Last min aapmr qbank review Flashcards
Pain after FOOSH. Tenderness with pain to palpation distal to the ulnar styloid between the FCU and ECU.
Dx?
Next best step?
triangular fibrocartilage complex (TFCC).
This structure is a stabilizer of the distal radioulnar joint and is composed of an avascular articular disc and radioulnar ligament complex. It is often injured with repetitive wrist activities or compressive loads.
TFCC tears are best imaged by magnetic resonance imaging (MRI). Injury to this complex would not be optimally evaluated on plain films, bone scan, or computed tomography scan.
baseball player had a twisting valgus deviation of the right knee during play. The MRI showed edema at the inferomedial patella and at the right lateral femoral condyle with ruptured fibers at the medial patellofemoral ligament. What is the most likely diagnosis based on MRI findings?
According to the MRI there is edema at the inferomedial patella and lateral femoral condyle, which are classic findings of patellar dislocation. When the patella returns to its natural position (after the traumatic patellar dislocation) the inferomedial portion of the patella touches the lateral femoral condyle, causing the classic findings at the MRI.
Which of the following is optimal initial treatment for congenital hip dysplasia in infants less than 6 months?
The Pavlik harness is the first line treatment. It is a brace which fastens around an infant’s legs and connects to the shoulders and torso to prevent mal-tracking of the femoral head within the acetabulum. Spica casting requires a series of hip casting to prevent femoral acetabular dislocation. Abduction braces are generally prescribed after completion of a spica cast series. Closed reduction is not the best initial treatment.
How long are hip precautions routinely continued after a posterior approach total hip arthroplasty?
Total hip precautions include avoiding flexion of more than 90 degrees, adduction past midline, and internal rotation past neutral. Total hip precautions for a posterior approach total hip arthroplasty should be continued for 12 weeks.
Treatment/management for stingers?
Stingers are a transient episode of unilateral pain and/or paresthesias in an upper extremity. There is a preponderance of C5 or C6 and upper trunk symptoms. All athletes require further diagnostic evaluation, with the exception of a first stinger (or second stinger in a separate season) with rapid resolution of symptoms prior to return to play. Athletes must have resolution of all symptoms with full, pain-free cervical ROM and full strength, along with an absence of any underlying risk factors for further injury, before they are allowed to return to play
Risk factors for plantar fasciitis
Obesity is a risk factor for plantar fasciitis. Plantar fasciitis affects both men and women equally, most commonly between the ages of 40 and 70 years. Factors that increase the tension on the plantar fascia, such as decreased subtalar motion, pes cavus, pes planus, and a tight Achilles’ tendon, may contribute to plantar fasciitis.
A 4-year-old child suffers an ankle inversion. When you examine him the following day, he has mild swelling laterally and is tender to palpation approximately 2-3 cm proximal to the distal aspect of the lateral malleolus and he reacts to pinch. The remainder of the examination is limited due to pain. Radiographs appear normal. What is the management of this patient?
Short leg non-weight bearing cast for 3 weeks.
Given the mechanism of injury, location of pain, and “normal” radiographs, the boy likely has a Salter Harris I Fracture of the distal fibular physis. A Salter Harris I fracture is a transverse fracture through the hypertrophic zone of the physis, and is typically not visible on radiographs though there may be widening of the growth plate. A walking boot is not sufficient to immobilize the ankle joint in a toddler. A CT scan is not required given there is not any significant abnormality on radiographs. A MRI to rule out an ATFL tear is not indicated. There is a significantly greater likelihood of a bony versus ligamentous injury.
A 4-year-old child suffers an ankle inversion. When you examine him the following day, he has mild swelling laterally and is tender to palpation approximately 2-3 cm proximal to the distal aspect of the lateral malleolus and he reacts to pinch. The remainder of the examination is limited due to pain. Radiographs appear normal. What is the management of this patient?
Short leg non-weight bearing cast for 3 weeks.
Given the mechanism of injury, location of pain, and “normal” radiographs, the boy likely has a Salter Harris I Fracture of the distal fibular physis. A Salter Harris I fracture is a transverse fracture through the hypertrophic zone of the physis, and is typically not visible on radiographs though there may be widening of the growth plate. A walking boot is not sufficient to immobilize the ankle joint in a toddler. A CT scan is not required given there is not any significant abnormality on radiographs. A MRI to rule out an ATFL tear is not indicated. There is a significantly greater likelihood of a bony versus ligamentous injury.
An adult patient is referred with a diagnosis of generalized hypermobility syndrome and a Beighton score of 8 points.
What is the best advice?
The Beighton score is a 9 point scale and a score of 5 or 6 is consistent with a hypermobility diagnosis. Family history is commonly positive but in the absence of hyperelastic skin, vascular complications, or neurologic signs, suggesting neuromuscular disease genetic testing is generally negative for hypermobile EDS. Pain and fatigue are common and may be severe and disabling; extensor, core strengthening and endurance training are indicated to improve symptoms and function.
What is the normal bladder capacity for a two-year old?
The bladder capacity in children is based on the Berger equation –age in years plus 2 – equals bladder capacity in ounces up until around age 12 years when the bladder capacity equals an adult size. If the detrusor muscle is overactive and can overcome the pressure of the external sphincter, the result will likely be a small capacity bladder. If the external sphincter is open, there will also likely have a small capacity bladder unless there is have a large flaccid bladder.
A 13-year-old right hand dominant baseball pitcher is seen in your clinic with right lateral shoulder pain that is aggravated by throwing. He denies any prior shoulder injury. Your examination is significant only for tenderness along the lateral deltoid. Radiographs of right shoulder are normal. The next best step in management of this patient is:
XR L shoulder
This adolescent has the hallmark history and potential signs of Little League Shoulder (LLS)/Glenohumeral Epiphysiolysis. LLS is a repetitive stress injury due to overuse and improper rest that typically occurs in young teenagers. It is likely a result of torsional overload of the proximal humeral epiphysis during maximal shoulder external rotation during the throwing cycle. In order to fully compare the physes, contra-lateral radiographs are needed as even subtle differences can make the diagnosis. MRI imaging not as efficient and more expensive. Treatment recommendations include elimination of throwing for 6 weeks after diagnosis and an additional 6 weeks of rehabilitation without throwing. A return to throw/pitch program is initiated once the patient is pain free and has completed a rehabilitation program without setbacks.
A 20-year-old college recreational athlete presents to your clinic after injuring his right ankle during a flag football game earlier in the day. On exam you note an antalgic gait with significant swelling, bruising, and tenderness to palpation at the anterior aspect of the lateral malleolus. No tenderness along the lateral and posterior aspect of the lateral malleolus, the medial malleolar region, or the foot. Regarding imaging, what should you order?
Given the history and examination, this patient most likely has a lateral ankle sprain. The Ottawa ankle and foot rules offer a high degree of sensitivity for fractures of the foot and ankle in patients presenting with acute ankle or foot pain. While the patient has pain in the lateral malleolar zone, he is able to bear weight, has no foot pain, and his ankle pain is not located at the posterior aspect of the distal 6cm of the fibula; hence, he does not satisfy criteria for obtaining an x-ray (with stress views or otherwise). There is no indication for ordering an MRI at this time.
In patients with degenerative disc disease of the lumbar spine, what percentage of weight do the zygapophyseal joints bear?
Normal zygapophyeal joints weight bear 33% of the total compressive load. Those with just zygapophyseal arthritis bear up to 47% and those with degenerative disc disease bear up to 70%.
Dupuytren contracture is associated with
Dupuytren contracture is caused by thickening and shortening of the palmar fascia and results in a flexion contracture of the MCP and PIP joints. It is associated with conditions that include alcoholism, cigarette smoking, human immunodeficiency virus infection, and diabetes. There are conflicting reports of an association with epilepsy.
A patient presents with pain in his ring finger after an opponent tried to slap a basketball out of his hand. On exam flexion and extension of his DIP is intact. X-ray of his finger shows a non-displaced distal phalangeal fracture. What is the next step in his treatment?
The goal of treatment for any finger injury is to restore the normal function of the finger. Restoration of bony anatomy is the basis for returning normal function; however, an anatomic reduction is not always necessary to achieve this goal, especially if it comes at the cost of soft tissue scarring and loss of motion. Early motion prevents adhesions of the gliding soft tissues of the extensor and flexor tendon systems and prevents contracture of the joint capsules. Immobilization of fingers much beyond 4 weeks will lead to long-term stiffness due to extensor tendon and joint capsular scarring. For example, non-articular phalangeal fractures treated with closed reduction and splinting are mobilized after 3–4 weeks, once the fractured phalanx is less tender. Even if splinting of one joint is needed, splints should be made small enough to allow early motion of uninjured joints. Therefore, in a case of a non-displaced distal phalanx fracture splinting that immobilizes the DIP joint only is sufficient. Closed non-displaced or minimally displaced fractures with acceptable alignment that are the result of a low-energy trauma usually have sufficient supporting tissues remaining intact making them stable and amenable to treatment by protected mobilization, either with local splinting of the fracture or buddy taping to adjacent fingers. Fractures with rotational or angular misalignment may be amenable to closed reduction and splinting, but these fractures are at risk for incomplete reduction and recurrent deformity. These more unstable fractures require careful and frequent clinical and radiographic follow-up. Surgical treatment is indicated for any fractures of the articular surface, open fractures, fractures with significant shortening or malrotation, and fractures which fail closed reduction. Delayed treatment of these surgically indicated fractures is always more difficult, with worse functional outcomes due to stiffness, incomplete deformity correction, and post-traumatic arthritis.
The most common organism responsible for septic arthritis in a one-year-old is:
Overall, the most common organism responsible for septic arthritis is Staphylococcus aureus. However, in children ages 2 months to 2 years old, the most common organism is Hemophilus influenza. Neisseria gonorrhea is the most common agent for septic arthritis in sexually active adolescents.
A 40-year-old patient is consulting you for management of her fibromyalgia and has failed to improve in the past with SSRIs, SNRIs, TCAs and Gabapentin. She asks you about other medications that have been developed for treatment of his condition. Which of the following drugs currently has the strongest research backed evidence for treatment of fibromyalgia?
For the pharmacological management of fibromyalgia, numerous research studies have been conducted on various drug classes. Most recently, both Tizanidine and low dose Naltrexon have been found effective only in small random controlled trials. Tramadol is classified as evidence level 5 (expert opinion) and like other opioids are generally less recommended for treating chronic pain. Cannabinoids fall under evidence level 1A (systemic review of random controlled trials) and would be the best choice among the choices above. For the pharmacological management of fibromyalgia, numerous research studies have been conducted on various drug classes. Most recently, both Tizanidine and low dose Naltrexon have been found effective only in small random controlled trials. Tramadol is classified as evidence level 5 (expert opinion) and like other opioids are generally less recommended for treating chronic pain. Cannabinoids fall under evidence level 1A (systemic review of random controlled trials) and would be the best choice among the choices above.
Gabapnetinoids (e.g. Gabapentin), TCAs (e.g. Nortryptiline) and SNRIs (e.g. Duloxetine) also all fall under evidence level 1A. In this question, the patient had not responded to these drug classes. Hence, choice D would be the best answer.
A 39-year-old male presents to your office after playing basketball with the inability to actively extend the DIP joint of his fourth finger. X-ray was negative for fracture. What would be your next step in the treatment of this patient?
A mallet finger results from the disruption of the terminal extensor tendon at its insertion on the distal phalanx that occurs most often due to impact of the fingertip on a ball or other object resulting in flexion force to the DIP joint. This is a common injury in basketball, baseball and football wide receivers. The patient will usually present with the inability to extend the DIP actively. Treatment for these injuries is a splinted DIP and an extension (PIP can be free) for 6 weeks. Surgery is only considered for fracture subluxation injuries so therefore there is no need for a surgical referral. Immobilizing with a cast is also not necessary as only the DIP needs to be immobilized. A CT scan is also not necessary as no fracture was seen on x-ray and treatment with splinting is still the treatment of choice.
This is performed by having the patient abduct the ipsilateral shoulder and resting the hand on top of the head. Individuals with cervical radicular symptoms will feel relief with this maneuver.
Bakody Sign
Iliotibial Band Syndrome (ITBS) is associated with which of the following rotary motions?
Tibial internal rotation:
ITBS has been associated with greater hip adduction and greater knee internal rotation. The concept of the knee internally rotating during flexion has implications for the biomechanics of Iliotibial Band Syndrome (ITBS). Consequently, ITBS has been associated with biomechanical abnormalities in the coronal plane, particularly at the hip, which controls orientation of the lower limb during stance. In a study of female runners, ITBS has been associated with greater peak hip adduction, and with greater peak knee internal rotation angle. Foot and ankle mechanics have not yet been shown to contribute to ITBS.
What is the most common complication after burn injury?
Hypertrophic scarring is the most common complication after burn injury, with a prevalence of 67%. Hypertrophic scars are raised, red, painful, pruritic, and contractile and stay within the margins of the original injury. Keloid scars have some of the same characteristics as hypertrophic scars, but they also extend beyond the original injury and invade into local soft tissues. Hypertrophic burn scars tend to develop in the first few months of injury, while increasing in volume and erythema. After several months, they can regress, becoming less erythematous and flatter, but the skin never returns to its original state. Younger individuals, particularly adolescents, and those with darker skin pigmentation tend to have a higher incidence of hypertrophic scarring. Wounds with a prolonged inflammatory wound healing phase and those that are open longer than 3 weeks are more likely to develop hypertrophic scars.
The most common bone for an osteoporotic fracture in women over age 65 is
Vertebral fractures are the most common osteoporotic fracture worldwide, they occur in 30-50% of people over age 50 but majority of them are asymtomatic with approximately two-thirds to three- fourths of vertebral fractures being clinically silent and often being diagnosed as an incidental finding on x-ray and less than 10% require hospital admission. Osteoporotic Hip fractures are the most common cause of hospitalization and substantially increase the risk of death and major morbidity in the elderly. The risk of hip fracture rises exponentially with age.
Which treatments may best prevent progression and improve symptoms of Complex Regional Pain Syndrome?
Range of motion exercises and NSAIDs
Early diagnosis and intervention in CRPS is associated with improved outcome and function. Rehabilitative therapies coupled with pharmacotherapy are the mainstays of early treatment. Although pain may decrease over time, detrimental changes arise from neuroplasticity. Interventional treatments are considered if conservative strategies fail. There are no well-accepted treatment guidelines for pharmacotherapy. Best evidence supports multidisciplinary care.
Medications trialed specifically for Complex Regional Pain Syndrome (CRPS) include calcitonin and bisphosphonates, corticosteroids, and most recently, intravenous immunoglobulin (IVIG). CRPS Treatments better studied in other related neuralgias include: augmentation of mono-amnergic transmission (serotonin- norepinephrine reuptake inhibitors and tricyclic anti-depressants (TCA). anti-Inflammatory Drugs/lmmunomodulators (NSAIDs, oral corticosteroids); alpha 2-adrenergic agonist (clonidine); NMDA receptor antagonists (e.g., MK-801, ketamine, amantadine, and dextromethorphan); calcium channel blockers (gabapentin, carbamazepine); and, opioids. Monotherapy is best to minimize adverse effects, cost, and patient noncompliance, but rational polypharmacy is often necessary, particularly to address different CRPS symptoms.
Panner’s disease?
Panner’s disease is bone growth disorder (osteochondrosis) of the humeral capitellum ossification centre, at the lateral aspect of the elbow[1].
Sever’s Disease
calcaneal; achilles tendon apophysitis
poor prognostic indicator for seronegative spondyloarthropathies?
Poor prognostic indicators include a younger age of onset, greater peripheral than axial joint involvement, uveitis, and elevated erythrocyte sedimentation rate (ESR), and poor response to non-steroidal anti-inflammatory drugs (NSAIDs).
How long is an abduction pillow utilized after a posterior approach hip replacement?
An abduction pillow prevents posterior dislocation of the hip prosthesis when the patient is lying in bed and should be used for approximately 6-12 weeks.
What percent of rheumatoid arthritis patients are rheumatoid factor positive?
70-80% of rheumatoid arthritis patients are RF (+), which carries a poorer prognosis.
The American Academy of Orthopedic Surgeons recommends weight loss to patients with symptomatic knee arthritis as a strategy to manage symptoms and improve function when the body mass index is calculated to be greater than or equal to ____ kg/m2:
The American Academy of Orthopedic Surgeons practice guidelines recommend advising patients with a body mass index greater/equal to 25 to use weight loss as a strategy to help with pain reduction and improvement in function.
A 22-year-old female runner presents to your clinic for right hip pain. She has been training hard for an upcoming half marathon. Recent MRI indicates a stress fracture at the superior aspect of the femoral neck. There is no clear cortical break. Based on these findings, what is the best next step in management?
Femoral neck stress fractures are categorized as “critical” due to the tenuous vascularity and the potential for poor outcomes with progression to fracture completion and displacement. Stress fractures of the inferior aspect may be managed non-operatively as this is the side of the femoral neck that is loaded in compression, which is relatively favorable for bone loading (exception: cortical breaks should be referred for evaluation). Management of inferior aspect, or “compression sided” stress fractures involves a period of 6-8 weeks of non-weight bearing followed by a slow progressive return to weight bearing, followed by physical therapy, addressing training and biomechanical errors, and ending with a slow progressive return to run program. However, stress fractures of the superior aspect of the femoral neck are particularly high-risk for completion and displacement, as the bone at the superior aspect is being loaded in tension. Non weight bearing status and urgent orthopedic surgical consultation is recommended.
A 27-year-old golfer presents with pain on the volar ulnar aspect of his hand. X-ray shows he has a fracture of the hook of his hamate bone. What is the treatment of choice?
Hamate hook fractures represent 2-4% of all carpal fractures and are a common injury in golf, baseball and hockey. Patients usually present with vague complaints of pain at the volar ulnar aspect of their hand with pain provoked when attempting a tight grip. Plain radiographs may not visualize the fracture thus a CT scan should be considered if one has a high suspicion for fracture. Excision of the hook of the hamate is considered the treatment of choice. Acute injuries and non-displaced fractures may be treated non-operatively but excision is the treatment of choice. Nonunion rates greater than 50% and as high as 80-90% can occur with conservative treatment. Therefore, all hamate hook fractures should be referred to a hand surgeon for possible surgical intervention.
What condition is commonly associated with lateral epicondylitis?
Lateral epicondylitis, or proximal wrist extensor tendinopathy, is associated with smoking and obesity. It occurs equally among males and females. It is not associated with hypercholesterolemia
What percentage of low back pain has a specific identifiable cause?
5-15%
Seat belt use during motor vehicle collisions has not reduced incidence of spinal injuries associated with
Thoracic and lumbar spine fracture patterns are influenced by the age of occupant and type and use of seat belts. Despite a reduction in overall injury severity and mortality, seat belt use is associated with an increased incidence of thoracic and lumbar spine fractures. Minor thoracic and lumbar spine fractures were associated with an increased likelihood of pelvic and abdominal injuries and higher Injury Severity Scores (ISS), demonstrating their importance in predicting overall injury severity. Extension injuries occurred in older obese individuals and were associated with a high fatality rate. Future advancements in automobile safety engineering should address the need to reduce thoracic and lumbar spine injuries in belted occupants.
A 15-year-old high school football player sustains a direct hit to the shoulder. He feels immense shoulder pain and decreased range of motion with associated numbness in his hand. Sideline evaluation confirms a glenohumeral joint dislocation and neurological symptoms resolve after joint reduction. Post-reduction radiographs confirm reduction and reveal a sizeable osseous depression in the posterior-lateral aspect of the humeral head. After providing a sling for comfort, what is the next best step in evaluation?
Young, active athletes with a first-time shoulder dislocation have a significant likelihood of suffering another dislocation in the future. Recurrence risk factors include age, activity level, in vs out of season, sex (male), and prior history of instability events with bony defects and/or capsular or ligamentous injuries. A true glenohumeral dislocation with an associated Hill Sachs lesion is an indication of instability of the shoulder joint. Absolute indications for an early orthopaedic consultation include a humeral head articular surface osseous defect of greater than 25%, greater than 50% rotator cuff tear, glenoid osseous defect greater than 25%, humeral head articular surface osseous defect greater than 25%, proximal humerus fracture requiring surgery, irreducible dislocation, interposed tissue or nonconcentric reduction, failed trial of rehabilitation, inability to tolerate shoulder restrictions, or inability to perform sport-specific drills without instability. There is no indication for an EMG given resolution of neurological symptoms after reduction. Sling use is limited to 1-3 weeks. Typically, physical therapy is not started within the first 1-2 weeks due to risk of re-dislocation.
Which are factors that increase the risk of developing hypertrophic scars after burn injury?
Hypertrophic scars are more prevalent in larger and deeper burns, in younger patients, those with darker skin, across areas of motion like joints, and when wounds are left open for prolonged periods of time (over 3 weeks).
A C6/C7 disc herniation into the neural foramen is most likely to produce paresthesias in which of the following areas?
Cervical disc herniations into the neural foramen affect the exiting nerve root, which is named by the lower vertebral body of the foramen. This nomenclature switches to the upper vertebral body after the emergence of the C8 nerve root between the C7 and T1 vertebrae. Thus, a C6/C7 foraminal disc herniation would compromise the C7 nerve root. The C7 nerve root dermatome is mapped to the third digit. The thumb represents the C6 dermatome, the fifth digit represents the C8 dermatome, and the medial epicondyle represents the T1 dermatome.
n young athletes, the likelihood of a 2nd shoulder dislocation after experiencing a first-time dislocation is:
Recurrence rates of shoulder dislocations in young athletes (<30 years old) range from approximately 60-90%. The t high re-dislocation rate is due to the fact that younger patients with strong, healthy rotator cuff tissue can withstand a high-energy insult but their weaker anterior static restraints (ie, labrum, shoulder capsule) cannot. Bracing may reduce the risk of recurrence, but restricts motion and may not be tolerated in certain sport-specific tasks such as throwing.
n young athletes, the likelihood of a 2nd shoulder dislocation after experiencing a first-time dislocation is:
Recurrence rates of shoulder dislocations in young athletes (<30 years old) range from approximately 60-90%. The t high re-dislocation rate is due to the fact that younger patients with strong, healthy rotator cuff tissue can withstand a high-energy insult but their weaker anterior static restraints (ie, labrum, shoulder capsule) cannot. Bracing may reduce the risk of recurrence, but restricts motion and may not be tolerated in certain sport-specific tasks such as throwing.
The HLA-B27 spondyloarthropathies include
psoriatic arthritis, ankylosing spondylitis, oligoarticular JIA, enteropathic arthropathy, and reactive arthritis (formerly known as Reiter syndrome).
What percentage of fractures in people older than 45 are related to osteoporosis?
70% of fractures in people over 45 years of age are related to osteoporosis. 1/3 of females greater than 65 years of age will have vertebral fractures. Hip fractures are the greatest cause of morbidity and mortality as related to osteoporosis.
Pseudogout is associated with which other conditions?
associated with hyperparathyroidism, hypothyroidism, hypomagnesemia, hypophosphatemia, hemochromatosis, and amyloidosis.
Which conditions are commonly associated with sacroiliitis?
Inflammatory bowel disease, reactive arthritis, psoriatic arthritis, septic arthritis, and ankylosing spondylitis are all associated with sacroiliitis. Lupus is not commonly associated with sacroiliitis.
Traditionally, there were four subtypes of spondyloarthritides: ankylosing spondylitis (AS), psoriatic arthritis (PsA), reactive arthritis (formerly Reiter Syndrome) (ReA), and spondyloarthropathy associated with inflammatory bowel disease (IBD). Recent developments have expanded the concept of SpA to include undifferentiated spondyloarthropathy (USpA). This category is for patients who are diagnosed with SpA, but do not fall into any specific subtype.
Jersey Finger
Complete or incomplete injury to the flexor tendon (superficialis and/or profundus) may be spontaneous as in the case of rheumatoid arthritis or more commonly due to a traumatic nature as seen in athletes in sports like football or wrestling. The classic mechanism of injury in athletes is when a player’s finger gets caught in the jersey of another when attempting to grab him. The profundus tendon is avulsed from its insertion and possibly accompanied by a bony fragment (usually the fourth digit). This is called Jersey Finger. The patient is unable to actively flex the DIP joint. In order to effectively test the function of the flexor digitorum profundus, the patient must flex the DIP while the examiner holds the PIP joint in extension. No imaging is really needed for diagnosis but plain films may show an avulsed fragment near the tendonous insertion. The treatment for Jersey Finger is hand surgery referral for early surgical repair.
A patient presents with an injury to his nail bed and a subungual hematoma that covers >50 % of the nail matrix. What is the next step in the management of this patient?
With any nail bed injury a plain radiograph should always be done to rule out any fracture of the phalanx. A subungual hematoma may also accumulate which can be very painful. This can be decompressed using cautery or an 18-gauge needle. If one has avulsion of the nail or a complex injury with loss of the nail bed, a surgical consult for possible repair is needed. If there is no damage to the matrix, observation and cleansing with a non-adherent dressing is recommended. Therefore, the correct and best answer in the next step managing this patient would be to x-ray the finger to rule out any type of fracture before any further treatment is necessary.
Indicators of poor outcome of juvenile idiopathic arthritis include
Indicators of poor outcome of juvenile idiopathic arthritis include greater severity or extent of arthritis at onset, late presentation to pediatric rheumatology, prolonged steroid use, symmetrical disease, early wrist or hip involvement, presence of rheumatoid factor, persistent active disease, and early radiographic changes.
Heterotopic ossification most commonly develops after arthroplasty of the:
The most common postsurgical site for heterotopic ossification after arthroplasty is the hip. The hip is also the most common site of heterotopic ossification occurrence in patients with spinal cord or traumatic brain injury.
Which stage of complex regional pain syndrome (CRPS 1) is characterized by burning pain, dependent edema, and vasomotor instability?
tage 1, the acute phase, is characterized by burning pain, dependent edema, redness, hyperhidrosis, coolness to touch. Stage 2, subacute phase, is characterized by severe pain, fixed edema, and cyanosis or pallor. Stage 3, chronic phase, pain may have subsided, edema subsided, and the extremity is generally stiff. There is no defined 4th stage.
The three clinical stages of type 1 complex regional pain syndrome (CRPS 1) are acute, subacute, and chronic. The acute form lasts approximately 3 months. Pain, often burning in nature, is one of the first symptoms that initially limits function. Swelling, redness with vasomotor instability that worsens with dependency, hyperhidrosis, and coolness to the touch are common physical find-ings. Demineralization of the underlying bony skeleton begins because of disuse.
If the process is not arrested or reversed in the acute phase, the condition may progress to the subacute stage, which can last for up to 9 months. The patient develops persistent severe pain in the extremity and fixed edema that would have been reversible with elevation during the acute phase. The redness of the acute stage gives way to cyanosis or pallor and hyperhidrosis to dry skin. Loss of function progresses, both because of increased pain and fibrosis of the joints caused by chronic inflammation. In the hand, this leads to flexion deformity of the fingers. The skin and subcutaneous tissues begin to atrophy. Demineralization of the underlying bony skeleton be-comes pronounced.
If the process continues, the chronic phase may develop approximately 1 year after disease onset. This stage may last for many years or can be permanent. Pain is more variable during this period. It may continue undiminished or abate. Edema tends to subside over time, leaving fibrosis around the involved joints. The skin is dry, pale, cool, and shiny. Flexion and extension creases are absent. Loss of function and stiffness are marked, and osteoporosis is extreme. In the upper extremity, this can manifest as a frozen shoulder and claw hand.
What should the serum uric acid level (mg/dl) be lowered to in patients with joint pain symptoms related to gout ?
The American College of Rheumatology recommends that the serum uric acid level be lowered to at least 6mg/dl in patients experiencing joint pain related to gout.
The American College of Rheumatology’s 2010 diagnostic criteria for fibromyalgia includes:
The American College of Rheumatology’s 2010 criteria for fibromyalgia uses a Widespread Pain Index (WPI) and Symptom Severity Scale (SSS) in lieu of the older criteria’s reliance on the number of myofascial trigger points present to make the diagnosis. A WPI score greater than 7/19 and a SSS score greater than or equal to 5 is sufficient to diagnosis a patient with fibromyalgia. The presence of major depression, although often comorbid with fibromyalgia, is not necessary for the diagnosis. The exclusion of an underlying rheumatological disease such as rheumatoid arthritis or lupus is not necessary to make a diagnosis of fibromyalgia.
What percent weight reduction in overweight patients has been shown to result in a moderate to large reduction in self-reported disability related to symptomatic knee arthritis ?
Meta-regression analyses show that a 10% reduction in body weight is associated with a moderate or larger clinical improvement in self-reported disability.
What is the initial deformity created in the cervical spine in a whiplash injury?
Whiplash injury initially creates an S-shaped deformation phase in the sagittal plane of the cervical spine, followed by a C-shaped in the sagittal plane phase.
A 28-year-old female runner presents to you with increasing right foot pain. She recently read an article about barefoot running and so has transitioned to that over the last month. She runs six days a week, but more recently she has had to stop running due to pain and has pain throughout the day, worsened by any weight bearing. On exam, there is no swelling or redness. She has tenderness directly over the 3rd metatarsal. No tenderness elsewhere within the foot. Normal neurological exam. Pain with attempts to hop. For your initial management, you decide to:
Her history indicates that she has undergone an abrupt change in her training (barefoot running) that would cause a significant change in the types of forces experienced by her skeletal system, and has an accompanying point of focal bony tenderness. Given this history and exam, the patient likely has a 3rd metatarsal stress fracture. This is not considered a “critical” stress fracture site and can be treated initially with a walking boot. If she is able to walk without limping in 3 weeks, she can be progressed out of the boot and to physical therapy. Non-weight bearing in a cast for 6 weeks is generally not needed with “non-critical” stress fractures and would be overly restrictive. Radiographs are relatively insensitive for stress fractures, and would not likely change management in this case as there is little concern for a “critical” stress fracture. Given her likely injury, pain, and functional limitations, returning her to activities at this time would be inappropriate
What is the most common form of JIA?
Oligoarticular JIA is the most common of the JIA subtypes affecting 50% to 60% of all children with JIA. Polyarticular RF (-) comprises 18-30% of children with JIA. Polyarticular RF (+) occurs in 10% of total JIA cases. Systemic JIA accounts for 2% to 17% of JIA cases.
Patient is involved in a motor vehicle collision. CT scan shows a fracture at the base of the odontoid process. What is the classification or name of this odontoid fracture?
Type 1 odontoid fracture involves a fracture in the tip of the odontoid process and is considered stable. Type 2 fractures are the most common and extend through the base of the odontoid process and are considered unstable with approximately 1/3 of these fractures resulting in nonunion. Type 3 fractures involve fracture of the body of the C2 vertebra and are considered stable. A hangman fracture is traumatic spondylolisthesis of the axis and involves bilateral fractures through the pars interarticularis of the C2 vertebra.
A 46-year-old healthy male recreational athlete presents to your clinic with a 3-day-old right Achilles tendon rupture. He asks about his treatment options. What do you tell him?
Re-rupture rates using functional bracing are similar to re-rupture rates after surgery.
Known risk factors for congenital hip dysplasia?
Breech positioning, female gender, and first born are known risk factors for CHD
What is the minimum recommended rating of pressure garments to reduce hypertrophic scarring in a patient with a burn injury?
To prevent hypertrophic scarring in patients following a burn injury it is advised that compression garments providing at least 25 mmHg of pressure be worn 23 hours per day. Compression garments should be kept clean and replaced routinely to prevent infection and maintain the minimum pressure requirement, respectively. Additional advised skincare includes lubricating the skin several times daily, protection from direct sunlight due to skin sensitivity, and avoidance of excessive heat exposure due to poor thermoregulation related to loss of sweat glands.
In Clay shoveler’s fracture, what anatomic region of lower cervical and upper thoracic spine is affected?
Clay shoveler’s fracture is a repetitive stress injury that affects the spinous process of the lower cervical and upper thoracic spine. In sports, deceleration forces caused by the pull of the trapezius, rhomboids, and the ligamentum nuchae on the neck probably exert repetitive traction on their attachment sites to the narrow spinous processes. The condition is known in manual laborers, but is rare in athletes. It is treated conservatively.
In addition to mechanical nerve root compression, which of the following is an alternative explanation for symptomatic spinal stenosis?
n the theory of venous engorgement, it is believed that the spinal veins of patients with lumbar spinal stenosis dilate due to vascular compression, resulting in venous congestion, interruption in venous flow, and elevated spinal canal pressures. This results in ischemic neuritis of the spinal nerve roots. Signs and symptoms are thought to result from vascular compromise to the vessels supplying the cauda equina (central stenosis) or from pressure on the nerve root complex (lateral stenosis) by the degenerative changes. The clinical impact of these changes is related to the speed by which the compression develops. There have been several hypothesized effects of the focal nerve root constriction: 1) A direct obstruction of the blood flow to the cauda equina; 2) An intraosseous and cerebrospinal pressure change affected by posture; and 3) a direct neuronal compression of the nerve roots.
How should the hand of a child with juvenile rheumatoid arthritis be positioned in splinting?
The correct position for splinting an involved hand in a child with juvenile rheumatoid arthritis is with the wrist in 15° of extension, the metacarpophalangeal joints in 25° of flexion, and the thumb in opposition. This position provides support for weakened structures and helps to reduce contractures.
Which of the following would typically be specified in a shoe prescription for a patient with a Charcot foot?
Rocker-Bottom Sole:
The purpose of custom shoe prescription in someone with a Charcot foot is to minimize the forces the foot sees during standing/ambulatory activity.
When entering the shoe, a large, wide throat assists in reducing trauma to the forefoot and heel by shearing forces.
This can be done by prescribing that the shoe has a Blucher opening, where the bottom of the lace stays are not sewn together across the base of the throat (as is the case with a Balmoral opening).
Using a Velcro strap in place of lacing across the throat reduced the static pressure the upper of the shoe places on the dorsal surface of the foot.
A high and wide toe box reduces pressure around the toes and metatarsal heads (particularly #1 & #5), while a firm heel counter captures the heel to reduce movement of the foot within the shoe, and aids in controlling the shoe during activity.
A custom insert to further relieve static pressure along the plantar surface of the foot and support the longitudinal and mediolateral arches can reduce further orthopedic injury.
Finally, incorporating a rocker bottom into the rubber sole of the shoe will significantly reduce the dynamic pressure experienced by the foot during stance phase by minimizing the plantar area in contact with the ground at any one time.
recommended static alignment for an uncomplicated transtibial amputee with no significant knee contracture?
The socket is prepositioned in 5° of adduction and 5° to 10° of anterior tilt.
The anterior tilt allows loading of the soft tissues of the anterior surface of the residual limb.
The foot is slightly inset relative to the socket.
The patella tendon bar is located halfway between the tibial tubercle and the distal end of the patella.
The posterior brim of the socket should end about an inch below the patella tendon bar, with relief made for the hamstring tendons.
What is the mechanical advantage of increasing the rear wheel camber of manual wheelchair?
Increasing rear wheel camber changes the structure of the wheelchair, which increases the lateral base for increased lateral stability.
The superior aspect of the wheels is narrower, which allows the user increased access to the pushrim and reduces need for increased shoulder abduction.
Changing the rear wheel camber does not have an impact on the anterolateral stability that would impact the need for antitippers.
What is the primary advantage of a body powered upper limb prosthesis compared to a myoelectric prosthesis?
What are the disadvantages?
Primary advantage = Greater sensory feedback
The advantages of body powered upper limb prostheses include the following factors: moderate cost, most durability, highest sensory feedback, and a variety of prehensors available for various activities.
Their disadvantages are that they require the most body movement to operate, have the most harnessing and require increased energy expenditure to use.
Myoelectric prosthesis advantages:
Myoelectric and/or switch controlled upper limb prostheses have the following advantages: They require moderate to no harnessing, require fewer body movements to operate, have moderate cosmesis, provide more function in proximal areas and, in some cases, provide a stronger grasp.
Myoelectric prosthesis disadvantages:
Battery powered prostheses are the heaviest and most expensive prostheses. They also require the most maintenance, provide limited sensory feedback and require extended therapy time.
What is the advantage of a polycentric knee during the pre-swing (terminal stance) phase of the gait cycle?
Many polycentric knees are designed so that the center of rotation moves anteriorly very rapidly during the first few degrees of knee flexion, quickly passing in front of the floor reaction line and facilitating the swing phase.
Because the polycentric knee can be flexed under weight-bearing during the terminal stance, when properly dynamically aligned it can offer both excellent stance stability and ease of swing-phase flexion.
All polycentric knees shorten mechanically to a slight degree during flexion, adding additional toe clearance during midswing.
What bone is more prone to terminal overgrowth s/p amputation in children?
Fibula > Radius
The primary advantage of an ischial containment socket over a quadrilateral socket in a transfemoral amputee is:
What are the advantages of a quadrilateral socket?
Promotion of femoral adduction by distributing the pressure through the socket along the shaft of the femur
An ischial containment socket is designed to stabilize the socket on the residual limb and to control socket rotation by containing the ischial tuberosity and the pubic ramus within the contours of the socket with a snug medio-lateral dimension. This socket has a sub-trochanteric contour that holds the femur in adduction and distributes the pressure through the socket along the shaft of the femur.
Quadrilateral socket:
Flat posterior shelf, ischial set, which provides a primary weight bearing surface for the ischium and gluteal muscles.
Allowance of the glut medius to contract and force the femur into the distal-lateral wall of the socket
The most effective nonsurgical treatment for de Quervain’s tenosynovitis is:
Local corticosteroid injection is proven effective as a treatment for de Quervain’s tenosynovitis, both with and without splinting. Injection alone produced an 83% cure rate, with injection plus splinting producing a 61% cure rate. Splinting alone produced a 14% cure rate, and rest and anti-inflammatories were of no benefit.
The patellar tendon bearing (PTB) socket for a transtibial amputee is designed with what position/alignment of the knee?
The socket is aligned in approximately 5° - 8° of flexion to increase initial tension on the quadriceps tendon (discouraging knee hyperextension) and enhance weight bearing to the anterior aspect of the residual limb.
The PTB socket is designed to accept weight at the patellar tendon, medial flare of the anterior tibia, lateral aspect of residual limb, pretibial muscle mass between the tibial crest and fibula and popliteal fossa.
The posterior wall should provide relief for the hamstring tendons.
What is the MOST important biomechanical factor for decreasing the vertical loading of the lumbar spine using a TLSO or LSO?
Reinforce core musculature to distract vertebral bodies
Abdominal compression increases intracavitary pressure, which acts to unload the spine and its disks by transmitting load onto the soft tissues of the trunk. The application of a 3-point pressure system typically aims to restrict triplanar motion (flexion/extension/lateral flexion and trunk rotation). Pressure over the bony prominences provides a kinesthetic reminder to maintain or correct posture. No spine orthosis achieves complete immobilization of the spine.
When should a child with congenital radial deficiency be fitted for transradial prosthesis? What is the best initial prosthesis?
Children with unilateral transverse radial limb deficiency should be “fit to sit,” meaning fitted by 6 months of age with an initial prosthesis that has a passive terminal device.
How are mobility devices paid for through Medicare?
Medicare part B pays 80% of the allowed purchase price in one lump sum
What is the positioning of the wrist, MCPs, PIPs, and DIPs when applying a resting wrist-hand-orthosis?
This position includes:
-The wrist slightly/moderately “cocked-up” between 10-30 degrees of hyperextension
-The metacarpophalangeal joints mildly flexed
-The proximal and distal interphalangeal joints in extension
-The thumb halfway between palmar and radial abduction.
This position – commonly referred to as a Functional “C” position – reduces the stress on the respective joints, reduces hypertonicity, and permits greater opportunity for functional restoration.
Why are endoskeletal pylons more advantageous than exoskeletal pylons?
Exoskeletal prostheses are more rugged, require less maintenance, cannot be adjusted for alignment after fabrication, and can accommodate only a restricted number of foot and knee units. Furthermore, these prostheses tend to weigh more than the equivalent endoskeletal prostheses. For these reasons, exoskeletal prostheses are prescribed less often than endoskeletal prostheses. Endoskeletal prostheses are modular in design, allowing relative ease of adjustment of alignment and replacement of parts. They are also easier to suspend by virtue of their relatively lighter weight.
In patients with knee arthritis affecting mostly the medial compartment, which shoe insert will most effectively reduce the knee adduction moment?
A lateral heel wedge can reduce the adduction moment at the knee and potentially reduce loading of the medial knee compartment. This may help reduce pain and improve function in some patients with knee arthritis.
The primary stabilizing effect of the flexible lumbosacral orthosis is its ability to:
Elevate intra-abdominal pressure
Although they do not effectively restrict motion to a significant degree, flexible lumbosacral orthoses elevate intra-abdominal pressure, thereby unloading the spine and supporting structures. This action also provides inhibitory kinesthetic feedback and warmth. Long-term use of binders and other flexible lumbosacral orthoses may, unfortunately, result in atrophy of trunk muscles.
What is the proper fighting height of a standard or rolling walker?
When properly fit, the height of the grips of a walker or cane should be near the level of the greater trochanter of the hip; this permits a 20 degrees of flexion in the elbow.
This also corresponds to the position of the ulnar styloid with the arms in a comfortable position.
A rolling or standard walker, in use for normal ambulation, is not meant to permit full weight bearing, but rather improve balance by providing a larger base of support.
The proper height of an assistive ambulatory device does not change based upon its intended use.
Indicators for poor prognosis for upper limb motor recovery after a stroke include:
Complete arm paralysis at onset
No measurable grasp strength at 4 weeks
Severe proximal spasticity
Severity of weakness at onset of stroke has been demonstrated to be the most important predictive factor.
The Bobath and Brunnstrom Approach to movement therapy differ primarily in their approach to:
Primitive movements
Constraint induced therapy (CIMT) requires that patients:
Participants in constraint induced therapy (CIMT) are required to be able to voluntarily extend their wrists and move their fingers in order to participate in this therapy. Therapy is usually initiated within 2 weeks of onset but not usually within 24 hours. Most CIMT protocols require constraint of the unaffected limb 90% of waking hours.
Following a stroke, deep tendon reflexes increase within:
Immediately following onset of hemiplegia, there is a loss or decrease in tendon reflexes. Increased deep tendon reflexes on the involved side develops within 48 hours.
Infarction of which blood vessel causes ipsilateral facial and contralateral body loss to pain and temperature sensation, Horner’s syndrome, ataxia, vertigo and dysphagia?
The symptoms given are classic for Wallenberg Syndrome, also known as Lateral Medullary Syndrome. This may be caused by occlusion of the Posterior inferior cerebellar artery (PICA), vertebral arteries, and lateral medullary arteries (superior, middle and inferior).
What imaging modality is used to measure size of a hemorrhagic stroke and and has also been shown to be a strong predictor of outcome?
CTH
In the setting of a high clinical suspicion for subarachnoid hemorrhage, with a negative CT scan, what diagnostic test should you perform next?
A spinal tap for evaluation of cerebral spinal fluid is the recommended exam to follow a negative non contrast CAT scan with high clinical suspicion of subarachnoid hemorrhage.
When is CT angiogram indicated in the setting of a stroke?
CT Angiogram is indicated to evaluate extracranial carotid stenosis, and internal cerebral circulation for identifiable vascular defects.
Which factor is associated with improved outcomes in hemorrhagic stroke patients?
The volume of hemorrhage is a strong predictor of outcome in hemorrhagic stroke patients. Patients with more than 5cm of hemorrhage in the basal ganglia had certain mortality by 30 days poststroke.
Studies demonstrate that persons who score higher than 9 on the Glasgow Coma Scale, and who require intracranial pressure (ICP) monitoring and experience persistent elevation of ICP are more likely to have herniation and poorer outcomes.
Aggressive antihypertensive management in the setting of intracerebral hemorrhage (ICH) remains controversial; consensus guidelines recommend systolic blood pressure above 200mmHg be treated with intravenous antihypertensives initially in order to not further extend the hemorrhage.
Cerebral perfusion pressure (CPP) should be maintained between 60-80mmHg when systolic blood pressure is above 180mmHg and intracranial pressure (ICP) is within normal range (8-18mmHg).
Your stroke patient has weakness affecting the hand and foot more than the proximal muscles on the same side. Sensation and cognition are intact. This person most likely has a stroke in which contralateral area?
Internal Capsule
Stroke in the brainstem would result in cranial nerve involvement.
With a midbrain stroke there would be additional findings such as decreased coordination, cranial nerve involvement, and sensory deficits.
With motor cortex involvement the patient would have extensive weakness in the arm or leg depending on the location of the stroke. Also with a cortical stroke there would be some cognitive and speech involvement.
Hemorrhagic strokes caused by hypertension are typically located in the:
Hemorrhagic strokes account for about 15 % of all strokes and are most often caused by hypertension. The lesions are typically located in the basal ganglia, thalamus, pons, and cerebellum.
A patient has right 3rd cranial nerve palsy, left side loss of pain and temperature, left side loss of joint position, and left side ataxia. Where is the brainstem stroke most likely located?
The characteristics of the findings are most consistent with a brainstem stroke in the region of the tegmentum of the midbrain (Benedikt syndrome).
This affects the 3rd cranial nerve, spinothalamic tract, medial lemniscus, superior cerebellar peduncle, and the red nucleus (this can lead to contralateral chorea).
The medial basal midbrain (Weber syndrome) affect the 3rd cranial nerve and the contralateral corticospinal tract resulting in hemiplegia.
The lateral pons (Millard-Gubler syndrome) involves the 6th and 7th cranial nerves and the corticospinal tract.
The lateral medulla (Wallenburg syndrome) involves the 5th cranial nerve, spinocerebellar tract causing ipsilateral ataxia, spinothalamic tract, vestibular nuclei causing nystagmus, sympathetic tract resulting a Horner syndrome, and nucleus ambiguus causing dysphagia and dysphonia.
An infarct anterior to the precentral gyrus within the frontal lobe is most likely to result in which one of the following deficits?
Anterior to the precentral gyrus in the frontal lobe is the premotor area, which is important in motor planning. Injury to this area can cause poor static and dynamic balance as well as movement disorders
Wernicke type of apahasia is due to injury in the
Wernicke type of apahasia is due to injury in the posterior superior portion of the first temporal gyrus near the primary auditory cortex.
An 80-year-old man presents with mild expressive aphasia and slight right sided weakness. Symptoms resolve within 15 minutes. He is diagnosed with a transient ischemic attack. Carotid ultrasound demonstrates 70%-99% occlusion of the left internal carotid artery (ICA) and 50%-70% occlusion of the right internal carotid artery. What is the most appropriate recommendation regarding carotid endarterectomy?
Consideration of carotid endarterectomy (CEA) involves several factors, including whether the patient is symptomatic or asymptomatic and the degree of internal carotid artery (ICA) stenosis.
For symptomatic patients with transient ischemic attack or mild stroke, CEA is recommended if ICA stenosis is 70% to 99% but should only be performed in select patients if ICA stenosis is 50% to70%.
The CEA procedure is not recommended for symptomatic patients if ICA stenosis is less than 50%. For asymptomatic patients, CEA may be considered if ICA stenosis is 60% to 99%, but typically is recommended only if ICA stenosis is greater than 70% to 80%, if the patient is medically stable and is expected to live 5 years or longer, and if performed in a center with less than 3% perioperative complication rate.
