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PAM 630 - CLINICAL MEDICINE I > MSK-1 > Flashcards

MSK-1 Flashcards

1
Q

What is the most common MSK complaint? What should you remember?

A
  • Pain
  • Remember OLD CARTS
  • Character & Timing are importanT for determining the mechanism of injury (MOI)
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2
Q

What is some pain due to?

A
  • Systemic
  • Infectious
  • Visceral
  • Neoplastic
  • Psychosocial problems –not mechanical or traumatic.
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3
Q

What are multiple MSK ROS topics you need to ask?

A
  • Constitutional – Fever, night sweats, weight loss, HIV or other immunosuppression like steroid use.
  • Any CA, ever
  • Eye discharge or pruritis
  • GU complaint/ sexual contact
  • GI recent illness
  • Any procedures to area of complaint, like epidural
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4
Q

TMJ disorder:
* Causes?
* S/S?
* Imaging findings? What do you need to rule out?
* What is treatment?

A
  • Causes: Stress, bruxism, hypermobility syndrome and malocclusion
  • S/S: Pain aggravated by jaw movement; may have restricted ROM, click/pop may be felt or heard
  • Imaging: normal x-ray, arthritis is late finding, Rule out OA, RA, tumor, congenital growth abnormalities
  • Treatment: Most resolve without tx; lifestyle modifications, behavior modification, possible referral to ENT or maxillofacial surgeon
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5
Q

What is the TM joint? What is inside the TM joint?

A
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6
Q

Torticollis:
* May result from what?
* May be caused by what?
* What is the sign?
* What may follow in children?
* What do you need to rule out?

A
  • May result from injury/illness in neonate
  • May be caused by sternocleidomastoid muscle contracture
  • Head will tilt toward side of contracture
  • May follow URI or mild trauma in children
  • Rule out: Spinal cord tumor, RA other etiologies
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7
Q

Torticollis in older child or adult:
* Results from what?
* What is spasmodic toricollis from?

A
  • Usually results from minor trauma
  • Sleeping in awkward position precipitates
  • Spasmodic torticollis (dystonia) results from stress, physical overload and sudden movement – and is the most common type
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8
Q

What is the torticollis treatment? (adult v children)

A
  • Passive stretching effective in 97% of all cases in infants
  • Surgical release of the muscle origin and insertion an option if no resolution in the first year of life
  • Acquired torticollis in childhood - traction or a cervical collar for 1-2 days usually effective
  • Adults will respond to gentle stretching, +/- muscle relaxants
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9
Q

What is a complication of infantil torticollis?

A

Striking facial asymmetry-> can have atropy

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10
Q

A child with chin tilted to the right and head tilted to left, has what and what muscle is affected?

A

Torticollis and left SCM

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11
Q

What is the most common condition affecting the cervical spine?

A

Spondylosis

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12
Q

What is spondylosis? What can happen?

A

This includes degenerative changes occurring in the disk (most C5-C6) with disk narrowing and osteophytes. Facet joints are affected later. Sometimes, paresthesia occurs in fingers. Pain increased with extension and decreased with flexion

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13
Q

Worse prognosis central disk protrusion of spondylosis can cause what?

A

can cause clonus and Babinski sign
with gait disturbance

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14
Q

Spondylosis:
What is the treatment?
What is the last resort?
What has a similar presentation to spndylosis?

A
  • treatment is conservative treatment with PT, collar, traction, and NSAIDs
  • Fusion or discectomy=last resort
  • Whiplash is similar as above with gentle ROM training soon after injury.
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15
Q

What are signs of strain and radiculopathy?

A

Strain
* Bilateral or unilateral symptoms
* Normal neuro exam
* NO radicular symptoms

Radiculopathy
* Neurological symptoms distal to complaint (sciatica) in a specific nerve distribution

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16
Q
  • What is the most common cause of radiculopathy?
  • What test do you need to do?
  • What is the choice of study (CT, x-ray, MRI, US)?
  • When do you refer to neuro?
A
  • Most common cause is cervical arthritis or disc nucleus pulposus herniation
  • Do a Spurling test
  • MRI is the study of choice
  • Refer to neurosurgery for management, in absence of loss of function
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17
Q

Kyphosis:
* What are some causes?
* What is treatment for older and younger patients?

A
  • May be congenital or age-related , Osteoporosis may cause small fractures, which collapse the spine
  • Treatment for many young patients is physical therapy
  • Treatment for older patients is pain management and calcium supplements
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18
Q
  • What degree of kyphosis is observed every 3-4mo?
  • What degree or sign can be treated with a milwaukee brace?
  • What is an option?
A
  • Curves of 45-60 degrees observed every 3-4mo
  • Curves >60 degrees or with persistent pain can be treated with Milwaukee brace
  • Surgery is an option
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19
Q

What is this

A

Kyphosis

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20
Q

Scoliosis:
* What is it?
* What is the mechanism? What is the most common?
* What is a sign?
* What test should you use?

A
  • Mediolateral curves of spine
  • Mechanism: Positive family history
    * Adolescent idiopathic scoliosis most common
    * Most commonly seen in teenage girls
    * Tuberculosis of the spine (Pott’s disease)
  • Uneven Appearance: asymmetry in shoulder and iliac height; asymmetric scapular prominence; flank crease with forward bending, showing right thoracic and left lumbar prominence
  • Use Adam’s Forward Bend Test
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21
Q

What does the USPSTF conclude about scoliosis screening?

A

”Most cases detected through screening will not progress to a clinically significant form of scoliosis. Scoliosis needing aggressive treatment, such as surgery, is likely to be detected without screening….the USPSTF concluded that the harms of screening adolescents for idiopathic scoliosis exceed the potential benefits.”

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22
Q

How is the cobb angle formed in scoliosis?

A
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23
Q

Scoliosis

  • What is the angle of cobb if only observation?
  • What is the angle of cobb if bracing is needed?
  • What is angle of cobb if surgery is needed?
A
  • Observation if curve is >10 but <25 degrees
  • Treatment is bracing if Cobb angle exceeds 25 degrees
  • Treatment is surgical if Cobb angle exceeds 45-50 degrees or if neuropathy is present
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24
Q
  • What does the straight leg raise test?
  • What is a positive sign? What can that be called?
  • What is bowstring sign?
  • There is also a contralateral straight leg sign that may be more specific for what?
A
  • This tests for radiculopathy—referred nerve pain, which may indicate nerve impingement at any level, usually lumbar
  • Positive if it elicits pain, sometimes referred to as Lasègue’s sign.
  • Bowstring sign means the pain is lessened when the knee is flexed.
  • There is also a contralateral straight leg sign that may be more specific for disc herniation.
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25
Q

What is the specificity and sensitivity of straight leg raise?

A
  • Specificity 40%
  • Sensitivity 95%

Both specificity and sensitivity don’t have anything to do with test just being positive or negative. They deal with probability of TRUEness of the negative or positive result.

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26
Q
  • What is specificity?
  • What does a large specificity means?
  • What does a positive result signifies?
A
  • The probability that the test will be truly negative among patients who do not have the disease.
  • Negative test/all patients without the disease, including false positives
  • A large specificity means the test can rule-in a disease
  • A positive result signifies a high probability of the presence of disease. A test with 100% specificity will recognize all patients without the disease by testing negative, so a positive test result would definitely rule in the presence of the disease.
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27
Q

SLR of 40% specificity means what?

A

40% with negative test don’t have the disease

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28
Q
  • What is sensitivity?
  • What can a large sensitivity mean?
A
  • Probability of a true positive test in patients with the disease
  • Positive tests/ all patients who have the disease, including false
    negatives
  • A large sensitivity can rule-out the disease
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29
Q

What does the SLR sensitivity of 95% means

A

95% with the disease test positive

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30
Q

Give example of poor specificity and good sensitivity using SLR?

A
  • A person with a negative straight leg raise probably does not have radiculopathy. (Good sensitivity)
  • A person with a positive straight leg raise is not so certain to have radiculopathy (poor specificity)
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31
Q

What does it mean when something is pathomneumonic?

A

We mean it has a great specificity. specificity. The sign or symptom is very specific to the disease.

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32
Q

Back Pain Differential
* Usually “Nonspecific” Mechanical is what (5)?

A
  • Lumbar Sprain/ strain
  • Degenerative processes of disks and facets
  • Spondilolisthesis
  • Spondylolysis
  • Scoliosis
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33
Q

Back Pain Differential, Mechanical is what? (7)

A
  • Sprain/strain
  • Degenerative discs
  • Spondylolysis, Spondylolisthesis
  • Herniated disc
  • Spinal stenosis
  • Fractures
  • Kyphosis
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34
Q

Back pain differential, Non-mechanical can include what? (cancer, infection, inflammation)

A
  • Cancer – MM (Multiple Myeloma), Metastatic, Lymphoma, Leukemia, Spinal tumor, Retroperitoneal tumor
  • Infection – Osteomyelitis, Septic disc, Abscess
  • Inflammation - Ankylosing Spondylitis, Psoriatic spondylitis, Reiter’s, IBS (inflammatory Bowel Syndrome), Paget’s
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35
Q
  • When is low back pain very common?
  • Can be caused by what factors?
A
  • Extremely common, especially in roofers, pregnancy, obesity, and inactive people. Very common in those with weak core muscles.
  • Caused by many factors, including osteoporosis with small fractures, herniated discs, muscle spasms, degenerative joint disorders like osteoarthritis, kyphosis and scoliosis, fibromyalgia and depression.
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36
Q

Low back pain:
* What are S/S?
* Pain from MSK causes will have what?
* What will be a sign in SI joint involvement?
* What will a sign in spinal stenosis?

A
  • S/S: Pain originated in the back and radiating down leg suggests nerve root irritation.
  • Pain from musculoskeletal causes=point tenderness
  • Unilateral low back and buttock pain that gets worse with standing in one position=sacroiliac joint involvement
  • Pain in the elderly that is increased by walking and relieved by leaning forward =spinal stenosis
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37
Q

LOW BACK PAIN

  • What is the most common cause of low back pain?
  • Can be secondary to what?
  • What are S/S?
  • What are tests?
  • What should you do during the physical exam?
  • When is imaging helpful?
A
  • The most common cause of low back pain is muscle strain
  • Can be secondary to prolapsed intervertebral disk and low back strain
  • Signs and symptoms: Pain may be dull, achy, or sharp with movement
  • Tests: Good H&P,
  • PE: palpate, assess muscle tone, neuro exam distally, straight-leg raise
  • Imaging is not helpful unless Red Flag or you have clinical suspicion in absence of red flags
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38
Q

What are the red flags of back pain?

A
  • Trauma
  • Hx CA, Osteoporosis, weight loss
  • Hx HIV, steroids, IV drugs
  • Hx of constitutional symptoms like fever, weight loss
  • Age >70
  • Disabling symptoms
  • Focal neuro deficit on exam (like sensory or motor deficit, change in reflexes, loss of rectal tone)
  • Symptoms for more than 4-6 weeks

GET IMAGING

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39
Q

When is x-ray, CT, MRI useful in low back pain?

A
  • Xray is sufficient in minimally traumatic events or persistent pain
  • CT useful for bony stenosis and lateral nerve root entrapment
  • MRI useful in cord pathology, tumors, stenosis, herniated disks, and infections.
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40
Q

Back sprain and strain:
* What is the first line of treatment?
* What treatment is short term?
* What is chronically used to treatement?

A
  • Acetaminophen is considered first-line, NSAIDS better than placebo
  • Muscle relaxants and opioids are short-term only
  • Chronically: anticonvulsants, tricyclic antidepressants
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41
Q

Back sprain and strain:
* ROM?
* What is not recommended? What should you use instead?
* What is prevention?
* Wha can be very beneficial in repeated episodes?
* What can be helpful?

A
  • Gentle slow movements increasing ROM
  • Bedrest is not recommended: use MICE (Motion + ICE) instead of RICE
  • Prevention: Lifting technique, physical therapy, increased regular exercise like walking, core muscle exercise.
  • Physical Therapy very beneficial in repeated episodes
  • Reassurance is helpful, avoid “degenerative”
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42
Q

Sacroiliitis:
* What is it?
* Stems from what?
* On exam patients will have what?
* What is txt?

A
  • Inflammation of SI joint
  • Stems from improper lifting
  • On exam patients will have reproducible point tenderness over SI joint, pain reproduced by hip flexion (climbing stairs) OR in Left lateral decubitus position (LLDP) apply pressure to pelvis
    * Pain can be referred to buttock
    * SLR is typically negative
  • Tx with NSAIDs and steroids for severe pain

Pain usually stays local

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43
Q

Sciatica:
* What is it?
* What are the s/s?
* Where is point tenderness?

A
  • Inflammation of the sciatic nerve
  • Pain, burning tingling
    that may start in low
    back or buttock, passing
    down posterior thigh, sometimes below knee.
    • Point tenderness is usually between PSIS and greater trochanter
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44
Q

Herniated disc:
* What is herniated?
* Where can it occur?
* If more central, then what is a higher chance?
* If more lateral, the more likely what?

A
  • Herniated Nucleus Pulposus
  • Can occur in the central, posterolateral foraminal and extraforaminal zones
  • The more central the herniation, the higher chance of compression of the traversing nerve root.
  • The more lateral the herniation, the more likely a compression of the exiting nerve root
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45
Q

A disc herniation will have a clinical presentation based upon what? Explain

Pance prep pearls

A

based upon where the herniation occurs

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46
Q
  • What is the mechanism of Herniated disc?
  • What cuases weakness, numbness and radicular pain?
A
  • Mechanism: Nuclear material displaced into the spinal cord causing pain
  • Compression of motor nerve causes weakness
  • Compression of sensory nerve causes numbness
  • Radicular pain results from inflammation of nerve
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47
Q

herniated disc:
* What is the most common
location?
* What happens with age?
* What is are the risk factors?

A
  • L4/5 , L5/S1 most common
  • With age, the levels move up in predominance (can happen at any spine level)
  • Risk factor – genetic inheritance, occupational and recreational injury, smoking, obesity
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48
Q

Herniated Disc:
* What does it cause?
* less than half have what?
* What are s/s?
* Pain and symptoms are worse and better when?
* Patient prefer what position?

A
  • Prodrome of low back pain that acutely changes to radiating leg pain (sciatica)
  • Less than half have an precipitating event
  • Numbness or weakness in dermatome
    * Pain and symptoms worse in forward flexion, better in extension
  • Prefer standing or lying to sitting
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49
Q

What is this?

A

herniated disc

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50
Q
  • Not all pain is what in the lower back?
  • What do you need to be careful of?
  • What does a disc protrusion need or not need?
A

Not all pain is a herniation, not all herniations cause pain!
* Be careful to correlate clinical findings with MRI findings – most patients develop asymptomatic herniations with age
* A “disc protrusion” on MRI does not necessary justify surgical intervention.

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51
Q

For a herniated disc, what test is positive? What is usually negative? What is necessary for evaluation?

A

Positive Straight leg raise (SLR), X-ray (negative usually), MRI is necessary for evaluation of soft tissue and is a gold-standard

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52
Q

What is the treatment for a herniated disc?

A

Physical therapy, NSAIDs, muscle relaxants, narcotics, for chronic pain: send the patient to a pain specialist—narcotic medications on a regular basis, intrathecal midazolam (versed), and epidural steroid injections
* Short course of steroids are beneficial initially

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53
Q

What are the indications for operative treatment for back pain?

A
  • Persistent treatment in spite of a reasonable course of nonoperative treatment
  • Profound or progressive motor deficit
  • Cauda Equina Syndrome
  • Intractable pain
  • Patient preference
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54
Q

Waddell signs=

A

Determines further imaging

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55
Q

Overview: What are the waddell signs for back pain? How many do you need positive for further imaging?

A
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56
Q

Waddell Signs
* What is superifical tenderness?
* What is non-anatomic tenderness?
* What is axial loading?

A
  • Superficial tenderness: Tenderness over a wide area of lumbar skin to light touch or pinch.
  • Non-anatomic tenderness: Deep tenderness over a wide area that crosses the over non-anatomic boundaries.
  • Axial loading: In axial loading patient stands and the examiner presses downwards vertically on the patient’s head, eliciting lumbar pain.
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57
Q

Waddell Signs
* What is acetabular rotation?
* What type of leg raise?
* What is regional sensory disturbance?

A
  • Acetabular rotation: The examiner rotates the shoulder and the pelvis passively in the same plane while the patient is standing. It is a positive sign if pain is elicited in the first 30 degrees of rotation.
  • Distracted straight leg raise
  • Regional sensory disturbance: The patient’s reports pain that follows a stocking-like disturbance and doesn’t follow a dermatomal pattern
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58
Q

Waddell signs
* What is regional weakness?

A

Weakness or cogwheel “giving away” that can’t be explained on neuroanatomical basis.

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59
Q

A 35-year-old professor complains of sudden left-sided low back pain that began when he picked-up and swung his 40-pound child yesterday. Pain is 6/10 constant worse with movement, relieved with Tylenol. He denies other trauma or fall. PMHx is unremarkable. He walks leaning forward slightly. HR is 80, BP is 110/60, T is 97.6. Paraspinal musculature is hypertonic and mildly tender. Straight leg raise is negative. Sensation is intact. Strength 5/5 in bilateral legs.

What is the most appropriate plan for this patient?
A. Plain AP back x-ray
B. MRI
C. Emergent Neurology consult
D. Symptomatic management and follow-up as needed
E. CT L-Spine

A

D. Symptomatic management and follow-up as needed

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60
Q

Ankylosing Spondylitis:
* What is the mechanism?
* What does it present as?
* What might it also involve?
* What is the incidence?
* What age ranges?
* What is the male to female ratio?

A
  • Mechanism: Chronic inflammatory disease of the axial skeletal joints,
    progressively ascending
  • Presents as intermittent diffuse low back pain and morning stiffness, with decreased ROM
  • Also may involve the aorta, lung and uvea (multi-system disease with hereditary component)
  • 1 in 1,000 incidence
  • Disease presents between ages 20-30
  • Male to Female ratio 3>1
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61
Q

Signs and symptoms of ankylosing spondylitis:
* Acute?
* Chronic?

A

Acutely —pain and stiffness, worst in the morning, improves throughout the day (similar to RA)
* SI joints are earliest involved
* Should be considered in young adult male with morning joint stiffness

Chronically—fusion and fibrosis of vertebrae with decreased ROM and progressive worsening if natural spinal curves, osteopenia starts to develop

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62
Q

Ankylosing Spondylitis:
* What is it associated with?
* What is a typical triad?

A
  • Associated with thoracic hyperkyphosis, painless joint effusions and restricted thoracic expansion
  • Hyperkyphotic curve, plantar fasciitis, inflamed costosternal joints – typical triad, though not all will be present in all patients
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63
Q

Ankylosing Spondylitis:
* What does the x rays show?
* What are the labs?
* What is the treament?

A
  • Tests: X-ray “Bamboo Spine” secondary to a fusion and generalized osteopenia,
  • Labs–elevated ESR, HLA B27+, (although specificity is low so it is not a screening test)
    * It is thought that the combo of this antigen and an exogenic component (Klebsiella or Chlamydia) trigger disease process
  • Treatment: Anti-inflammatories, physical therapy and exercise, oral or injected steroids, and surgery
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64
Q

What is this?

A

Ankylosing spondylitis

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65
Q

Again: what is the treatment of Ankylosing spondylitis?

A
  • Nothing prevents progression
  • Bracing helps with comfort early
  • NSAIDs, PT with emphasis on posture, extension exercises, and breathing exercises. Swimming is great!
  • May develop spinal cord compression requiring surgical intervention
  • Bony growth may necessitate surgical intervention
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66
Q

Spinal stenosis:
* What is the mechanism?
* What population it is more common?
* What is the most common cause of spinal stenosis?
* Inherited or degenerative?
* What spinal levels?
* What can it be assoicated with?

A
  • Mechanism: nerve compression caused by narrowing of the spinal canal, nerve root canal and intervertebral foramina
  • More common in men and women >50yr (most common in 60s)
  • Aging with secondary changes is most common cause of spinal stenosis
  • Inherited or degenerative
  • Can occur at single or multiple spinal levels
  • May or may not be associated with sciatica
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67
Q

Which type of spinal stenosis is non-dematomal pain and which one is dermatomal?

A
  • “Central” stenosis – bilat non-dermatomal pain
  • “lateral” - dermatomal
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68
Q

What are the signs and symptoms of spinal stenosis?

A

Signs and Symptoms: Persistent pain in arms and legs (exacerbated with walking or prolonged standing), pain relieved by leaning forward, decreased sensation, numbness, decreased ROM, and weakness

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69
Q

What is pseudoclaudication or neurogenic claudication? What is it relieved by?

A

“Pseudoclaudication” or neurogenic claudication- pain, even paresthesias in ambulation from compression of cord or nerves.
* Relieved by leaning forward

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70
Q

Spinal stenosis:
* What are some tests that can be done?
* What tests can rule out but not assure something?

A
  • Tests: H&P, X-ray (degenerative changes), CT, MRI, myelogram, Bone Scan
  • CT and MRI can rule OUT spinal stenosis but can not assure the visualized stenosis is causing patient symptoms
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71
Q

What is the treatment of spinal stenosis?

A

Treatment: Stretching and strengthening exercises, NSAIDs, analgesics, steroid injections, nerve blocks, braces, surgery (decompression and fusion)
* Percutaneous image-guided lumbar decompression(PILD) – “band-aid” surgery specifically for lumbar spinal stenosis caused by a thickening of a ligamentum flavum
* Surgical decompression in setting of neurogenic compromise

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72
Q

What are the different surgical options for spinal stenosis?

A
  • Laminectomy – most common, removal of lamina, bone spurs
  • Laminoplasty – lamina removed, plates and screws replace
  • Foraminotomy - decompression allowing room for nerve root exit
  • Interspinous Process Spacers – spacers placed between spinous processes to create room, also involves a partial laminectomy
  • Spinal fusion – reserved for patients with radicular pain, or unstable spine and if other options have not been effective. Long recovery.
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73
Q

Spine trauma:
* Early _
* Early _
* 85% of c-spine injuries are due what?
* What do you need to stabilize and identify?
* What do you need to presume?
* What should you suspect with a head and brain trauma?
* What should you perform?
* What orders needs to be done?
* Immediate _ consult

A
  • Early recognition
  • Early immobilization
  • 85% of c-spine injuries are due to MVAs, many multi-trauma
  • Stabilize neck, identify life-threatening injuries
  • PRESUME a spinal cord injury with multi-trauma
  • Suspect a spinal cord injury with head/brain trauma
  • Perform impeccable neurologic exam to include sensory
  • CT or MRI – whichever is available fast
  • Immediate neuro consult
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74
Q

What are the most common spinal cord syndromes?

A
  • MVA 41%
  • Falls 13%
  • Firearms 9%
  • Recreation 5%
  • Tintinalli, EM 4th Ed., P. 1147
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75
Q

For complete v partial cord syndromes, when can the prognosis be made?

A

Prognosis cannot be made until spinal shock has resolved , about 24 hours

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76
Q

What does complete and partial cord injuries result in?

A
  • Complete cord injury results in paralysis distal to the lesion
  • Partial cord injuries will have “some degree of recovery”- Tintinalli
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77
Q
A
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78
Q

What happens in an anterior cord injury?

A

Motor paralysis below the lesion, loss of pain and temperature, preservation of sensation, proprioception and vibratory sense

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79
Q

What is the result from a central cord injury? What usually causes this injury?

A

Central Cord (usually from hyperextension, spondylolisthesis, or stenosis)
* Weakness, loss of pain in the upper extremities worse than in lower (Good prognosis)

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80
Q

What happens in a posterior cord injury?

A

Posterior Cord – aka posterior spinal artery syndrome damaging dorsal columns
* Loss of vibration, proprioception and fine touch

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81
Q

What is happening with brown sequard injury?

A

Contralateral symptoms explained by decussating fibers at nerve roots and medulla
* Ipsilateral weakness, loss of proprioception and vibratory; Contra-lateral loss of pain and temperature

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82
Q

What is not a true cord syndrome? What are the characterics

A

Cauda Equina (not a true cord syndrome)
* motor and sensory loss in legs, sciatica, bowel/bladder dysfunction and “saddle anesthesia”

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83
Q

A 52-year-old steelworker, regular patient with chronic low back pain
calls the office in a panic suddenly developed “saddle” distribution numbness, and urinary bladder incontinence after lifting.
* Your next step would be?
1. Immediate surgical consult
2. Urology consult
3. Muscle relaxers and analgesic medication
4. Psych consult
5. Massage referral

A
  1. Immediate surgical consult
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84
Q

Cauda Equina Syndrome:
* What does the cauda equine composed of?
* What is the mechanism of this issue?
* What are the casues?

A
  • Composed of lumbar, sacral and coccygeal nerve roots
  • Mechanism: Rare condition involving large midline disc herniation that compresses several nerve roots, usually at L4-L5 level
  • Causes: trauma, lumbar disc disease, abscess, spinal anesthesia, tumor, metastatic disease, late stage ankylosing spondylitis, and idiopathic
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85
Q

Cauda Equina Syndrome
* What are the signs and symptoms?
* If there is back pain, what do you always need to ask about?
* What do you need to look for?

A
  • Signs and Symptoms: low back pain, unilateral and more likely bilateral sciatica, saddle anesthesia with poor rectal tone, bowel/bladder incontinence or urinary retention, lower extremity motor and sensory loss
  • Back pain, Always ask about bowel and bladder incontinence! Do a rectal and note tone.
  • Clinical PEARL – Look for risk factors for epidural hematoma or abscess
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86
Q
  • What is the classic clinical finding of Cauda Equina Syndrome?
  • What is the gold standard diagnostic study?
A
  • Saddle anesthesia
  • MRI
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87
Q

Cauda Equina Syndrome:
* What are the tests usually done?
* What is the treatment?

A
  • Tests: X-ray (usually normal), MRI of the thecal sac is preferred, lumbar myelogram, post-void residual (urinary retention=neurogenic bladder)
  • Treatment: Emergent ortho referral. Pain control, high dose corticosteroids is standard, laminectomy to decompress the posterior spine has variable support
  • Admission with immediate consults to neurosurgeon, neurologist and orthopedist
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88
Q

Use the picture to explain cauda equina syndrome?

A
89
Q

Pectus Excavatum:
* What is it?
* When does this present?
* Where can the deformity be?

A
  • An abnormal development of the rib cage, in which the breastbone caves in, causing the chest to “sink” inward.
  • This developmental abnormality often presents at birth, and can be mild or severe.
  • Although the sunken chest wall deformity is most common in the middle of the chest, it may move to one side of the chest, usually the right.
90
Q

Most patients with pectus excavatum do not have symptoms, though a minority of patients may have what symptoms?

A

1.Fatigue
2.Shortness of breath/decreased exercise tolerance
* Creates restrictive lung disease

3.Chest pain
4.Fast heart rate (tachycardia)

91
Q

What are the four risk factors of Pectus excavatum? Define them

A

Marfan Syndrome
* A connective tissue disorder, which causes skeletal defects.
* Is typically recognized by long limbs and ‘spider-like’ fingers, chest abnormalities and spine curvature. High risk of mortality from aortic rupture.

Rickets
* Due to a lack of vitamin D or calcium and from inadequate sunlight exposure, which destroys normal bone growth.
* This primarily occurs in children

Scoliosis: This is the curvature of the spine

Asthma dt use of accessory muscles

92
Q

What is this?

A

Marfan syndrome

93
Q

What are the diagnostic tests for symptomatic patients with pectus excavatum ?

A

1.Complete Physical Exam
2.Comprehensive Blood Tests, such as chromosome studies or enzyme in assays
3.Physical (stress) Tests
4.Chest x-ray
5.CT scan of the chest
6.Electrocardiogram (EKG)
7.Echocardiogram (picture of the heart)

94
Q

Pectus excavatum treat only needs surgery if heart and lungs are compromised. Explain the process of surgery

A

The primary goal of pectus excavatum repair surgery is to correct the chest deformity to improve a patient’s breathing, posture and cardiac function. Removing a portion of the deformed cartilage and re-positioning the breastbone typically accomplishes this. Repair of pectus excavatum is not recommended unless the patient has symptoms.
1.Risks of Surgical Repair Pneumothorax (accumulation of air or gas in the pleural space)
2.Bleeding
3.Pleural effusion (fluid around the lungs) 4.Infection
5.Pectus excavatum recurrence

95
Q

Shoulder pain:
* What can it be referred by?
* Encompasses may etiologies like what?

A
  • Can be referred by cervical spondylosis
  • Encompasses many etiologies including MSK, malignancy, inflammatory, endocrine, infectious etc.
96
Q

What is frozen shoulder and who is it most commonly seen in?

A
97
Q

Frozen shoulder:
* What is decreased?
* When is pain worst?
* In sling users, when do symptoms starts? What do you need to do with your sling users?
* What is the tx?

A
98
Q

Shoulder dislocation:
* Injury of what?
* What is a shoulder dislocation?
* What is the mechanism?

A
  • Injury of the glenohumeral joint
  • Displacement of the head of humerus outside glenoid fossa of the scapula
  • Mechanism: Combination of abduction, extension, and a posteriorly directed force to the arm
99
Q

Shoulder Dislocation:
* What are the S/S?
* What do you need to do during the physical exam?
* When is x-ray used?

A
  • Signs and Symptoms: Pain, Prominent acromion due to lack of humeral head in glenoid fossa, the deltoid muscles do not look rounded
  • PE Check shoulder patch sensation and deltoid strength for axillary nerve dysfunction (40%, resolves)
  • X-ray: sometimes pre and post reduction, AP, Y and axillary view
    * NV testing pre and post reduction as well
100
Q

What are these 3 different dislocations?

A
  • Most are anterior.
  • Most posterior are due to electrocution or seizures.
101
Q
  • What does evidence show for shoulder reduction?
  • What might be necessary during the reduction?
  • How long does the patient need to be immobilized for?
A
  • Evidence does not favor one reduction technique. Patients tolerate scapular manipulation well.
  • Sedation may be necessary, encourage patient to relax shoulder
  • Immobilization 3 weeks for the <30yo, less for >30yo (to prevent frozen shoulder)
102
Q

What are the two tests for recurrent dislocations? Explain them

A
  • Apprehension test- patient is supine, arm is abducted to 90 degree and externally rotated. If the patient expresses apprehension, it is positive
  • Jobe’s relocation test is with apprehension test. If the patient expresses apprehension, apply pressure to anterior humeral head. + If it relieves apprehension, (the patient feels shoulder is supported and it will not dislocate).
103
Q

Dislocation complications:
* What is the most common?
* What are the two types of lesions?
* When does nerve dysfunction resolve?

A
  • Most common is recurrent dislocation, probably from a loosened Labrum.
  • Bankart lesion is a loosened/fractured glenoid labrum, sometimes with boney detachment
  • Hill-Sachs lesion is a break in anterior humeral head cortex from contact with the inferior labrum
  • Nerve dysfunction usually resolves after reduction
104
Q

What is this?

A

Hill sachs lesion

105
Q

What is this?

A

Bankart lesion

106
Q

What PE test can help determine if a patient has the most common complication of shoulder dislocation?
1. Drop arm
2. Impingement
3. X-ray
4. Apprehension
5. Speed’s Test

A

Come back

107
Q

Shoulder separation:
* What is it?
* What is the mechanism?

A
  • Injury of the acromioclavicular joint (AC and/or coracoclavicular ligaments)
  • Mechanism: Falling on the Shoulder, or exclusively trauma to shoulder
108
Q

Shoulder separation:
* What will present in the physical exam? What PE test can you do?
* What are some tests you can order?

A
  • PE: Tender AC joint
  • “Crossover test” causes AC compression, pain
  • Tests: X-ray comparing 2 sides with internal rotation, sometimes with weightbearing
109
Q

What are the 6 degrees of AC separation

A
  • Type 1 sprain
  • Type 2 AC disruption
  • Type 3 25-100%increase in space compared to contralateral side
  • Type 4 posterior displacement of clavicle into trapezius
  • Type 5 Partial tear of deltoid and trapezius, acromioclavicular space >2X
  • Type 6 decreased acromioclavicular space with clavicle inferiorly displaced
110
Q

What are the treatments of AC separation based on the different types?

A
  • Type I: RICE, ROM exercises
  • Type II, III: Sling use for 1 week, RICE, ROM exercises
  • All others: likely surgical
111
Q
  • A 14-year-old boy was playing tackle football and was hit on his anterior left shoulder. Now it hurts and he is reluctant to move it. The clavicle is nontender and not deformed or displaced.
  • What is the next best step in diagnosis of this patient? 1. Figure 8 dressing
    2. Bilateral AP X-ray
    3. Arm drop test
    4. Tin can test
    5. CT scan
A

Come back

112
Q

Shoulder Impingement Syndrome:
* What is it?
* What are risk factors?
* What are the symptoms?
* What tests would be positive?
* What is the treatment?

A
  • Compression of tissues through the exiting area on the shoulder.
  • Risk – overuse, overhead activity (mechanic, construction, volleyball, tennis, swimmer)
  • Sxs – pain with overhead activity, pain waking you up at night, atrophy of muscles affected.
  • Neer impingement test or Hawkings test are positive.
  • Tx: RICE, NSAIDs, PT, up to 3 injections to shoulder if no improvement.
113
Q

What is reduced in shoulder impingement syndrome?

A
114
Q

What are the rotator cuff muscles? What do each one of those muscles do?

A
  • supraspinatus most commonly injured, an abductor
  • Infraspinatus and teres minor, external rotators
  • Subscapularis, reinforces anterior capsule
  • Teres minor
115
Q

Rotator Cuff Tears:
* Injury to the SITS muscles typically occur how?
* What is the most likely the reason for presentation of symptoms?

A

Injury to SITS muscles typically occurring from eccentric overload (Throwing objects), underlying glenohumeral instability, poor muscle strength and training errors
* impingement of the supraspinatus tendon as it passed beneath the subacromial arch is the most likely presentation of symptoms

116
Q

Rotator cuff tears:
* What is the mechanism?
* What are the S/S?
* What are tests that can be done?
* What is the treatment?

A
  • Mechanism: poor vascularity, trauma, overuse, overhead activity
  • Signs and Symptoms: Deep pain, often at night, pain with ROM
  • Tests: Physical exam techniques??? US, X-ray, MRI is the best test
  • Treatment: Analgesics, sling, referral, surgery with decompression
117
Q

How does the arm drop test work? What will happen if the patient ahs a rotator cuff tear?

A
  • Start with the patient’s arm abducted 90 degrees.
  • Ask the patient to slowly lower the arm.
  • With a rotator cuff tear, the patient will be unable to lower the arm slowly and smoothly.
118
Q

Lateral epicodylitis:
* What is the mechanism?
* What is another term?
* What are the S/S?
* What is are the tests that are ordered/preformed? Explain how to do it?
* What is the treatment?

A
119
Q

Medial Epicondylitis:
* What is the mechanism?
* What is also called?
* S/S?
* What are tests that can be done?
* What is the treatment?

A
120
Q

Bicipital Tendinitis:
* What is the mechanism?
* What are the S/S?
* How do you diagnosis this?
* What is the treatment?

A
  • Chronic extension force against flexed elbow
  • Signs and Symptoms: bicipital tendon tenderness and sometimes rupture (POPEYE) maybe seen of both tendons are involved
  • Dx: Xray to r/o other pathology or an US to evaluate the tendons
  • Tx: Surgery in case of rupture, RICE/Sling and later PT in case of tendinitis
121
Q

Olecranon bursitis:
* S/S?
* What imaging is done?
* What is the treatment?
* What is not common?
* What do you need to leave alone?

A
  • S/S: Swelling in that region with mild pain; ROM is good.
  • Imaging: Nothing unless fracture is suspected
  • Treatment: activity modification, ACE wrap for compression. Aspiration of the bursa not recommended unless infection is suspected.
  • NSAIDs and warm compresses
  • Surgery to remove bursa not common
  • Leave asymptomatic masses alone unless they restrict movement

Usually from fall

122
Q

Nursemaid elbow:
* What is it?
* What is it caused by? What is it usually caused by?
* When does it occur?

A
  • Subluxation of head of radius from the annular ligament
  • Mechanism: Caused by traction along the long axis of the arm
  • Child usually being pulled by the hand and will not move the elbow
  • Can occur from birth to 6 y/o, most common 1-4 yrs.
123
Q

How do you fix nursemaid’s elbow?

A

Supinate, flex and extand arm super fast

124
Q

Nursemaid’s Elbow:
* How will the child present during the PE?
* What are the tests?
* What is the treatment?
* What will happen with child after reduction? What do you need to do?

A
  • Child won’t use affected arm and may or may not have tenderness over radial head, but tenderness is elicited upon pronation/supination
  • On exam, child will be holding arm in slight flexion and pronation
  • Tests: X-rays are normal
  • Treatment: Reduction by flexion and supination of the forearm
  • Child will immediately use arm
  • Watch child for 15-30 minutes before discharge home
125
Q
  • A 30-year-old female presents for cast removal following supracondylar fracture. Fracture occurred 6-months prior but patient was lost to follow-up.
  • What’s going on with this patient?
A

Volkmann contracture

126
Q

Volkmann Contracture:
* When does this occur?
* What do you clinically see? What are typical causes?

A
  • Typically develops as a result of ischemia from missed compartment syndrome or vascular injury.
  • Clinically see: permanent shortening of forearm muscles, that gives rise to a clawlike deformity of the hand, fingers, and wrist.
    * Supracondylar, ulnar or radial fractures are typical causes
127
Q

Volkmann Contracture:
* How do you diagnosis?
* What is the treatment for mild, moderate, severe?

A

Dx: Imaging to visualize shortening

Tx:
* Mild - Dynamic splinting, physical therapy, tendon lengthening, and slide procedures
* Moderate - Tendon slide, neurolysis, and extensor transfer procedures
* Severe - More extensive and radical intervention is required, often involving extensive debridement of damaged muscle with multiple releases of scar tissue and salvaging procedures

128
Q

Explain the clinical picture of the forearm?

A
129
Q

Cubital Tunnel Syndrome:
* What is it?
* How do you diagnosis it?
* What is treatment?

A
  • Compression of ulnar nerve at elbow leading to paresthesias, wasting, weakness.
  • Dx with combined elbow flexion and pressure, electromyography.
  • Tx symptomatically.
    * Decompression surgery if severe symptoms.
130
Q

Carpal Tunnel Syndrome:
* What is the mechanism?
* What is cause?
* Who it is common in?
* What are the S/S?

A
  • Mechanism: Inflammation of the carpal canal, resulting in compression of median nerve
  • Repetitive wrist flexion (computer use, assembly line worker)
  • Common in women, pregnancy, diabetes
  • Signs and Symptoms: Paresthesias in median nerve distribution, Pain may radiate from anterior flexor retinaculum to entire arm.
131
Q

What are the Physcial Exam tests can you do for carpal tunnel?

A
  • Positive Phalen’s and Tinel’s sign
  • Positive Flick signal= patient flicks hand as if shaking down a
    thermometer to relieve symptoms
  • Thumb abduction test=the abductor pollicis brevis is innervated by the median nerve only. Weakness is associated with CTS
132
Q

What is the rate of false postives with phalens and tinels sign?

A
133
Q

What is the manual compression test? What is the sensitivity and specificity?

A
  • Apply pressure over transverse carpal ligament for 30 seconds.
    • if pain/ paresthesias
  • 64% sensitivity
  • 83% specificity
134
Q

What is another test for carpel tunne?

A

Nerve Conduction Velocity Test

135
Q

What is the treatment for carpal tunnel syndrome?

A
  • Conservative at first: volar or cock-up wrist splinting at night or all day, NSAIDs, rest from repetitive movements
    * Corticosteroid injections if conservative therapy fails
  • Surgical: “Release” has 15-20% failure rate. Now available endoscopically. For intractable cases only.
136
Q

De Quervain’s Tenosynovitis:
* What is it?
* What is the mechanism?
* What does it involve?

A
  • Stenosing Tenosynovitis in which the synovial lining of the tunnel becomes inflamed and hurts with movement.
  • Mechanism: Excessive use of the thumb
  • Involves the tendons of 2 muscles—extensor pollicis brevis and abductor pollicis longus

Usually seen in golfers and tennis players

137
Q

De Quervain’s Tenosynovitis:
* What are the S/S?
* What is a physical exam test that can be done?
* What are tests that can be done to diagnosis?
* What is the treatment?

A
  • Signs and Symptoms: Pain, tenderness, redness, swelling at side of wrist beneath base of thumb
  • Positive Finkelstein test—pain when thumb is folded across palm and fingers are flexed over thumb as hand is pulled away from wrist
  • Tests: Excellent history and physical exam (common postpartum when lifting a child)
  • Treatment: Thumb and wrist splinting (thumb spica splint), NSAIDs, steroid injections, surgery to decompress first dorsal compartment if severe
138
Q

For the finkelstein’s test, what muscles are being pulled on?

A
139
Q

What is the issue with these two?

A
140
Q

Intersection syndrome:
* What is it?
* What will patients have a history of?
* Where is the pain?
* What is the treatment?

A
  • Is inflammation of the crossover point of the abductor pollicis longus and extensor pollicis brevis with the extensor carpi radialis longus and brevis.
  • Patients have a history of overuse (rowing/pulling/weight lifting). Pain is worse with wrist motion.
  • Pain, edema and crepitus 4 to 8 cm proximal to radial styloid is pathognomonic
  • Splint wrist in 15 degrees extension, rest, Rx NSAIDs for 2 to 3 weeks. PT extensor strengthening
141
Q

What are the muscles involved in intersection syndrome?

A
142
Q

Gamekeeper’s thumb:
* What is it?
* What is the most common cause?
* Why is it important?
* What is the dx test?
* What is the treatmetn?

A
  • Valgus Injury of Ulnar collateral ligament of thumb at medial proximal phalanx/MCP joint.
    * The injury occurred as the gamekeepers sacrificed game such as rabbits by breaking the animals’ necks between the thumb and index finger of the gamekeeper and the ground.
  • Nowadays, MCC is from ski poles injuries. (dt hyperext.)
  • Important because it affect pincer function and opposition function.
  • Dx: MRI
  • Tx: Thumb Spica, RICE, NSAIDs
143
Q

Ganglion cyst:
* What is it refer as?
* Most develop how?
* The cyst are almost always filled with what?
* Treatment?

A
  • Some refer to it as Bible Bump
  • Most develop spontaneously and are idiopathic
  • Cyst are almost always filled with pure hyaluronic acid
  • Treat only if they are troublesome
144
Q

Hip joint:
* Explain the joint?
* What is the irony?

A
  • Ball of the femur and acetabular socket of the pelvis
  • Irony – neither a fracture of the ball of the femur (femoral head) or the acetabular socket is considered a “hip fracture”
    * Hip is a joint, not bony landmark
145
Q

Trochanteric Bursitis:
* What is it?
* What is it caused by?
* What can we do for analysis? What is txt?

A
  • Pain over superficial greater trochanter which may radiate over to lateral thigh. Hip joint is not involved.
  • Caused by repetitive trauma.
    * Differentiate from ischiogluteal bursitis (from sitting).
  • May aspirate for analysis, but usually Tx is symptomatic with NSAIDs
146
Q

Meralgia Paresthetica:
* What is it due? Common in who?
* What will the PE of the leg be like? What can it be caused by?
* What relieves the symptoms? What aggravates symptoms?
* What is the tx?

A
  • Due to entrapment of lateral femoral cutaneous nerve.
    * Common in DM/obese and pregnant pt’s – see pain,
    paresthesia and numbness in the LATERAL portion of thigh
  • Exam of the leg will be normal. Can be caused by wearing low cut jeans. Can be bilateral in 20% of cases.
  • Sitting tends to relieve Sxs. Walking/Standing aggravates Sxs. Hyperextension of thigh or deep palpation may aggravate Sxs also.
  • Tx – Wt loss and neuro meds for nerve pain
147
Q

Slipped capital femoral epiphysis (SCFE):
* What is it?
* Most common what?
* What is the prevalence?
* What is the mean age of presentation? that is the male to female ratio? What is a significant risk factor?

A
  • SCFE is a displacement of the capital femoral epiphysis from the femoral neck through the physeal plate (SH1).
  • Most Common adolescent hip disorder
  • Prevalence: 10 cases/100,000 persons
  • The mean age of presentation is 12yo in females and 13.yo in males, near the time of peak linear growth. The male-to-female ratio is approximately 1.5:1. Obesity is a significant risk factor. African- American and athletes are a risk factor.
148
Q

Slipped Capital Femoral Epiphysis:
* What do you clinically see?
* What is the classic presentation?

A

Clinically see pain and altered gait (limp). The classic presentation is that of an obese adolescent with a complaint of non-radiating, dull, aching pain
* hip, groin, thigh, knee or groin
* Increased with physical activity
* no history of preceding trauma.
* It is important to remember that knee pain in the child can be secondary to hip disease.

149
Q

What is present on the PE of slipped capital femoral epiphysis?

A

On physical examination, there is frequently limitation of motion, especially internal rotation and abduction. As the examiner flexes the hip, it moves into external rotation and the patient often holds the leg externally rotated when standing.

150
Q
A

slipped capital femoral epiphysis

151
Q

What is acute, chronic and acute on chronic of slipped capital femoral epiphysis?

A
152
Q

What is trendelenburg? What is the primary musculature involved?

A

Trendelenburg gait is an abnormal gait resulting from a defective hip abductor mechanism. The primary musculature involved is the gluteal musculature, including the gluteus medius and gluteus minimus muscles. The weakness of these muscles causes drooping of the pelvis to the contralateral side while walking.

153
Q

Slipped Capital Femoral Epiphysis:
* What is on x-ray? What is needed if x-ray is normal?
* What is the treatment?
* Who will eventally have SCFE in contralateral hip?
* What are the complications of SCFE?
* The prognosis of SCFE is related to what?

A
154
Q

Who with SCFE regardless of classification should be admitted to an orthopedic surgeon?

A

Children with SCFE, regardless of classification, should be referred promptly or admitted to an orthopedic surgeon; they must avoid bearing weight until they have undergone orthopedic evaluation.

155
Q

Slipped Capital Femoral Epiphysis
* What is the klein line?
* How can you determine whether Klein line is present?

A
  • Klein Line = “Arbitrary line along superior edge of femoral neck”
  • Determine whether Klein Line is present—on A/P view, a line drawn along superior border of femoral neck should pass through a portion of the femoral head; if not, SCFE is diagnosed
156
Q

What is the vascular supply around the femoral neck

A
157
Q

Osteonecrosis:
How many people in the US get ON? What is the percentage of it being the underlying dianosis in all total hip replacements in the US?
Most experts believe that it is the result from what?
What are the risk factors?

A
158
Q

Avascular Necrosis:
* Most commonly involves what? What is it usually caused by? Less frequently with what?
* When does necrosis happen?
* Non-traumatic AVN occurs in who?

A
  • Most commonly involves the femoral head. It is usually caused by trauma, typically occurring after a displaced femoral neck fracture and less frequently after a fracture-dislocation of the hip.
  • Necrosis results when the vascular supply to the femoral head is disrupted at the time of injury.
  • Non-traumatic AVN occurs in a younger population and is commonly bilateral.
159
Q

What is the name of the artery with the Blue arrow?
1. Retinacular
2. Medial circumflex
3. Profunda femoris
4. Lateral circumflex femoral
5. Acetabular branch of the femoral (foveolar)

A

Acetabular branch of the femoral (foveolar)

160
Q

What is the most common presenting symptom of osteonecrosis is pain?

A

1.Groin pain is most common in patients with femoral head disease, followed by thigh and buttock pain.
2.Weightbearing or motion-induced pain is found in most cases.
3.Pain in the absence of activity (ie, rest pain) occurs in approximately two-thirds of patients, and nocturnal pain occurs in one-third. When an extremity is affected, the position of the limb (eg, elevated, dependent) does not alter the pain.
4.Although rare, pain in multiple joints suggests a multifocal process.

161
Q

Avascular Necrosis Tests:
* What is the gold standard?
* What is normal in early stage?

A
  • The Gold Standard is MRI w/o contrast, bone scan.
  • The X-ray in early stage is normal, late stage may show changes.
162
Q

What are the two approaches of treatment with avascular necrosis?

A
163
Q

Legg-Calve-Perthes Disease:
* What is it?
* What is the etiology?
* What is the incidence most common
* How is the pain?

A
  • A slow Unilateral osteochondrosis of femoral head (i.e. avascular necrosis)
  • Etiology idiopathic. 10% Familial (delayed bone age)
    * Most commonly see in kids
  • Incidence at 5-10yo, more common in boys
  • Gradual onset pain that progresses and worsens to severe pain.
164
Q

Legg-Calve-Perthes Disease:
* What is the gold standard?
* What is txt?

A
  • MRI is Gold standard with Bone SCAN.
  • Biphosphonates have been found effective with splinting and immobilization, but eventual surgery will likely be required
165
Q

What is developmental dysplasia?

A

Developmental dysplasia = Congenital Hip Dislocation

166
Q
  • In all cases of DDH, the socket (acetabulum) is what?
  • What can be loose?
A

In all cases of DDH, the socket (acetabulum) is shallow, meaning that the ball of the thighbone (femur) cannot firmly fit into the socket. Sometimes, the ligaments that help to hold the joint in place are stretched. The degree of hip looseness, or instability, varies among children with DDH.

167
Q

DDH:
What is dislocated, Dislocatable, Subluxatable?

A

1.Dislocated. In the most severe cases of DDH, the head of the femur is completely out of the socket.
2.Dislocatable. In these cases, the head of the femur lies within the acetabulum, but can easily be pushed out of the socket during a physical examination.
3.Subluxatable. In mild cases of DDH, the head of the femur is simply loose in the socket. During a physical examination, the bone can be moved within the socket, but it will not dislocate.

168
Q

DDH:
* Tends to run in _
* What hip is usually affects and what groups of people is it in?

A
169
Q

What are the symptoms of DDH?

A
  • Some babies born with a dislocated hip will show no outward signs.
  • Contact your pediatrician if your baby has:
  • Legs of different lengths
  • Uneven skin folds on the thigh
  • Less mobility or flexibility on one side
  • Limping, toe walking, or a waddling gait
170
Q

Congenital Hip Dislocation:
* What cannot diagnose this until 3 months of age?
* What can be done on all infants?
* What happens if it is not diagnosed and treated before the child begins to walk?

A
  • X-rays cannot diagnose this until 3 months of age
  • Ortalani and Barlow maneuvers must be done on all infants and documented as +or-
  • If it is not diagnosed and treated before the child begins to walk, it is not corrected by conservative means, and may result in permanent disability
171
Q

What is the most common successful lawsuit against pediatricians, that is completely preventable by a good PE?
1. Down’s syndrome
2. Congenital hip dislocation
3. Breech birth
4. Autism
5. Torticollis

A

Congenital hip dislocation

172
Q

What is the barlow and ortolani test?

A
173
Q

Congenital Hip Dislocation:
* What is the txt for newborns?

A
  • Newborns are placed in a soft positioning device, a Pavlik harness, for 1 to 2 months to keep the thighbone in the socket. This special brace is designed to hold the hip in the proper position while allowing free movement of the legs and easy diaper care. The Pavlik harness helps tighten the ligaments around the hip joint and promotes normal hip socket formation.
  • It is usually worn full-time for at least 6 weeks, and then part-time for an additional 6 weeks.
174
Q

Congenital Hip Dislocation:
What is the txt for 1m to 5m olds?

A
  • Similar to newborn treatment, a baby’s thighbone is repositioned in the socket using a harness or similar device. This method is usually successful, even with hips that are initially dislocated.
  • If the hip will not stay in position using a harness, you may try an abduction brace made of firmer material that will keep baby’s legs in position.
  • In some cases, a closed reduction procedure is required, followed by a body cast (spica cast-pic) to hold the bones in place. This procedure is done while the baby is under anesthesia.
175
Q

Congenital Hip Dislocation:
What is the txt for 6m to 2year olds?

A
  • Most are managed by spica casting.
  • Open Surgical Treatment is necessary if closed reduction is not successful. In some cases, the thighbone will be shortened in order to properly fit the bone into the socket. Spica cast is then again applied.
176
Q

What is genu varum and valgum?

A
177
Q

Knee Effusion:
* What is it?
* What are the several tests that can help evaluate this?
* _ cyst
* What is the differential diagnosis?

A
  • “Water on the knee” is increased synovial fluid in the joint.
  • Several tests help evaluate this:
    * Balloon
    * Ballottement
    * Bulge
  • Baker’s Cyst
  • DDx of someone with knee effusion includes internal derangement, inflammation, infection
178
Q

What is the bulge sign?

A

Gently press just medial of the patella, then move the hand in an ascending motion. Then press firmly on the lateral aspect of the knee. Commonly, no fluid will be appreciated. A medial aspect that ‘bulges’ out after lateral pressure (positive “bulge sign”) is consistent with a moderate amount of fluid.

The presence of bulge sign identifies individuals at increased risk of frequent knee pain, progression of ROA and TKR.

179
Q

What is a ballottement?

A

Patella tap test or ballottement test is used to examine the knee swelling or knee effusion. This test is also know as dancing knee sign.

Place patient in supine position and knee extended. Clinician’s one hand is push down front of the leg to the top of the patella this moves any fluid in the thigh to the knee. Then you need to keep pressure on with other hand gently tap over the patella. Positive sign when floating or bouncing of patella occurs and indicates knee joint effusion. Always compare with normal side or opposite side.

180
Q

Baker’s cyst:
* What is another name?
* What does it result from?

A
  • “Popliteal cyst”
  • Results from knee effusions – path of least resistance
181
Q

Chondromalacia Patella:
* What can is also be called?
* What group is affected?
* What is broken down?
* Where is the pain?

A
  • AKA Patellofemoral Pain or Runner’s knee mm
  • 60% are women due to pelvis widening
  • The softening and breakdown of the tissue (cartilage)
    on the underside of the patella
  • Pain may refer locally or to posterior knee. Crepitus maybe presen
182
Q

Chondromalacia Patella:
* What increases the risk?
* What is diagnosis by?
* What type fo patellar tracking?
* What is treatment?

A
  • Risk = aggressive physical training, obesity, weak Quadriceps
  • Dx by apprehension test – at 30 degree bend push patella laterally and look for patient apprehension signs.
  • Non-linear patellar tracking.
  • Tx with RICE NSAIDs for pain and PT = Quadriceps strengthening
183
Q

Knee meniscal injuries:
* What is it caused by?
* What meniscal injury the most common?
* Usually with what?

A
  • Excessive rotational force of the femur on the tibia
  • Medial most commonly affected
  • Usually with other ligamental injuries
184
Q

Meniscus Tear:
* What are the signs and symptoms?
* What are the tests that can be done?
* What is the treatment?

A
  • Signs and symptoms: pain on joint line on the side of injury, “clicking”, “locking”-inability to extend knee, effusion, and joint line tenderness
    * Pain and effusion are often delayed a day after injury
  • Tests: MRI, positive McMurray/Apley sign
  • Treatment: analgesics, knee immobilization, conservative vs. surgical intervention
185
Q

Cruciate Ligament Tear:
* What does the cruciate ligament provide?
* What may we see?
* Is ACL or PCL more common?
* What is the mechanism of injury?

A
  • Provides anterior/posterior stability
  • May see partial or complete tear (grade 3 sprain) from pivoting motion during running, jumping, or other sports
    * Injury is considered a sprain
  • ACL is more common than PCL
  • MOI = abrupt stopping/twisting of knee
186
Q

Cruciate Ligament Tear:
* What are the signs and symptoms?
* What are tests that can be done for diagnosis?
* What is treatment?

A
  • Signs and Symptoms include pain, swelling, hemarthrosis and instability
  • Dx: MRI, Drawer test, Lachman test
  • Treatment: RICE, knee immobilizer, analgesics,
    surgery
187
Q

Knee dislocation:
* What artery is at risk? What should be evaluated?

A
  • Popliteal artery is at risk for injury whenever a patient sustains a posterior dislocation of the knee and should be evaluated with an arteriogram despite the presence of pedal pulses.
  • Alternatively, CTA with Runoff can be performed in ER
188
Q

Knee Dislocation:
* What are the s/s?
* Why must you perform a thorough vascular exam?

A
189
Q

Traumatic Extensor Knee Injuries:
* Common or rare?
* What does it usually involve?
* What is the highest risk factors?
* What is clinically seen?

A
  • Rare (1.67 per 100,000)
  • Usually involve quadriceps contraction against a flexed knee, such as when a patient is attempting to regain balance after a fall, jumping, or missing a step on the stairs
    * Patellar ligament is often involved
  • Highest risk factors: CTD disease (Ehlers-Danlos, lupus, RA &
    Marfans)
  • Clinically see lateral dislocation (most common) or inferior patellar displacement (patella baja)
190
Q

Traumatic Knee Extensor Injuries:
* How do you diagnosis?
* What is the treatment?

A
  • Dx: clinical, but get a sunrise view knee xray or an US.
    • CT is some cases when other injuries are suspected
  • Tx: preserve extensor function (Splint) and consult surgeon
191
Q

Osgood Schlatter (OS) Disease:
* What is it?
* What is it caused by?
* When does OS disease occur most frequently?
* What is the most common presenting complaint?

A
  • Osgood-Schlatter’s Disease = Osteochondritis of tibial tuberosity = Tibial tuberosity avulsion
  • OS disease is an overuse injury caused by repetitive strain and chronic avulsion of the secondary ossification center of the tibial tubercle, which then heals and repeatedly reavulses.
  • Osgood-Schlatter occurs most frequently in participants of sports that involve running, cutting, and jumping and who have recently undergone a rapid growth spurt.
  • The most common presenting complaint is anterior knee pain that increases gradually over time; the pain is exacerbated by direct trauma, kneeling, running, jumping, squatting, climbing stairs, or walking uphill, and is relieved by rest.
192
Q

What is this?

A

Osgood-Schlatter’s Disease

193
Q

Osgood-Schlatter:
* How is it diagnosised?
* When is pain worst?
* Imaging?
* What may be evident 3-4 weeks following onset?

A
  • The diagnosis is made clinically. The characteristic findings are tenderness and soft tissue or bony prominence of the tibial tubercle
  • Pain is exacerbated by knee extension and squatting.
  • Initial imaging may be normal
  • Bone fragmentation maybe evident 3-4 weeks following onset
194
Q

Osgood Schlatter disease:
* When does symptoms generally do?
* Conservative measures are what?
* When should sports be continued?
* What is PT for?
* What is not common?
* What is prognosis?

A
  • Osgood-Schlatter disease usually is a benign and self-limited condition. Symptoms generally resolve once the growth plate is ossified.
  • Conservative measures are the mainstay of therapy. RICE, NSAIDs, stretching
  • Continued sports participation, provided that the pain can be tolerated and resolves within 24 hours.
  • Physical therapy to strengthen the quadriceps and stretch the quadriceps and hamstrings.
  • Surgery is not common.
  • Prognosis is great and resolves when epiphyseal plates close.
195
Q
  • A 13-year-old male complains of bilateral knee pain. There is no history of trauma. Examination reveals tenderness directly over the enlarged tibial tuberosity. X-rays show bilateral fragmentation of the tibial tubercle apophysis. Which of the following is most likely on history and physical examination?
    1. Hop and knee pain that is worsened with internal rotation
    2. Knee instability and buckling
    3. Knee pain that is exacerbated by descending stairs
    4. Increased pain when walking on flat surfaces
    5. Popliteal tenderness
A

Knee pain that is exacerbated by descending stairs

196
Q

Bursitis:
* Can be what?
* What are the different bursitis?

A

Can be acute or chronic inflammatory reaction as a result to most commonly pressure to the area
* Suprapatellar Bursitis (Carpeter’s knee)
* Prepatellar bursitis (Housemaid’s knee)
* Infrapatellar bursitis (Plumber’s knee)
* Pes Anserine Bursitis

197
Q

Bursitis:
* What can help you differentiate abscess vs bursa vs mass? What is not necessary?
* What is generally the only diagnostic?
* What is the treatment?

A
  • US may help differentiate abscess vs bursa vs mass; XR not necessary
  • Aspiration is generally only diagnostic, NOT therapeutic
  • Tx: NSAIDs, steroids injection and pressure avoidance
198
Q

Osteochondritis Dessicans:
* What is it? where is it more common?
* May lead to what?
* What might help with OD?
* OD is _
* What is treatment?

A
  • Articular cartilage breakdown
    * Most common in knee, but can occur anywhere there is cartilage
  • May lead to aseptic necrosis and recalcification which may cause loose bodies in the knee, furthering the damage
  • XR may help with OA but MRI diagnostic
  • OA is inevitable
  • Tx: surgery for Grade 4, all others get immobilization for 2-4 months
199
Q

Plica Syndrome:
* What is it?
* What does it cause?
* What are risk factors?
* Differentiate from what?
* Misdiagnosed dt what?
* What is the treatment?

A
  • Abnormal intraarticular band of fibrotic tissue (abnormal Plica)
  • Causes anterior knee pain.
  • Risk factors are knock knees or genu valgum. Pain worse with activity, have clicking and locking with knee flexion. Can feel palpable fibrotic cord over medial femoral condyle.
  • Differentiate from pes anserine bursitis
  • Misdiagnosed d/t similarities of other knee pain
    etiologies – common dx on arthroscopy
  • Tx with activity modification, Ice, NSAIDs
200
Q

Edema History:
* What should you ask a patient?
* What do you need to be sure of?
* What is pitting edema?
* Pitting edema is documented as what?

A
  • Ask a patient if his legs are swollen, or if rings are tight.
  • Be sure to determine Onset, duration, Aggravating factors.
  • If the pressing causes an indentation that persists for some time after the release of the pressure, the edema is referred to as pitting edema.
  • It is measured, and therefore documented as 1+, 2+, 3+ and 4+.
201
Q

Pitting Edema:
* What are the causes?
* What is the ratio? What are the levels?
* What is the most common local conditions that causes edema?

A
202
Q

Nonpitting edema:
* What does the skin not result in?
* Non-pitting edema can occur when?
* What is pretibial myxedema?

A
  • The skin does not result in a persistent indentation.
  • Non-pitting edema can occur in certain disorders of the lymphatic system such as lymphedema, that may occur after a mastectomy, lymph node surgery, or congenitally.
  • Pretibial myxedema is a swelling over the shin that occurs in some patients with hyperthyroidism.
203
Q

For Unilateral pedal edema, DVT should be at the top of your DDx. Pertinent positives (and negatives) include:
1. Hx DVT
2. Oral birth control
3. Smoking
4. Recent inactivity (plane, injury)

A

Recent inactivity (plane, injury)

204
Q

Ankle sprain:
* What is the mechanism
* Patient will hear what?
* When do x-ray?
* What is treatment?
* How long is recovery?

A
  • Mechanism: Typically Inversion forces (most common)
  • Most common injury of the ankle
  • Patient will hear pop with bruising and tenderness to specific area
  • Xray imaging based on Ottawa Ankle Rules
  • Tx: Immobilization with splint (boot, ankle stirrup or posterior short leg), RICE, analgesia OTC
  • Recovery can take 3-4 months
205
Q

What is ligament is involved with inversion and eversion ankle injury?

A
  • Inversion ankle injury = Anterior Talo-Fibular ligament mc involvement
  • Eversion = less common – Deltoid ligament mc involvement
206
Q

What is a sprain vs strain?

A
  • Sprain: involves collagenous tissue such as ligaments and tendons
    * Mechanism by twist or stretch
  • Strain: injury to the bone-tendon unit at the myotendinous junction (muscle overuse) or the muscle itself
    * Mechanism by muscle contraction
207
Q

What are the ottawa ankle rules?

A
208
Q

Plantar Fasciitis:
* Most common cause of what?
* What is it?
* When is pain worse?
* What is often associated with?

A
  • Common cause of foot/heel pain
  • Inflammation of the plantar fascia as it inserts into anterior calcaneus
    * Origin at the medial plantar calcaneal tubercle
  • Pain is worse upon getting out of bed in the morning is almost pathongnomonic.
    * Pain gets better with increased ambulation throughout the day
  • Often associated with a bony exostoses on calcaneus i.e. a “spur”.

Plantar flexion causes pain

209
Q

Plantar Fasciitis:
What is the treatment? What does it respond well to?

A
  • Tx: Ice, NSAIDS, Stretching, arch supports, night brace
  • Responds very well to local steroids.
210
Q

How do you describe pitting edema that is 6mm deep?
1. 1+
2. 2+
3. 3+
4. 4+
5. 5+
6. 6+

A

3+

211
Q

What are the different achilles tendon problems?

A
212
Q

Achilles tendinitis:
* What are the symptoms?
* What imaging is done?
* What is useful?
* What is treatment?
* What is last resort?

A
  • Sxs: Stiffness and pain along the tendon, worse with activity, pain getting worse as the day goes
  • Imaging: X-rays may show soft-tissue shadowing and calcifications along tendon (bone-spurring)
  • MRI is useful
  • Treatment: NSAIDs, PT, stretching, no steroid injections.
  • Surgery is last resort
213
Q

Morton neuroma:
* What is it?
* How is it diagnosised?
* What is the treatment?

A
  • Fibrosis and nerve degeneration of common digital nerve causing neuropathic pain between the 3rd and 4th metatarsals
  • Dx by squeeze test of the affected nerve. Dorsiflexion aggravates the pain. No imaging necessary
  • Surgery if no relief with 1 year of conservative treatment (appropriate footwear and steroid injections)
214
Q

A 40 year old distance runner complains of heel and sole pain when she gets out of bed every morning, which improves as they day goes. The most likely diagnosis is
1. Ankle fracture
2. Shin splints
3. Overuse injury
4. Plantar Fasciitis
5. Morton Neuroma

A

Plantar Fasciitis

215
Q

Hallus Valgus (i.e. Bunions):
* What is it?
* More common in who?
* Clinical diagnosis with what?
* Treatment is what?

A
  • proximal phalanx deviating laterally and the first metatarsal head deviating medially and due to the adduction of the first metatarsus,
  • More common in females, typically arise due to footwear.
  • Clinical Dx assisted with XR.
  • Treatment is directed towards pressure reduction and eventual surgery
216
Q

Hammertoes:
* What is it?
* Complains what?
* What is the treatment?

A
  • Most common deformity of toes.
  • See flexion of PIP and hyperextension of MTP/DIP joints.
  • Complain of pain on dorsal aspect of PIP joint. Callus maybe present.
  • Tx by stretching and night splinting. Surgery if severe
217
Q

Talipes Equinovarus:
* How many people have it?
* Who is it diagnosised?
* Typically found when?
* Generally managed by what?
* What might be necessary?

A
  • 1 in 1,000 will have it; Male to Female 2>1
  • Dx by PE with newborn/well child visit
    • Typically found on prenatal US
  • Generally managed by stretching,
    casting and bracing
  • Surgery maybe necessary if noninvasive treatment is not successful
218
Q

What are the 6 P’s of compartment syndrome?

A

The six P’s include: (1) Pain, (2) Poikilothermia, (3) Paresthesia, (4) Paralysis, (5) Pulselessness, and (6) Pallor

PAM 630 - CLINICAL MEDICINE I (3 decks)

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