR good for trauma, scapulothoracic syndrome
Views: AP, lateral
CT for trauma work up

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22
Q

What imaging modality is useful, and what view are needed for the AC joint

A

XR (bilateral) with and without weights to assess for separation
AP shoulder

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23
Q

What imaging modality is useful, and what view are needed for the clavicle

A

XR good for #
AP at 0 + 10 degree angle
CT for medial clavicle #

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24
Q

What imaging modality is useful, and what view are needed for toes

A

XR good for trauma, FB, mass
AP, medial oblique, lateral
US for radiolucent FB
MRI or US for soft tissue

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25
Q

What imaging modality is useful, and what view are needed for the foot

A

XR good, wt bearing for foot alignment, non wt bearing for FB, mass or ?osteomyelitis
AP (dorsoplantar), medial oblique, lateral
Sesamoid view (for sesamoid OA)
PA axial + lateral calcaneus (for heel pain)
US or MRI for morton’s neuroma, plantar fasciitis
MRI for occult # or mass
CT for Lisfranc injuries

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26
Q

What imaging modality is useful, and what view are needed for the ankle

A

XR (wt bearing for alignment, non wt bearing for trauma or mass)
AP, mortise, mediolateral lateral
Calcaneal or heel projections for heel pain
Broden view for posterior subtalar joint for intra-articular # or arthritis
Stress views (AP w/ varus stress) for ligamentous laxity (get bilateral)
CT for complex hindfoot #
MRI for tendons + ligaments + occult #
US for tendon injuries

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27
Q

What imaging modality is useful, and what view are needed for tib + fib

A

XR should include ankle + knee joints. Useful for trauma, FB, mass
AP, mediolateral lateral
MRI or bone scan for stress #

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28
Q

What imaging modality is useful, and what view are needed for the knee

A

XR good for arthritis
AP, mediolateral lateral
Trauma: AP, mediolateral lateral + lateromedial crosstable lateral
Merchants + sunrise view for patella alignment
MRI for internal derangement (less helpful when obvious OA on XR)
CT for occult tib plateau # + for surgically planning

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29
Q

What imaging modality is useful, and what view are needed for the femur

A

XR should include hip + knee
Nontraumatic: AP proximal + distal, mediolateral lateral to include knee, lateral frog leg hip
AP proximal + distal, cross table lateral femur, inferosuperior lateral to include proximal femur

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30
Q

What imaging modality is useful, and what view are needed for the pelvis + hips

A

XR for trauma
Nontrauma: AP pelvic, frog leg lateral
Trauma: AP pelvis, crosstable lateral, oblique pelvis
CT for full assessment of trauma

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31
Q

What imaging modality is useful, and what view are needed for the SI joints

A

XR good for screening for sacroiliitis
AP pelvis, AP oblique of each SI joint
MRI good for sacroiliitis

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32
Q

What imaging modality is useful, and what view are needed for the skull

A

XR not often used
PA, lateral, Townes
CT best

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33
Q

What imaging modality is useful, and what view are needed for the face

A

XR useful in facial trauma
Occipitofrontal, occipitomental, occipitomental w/ 30 degree cranial angulation, lateral face
Mandible views: Occipitofrontal, AP axial, inferosuperior oblique
Nose views: coned down occipitofacial, lateral
CT for further assessment of facial trauma

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34
Q

What imaging modality is useful, and what view are needed for C spine

A

XR
AP, lateral, AP odontoid, swimmers view (if C7-T1 not visualised on lateral view)
Flexion-extension series (to assess for stability, delay for 10 days after acute injury) - flexion + extension lateral, AP
CT for acute trauma
MRI or CT for chronic pain/ radiculopathy

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35
Q

What imaging modality is useful, and what view are needed for T spine

A

XR
AP, lateral
CT for any #
MRI in cases of long tract signs

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36
Q

What imaging modality is useful, and what view are needed for L spine

A

XR
AP pelvis, AP lumbar, lateral lumbar

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37
Q

What imaging modality is useful, and what view are needed coccydynia

A

XR
AP, AP caudal, lateral

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38
Q

What imaging modality is useful, and what view are needed for scoliosis

A

XR - scoliosis series
Used for measuring Cobb angle
PA + lateral wt bearing

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39
Q

What XR view is needed for ?rib #

A

PA erect chest

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40
Q

What imaging modality is best for sternoclavicular joint

A

CT

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41
Q

How to calculate sensitivity

A

True positive / (true positive + false negative)

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42
Q

How to calculate specificity

A

True negative / (true negative + false positive)

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43
Q

How to calculate positive predictive value

A

True positive / (true positive + false positive)

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44
Q

How to calculate negative predictive value

A

True negative / (true negative + false negative)

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45
Q

What is sensitivity?

A

Probability of detection (true positive rate)

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46
Q

What is specificity?

A

Probability of healthy people measured as a negative test (true negative rate)

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47
Q

What is incidence?

A

The rate of new cases of a disease
Usually number of new cases in a given time frame
Equivalent to risk of getting disease

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48
Q

What is prevalence (+ point prevalence + period prevalence)?

A

Actual number of cases alive
Point prevalence = actual number of cases on a particular date in time
Period prevalence = actual number of cases during a given period

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49
Q

What is level I evidence?

A

Systematic review or meta analysis of all RCTs

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50
Q

What is level II evidence?

A

RCT

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51
Q

What is level III evidence?

A

Well designed, well controlled trial with no randomization

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52
Q

What is level IV evidence?

A

Case control or cohort study

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53
Q

What is level V evidence?

A

Systematic reviews of descriptive and qualitative studies

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54
Q

What is level VI evidence?

A

Single descriptive study (case report)

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55
Q

What is level VII evidence?

A

Opinions, expert committee reports

56
Q

What is NNT?

A

Number of pts needed to treat to prevent 1 additional bad outcome
Inverse of absolute risk reduction

57
Q

If a drug reduces the risk of a bad outcome from 50% to 40%, what is the ARR + NNT?

A

ARR = 0.5-0.4 = 0.1
NNT = 1/0.1 = 10

58
Q

What is ARR?

A

The difference in event rates between the control and treatment groups
Control event rate (CER) - experimental event rate (EER)

59
Q

What is the NNH?

A

Indicates how many pts need to be exposed to a RF over a specific period to cause harm to one patient
Inverse of attributable risk

60
Q

What is relative risk?

A

Incidence with exposure / incidence without exposure

61
Q

What is attributable risk?

A

Incidence with exposure - incidence without exposure

62
Q

What questions to think about when appraising a research paper

A

What is the research question? Is it concerned with impact of intervention, causality or determining magnitude of health problem? Is it a well stated research question?
What is the study type? Is the study type appropriate to the research question? How useful are the results produced by this type of study?
What are the outcome factors and how are they measured? Are all relevant outcomes assessed? Is there measurement error? How important are omitted outcomes?
What are the study factors and how are they measured? Is measurement error an important source of bias?
What important potential confounders are considered? Are potential confounders examined and controlled for? Is confounding an important source of bias?
What are the sample frame and sampling method? Is there selection bias? Does this threaten the external validity of the study?
In an experimental study, how were the subjects assigned to groups?
In a longitudinal study, how many reached follow up?
In a case control study, are the controls appropriate?
Are statistical tests considered? Were the tests appropriate for the data? Are CI given? Is the power given if a null result? Are results presented as absolute risk reduction + relative risk reduction?
Are the results significant? Was the sample size adequate? Is the study useful?
Are ethical issues considered? Does the paper have ethics approval?
What conclusions did the authors reach about the study question? Do the results apply to the population?

63
Q

Types of articular osteochondroses and site

A

Perthe’s - femoral head
Kienbock’s - Lunate
Kohler’s - navicular
Freiburg - 2nd metatarsal
Osteochondritis dissecans - medial femoral condyle, capitellum, talar dome

64
Q

Types of non-articular osteochondroses and site

A

Osgood schlatter - tibial tubercle
Sinding Larsen Johansson disease - inferior pole of patella
Sever’s - calcaneus

65
Q

What is an osteochondroses?

A

Conditions affecting secondary ossification centres

66
Q

Management of growth plate distal radius fracture

A

Cast immobilisation four weeks

67
Q

Management of growth supracondylar # of elbow

A

Sling x3 wk

68
Q

Management of growth plate distal fibula or tibial fracture

A

Cast non wt bearing x4-6 wks

69
Q

What are growth plates?

A

Cartilage at end of long bones that grow to allow lengthening of bone
Solidify in teens

70
Q

Describe the salter harris classification

A

Type 1 - # Straight across growth plate
Type 2 - # Above growth plate
Type 3 - # beLow the growth plate
Type 4 - # Through the growth plate
Type 5 - ERasure of growth plate

71
Q

Describe MOI for different growth plate #s

A

Type 1, 2 + 3 = rotating/ twisting force
Type 4 + 5 = compression/ crushing force
Type 5 can also be caused by bone infection

72
Q

Management of salter harris # based on type

A

Type 1-3 = closed reduction
Type 4+5 = open reduction

73
Q

What is a greenstick # ?

A

Incomplete # that occur when bone is exposed to angulation + rotational bending forces
Bone fractures on tension side but not compression side
Most common in forearm

74
Q

What do XRs show in greenstick #

A

show tearing of periosteum + cortex on the convex side of affected bone

75
Q

Management of greenstick #

A

Ice
Splint
Reduce
Forearm - reduce by rotating palm towards apex of #
May need to complete # to adequately reduce
Immobilize
NSAIDs
FU XRs at 2 + 6 wk post injury

76
Q

Describe basic principles of acute # management

A

Controlling external bleeding
Assess for NVI
Pain control
Traction or reduction
Immobilisation
Elevation

77
Q

Indications for joint injections

A

Diagnostic
LA providing temporary pain relief allows more accurate physical exam
Joint aspiration for dx of gout, pseudogout, septic arthritis, hemarthrosis

Therapeutic
Decrease pain
Increase ROM

Treatment of conditions

78
Q

What conditions can be treated w/ joint injections?

A

Crystalline arthropathies
Osteoarthritis
Inflammatory arthritis
Bursitis
Tendonosis
Ganglion cysts
Nerve entrapments
Fasciitis
Trigger points

79
Q

Absolute CI to joint injections

A

Infection (overlying cellulitis)
Lack of informed consent
Allergy to injection medications
Injection into weight-bearing tendons such as Achilles and patella due to high risk of rupture

80
Q

Relative CI to joint injections

A

Brittle or uncontrolled diabetes
Coagulopathy (safe in patients with international normalized ratio [INR] <3.5)
Previous joint replacement/hardware
History of avascular necrosis
History of steroid or hyaluronic acid (HA) flare

81
Q

Supplies needed for joint injection

A

Gloves
3-5ml syringe (unless aspiration is planned)
Needles:
18G for drawing up
18G for large aspiration or HA injection
22G 1.5” for medium to large joints
25G 1.5” for small joints
22G 3.5” for hip injections in large pts
Chlorhexadine swabs
Gauze
Band aids
LA
Lidocaine - onset in 3-5 mins, lasts 1-2hrs
Bupivacaine - onset 5 mins, lasts 3-4hrs
Viscosupplementation
Synvisc (sodium hyaluronate)

82
Q

Complications of joint injection

A

bleeding, infection, tendon rupture, steroid flare, fat pad or soft tissue atrophy, and skin depigmentation

83
Q

How do you treat a steroid flare after joint inj?

A

rest, ice, NSAIDs and usually resolves spontaneously after 24 to 36 hr.

84
Q

How do you treat a HA flare after joint inj?

A

rest, ice, NSAIDs and usually resolves spontaneously after several days. HA flare can be more drastic than steroid flare, and severe flares may require synovial aspiration and cultures to distinguish between pseudosepsis and true infection.

85
Q

Aftercare after joint injection

A

Rest joint for several hours
Monitor for signs of infection
Ice for pain control
Resume activities after 3-5 days

86
Q

How to do trigger point inj

A

Palpate tender nodule
Inject 1ml 1% lidocaine directly

87
Q

Purpose, anatomy + approach for subacromial injection

A

For diagnosis + management of rotator cuff sprain or tear or impingement
Anatomy
The subacromial space is bordered superiorly by the coracoacromial ligament stretching between the coracoid process and acromion.
The contents of the subacromial space include the subacromial bursa, supraspinatus tendon, and tendon of the long head of the biceps.
Lateral approach:
Use
5-mL syringe with 22-gauge or 25-gauge 1½-inch needle
4-mL anesthetic (can combine 2 mL 1% lidocaine and 2 mL 0.25% bupivacaine [Marcaine])
1 mL (40 mg) Kenalog
The lateral edge of the acromion is palpated
The needle is inserted at the midpoint of the acromion and angled slightly upward under the acromion to full length (up to hub of needle)

88
Q

Purpose, anatomy + approach for glenohumeral inj

A

Useful in OA, RA + adhesive capsulitis to improve ROM
Use when conservative therapy has failed
Anatomy
The glenohumeral joint is a ball and socket joint composed of the clavicle, scapula, and humerus.
The glenoid cavity is very shallow but contains a lip of fibrous tissue called the glenoid labrum, which deepens the glenoid and increases shoulder joint stability.
Posterior approach
Use
3-mL syringe with 22-gauge or 25-gauge 1½-inch needle
1 to 2 mL anesthetic
1 mL (40 mg) Kenalog
​​Posterior approach: The distal, lateral, and posterior edges of the acromion are palpated, and the soft spot 1 cm below the posterolateral corner is marked with the needle cap
The needle is inserted just inferior to the posterolateral edge of the acromion. The needle is directed anteriorly and may need to be walked into the joint.
Accuracy can be significantly improved with ultrasound guidance.

89
Q

Purpose, anatomy + approach for AC joint inj

A

Indicated for shoulder pain d/t pathology of AC joint if conservative therapy has failed
Anatomy
The AC joint can be palpated as a narrow indentation at the distal end of the clavicle, about one thumb’s width medial to the lateral edge of the acromion.
The joint line runs obliquely medially at approximately a 20-degree angle.
Approach:
Use
3-mL syringe with 25-gauge 5/8- to 1-inch needle
½ mL 1% lidocaine
½ mL (20 mg) Kenalog
Palpate the depression of the AC joint at the distal clavicle and mark it with the needle cap
Insert the needle at a 15- to 20-degree angle (needle pointed more medially)
Avoid repetitive or heavy lifting afterwards

90
Q

Purpose, anatomy + approach for elbow joint inj

A

Indicated for elbow pain d/t arthritis or trauma if conservative therapy has failed
Anatomy
The elbow joint is composed of the ulnohumeral, radiocapitellar, and proximal radioulnar joints.
The elbow joint can be approached via the triangle formed by the lateral olecranon, head of the radius, and lateral epicondyle.
Approach:
Use
3-mL syringe with 25-gauge 1-inch needle
5- to 10-mL syringe with 20-gauge or 22-gauge needle if aspirating
1 mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Place the patient’s arm on the table at a 45-degree angle.
Mark the soft depression in the center of the triangle formed by the lateral olecranon, head of the radius, and lateral epicondyle with the needle cap
The needle is inserted into the elbow joint between the lateral epicondyle and the radial head
Instruct the patient to perform flexion/extension ROM exercises to disperse the fluid within the joint.

91
Q

Purpose, anatomy, medial + lateral approach + aftercare for epicondylitis inj + aftercare

A

Anatomy
The origin of the common extensor tendon is at the lateral epicondyle.
The origin of the common flexor tendon is at the medial epicondyle.
Use
3-mL syringe with 25-gauge 5/8- or 1-inch needle
½ mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Lateral epicondyle:
Place the patient’s arm on the table at a 45-degree angle with the lateral elbow facing up:
Palpate the area of most tenderness over the epicondyle and mark this with the cap of the needle.
The needle is inserted down to the bone of the lateral epicondyle

Medial epicondyle:
Medial epicondyle: Place the patient’s arm on the table at a 45-degree angle with the medial elbow facing up:
Palpate the area of most tenderness over the epicondyle and mark this with the cap of the needle.
The needle is inserted down to the bone of the medial epicondyle.
Take care not to inject the ulnar nerve because it traverses posterior to the medial epicondyle in the cubital tunnel. If the patient experiences pain or numbness in the ulnar nerve distribution while the needle is inserted, then back out and reposition the needle more anteriorly before injecting cortisone. At this time, doing this injection without ultrasound guidance increases the risks of injury to the ulnar nerve.

Aftercare
Consider an elbow extension splint to rest the elbow and/or wrist splint to avoid wrist flexion/extension for 1 to 2 wk to allow the injection to take effect.
The patient should avoid repetitive wrist extension or flexion.

92
Q

Purpose, anatomy + approach for wrist inj + aftercare

A

Indicated for arthritis or trauma if conservative therapy has failed
Anatomy
The wrist joint capsule is not continuous but has septa, which makes the wrist injection sometimes difficult.
The radiocarpal joint can be palpated just distal to the distal radius in a depression near the scapholunate articulation.
Approach:
Use
3-mL syringe with 25-gauge 5/8- or 1-inch needle
5- to 10-mL syringe with 20-gauge or 22-gauge 5/8- or 1-inch needle for aspiration
½ mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Palpate the depression distal to the distal radius near the scapholunate articulation.
The needle is inserted into the wrist joint
If aspirating, withdraw fluid with 5- to 10-mL syringe, then stabilize needle and exchange 3-mL syringe containing steroid mixture and inject.
If injecting, use 3-mL syringe with 25-gauge 1-inch needle and inject fluid into joint.
Have patient perform wrist flexion and extension exercises to disperse the fluid through the wrist joint.
Consider wrist splint x1-2 wks

93
Q

Anatomy + approach for de quervain tenosynovitis inj + aftercare

A

Anatomy
The dorsal wrist has six compartments containing tendons.
The 1st dorsal compartment contains the abductor pollicis longus and the extensor pollicis brevis tendons.
de Quervain tenosynovitis occurs when the tendon sheath becomes inflamed and thickened causing pain, swelling, and occasional triggering.
Approach
Use
​​3-mL syringe with 25-gauge 5/8- or 1-inch needle
½ mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Palpate the area of most tenderness over the 1st dorsal compartment and mark this with the needle cap.
The needle is inserted into the tendon sheath between the abductor pollicis longus and extensor pollicis brevis tendons at ~30-degree angle.
Ultrasound dramatically increases accuracy of this injection and improves outcomes.
An elliptical shaped bulge occurs with the injection of the bolus of fluid into the sheath.
Consider thumb spica wrist splint for 1-2 wks

94
Q

Purpose, anatomy + approach for 1st CMC joint inj

A

Indicated d/t arthritis
Anatomy
The thumb CMC joint is composed of the saddle-shaped base of the 1st metacarpal as it articulates with the trapezium.
The thumb CMC joint can be approached on the extensor surface proximal to the 1st metacarpal, taking care to avoid the radial artery and extensor pollicis tendons.
Approach
​​Use
3-mL syringe with 25-gauge 1-inch needle for injection
½ mL 1% lidocaine without epinephrine (if using)
½ mL (20 mg) triamcinolone suspension (Kenalog)
Place the patient’s hand and forearm on the table palm down.
Palpate the CMC joint between the base of the 1st metacarpal and the wrist trapezium between the extensor pollicis longus and extensor pollicis brevis tendons.
Mark the depression at the base of the 1st metacarpal with needle cap.
To avoid the radial artery, the needle should enter on the ulnar side of the extensor pollicis brevis tendon. Distraction of the thumb can increase the space to get the needle into the joint.
Corticosteroid alone can be injected without anesthetic, given the small size of the CMC joint. Usually, not more than ½ mL volume will fit into the joint space.
Thumb spica splint x1-2 wks

95
Q

Anatomy + approach for carpal tunnel inj

A

Anatomy
​​The carpal tunnel is bounded by the carpal bones dorsally and the transverse carpal ligament (flexor retinaculum) ventrally.
The contents of the tunnel include the median nerve and flexor tendons of the hand.
Approach
Use
3-mL syringe with 25-gauge 1½-inch needle
1½ mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog
Have the patient lay the hand palm up on the table and make a fist with slight wrist flexion.
Observe the tendons of the palmaris longus (10% of the population will not have one) and the flexor carpi radialis.
Mark a spot with the needle cap 4 cm proximal to the distal palmar crease between the two tendons mentioned above.
With the fist clenched and the wrist slightly flexed, the needle is inserted at a shallow angle (~20 degrees) along the tendon sheath, aiming toward the ring finger. Have the patient slowly extend the wrist and fingers noticing the needle advance toward the carpal tunnel. This indicates proper needle placement
Ask the patient if they feel any increased pain or numbness. If they do, remove the needle because it may be in the median nerve.
DO NOT INJECT INTO THE MEDIAN NERVE.
Wrist splint x1-2 wks

96
Q

Anatomy + approach for trigger finger inj + aftercare

A

Anatomy
Nodule or thickening occurs in the flexor tendon, which catches on the A-1 proximal pulley making finger extension difficult.
Approach
Use
​​3-mL syringe with 25-gauge 5/8- to 1-inch needle
½ mL 1% lidocaine
½ mL (20 mg) Kenalog
Palpate the tender nodule on the palm of the hand and mark with needle cap.
Injection site is either directly into the nodule or at the proximal interphalangeal digital crease.
Insert needle at a 45-degree angle—when you feel rubbery resistance, you are at the level of the tendon. Back needle out slowly until it is no longer in tendon and the fluid flows easily within the tendon sheath
Finger splint x1-2 wks
After 3 days, start extension exercises—hold finger in extension 10 sec × 10 times for one set. Complete three sets per day.
Avoid repetitive gripping or use padded gloves for any vibrating tools (i.e., jackhammers).

97
Q

Anatomy + approach for ganglion cyst inj

A

Anatomy
Ganglion cysts are the most common soft tissue tumors of the hand and wrist, more commonly in women (3:1).
These thick mucin-filled cysts may out pouch from synovial or tendon sheaths from trauma or repetitive irritation.
Ganglion cysts are often connected to an underlying ligament or joint, most commonly at the scapholunate joint (60–70%), and next most frequently at the volar wrist (20–25%), and thirdly at the palmar flexor tendon sheath (10–12%).
Approach
Use
5- to 10-mL syringe with 18- to 22-gauge 1-inch needle if aspirating viscous cyst contents
3-mL syringe with 22-gauge 1-inch needle if injecting
½ to 1 mL 1% lidocaine without epinephrine (if using)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
Position the patient in sitting position with his or her arm on the table with the ganglion cyst facing upward.
Aspirate using the 18-gauge needle—the thick mucoid cyst contents may be difficult to aspirate and may actually be more effectively milked out of the puncture site after the needle is removed.
First, aspirate the cyst contents if possible and then stabilize the needle position with a hemostat, remove the aspiration syringe, secure the syringe with the steroid mixture, and inject.

98
Q

Purpose, anatomy + approach for trochanteric bursitis inj

A

Indicated for bursitis, greater trochanteric pain syndrome
indicated if pain persists despite conservative therapy, including avoiding direct pressure and repetitive trauma, ice, NSAIDs, and stretching of the iliotibial band, tensor fascia lata, external hip rotators, hip flexors, and quadriceps.
Anatomy
The trochanteric bursa lies superficial to the greater trochanter of the femur, between the trochanteric process and the gluteus medius/iliotibial tract.
Tenderness to palpation over the trochanteric process is the classic finding for trochanteric bursitis.
Approach
Use
​​6-mL syringe with 21- to 22-gauge 1½- to 2-inch needle for thin patients
21- to 22-gauge 3.5-inch spinal needle may be needed for heavier patients.
5 mL 1% lidocaine without epinephrine and/or 0.25% bupivacaine
1 mL 40 mg/mL (40 mg) triamcinolone suspension (Kenalog)
Lay the patient in lateral recumbent position, with the affected side up.
Flex the patient’s hip at 50 degrees, and flex the knees 60 to 90 degrees.
Palpate the greater trochanteric process and identify the point of maximal tenderness, which usually corresponds well to the most superficial point of bony prominence. Mark this area with the needle cap.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Position the needle perpendicular to the skin and advance toward the site of maximal trochanteric tenderness.
Advance the needle until the tip reaches bone level to ensure delivery of the steroid below the tendon. Never inject under pressure, which may indicate placement within the tendon.
Withdraw the needle 2 to 3 mm to remain within the trochanteric bursa.
For acute bursitis, the 5 to 6 ml of corticosteroid and lidocaine can be directly injected into the bursa.
For chronic bursitis, a clockwise peppering motion may help break up scar tissue—each time, the needle should reach the level of bone and then inject.
Avoid pressure to area afterwards, rest x3 days
Repeat in 6-12 wks if pain relief was <50%

99
Q

Purpose, anatomy + approach for olecranon bursa inj

A

Indicated for bursitis
Anatomy
The olecranon bursa overlies the olecranon process at the proximal ulna.
Olecranon bursitis is visible as posterior elbow swelling, often described as a golf ball or goose egg over the elbow tip.
Approach
Use

3-mL syringe with 25-gauge 1-inch needle if injecting
5- to 10-mL syringe with 18- to 22-gauge needle if aspirating
1 mL 1% lidocaine without epinephrine
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
Place the patient’s arm on the table at maximal elbow flexion to accentuate the swelling.
Palpate over the olecranon bursa for fluctuance.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Aim the needle perpendicular to the olecranon bursa.
Aspirate bursa fluid until the bursa is flat.
If infection has been ruled out, inject steroid/lidocaine into bursa.
Compressive elbow sleeve may help fluid reaccumulation
Avoid direct pressure afterwards
Consider posterior splint or elbow pads for 1-2 wks

100
Q

Purpose, anatomy + approach for prepatella burse inj

A

Indicated for chronic bursitis if not improving w/ conservative rx
Anatomy
Use
5- to 10-mL syringe with 18- to 22-gauge 1-inch needle if aspirating
1 mL 1% lidocaine without epinephrine (optional)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
The prepatellar bursa lies between the patella and the overlying skin.
Prepatellar bursitis is visible as a well-circumscribed region of swelling over the patella.
Approach
​​Position the patient in supine position with the knee flexed at 30 degrees on a pillow.
Position the affected leg with patella facing upward.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
The prepatellar bursa swelling should be clearly visible.
Aspirate by approaching from the side of the visible prepatellar swelling.
Pressure dressing after

101
Q

Purpose, anatomy + approach for pes anserine bursa inj

A

For bursitis - can be done w/ conservative therapy
Anatomy
Use
3-mL syringe with 25-gauge 1-inch needle
1 mL 1% lidocaine without epinephrine
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
The pes anserine bursa lies between the conjoined tendon of the sartorius, gracilis, and semitendinosus muscles and the tibial insertion of the medial collateral ligament.
Diagnosis is made by tenderness to palpation over the anserine bursa, ~2 cm below the medial joint line at the proximal medial tibia.
Swelling is not usually visible with anserine bursitis.
Approach
Lay the patient in supine position.
Position the affected leg with the medial joint line accessible.
Identify the anserine bursa 1 to 2 cm below the middle of the medial joint line.
The point of maximal tenderness along the medial tibial plateau often serves to identify the ideal injection site—mark this site with the needle cap.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Insert the needle perpendicular to the skin.
Advance the needle to the level of bone to find the bursa space between the conjoined tendons and the tibia.
Inject the steroid/lidocaine mixture into the bursa—resistance to flow should be minimal.
Sleep w/ cushion between knees

102
Q

Purpose, anatomy + approach + when to repeat for knee inj

A

Indications: dx of knee effusion, treatment of OA, crystalline dz, synovitis
Anatomy
The knee joint consists of the femoral–tibial and femoral–patellar joints, with stabilization from the anterior and posterior cruciate ligaments and the medial and lateral collateral ligaments.
Approach
Use
3-mL syringe with 25-gauge 1-inch needle for injection
20- to 60-mL syringe with 18- to 22-gauge 1½-inch needle if aspirating
5- to 10-mL syringe with 21- to 22-gauge 1½-inch needle for injecting
5 to 7 mL 1% lidocaine without epinephrine and or 0.25% bupivacaine (if using)
1 mL 40 mg/mL (40 mg) triamcinolone suspension (Kenalog)
For the supine medial or lateral midpatellar approach, position the patient’s knee either in full extension, which gives the most patellar mobility, or slightly flexed at 5 degrees with a rolled towel supporting underneath. The needle is advanced parallel to the floor directed straight toward the patellar midpole.

Repeat injection can be done after 3 mo if the steroid injection afforded adequate pain relief—average duration of effect for joint steroid injections is 4 wk.

103
Q

Purpose, anatomy + medial + lateral approach + when to repeat for ankle inj

A

Indicated to dx ankle effusions or to treat OA, crystalline dz, synovitis
Anatomy
The ankle joint consists of the articulation of the tibiotalar and talofibular joints.
The ankle joint space can be approached either medially or laterally.
Use
3-mL syringe with 25-gauge 1-inch needle for injection
Extra 3- to 5-mL syringes if needed for aspiration of effusion
½ to 1 mL 1% lidocaine without epinephrine (if using)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)

Medial approach
Identify the soft spot between the anterior tip of the medial malleolus and the medial edge of the tibialis anterior tendon:
Palpate down to feel the tibiotalar joint line—mark this site with the needle cap.
Advance the needle in a posterolateral direction and inject.
Having an assistant apply mild eversion/plantarflexion pressure may help to open the joint.

Lateral approach
Identify the triangular depression between the lateral tibia, fibula, and the talus:
Palpate down to feel the tibiotalar joint line—mark this site with the needle cap.
Advance the needle in a posteromedial direction.
If aspirating, remove as much fluid as possible and then stabilize the needle in the joint with a hemostat and switch between the aspiration and therapeutic syringes. Keep the needle hub and syringe tips sterile.
After securing the therapeutic syringe, inject the steroid/lidocaine mixture.

Repeat injection can be done after 3 mo if the steroid injection afforded adequate pain relief—average duration of effect for joint steroid injections is 4 wk.

104
Q

Purpose, anatomy + approach for plantar fascia inj

A

2nd line after conservative therapy failed
Anatomy
The plantar fascia supports the medial longitudinal arch of the foot and stretches between the base of the phalanges and the medial tuberosity of the calcaneus.
The plantar fascia lies deep to the fat layer of the heel.
On physical exam, the plantar fascia insertion point on the calcaneus is usually markedly tender to palpation.
Approach
Use
3-mL syringe with 25-gauge 1.5-inch needle for injection
½ mL 1% lidocaine without epinephrine (if using)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
Position the patient in the lateral recumbent position with the painful side down.
Position the affected foot medial side up.
Palpate the maximal point of tenderness at the plantar fascia insertion on the calcaneus, usually in the middle of the heel—this gives the injection target depth along the width of the heel.
Find the medial edge of the calcaneus and mark with needle cap—this marks the injection point along the length of the foot.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Apply ethyl chloride for topical cooling.
Inject perpendicular to the medial foot, aiming just distal to the calcaneal edge in order to avoid the heel fat pad.
If the calcaneus is reached with the needle tip, walk the needle off the bony edge and then down to the depth of the point of maximal tenderness.
Inject the steroid/lidocaine mixture.

105
Q

Purpose, anatomy + approach for morton neuroma inj

A

Indicated if conservative therapy has failed
Anatomy
Morton neuroma usually develops between the 2nd and 3rd or between the 3rd and 4th metatarsal heads.
Tenderness to palpation between the metatarsal heads usually confirms the diagnosis.
Approach
Use:
3-mL syringe with 25-gauge 1-inch needle for injection
½ mL 1% lidocaine without epinephrine (if using)
½ mL 40 mg/mL (20 mg) triamcinolone suspension (Kenalog)
Lay the patient in a supine position with a bent knee and the foot flat on the table.
Identify the point of maximal tenderness between the metatarsal heads on the dorsal foot—mark entry site with needle cap.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Apply ethyl chloride for topical cooling.
Advance the needle at a 45-degree angle proximally toward the point of maximal tenderness or nodule—aim toward the heel and stop at the level of the interdigital fullness.
Do not inject at the level of the plantar fat pad to avoid fat pad atrophy.

106
Q

Purpose, anatomy + approach for 1st MTP inj

A

Indicated for dx of gout or for treatment of OA, RA, gout
Approach
Use:
3-mL syringe with 25-gauge 5/8- to 1-inch needle
1 mL 1% lidocaine without epinephrine
½ mL (20 mg) Kenalog or equivalent
Lay the patient in a supine position with a bent knee and the foot flat on the table.
Flex and extend the 1st MTP joint to identify the joint line and mark with needle cap.
Cleanse the skin with alcohol swab and then Betadine × 3 or chlorhexidine × 45 sec.
Distal traction may help open the joint space.
Aim the needle distally toward the toe and enter at a 60-degree angle to match the joint slope.
The joint lies fairly superficially, and the injection solution should flow freely within the joint.

107
Q

What are the individual, relational and organisational forms of violence that threaten athletes?

A

Individual:
Injury, depression, self harm, eating disorders
Relational:
Sexual harassment, sexual abuse, physical abuse, forced physical exertion, emotional abuse, neglect, bullying, doping
Organisational:
Abuse from spectators, discrimination, unhealthy training programs, hazing, medical mismanagement, age cheating

108
Q

Signs and symptoms of athlete maltreatment

A

Unexplained or unwarranted injuries, decline and performance, nightmares, poor self image, inability to trust others, aggressive behaviour, intense anger, acting out sexually, self-destructive behaviour, appearing sad or withdrawn, difficulty forming new relationships, drug or alcohol use, avoidance of certain places, change behaviour patterns, fear of certain adults

109
Q

How should you manage athlete disclosure of allegations of harassment or abuse?

A

Actively listen to athlete, provide empathy, acknowledge courage in speaking out, assure athlete experiences not their fault, encourage disclosure, do not denigrate the perpetrator, keep accurate records, ensure athlete safety, stop the abuse (report disclosure to authorities including police and sporting organisation), support teammates and family members, encourage whistleblowing culture

110
Q

What are the risks to mental health from elite sport participation?

A

Mental burnout, overtraining, Licht with coaches or teammates, school of work issues due to increased time demands
Concussion, debilitating injury illness
Eating disorders, violence, or harassment

111
Q

How to manage someone in a mental health crisis

A

Provide timely access to support
Provide services in the least restrictive manner
Ensure support is available
Spend adequate time with the individual in crisis
Ensure that people intervening have appropriate training and competence
Healthy individual to regain a sense of control
Attend to issues of culture, gender, race, age, sexual orientation and communication needs
Insure services trauma informed
Take measure to reduce the likely of future emergencies

112
Q

Classification of ligament injuries

A

Grade 1: disruption of some collagen fibres
Localised tenderness, minimal inflammation, normal range and end fill on ligament stress test but maybe painful, little functional deficit
Grade 2: disruption of considerable proportion of collagen fibres
Significant tenderness, considerable swelling, increased ligament laxity but definite endpoint, moderate functional deficit
Grade 3: complete disruption of collagen fibres
Audible pop, immediately painful but may become pain-free, considerable swelling, significantly increased ligament laxity with no designable endpoint, significant functional deficits

113
Q

What are the classifications of tendinopathy?

A

Stage 1 = reactive tendinopathy - tendon cells activate + proliferate, occurs w/ trauma + acute overload
Stage 2 = tendon disrepair - increased matrix breakdown, myofibroblasts appear, cells more rounded (chondrocytic). Collagen separates which allows ingrowth of vessels. Seen in overloaded tendons in young (but can occur at any age)
Stage 3 = degenerative tendinopathy - end stage overuse progression of cell changes to point of apoptosis. Large areas of disordered matrix w/ ingrown vessels, heterogenous on pathology

114
Q

What is an apophysis?

A

Normal bony outgrowththat arises from a separate ossification centre + fuses w/ bone
Site of tendon or ligament attachment
Weakest link of the muscle - tendon unit in the skeletally immature

115
Q

What is apophysitis?

A

Traction injury - repeated microavulsion of apophysis caused by disproportionate growth of bone in relation to associated myotendonous units

116
Q

How does apophysitis present?

A

Pain during + after activity, insidious onset
Localised tendnerness + swelling, pain w/ resisted activation + passive stretching

117
Q

What do you see on an XR of apophysitis?

A

Hypertrophied, fragmented or separated apophysis - XR can also be normal

118
Q

Rx for apophysitis

A

Relative rest from activities that cause pain (inadequate protection can lead to avulsion #), ice, NSAIDs, stretching, PT, 4 wks pain free then gradual RTP

119
Q

Describe the physiological response to physical activity?

A

Increased swept right, increase liver glucose output mainly from glycogenolysis, also gluconeogenesis. Increased adipose tissue lipolysis. Increased whole body oxygen uptake, increased heart rate and cardiac output, increased ventilation. Increased ATP turnover in Nito muscle, creased glucose uptake and lipolysis in the muscle increased oxygen neutralisation, CO2 and heat production and increased blood flow. Release of myokines

120
Q

What are the benefits of warming up?

A

Increased contraction and nerve conduction velocity
Decreased viscous resistance of muscle and joint
Increased vasodilation
Increased rate of four and power
Improve mental focus
Cardiovascular preparation

121
Q

Approach to injury prevention

A

Identify type and severity of injuries
Identify risk factors and injury mechanisms
Introduce measures to reduce future risk or severity of injuries

122
Q

What risk factors for injury are modifiable?

A

Athlete fitness
Human factors
Protective equipment
Sports equipment
Environment

123
Q

How to prevent hamstring strains

A

Increase hamstring strength and increased hip range of motion

124
Q

Preventing ankle sprains

A

Taping or bracing for one after an ankle sprain
Balance board training program

125
Q

How to prevent acute knee injuries

A

Structured warm up targeting strength, balance and neuromuscular control (eg FIFA 11)

126
Q

How to prevent overuse injuries

A

Structured training program
Technique modification
Nutritional strategies to prevent stress fractures
Modifying risk factors such as shoes and sporting equipment
Managing the rate of load increase

127
Q

What should be included in recovery?

A

Active recovery (low intensity work after exercise)
Massage within 2 hrs
Neuromuscular electrical stimulation ASAP
Stretching
Cold water immersion ASAP, max 10 mins, temp 10-15 degrees
Compression clothing ASAP for min 60 mins
Nutrition - replacing fluids (1.5x weighed fluid loss) + fuel (carbs) + repair (protein)
Optimal sleep

128
Q

Types of manual treatment

A

Joint mobilisation and manipulation
Soft tissue therapy
Dry needling
Taping
Therapeutic ultrasound
Transcutaneous electrical nerve stimulation (TENS)
Neuromuscular stimulators
Laser
Electromagnetic therapy
Shockwave therapy

129
Q

Benefits of dry needling

A

Treating intramuscular trigger points for pain relief

130
Q

Benefits of taping

A

Restriction of range of motion
Altering anatomical alignment
Cutaneous stimulation for pain relief
Improved proprioception

131
Q

What conditions is taping useful for?

A

Patellofemoral pain
Ankle sprain
de Quervains tenosynovitis
Plantar fasciitis
Shoulder pain

132
Q

Benefits of therapeutic ultrasound

A

Increased blood flow, metabolic activity
Treatment of acute bone fractures

133
Q

Benefits of TENS

A

Short term pain relief

134
Q

Benefits of neuro muscular stimulators

A

Enhance recovery, improved performance, reduced muscle soreness

135
Q

Benefits of laser

A

Pain relief

136
Q

Benefits of shockwave therapy

A

Treatment of tendinopathy

CASEM (13 decks)

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