MSK Exam 1 Flashcards
1
Q
Type of tissue causing catching or locking
A
Typically cartilage issue
2
Q
Type of issue causing instability of joints
A
Ligament issue
3
Q
5 things to expect for in MSK exam
A
Swelling
Erythema
Atrophy
Deformity
Scars/Skin
4
Q
Quantitative way to measure swelling
A
Measure it
5
Q
Place to locate with palpation
A
Point of MAXIMAL tenderness
6
Q
What to do if palpation might hurt the patient
A
Don’t skip the exam - you need to examine even if it hurts them a bit
7
Q
Two ranges of motion
A
Active and passive - Take both!!
8
Q
Goniometer
A
Measures angles of joints, hard to do for hip and shoulder
9
Q
Muscle testing grade 5
A
Full ROM even with full resistance
10
Q
Muscle strength grade 4
A
Full ROM with some resistance
11
Q
Muscle strength grade 3
A
Against gravity but not resistance
12
Q
Muscle strength grade 2
A
Only when not against gravity
13
Q
Muscle strength grade 1
A
See muscles twitching but can’t move limb
14
Q
Muscle strength grade 0
A
No movement
15
Q
What should a long bone x ray include
A
Joint above and joint below
16
Q
How many planes should be obtained
A
2 planes/views always
17
Q
Indications for an X ray
A
Trauma, Deformity, Inability to use joint/extremity
Unexplained pain and localized tenderness to a bone or joint
Asymmetry or mass
Foreign body
18
Q
Highest bony detail imaging
A
CT scan
19
Q
When do you need contrast for a CT
A
When looking as soft tissue
20
Q
MRI Uses
A
Good for soft tissue
Bone death
Osteomyelitis
Stress fractures(harder to see on Xray)
21
Q
Ultrasound in MSK
A
Need a skilled tech
Soft tissues and bursae
22
Q
Bone scan
A
Scintigraphy
Looks at metabolic activity of bone rather than tissue (pet scan)
23
Q
Myelography
A
Dye injected to look at the spinal cord
Used for spinal cord imaging when we cannot take an MRI
24
Q
Arthrography
A
Dye injected into a joint to visualize it with CT or MRI
Good image of joint space border
Used for meniscal tears or labral tear
25
Arthrocentesis
Can use an ultrasound to guide
Draw off and analyze fluid
26
Muscle biopsy purpose
Differentiate between myopathy or neuropathy
VERY painful
27
Indications for emergent MSK referral
Pain out of proportion
Paresthesia
Pulselessness
Pallor
Paralysis
Open/Unstable fracture
28
Urgent MSK complaints
Stable fracture
Reduced joint dislocation
Locked joint
Tumor
Get in within a week
29
Strain v. Sprain
Strain muscle
Sprain ligaments
30
Muscle sprain
Usually distal, wheere the muscle attaches to the tendon
MC in muscle attached to two joints
Forceful eccentric loading
31
Ligament sprain
Joint is overextended and the ligament is damaged
Bone can evulse instead
32
Clinical presentation of strain/sprain
Feel a popping, snapping, tearing sensation
Difficult to use limb
Assymetric tenderness and ecchymosis
Muscle may ball up
Loss of contraction or pain
Sprain - results in joint overextending
33
Muscle strain categories
1-4 More muscle fibers torn as we go up - muscle fascia is torn in 4
34
Grades of ligament sprain
1-3 - 3 is a complete tear of the ligament
35
Dx for sprain/strain
Usually a clinical diagnosis
X ray for fracture if not healing or if they meet criteria to suspect a break - Ottoawa ankle rules
36
4 phase healing process for strains and sprains
Hemostasis - clot forms, skin blanches
Inflammatory destructive phase - days 1-3 with swelling
Proliferative - Scar formation occures
Maturation phase - Remodeling
37
Over time management of strains and sprains
Immobilize and control pain/swelling in phase 1-2
Continued protection with ROM and strength activities in phase 3
Maintenance and increased endurance, speed and agility in phase 4
38
PRICE Inflammation stage management
Protection
Rest Ice
Compress
Elevation
39
Ice recommendations for sprain/strain
NO HEAT
15-20 minutes every 2-3 hours
40
Surgical repair for sprain/strain
Indicated with complete tear
41
Pain management for strain/sprain
NSAIDs
42
Presentation of overuse syndrome
Local or general tendon swelling
Loss of muscle strength
Repetitive activities in hx
May see a spur on XR
Neuro study for numbness and tingling
43
Management for overuse syndrome
Avoidance of activity
Ice/Heat/NSAID
Steroid injections
PT
44
Periosteum
Thick outer bone layer
Nerve and vessel rich
45
Endostium
Lines marrow cavity
46
Epiphysis
Growth plate area - very prone to infection or fracture
47
Metaphysis
End of the bone in adults, where the growth plate was, succeptible to compression fractures
48
Diaphysis
Long part of the bone - structural support
49
Fracture
Any broken bone
50
Pathologic fracture
Bone cancer or osteoporosis cause a fracture that normally would not occur
51
H&P for fracture
Palpate above and below the joint
Palpate
Assess neurovascular status!!
52
Imaging for fractures
X ray is first line
MRI/CT for complicated cases or for surgical planning
53
Open fracture grades
Grades I-IIIC
Determines how we use abx for the fracture
54
Gustilo and Anderson Grade I
Low energy injury with open wound under 10cm and no evidence of contamination
55
A&G Grade II
Moderate injury with comminution of the fracture and a 1-10 cm wound with some contamination
56
G&A grade IIIA
High energy fracture pattern with wound over 10cm and gross contamination
57
G&A Grade IIIB
High energy fracture with over 10cm contaminated wound exposure and exposed bone
58
G&A grade IIIC
Grade IIIB with vascular involvement
59
Transverse fracture
Straight across fracture
60
Oblique fracture
Diagonal fracture
61
Spiral fracture
Multiplanar and complex fracture line - red flag for child abuse!!
62
Comminuted fracture
Two or more fracture fragments
63
Segmental fracture
2 fracture lines isolating a segment of bone
64
Avulsed fracture
Detached bone fragment that results from excess pulling of a ligament, tendon, or joint capsule from its point of attachment
65
Compression fracture
Often spinal and osteoporosis
Can cross joints
66
Displacement
Distal fragment is out of alignment - direction that the distal bone has gone relative to proximal bone
67
Distraction
Segments of bone have been pulled away from each other - measured in mm
68
Angulation
Distal bone is rotated relative to its proximal half
69
Description of broken bone displacement and angulation
Displacement as a percent (deviation from bone midline with 100% completely off the midline
Angulation - Degrees of rotation - with direction the distal end is pointing
70
Shortening
Fractured ends of the bone slide past each other - causing shortening
Distal and proximal segments overlap describe in mm
71
Rotational deformity
Bone has rotated on itself, usually visible on PE
(Foot is pointing the wrong way)
72
Buckle fracture
Incomplete fracture line at the metaphysis
Need to look at multiple views
MC in distal radius
73
Greenstick fracture
A fracture that doesn't extend through the entire periosteum
More splintery
74
Salter Harris classification
Describe fracture involving a growth plate
I - Slipped - through the growth plate
II - Above - through the growth plate and metaphysis
III - Lower - through the growth plate and epiphysis - affects joint
IV - Through Everything - Through metaphysis, epiphysis and growth plate
V - Rammed - Crush injury to growth plate
75
3 phases of bone healing
1 - Inflammatory
2 - Reparative w/ neovascularization, laying down collagen callous
3 -Remodeling phase - Imaature bone becomes hardened can take 6-10 weeks
76
Closed fracture meneagment
Reduce the fracture - refer if you cannot
77
Open fracture
Emergent for infection or compartment syndrome - immediate ortho referral
78
Abx for I or II open fracture
Cefazolin
79
Abx for type III fracture
Cefazolin AND Gentamycin
Add Flagyl if at risk for an anaerobic infection
Update Td if needed
80
Fracture risk factors
Intra articular
Older
Oblique or comminuted
81
Malunion
Poo alignment of bone - have to rebreak
82
Nonunion
No healing in 6 months or no progress in 3 months
May require surgical fixation or bone graft
83
Risk factors for nonunion
Smoking, Infection, NSAID overuse, malnutrition, inadequate immobilization
84
Stress fracture
Combined load over time creates a small break in the bone - runners, athletes, etc.
85
Risk factors for stress fractures
Acceleration of physical fitness
Prior stress fracture
Low calcium/Vitamin D
Eating disorder
Female
Poor biomechanics
86
Presentation of stress fracture
Don't do much activity and get pain that is severe
87
Imaging for stress fracture
Not healing with conservative therapy
88
Management of stress fracture
Let it heal in its own usually unless in
Patella
Femoral head
Medial malleolus
etc.
89
Casting pearls
Always check neurovascular status
Use X ray to check for healing
90
Clinical presentation of osteomyleitis
Fever, bone pain and tenderness
Blood cultures
91
Imaging for osteomyelitis
Takes weeks to see changes on XR
CT might be helpful early on -expensive!!
US may also be helpful
92
Labs for Osteomyelitis
CRP and ESR more useful than CBC w/Diff for chronic osteomyelitis
93
Common sources of hematogenous osteomyelitis
UTI, Skin, Intravascular, Dental, Catheter, endocardium
94
MC osteomyelitis organisms and infection site in children
Metaphysis of long bones (more common in males)
S aureus, Salmonella, Strep, E. coli
95
Sites and sources of hematogenous osteomyelitis common in adults
More common in vertebral column - usually lumbar spine
IVDU, DIabetes, Catheters
Staph MC or pseudomonas for IVDU
Tenderness of spinal cord percussion
96
Continuous spread osteomyelitis
Often polymicrobial from diabetic foot ulcer, etc.
Find precipitating event
Fevers and rigours, tenderness, warmth, erythema
97
Probing for bone
Put cotton applicator into wound to see if it touches the bone
May be painless in diabetics
98
Dx for osteomyelitis
Blood cultures + in 60% of cases
Cultures from wounds NOT reliable
Left shift on CBC=Acute
ESR and CRP
Bone biopsy may be useful
99
X ray in osteomyelitis
Takes TIME to happen
May see swelling first
Eventually see scalloping or onion skinning
Moth eaten appearance of bone
100
Bone biopsy in osteomyelitis
When we have radiologic evidence of osteomyeltis without positive blood cultures
Do not delay for abx
Must be collected through an uninfected site
101
Management for osteomyelitis
COnsult ID and Ortho
Vanc AND a 3 or 4 gen cephalosporin (triaxone, tazidime, cefipime)
Tailor after C&S results
102
IV therapy for osteomyelitis
MAX dose for 4 weeks at least
Vanc for MRSA
Cephalosporin for MSSA
Monitor trough levels
103
Abx for S aureus osteomyelitis oral therapy
Need IV first, will need PO combo
Use a PO FQ and rifampin
104
Indication for debridement in osteomyelitis
Infection related to open fx or surgical hardware
Extensive disease
Concomitant joint infection
Recurrent or persistent
105
Monitoring for abx therapy for osteomyelitis
CMP and CBC for liver and renal function
ESR and CRP should go down 2 weeks after completion
SERIAL EXAMS!! but not serial imaging
Trend the four labs
106
Sequestrium
Dead bone stuck in healthy bone with a cloaca seeping out of the bone
May need to remove and put in a rod
107
Involcrum
New bone is layed down over lesion to make the bone stronger
108
Chronic osteomyelitis workup
Same but no leukocytosis
Very long term tx
Pathologic fractures
Extensive debridement or amputation
109
Pathophys of compartment syndrome
Pressure in muscle is greater than BP
Muscle death
110
Normal compartment pressure
10mmHg (20mmHg is intolerable
111
Reversibility of compartment syndrome
2-4 hours = reversible may loose nerve conduction
6 hours - Variable damage
8 hours - Irreversible damage
12 hours - Myocyte death
112
5 P's of ischemia
Pain out of proportion
Pulseless
Pallor
Paresthesia
Paralysis
113
Compartment pressure requiring decompression
Anything over 45mmHg or within 30 points of DBP for hypotensive patients
Take two readings with a manometer to measure
114
Management for fasciotomy
Remove cast or tourniquet
Fasciotimy with open sutures
Delayed closure
CI in patients whose symptoms began over 24 hours ago - observe
115
Rhabdomyolysis presentation
Crush injury, drugs can be overexertion
Electrolyte abnormalities with kidney failure - ATN from purine crystals
Aches with low grade fever
116
Dx for rhabdomyolysis
CK 5x upper limit
Tea colored urine
Positive hemoglobin with negative RBCs on UA
CMP for electrolytes - uric acid and phos elevated
EKG for hyper/hypocalcemia
117
Tx for rhabdomyolysis
LOTS of fluids
Measure I/O with foley
Give bicarbonate to help with process
Consult nephro
118
Monitoring for rhabdomyolysis
Monitor electrolytes and EKG
CK should drop
119
3 complications of rhabdomyolysis
AKI
Compartment syndrome
Disseminated Intravscular Coagulopathy
120
Fibromyalgia presentation
Widespread MSK pain in different trigger points with no clear cause 3+ months
Fatigue and aching
Thought to be overactive nerves
Joints UNAFFECTED!!
121
Dx for fibromyalgia
Assessment for regions and severity
7+ areas and 5+ impact rating or 3-6 areas with 9+ severity
Blood work to rule out other causes
122
Management of fibromyalgia
Difficult to treat - chronic condition
CBT and Low aerobic activity ie. yoga or swimming, weight loss
123
Pharm for fibromyalgia
Cymbalta - fatigue or anxiety, Cyclobenzaprine - MC first line, Lyrica/Neurontin - sleep disturbance, Tramadol - An opioid is NOT sustainable because of length of tx
124
FDA approved fibromyalgia drugs
Duloxetine
Milnacipram
Gabapentin (Neurontin)
Pregabalin (Lyrica)
125
Charcot foot
Neurogenic arthropathy
Arch of the foot drops with destruction of soft tissue
Rocker bottom foot
126
Presentation for charcot foot
Rocker bottom
Less pain than expected
May look like/result from infection
127
Dx for charcot foot
Weight bearing XR - Yellow angle measurement
MRI if XR is negative and need to r/o osteomyelitis
128
Stage 0 charcot foot
Early inflammatory stage with little change on XR
129
Stage 1 charcot foot
Swelling, redness and warmth persist
Bony fracture, subluxation, etc. seen
130
Stage 2 charcot foot
Clinical signs of inflammation decerase
Fracture healing, debris resorption and new bone formation
131
Stage 3 charcot foot
No signs of inflammation with bony deformity
Fracture callus is present
132
Charcot 0-2 management
Avoid weight bearing
Boot!!
Grdaul progression back to exercise
133
Charcot 3 treatment
consider surgery
134
Raynauds phenomenon
Abnormal vasculature at finger tips
Turns cyanotic or white in the cold, then red inside
Primary or secondary to autoimmune condition
135
Presentation of raynauds phenomenon
Attacks of ischemia - white or blue
Followed by painful reperfusion of digits
Sclerodactyly (calcified tendons from calcinosis), or digital ulcers
136
Dx for raynauds phenomenon
Ophthalmascope shows corkscrew blood vessels in nail beds
Usually clinical dx
137
Tx for raynauds phenomenon
Educate!!! - keep fingers warm, etc.
CCB - first line pharm
Viagra
Treat underlying conditions
Decongestants
Smoking cessation
138
Presentation of Marfans syndrome
Wingspan greater than height
Scoliosis
Pectus excavatum
May have aortic or eye issues - Myopia, MVP
Long-spidery fingers
139
Thumb sign for Marfans
Thumb sticks out the other side of the fist
140
Genetics for Marfan
Mutation in Fibrillin gene
Autosomal dominant
141
Management for Marfan's syndrome
BB - Atenolol or Atenolol for aortic root disorders
Limit exercise
Ortho, Ophtho, and Cardio consult
142
Complication of undiagnosed Marfans
Aortic dissection is a common cause of death in undiagnosed Marfans
143
4 rotator cuff muscles
Supraspinatus
Infraspinatus
Subscapularis
Teres minor
144
Shoulder injuries common under 30
Usually trauma
Dislocation or separation
RC tears in athletes
145
More common shoulder dislocation
Anterior rather than posterior
146
Subluxation
Joint slides out and in
147
PE for shoulder complaint
Start at sternoclavicular joint
Shirt off and standing
148
Deltoid muscle testing
Stabilized at shoulder, abduct to 90 degrees, bend elbows
Patient able to resist downward pressure
149
Supraspinatus test
Empty can test
90 degree abduction with 30 degree forward flexion and thumbs down
Push down with resistance
Weakness is a positive sign
150
Hornblowers test
Support flexed elbow and attempt external rotation
Evaluates infraspinatus and teres minor
151
Gerber lift off test
Subscapularis
Patient places hands behind their back palms facing wawy from back
Lift hands against resistance
152
Serratus anterior test
Correct - stabilize scapula, flex shoulder at 90 degrees
Push am anteriorly with hand on scapula for winging
Can also have patient lean on a wall
Winging scapula is a positive sign
153
Rhomboid test
Pot arm on back with palm facing away from back
Push up with the elbow
154
Neer Impingement sign
Depress scapula with one hand and elevate the arm with the other
Checks for rotator cuff tear or impingement syndrome
155
Hawkins-Kennedy test
Forward flex shoulder to 90 and elbow at 90
Internally rotate shoulder (push forearm down)
Pain indicates supraspinatus impingement
156
Crossover test
Stabilize shoulder and cross arm over body
Pain suggests arthritis or AC joint pathology
157
Apprehension sign
Place arm supine
90 abduction and 90 flexions
Crank forearm towards head
Indicates anterior shoulder instability
158
Sulcus sign
Pull down arm and see simple in the shoulder
Indicates inferior instability
159
Jerk test
For posterior instability
90 flexion
Max internal rotation with elbow flexed
Adduct arm with pushing the humerus
160
Shoulder diagnostics
Imaging 1st line
AP, Scapular, and Axillary views possible
161
Point of rotator cuff muscles
Stabilization
162
Progression of rotator cuff injuries
Overuse
Edema
Inflammation
Fibrosis
Microscopic tear
Partial thickness tear
Full thickness tear
163
Impingement syndrome
Precursor for tear
Due to repetitive use of rotator cuff
164
Impingement presentation
Gradual onset worsening when reaching behind self
Night pain
May see atrophy after a long time
Tender to palpation over greater tuberosity and subacromial bursa
Pain with abduction and crapitus
+ Neer and Hawkins Kennedy
165
Diagnostics of impingement syndrome
XR to r/o fracture, check for spurs
MRI - more definitive
Can inject lidocaine or steroids - will improve ROM
166
Tx for impingement
Rest and NSAIDs - Topical
Gradual exercise with PT
Red flag for tear if worsening
Steroids if failing conservative therapy
167
Rotator cuff tendonitis
Next step after impingement
Throwing athletes and diabetic patients or hyperlipidemia
Painters and stockers
168
Presentation of rotator cuff tendonitis
Worsening from an ache
Can't throw as far, can't wash hair, get things out of cabinets
Pain and no active ROM
169
Dx and Treatment for rotator cuff tendonitis
Shoulder XR, MSK US if good tech - thickened tendon, MRI
Rest - Stage I
Rest and refer to PT - Stage II
170
Rotator cuff tears
Uncommon in persons under 40
Supraspinatus is most common torn
d/t degeneration, mechanichal impingement, altered blood flow
171
Presentation of rotator cuff tear
Chronic shoulder pain
Crepitus and catching
Can't put shirt on or put on bra
172
Drop arm test
Take patient through pass ive range of motion and let it go - it will drop - can't hold it up
173
Tests for rotator cuff injury
Empty can, Neer's, Hawkins-Kennedy
Passive ROM okay but inhibited Active ROM
174
Dx for rotator cuff tear
XR to rule out other pathologies
US
MRI - best to see tear
Arthography
175
Management for rotator cuff tear
Rest
NSAIDs
PT - 6 weeks at least
Steroids - once every 3 months
176
Adehsive capsulitis
Frozen shoulder
Both active and passive ROM are affected
Idiopathic inflammation
Women 40-60
DM I is common cause
177
Presentation of adhesive capititis
Freezing phase - loss of ROM (active AND passive)
Thawing phase - gradual improvement
Tender at deltoid insertion
178
Imaging for adhesive capsulitis
XR - Normal
Get an MRI - Absent axillary recess
179
Management for adhesive capsulitis
NSAIDs
Stretching - conservative takes years to work
Surgery after three months with failed treatment - followed by PT
180
MC shoulder dislocation
Anterior
181
Mechanism of anterior shoulder dislocation
Blow to abducted, externally rotated, extended arm
ie. blocking a basketball shot
182
Clinical presentation of anterior shoulder dislocation
Arm abducted and externally rotated
Prominent acromion
Loss of shoulder rounding
No ROM
Feel humeral head on PE
183
Posterior dislocation cause
Axial loading of an adducted internally rotated arm
Seizure, anterior blow, arm gets pulled
184
Posterior dislocation presentation
Arm is adducted and internally rotated
No ROM
Shoulder prominence posteriorly
185
Inferior shoulder dislocation
Uncommon - can't put their arm down - often have neurovascular compromise
186
Multidirectional instability
Can voluntarily dislocate shoulder
Poor prognosis for surgery and treatment
187
PE tests for joint instability
Apprehension - Anterior
Jerk - Posterior
Sulcus - Inferior
188
Complications of shoulder instability
Damage to brachial plexus - numbness over arm
Vascular issue
189
Hill sachs lesion
Fracture of humeral head - can be seen on XR
We don't care if they have no pulse
190
Bankart lesion
Tearing of labrum - (meniscus of the shoulder
Complication of shoulder dislocation
191
Dx for shoulder instability/dislocation
XR - AP, Y, and Axillary views
CT if XR unclear
MRI post reduction for Bankart lesion under 30 or RC tear under 40
192
Posterior v. Anterior shoulder dislocation on XR
Anterior will be down and turned away
193
Management for anterior shoulder instability
Stimson - Hanging weight from arm
or Longitudinal traction method
Sedate and informed consent
194
Inferior dislocation management
Axial traction - traction and counter traction
Sedate and informed consent
195
Post relocation management
Assess neurovascular status
Post reduction films
Immobilize for 3 weeks
PT and Ortho referral
196
Type one AC injury
Just a sprain - no deformity
No separation
197
Type two AC injury
Acromioclavicular ligaments disrupted
Coracoclavicular ligaments intact
198
Type three AC joint injury
Acromioclavicular and coracoclavicular ligaments disrupted
199
Type 4-6 AC joint injury
Acromial end of the clavicle is moved out of place with increasing severity
200
Presentation of AC joint injury
Pain in the AC joint on abduction
Deformities in grades III-VI
Tenderness over AC joint
Supports arm adducted
Asess NV statues
201
Imaging of AC joint
Zanca veiw - from below XR
Greater gap with greater separation
202
Grade 1-2 AC injury management
Ice compress
NSAIDs
Sling for 2-3 days
ROM exercises for 2-4 weeks before return to sports
203
Management of grade 3 AC injury
Conserative as in 1 and 2
Surgery if career impacted
6-12 weeks to return to activity
Deformity w/o surgery - can be acceptable
204
Management of grade IV-VI AC injury
Refer to ortho for surgery - emergent if NV compromise
Deformity if no intervention
205
MOI fo sternoclavicular injuries
Crushing or rolling movement on chest
Can be sprained or dislocated
206
Presentation of sternoclavicular sprain
Mild to moderate swelling and tenderness with no change in joint structure
207
Presentation of sternoclavicular dislocation
Severe pain, swelling, and ecchymosis
Prominent medial clavicle for anterior dislocation
Less visible for posterior - hoarseness, dysphagia, dyspnea, upper extremity paresthesia possible
208
Diagnostics of sternoclavicular injury
XR not sensitive
CT of chest considering contrast
209
Management for sternoclavicular injury
Sling
May want to relocate
Figure eight or sling and swath brace
Surgery for posterior dislocation
210
MC site of clavicle fracture
Middle clavicle
Distal is least severe
211
Presentation of clavicle fracture
Pain, swelling, deformity
Skin tenting
Tenderness along fracture site
Grinding during ROM
212
Imaging for clavicle fracture
XR helpful
The more medial or proximal the fracture is the more you need a CT
213
Management for clavicle fracture
Sling only for uncomplicated 6-8 weeks with gentle ROM for 2-3 weeks after
Surgery for any reduction, rotation, medial fracture
214
Biceps tendinopathy
Due to overuse of tendon - leads to a rupture
Inflamed - MC in long head between the tubercles of the humerus
Anterior night pain
Improves with ice and rest
215
PE test for biceps tendinopathy
Yergason's test - Flex elbow at 90 degrees pronate arm and have patient supinate against resistance
Pain is a positive test
216
Presentation of biceps tendinopathy
Tenderness along the bicipital groove
Pain with active AND passive ROM
217
Management for biceps tendinopathy
Rest, ICE, NSAIDs
May inject steroids or do surgery
218
Biceps tendon rupture
Most often proximal head
Bulge and bruising on tednon
XR to r/o evulsion
MRI to r/o rotator cuff
219
Management ofr biceps tenson rupture
Only fix surgically in young patients - need to do it sooner rather than later
Can leave as is and it will be okay
220
Proximal humeral fracture
Generally from direct blow for Fall on outstreched hand (FOOSH)
Proximal, midshaft, or distal
221
Presentation of humeral fractures and PE
Pain swelling and ecchymosis
Tenderness over fracture site
Limited ROM
Assess NV status
222
NV status assessment for humeral fracture
Check axillary for proximal
Check radial for shaft
223
Treatment for hymeral fracture
Sling if not displaced
Reduction and fixation if complicated
May need a replacement for a fractured humeral head
224
Splint for humeral shaft fracture
If angulation under 20% - U shaped or sugar tong splint for 2 weeks followed by humeral fracture brace
225
Indications for surgery in humeral fracture
Open fracture
NV compromise
Pathologic
Ipsilateral forearm fracture
226
Capitulum articulation
Articulates with the radius (rad cap)
227
Flexors location
Ventral aspect of forearm
228
Extensors location
Posterior aspect of the forearm
229
3 Elbow imaging views
AP, Lateral and oblique views (Oblique best for radial head)
230
What a lateral view of the elbow joint should look like
Anterior humeral line bisects the middle third of the capitulum; radiocapitellar line passes through the center of the capitulum
231
Normal ROM for elbow: Flexion, Hyperextension, Sup/Pronation
Flexion: 0-150; Hyperextension: 10-15; Supination/Pronation: 80
232
Innervation of Bicep
C5 and C6, also control pronation and supination
233
Innervation of Tricep and extensors
C7-C8
234
Innervation of pronation
Median nerve and C6-C7
235
Varus stress test
20 degree flexion of elbow with pressure on medial aspect - test radial collateral ligament
236
Test for radial and ulnar collateral ligament
Valgus and Vaus stress tests
237
Distal humeral fracture
Generally from direct trauma; usually supracondylar in kids
238
Type A,B, and C fractures for distal humerus
A - Above both condyles, B - One condyle involved C - Both condyles involved
239
Presentation of distal humeral fractures
Pain, tenderness, swelling, eccymosis, crepitus; Limited ROM of elbow
240
PE for supracondylar distal humeral fracture
Radial artery and median nerve affected
241
PE for epicondylar distal humeral fracture
Ulnar and radial nerves affected
242
XR for distal humeral fracture
Sail sign from pushed out fat pad due to intrarticular bleeding - posterior fat pad is pathologic always
243
Supracondylar fracture management
If not displaced or angulated - can use just a cast - surgery if more complex
244
Epicondylar fracture management
Long arm posterior splint/cast with elbow at 90 degrees, pronated for medial, supinated for lateral, Percutaneous pinning or ORIF for 2-4+ mm displacement
245
Olecranon fractures
From a fall on the elbow or tricep evulsion from falling with flexed arm
246
Prsentation of olecranon process fracture
Limited ROM, Swelling, Ulnar nerve dist. Affected
247
XR for olecranon fracture
AP and radiocapitular view if needed for better management
248
Tx for nondisplaced olecranon fracture
Posterior long arm splint, monitor for vasc compromise, squeezing of ball, put in a degree of flexion
249
Tx for displaced olecranon fracture
Splint and ORIF, Admit for IV abx for open fracture
250
ORIF
Open reduction and Internal Fixation
251
MCC of radial head and neck fractures
Fall on outstretched hand
252
Mason type I radial head fracture
Under 2mm displacement
253
Mason type II radial head fracture
Displaced over 2mm
254
Mason type III radial head fracture
Comminuted
255
Mason type IV radial head fracture
Radial head fracture with elbow dislocation
256
Presentation of radial head/neck fracture
Tenderness along lateral aspect og elbow; pain with supination/pronation, effusion and ecchymosis
257
XR for radial head fracture
AP and Lateral views; Fracture line and posterior fat pad sign, may need an oblique view
258
Management for radiakl head and neck fracture
Type 1 - ROM in 2-4 days may need to aspirate joint if bloody effusion; Type 2-3 Sling and splint with ORIF 4 - ORIF
259
Radial head subluxation
Nursemaids elbow, pulling pronated on extended arm pops radial head out of annular ligament; More often is NOT child abuse but education of aprents needed
260
Presentation of radial head subluxation
Mechanism followed by crying - flexed, adducted, and pronated arm. Tenderness alone
261
Management for radial head subluxation
Supinate and flex or hyper pronate arm. Check NV status and monitor for resolution. Relocate ASAP. Imaging not needed unless there is concern for some other injury
262
Hyperpronation
Better for nursemaids elbow for reduction
263
Failed reduction of radial head subluxation
XR for fracture/other issues
264
Epicondylitis
Tennis lateral, Medial golfers. Chronic repetetive use resulting in tendon trauma
265
Presentation of lateral epicondylitis - Tennis elbow
Tenderness a cm distally to the epicondyle, shaking hands and difficulty opening jars. Pain with ROM against resistance
266
Presentation of medial epicondylitis - Golfers
Pain with pronation and wrist flexion, Point tenderness 1 cm distal to the epicondyke, Pain with ROM against resistance
267
Dx for epicondylitis
Clinical dx, imaging not needed
268
Management for epicondylitis
Activity modification, NSAID, Ice, PT, Counterforce brace, Steroid injection 3 max per year
269
Olecranon bursitis
Direct trauma or chronic inflammation - can also be part of autoimmune
270
Presentation og olecranon bursitis
Swelling of bursa, may or may not have pain, Limited ROM. Redness and warmth if acute/infectious
271
Diagnostics of olecranon bursitis
Aspirate if large and symptomatic - CBC, gram stain, C&S, Crystals. XR if hx of trauma
272
Treatment for olecranon bursitis
Control swelling with activity mod and NSAIDs, Aspirate and apply compression bandage, reculture if continues, steroids if all cultures are negative
273
Tx for septic bursitis
Bactrim or Keflex in non-immune compromised
274
Tx for severe septic bursitis
IV vanc
275
Tx for severe septic bursitis associated with trauma
Cipro or Zosyn for pseudomonas coverage
276
Usual forearm imaging
AP and Lateral
277
Usual wrist, hand, finger
AP, Lateral, Oblique
278
Monteggia fracture
Ulnar fracture with dislocated radial head, proximal break
279
Galeazi fracture
Radius fracture with dislocation of the distal radioulnar joint
280
Mneumonic for Forearm fractures
MUGR - A is proximal, Z is distal
281
Presentation of forearm fracture
Deformity, swelling, point tenderness, Limited ROM
282
Diagnosis of forearm fracture
XR to diagnose
283
Emergent forearm fracture
Arterial compromise or open fracture, ortho referral in under an hour
284
Urgent forearm fracture
Under 50% opposition or over 10 degrees angulation, ulno-radial joint instability, peripheral nerve injury, both bone fx with displacement
285
Priority forearm fracture
Less than urgent, ortho referral in 24-72 hours, both bones with minimal or no displacement, isolated radial shaft fracture, isolated proximal third ulnar fracture
286
Management for simple isolated forearm fracture
Long arm posterior splint for under 50% displacement under 10% angulation, elbow at 90 degrees, Splint for weeks 1-3 brace for weeks 4-6
287
Follow up XR for simple isolated forearm fracture
At 1 week then Q4 weeks
288
Long arm posterior splint
Double sugar tong, flexes elbow at 90 degrees both fold around the elbow
289
Colles wrist fracture
Dorsal wrist displacement - looks like a dinner fork, usually a FOOSH with palm DOWN
290
Smith's fracture
Anterior wrist displacement - looks like a garden spade, usually a FOOSH with palm UP
291
Management for wrist fracture
Sugar tong splint or short arm cast for 2-3 weeks - not placed until 72 hours post injury, ORIF for open or displaced fractures
292
Follow up XR for Smith's/Colles fx
Each week for two weeks
293
MOI for scaphoid fracture
Hyperextension of wrist/ Fall on outstretched hand
294
Palpation for scaphoid fracture
Anatomic snuff box
295
Presentation of scaphoid fracture
Snuffbox tenderness, decreased wrist ROM
296
XR for scaphoid fracture
Sacaphoid/Navicular view - put in Ulnar deviation for XR. CT or MRI if neg with high suspiscion
297
Management for scaphoid fracture
Thumb spica cast or splint, repeat XR in 1-2 weeks if initially negative, Pins or ORIF if displaced
298
Thumb spica cast
Holds thumb out from the other fingers, originates mid forearm and inserts at distal PIP joint of thumb. Wrist at 25 degree extension with thumb as if holding a can
299
Indications for a thumb spica cast
Scaphoid, lunate, trapezium, thumb fractures, UCL tear
300
Risk factors for carpal tunnel syndrome
Sedentary, repetetive hand movement, multiple systemic issues
301
Presentation of carpal tunnel syndrome
Burning, tingling, pain over median nerve distribution (hand of benediction) worse at night. Tadiates to elbow and shoulder
302
PE for carpal tunnel
Positive Tinel, Phalen, Carpal compression, hand elevation, thenar atrophy
303
Tinel's sign
Tap on carpal tunnel to elicit pain
304
Phalen sign
Praying hands for CTS
305
Dx for CTS
EMG/NCS
306
Management for CTS
Activity modification, Cock up wrist splint, Steroid injection, Refer to ortho for realease if 3+ months of conservative therapy fail
307
Boxer's fracture
Fracture of the fifth metacarpal, most likely to be malrotated
308
Phalangeal fractures
MC in children, usually distal in adults
309
Presentation of metacarpal/phalangeal fractures
Hx of trauma, Local tenderness, swelling, deformity, decreased ROM and knuckle definition
310
Managemeng of metacarpal neck fracture
Open or close reduction for any fracture with over 30 degree angulation
311
Management for metacarpal phalangeal fractures with under 30 degrees of angulation
Metacarpals 4-5 = Ulnar Gutter spliont Metacarpals 2-3 = Radial gutter splint
312
Gutter splint
Radial or Ulnar - Holds the two fingers on its side, originates mid forearm and insterts distally to the DIP of the 2-3 or 4-5 phalanges. Thumb is free for radial. Slight extension with can-holding position
313
Management for non displaced fractures of metacarpal/phalangeal shafts of 2-5
Splint 3-4 weeks, Gutter for metacarpal, Buddy splint/Tape for phalanx
314
Thumb fracture management
Thumb spica with 30 degree wrist extension
315
Management for angulate, displaced or articulat phalangeal fractures
Refer to ortho - may need reduction
316
Buddy taping
Tape fingers together or single finger splint
317
Game keepers tumb
Rupture UCL of 1st MCP joint also known as Skier's thumb d/t forced radial abduction
318
Presentation of gamekeepers thumb
Pain, swelling, and tenderness along the medial 1st MCP joint
319
Presentation of gamekeepers thumb
Pain, swelling and tenderness along 1st MCP joint, weak pincer function (opposition) Dx via stress test or XR
320
Management for gamekeepers thumb
Thumb spica splint, refer to rotho for repair
321
Mallet finger
Rupture, evulsion, or laceration of the extensor tendon at the distal phalanx d/t DIP hyper extension
322
Presentation of mallet finger
DIP flexed at 40 degrees, PROM intact, Tenderness over DIP, finger like a mallet, swan neck deformity
323
Management of mallet finger
Finger splint for 4-8 weeks, splint CANNOT be removed - results in swan neck deformity
324
Boutinierre deformity
Rupture of the central slip of the extensor tendon where it inserts on the middle phalanx d/t forced plexion of the PIP
325
Presentation of Boutoniere deformity
Finger partially flexed at PIP with PROM but no AROM, Swelling apin and point tenderness
326
Management for Boutonierre deformity
Finger series to tule out evulsion fx, Splint PIP in extension leaving DIP free for 4-8 weeks
327
Indications for Boutinierre deformity ortho referral
Conservative therapy failure, Irreducible PIP dislocation, Open fracture
328
DeQ Tendinosynovitis
Inflammation of tendon sheeth covering extensor/ abductors, an overuse syndrome
329
Presentation of DeQ Tendinosynovitis
Aching pain and point tenderness, positive finklesteign test, Thickened 1st dorsal compartment creating prominence at radial styloid
330
Finkelstein test
For Dequervain Tenosynovitis, hold thumb in fist and ulnar deviate. Positive if painful
331
Management for DeQ Tenosynovitis
Thumb spica splint, Activity modification, NSAIDs, Refer to ortho if conservative therapy fails for surgery/steroids
332
Ganglion cyst
Outpouching of fluid from joint capsule MC in dorsal wrist
333
Presentation og ganglion cyst
Rubbery to palpation, Cyst that can be transluminated - clear fluid filled. XR not needed if non-concerning (nontender, stable)
334
Management for ganglion cyst
Most will regress spontaneously, Aspiration with or w/o steroid, Surgery also an option, Smashing generally not effective
335
Trigger finger
Idiopathic dysfunction of the flexore tendon - gets sticky, MC in Digits 3-4
336
Presentation of trigger finger
Catching, snapping or locking of finger in a flexed position, Pain and dysfunction with a painful palm nodule
337
Management for trigger finger
NSAID and steroids, surgery if no results after 2nd injection
338
Second steroid injection for trigger finger
Not done in RA patients, surgical release if fails, done 3-4 weeks after 1st injection
339
Dupuytren cotnracture
Fibrosis of palmar fascia, can't extend fingers, MC in men 50+ 4th finger MC
340
Presentation of DP Contracture
Non-tender, thickening nodule, flexion is normal but extension is limited, nodules thicken to a cord
341
Dx for DP contracture
Clinical dx, imaging not needed
342
Management of DP contracture
Night splinting to skow progression, Surgery indicated for 30+ degrees of flexion. Excision of thickened tissue bands
343
Superior BP trunk
C5-6
344
Middle BP trunk
C7
345
Inferior BP trunk
C*-T1
346
Lateral brachial plexus cord
Middle and superior trunks
347
Posterior BP Cord
All three trunks
348
Medial BP cord
Inferior trunk only
349
Musculocutaneous nerve origin
Lateral BP cord
350
Axillary nerve origin
Posterior cord
351
Median nerve origin
Lateral and Medial cords
352
Radial nerve origin
Posterior cord
353
Ulnar nerve origin
Medial cord only
354
MOI of BP injury
Traction/Stretching focrse, side bening of head
355
Presentation of BP injury
Sharp, burning pain with radiculopathy in the effected nerve root distribution, Weakness is common
356
Associated symptom with C8-T1 lesion
Horner's syndrome!!
357
C5 functions
Elbow flexion and shoulder abduction
358
C6 function
Elbow flexion, wrist extension, thumb and radial hand sensation
359
C7 function
Elbow extension, wrist flexion, finger extension
360
C8 function
Finger flexion
361
T1 function
Abduction of the fingers
362
Dx for brachial plexus injury
XR, CT of C spine - MRI is best. May get an EMG
363
Management of BP injury
Conservative woth PROM and stretching, strengthening, no participation in sports until complete resolution of symptoms
364
Thoracic outlet syndrome
Compression of SC artery and BP
365
Presentation of thoracic outlet syndrome
Fatigue, aching, weakness of extremity, worsens when arm lifted above head
366
PE for thoracic outlet syndrome
Check for mass, check pulses, swelling and discoloration
367
Elevated arm test for TOS
Both shoulders abducted 90 degrees and supported posteriorlu have patient open and close fists at moderate speed for 3 minutes. Reproduction of symptoms = positive test
368
Dx for TOS
r/o tumor, PA and Lateral CXR, may want to look at spine
369
Management of TOS
Home exercise program, avoidance of heavy shoulder bags, NSAIDs, Muscle relaxers - Surgery usually not required
370
Normal hip ROM
0-110 or 130 degree range
371
Normal range for hip extension
20-30 degrees
372
Normal hip abduction/adduction
AB - 35-50 degrees; AD 25-35 degrees
373
Internal and external rotation hip ROM
25-35 degrees
374
Thomas test
Look at tight hip flexor, contralateral leg comes up when knee is brought to chest
375
Trendelenburg test
Patient stand on one leg, opposite hip with drop - looks at abductors - weakness
376
FABER test
Flexion, abduction, external rotation test (figure of four) press on knee; ipsilateral pain = hip problem contralateral pain = sacroiliac dysfunction
377
Leg length measurement
Measure from ASIS to Medial malleolus, 3+ cm difference can lead to hip prblems; send to podiatry and r/o fracture
378
Log roll test
For osteonecrosis, roll leg in and out to put pressure on the femoral head
379
Piriformis test
Patient lies on unaffected side or supine, hip and knee flexed 90 degrees, stabilize pelvis and apply flexion, adduction, and internal rotation pressure at knee
380
Positive piriformis test
Pain in the buttock or down the leg indicates impingement of sciatic nerve by the piriformis
381
Scouring test
Pushing the femoral head into acetabulum - look for crepitus of damaged cartlidge, may also have pain
382
Specialty views of the hip
Frog leg - from below - better for the femoral head and neck Oburator - Helps to look at the pelvic floor
383
MOI of posterior hip dislocation
More common. MVA knee to dashboard, hard fall on knee, posterior force to flexed knee
384
MOI of anterior hip dislocation
Hyperextension against an abductedleg or anterior force on posterior femoral head
385
Hip dislocation more likely to have NV complications
Posterior dislocation
386
Presentation of any hip dislocation
Severe pain, unable to move leg, paresthesias, deformity, NV status changes
387
Posterior hip dislocation presentation
Leg is shortened, adducted, and internally rotated
388
Presentation of anterior hip dislocation
External rotation and flexion of the hip - Inferior or Superior depending on degree of flexion
389
Dx for hip dislocation
Stat XR - CT scan if uncertain
390
Management of hip dislocation
Need to get back in place within 6 hours - MC use Allis maneuver for posterior anterior dislocation may require open reduction all need sedation and post reduction films, always involve ortho
391
Post reduction immobilization for hip dislocation
Triangular abduction pillow or knee immobilizer
392
Allis procedure
Requires two people, one to hold pelvid and one to push on knee
393
Post reduction care for hip dislocation
Most need admission and parenteral pain control, crutch assisted weight bearing PT until ambulation w/o pain uncomplicated, Follow for avascular necrosis 2-3 years
394
Traction bed
For complicated hip dislocation - hilds up the leg
395
Intracapsular Hip Fracture
Femoral head or femoral neck
396
Extracapsular Hip Fractures
Intertrocanteric or Subtrochanteric
397
Risk factors for hip fracture
Elderly, smoking, Psych meds, alcohol, dementia, female
398
Presentation of hip fracture
Groin pain!! Externally rotated, abducted, shortened leg, pain even with tiny movement, inability to ambulate
399
Dx for hip fx,
Hip XR with other images as needed, CT or MRI if uncertain with shortened leg
400
Management for Hip Fx
Urgent ortho consult w/ in 24 hours, surgery w/in 48 hours ORIF for young - don't want to have to replace prosthesis later, Arthroplasty for Old - allows for immediate ambulation, Immobilization not necessary
401
Contraindications for surgery in hip fx
Medically unstable, patients who were non ambulatory, dementia patient with minimal pain during transfers
402
Complication of Hip Fx
Infection, DVT, Pneumonia, Ulcer, Avascular necrosis
403
Greater trochanteric bursitis
Due to repetitive trauma/walking, greater trochanter is prominent bone of the hip
404
Presentation of greater trochanteric bursitis
Pain radiates down lateral aspect of the thigh and up into buttock, worse when rising, nighttime, improves with a few steps and wprsens with prolonged walking, Point tenderness, Pain with abduction as well as adduction and internal rotation
405
Dx for GT Bursitis
R/O trauma
406
Management of GT Bursitis
NSAIDs, activity modification, ice, Cate in opposite hand, heat 15 then stretch, then ice for 20, local anesthetic/steroid injection
407
Avascular necrosis
Bone infarction in the hip, can be d/t steroids!! Smoking, transplant, trauma
408
Presentation of avascular necrosis
Extreme pain during cell death - becomes dull and aching. Crescent sign on XR - patchy white infiltate around femoral head
409
Management for AVN
Avoid weight bearing, NSAID and opiates for breakthrough pain, Ortho - may do surgical intervention - only way to reverse
410
Emergent concern for femoral shaft fracture
Bleeding from femoral artery
411
Cause and presentation for femoral shaft fracture
High energy trauma, Pain swelling, tenderness, NV status must assess
412
Femoral shaft fracture complications
Blood loss, Compartment syndrome, Multi-system injuries
413
Management of femoral shaft fx
Pain management, fluids for blood loss, Stabilization, ortho for surgery
414
Knee muscles
Quads - Extend, Hamstings - flex
415
Valgus deformity
Knock knee - come together (gum sticking together)
416
Weak abductor location in a trendelenberg gait
Contralateral to hip drop
417
Gaits to watch for
Antalgic, wide, wddle, trnedelenburg
418
PE for knee
Squat, gait, inspect
419
Joint space palpation of the knee
Can ONLY be done on a flexed knee!!
420
Bulge sign
Milking the patella - superior on medial knee and inferior on the lateral side - wave is positive for an effusion
421
Normal knee ROM
0-145 degrees flexion
422
Patellar tracking
Patellar does not travel directly up and down - watch patella during flexion/extension
423
Patellar aprehension sign
Supine with 30 degree knee flexion, displace patella, aphrehension d/t pain or quad contraction (knee extension) is positive
424
3 indication for patellar aprehension sign
Patellofemoral syndrome, patellar subluxation, patellar dislocation
425
Patellar grind test
For chonromalacia patella - assess for cartilage degeneratin, fully extend knee push patella inferiorly and feel crepitus if positive sign
426
Valgus stress test
Abduct and flex knee to 30 degrees, apply lateral pressure same for varus stress test but pressure to medial knee - tests collateral ligament across from pressure
427
McMurray test
For mensical injury - valgus or varus depending on which meniscus is being tested
428
McMurray test for medial meniscus
MEG - Exteral rotation with valgus stress and slowly extending knee
429
McMurray test for lateral meniscus
LIR - Internal rotation with varus stress and slow knee extension
430
Positive McMurray test
Pain, popping or clicking is notede
431
Lachman test
BEST test for ACL tear - stabilize femur and pull up on the tibia - shoulod see NO translation
432
Most sensitive test for ACL
Lachmans
433
Anterior drawer test
For ACL tear - Pull forward on tibia - foot stabilized on table
434
Pivot shift test
ONLY on sedated patient - Used to assess ACL FIG technique full extension, then slowly flex knee, valgus stress and internal rotation subluxation at 20-40 degrees is positive
435
Posterior drawer test
Push tibia backwards to evaluate for PCL tear
436
Noble's test
Asess for iliotibial band - supine with knee flexed at 90 degrees, apply pressure to lateral femoral condyle or 1-2 cm proximal to pt knee, positive if complaint of tenderness at 30 degrees flexion
437
Valgus stress test
Apply force to lateral aspect of knee
438
Ober's test
Asess for tight IT band and tensor fascia latae
439
Procedure for Ober's test
Patient lies on unaffected side with affected knee at 90 degrees of flexion, abduct and extend ipsilateral hip while stabilizing the pelvis
440
Positive Ober's test
Extremity cannot drop below horizontal - tight fascia or IT band
441
Knee XR options
Sunrise view in addition to AP and LAT
442
Iliotibial band syndrome
Feel IT band when flexing/extending, common in runners/cyclist
443
IT band syndrome presentation
Pain in anterolateral aspect of the knee, popping with walking running, Positive Ober's and Noble's, healstrike pain, tender over lateral femoral epicondyle
444
Management and Dx of ITBS
Clinical dx, Knee XR, NSAID, rest, Ice, modify exercise and refer if no improvement (last resort to surgically lengthen IT band)
445
Distal femur fracture
Easier to sustain - fall on knee can affect any potion of the joint - red flag for infection with open wound - need IV abx
446
Dx for distal fem fracture
XR conventional, CT, MRI, CTA for vascular and other sructure assessment
447
Management of distal femoral fracture
Splint if non-displaced, surgery if displaced (ORIF), emergent ortho consult for comp. syndrome, open fx, vasc compromise
448
Patellar fracture
Fall, direct blow, forceful quad contraction
449
Presentation of patellar fx
Localized tenderness and swelling, palpable defect, lack of extensor mechanism
450
Dx for patellar fx
Sunrise XR view
451
Management for patellar fx
Long leg splint with immobilization, surgery for displaced or complex fx, ortho referral - LONG Recovery
452
Patellar dislocation
Usually a lateral dislocation, may have a bloody effusion and positive apprehension test
453
Dx for patellar dislocation
Sunrise XR view
454
Management for patellar dislocation
Sedate, flex hip and extend the knee while putting pressure on the patella, patella immobilize in full extension for 4-6 weeks with ortho f/u
455
Patellofemoral syndrome
Overuse syndrome in runners - have to rest it. Can result from and angular dysalignment
456
Q angle
Angle between femur and tibia should be 15-20 degrees or LESS
457
Presentation of patellofemoral syndrome
Diffuse aching and pain "behind the knee cap" with running, walkingm squats, etc.
458
PE for patellofemoral syndro,e
Gait shows patellar squinting, instability on apprehension test, positive grind test, trendelenbuerg sign, longer sitting = more pain on getting up
459
Patellar squinting
Kneecaps rotated inwards risk of patellofemoral syndrome
460
Dx for patellofemoral syndrome
Clinical, XR to r/o trauma, MRI for surgical planning if severe
461
Management for patellofemoral syndrome
Rest, ICE, NSAID, Weight loss, PT is mainstay quad and hamstring stretch ortho if no improvement
462
Prepatellar bursitis
Chronic compression - praying, kneeling, wrestling - can become septic if punctured
463
Presentation of prepatellar bursitis
Early on pain only with activity, localized swelling over the knee, lack of patellar differentiation, erythema, warmth pain
464
Dx for prepatellar bursitis
XR, Aspirate if septic bursitis is suspected C&S
465
Tx for inflammatory NON-Septic bursitis
NSAID, Ice, Activity, Corticosteroid injection
466
Tx for septic bursitis
Oral abx for mild Keflex for MSSA Bacrtim or Clinda for MRSA IV rocephin for MSSA inpatient IV vanc for MRSA inpatient
467
Ottowa knee rules (5 criteria)
Need 1+ criteria: 55+ y/o, Tenderness at fibular head, Isolated patellar tenderness, Inability to flex knee to 90 degrees, inability to bear weight for 4 steps both immediately after the injury and in the ED
468
ACL tear MOI
ACL keeps femur from moving forward - quick stop, hyperextension of the knee, popping sound
469
Presentation of ACL tear
Sudden pain and knee giving way with pop, Swelling of joint, limited weight bearing and ROM
470
3 PE tests for ACL tear
Lachman (best), Anterior drawer, Pivot shift (only on sedated pt)
471
Diagnostics for ACLE tear
May see an avulsion fracture of the lateral capsular magin of the tibia; Tunnle view XR, Cloudy joint effusion seen
472
Management of ACL tear
Rest, Ice, Compression, Immobilize, Acetominophen before NSAID, Aspirate effusion if needed, Graft for young pt's PT for older pts
473
Sequeklae to ACL tear
Medial meniscus tear
474
MOI of PCL tear
Direct blow to tibia, MVA, Extreme hyperextension (with an ACL tear
475
Presentation of PCL tear
Same as ACL with a positive posterior drawer test, assess NV status
476
Management of PCL tear
Rest, ICE, etc.ROM after 1-5 days, PT followed by reconstruction if failure for PCL only; Reconstruction if multiple ligaments affected
477
Collacteral ligament knee tear
MCL more common - blow to the side of the knee
478
Presentation of collateral ligament tear
Localized pain/tenderness worsens over 6-8 hours, may be able to walk, eccymosis, positive valgus/varus stress test
479
Dx of collateral ligament tear knee
Lack straight line on side of knee on MRI
480
Tx for collateral ligament tear
Rice and knee brace for sprain or partial tear; Ortho with potential repair for complete rupture
481
MOI of meniscal injury
Rotational force to the knee, less intentse MOI in older patients
482
Presentation of meniscal knee tear
Can walk but with stiffness, locking, catching, or popping sensation, tenderness along flexed joint line, effusion (bigger in lateral tear, positive McMurray test
483
XR for meniscal tear
Do weight bearing and flexed XRs in over 40. Knee MRI
484
Management for meniscal injury
RICE, NSAID, Ortho for repair in Young patients, patients who fail conservative therapy, mechanical sympom pts, unstable patients, otherwise PT
485
Knee dislocation
Not common - MVA, Martial arts. Obese, trampoline falls - define by where the tibia is in relation to the femur
486
Presentation of knee dislocation
Severe pain - spont. Reduction in 50%, swelling, check NV status, knee may be very unstable, hyperextension indicates ligament injuries
487
Imaging for knee dislocation
2 view XR, CT for occult fracture, MRI for soft tissue injuries
488
Management for knee dislocation
Sedation and reduction with longitudinal traction, repeat NV status check and imaging, immobilize at 20 degree flexion, Admit for observation
489
Tibial plateu fracture
Due to a valgus stress - a lateral plateu fracture, usually high energy trauma
490
Presentation of tibial plateau fracture
Sudden onset, NWB after trauma, may be deformed, limited ROM, Effusion of joint
491
Imaging for tibial plateau fracture
AP, lateral maybe oblique XR - CTA/MRI for soft tissue and NV compromise
492
Management for tibial plateau fracture
Splint at full extension - emergent ortho if any complications like compartment syndrome, Urgent referral if displacement for depression, ORIF for displaced, Splint, crutches, NWB for non displaced with 1 week ortho f/u
493
Tibial tubercle fracture
Due to sudden force to flexed knee - avulsion fracture of the patellar tendon
494
Presentation of tibial tubercle fracture
Pain, tenderness and swelling over tibial tuberosity, superior displacement of the patella, loss of ROM
495
Dx for tibial tubercle fracture
2 views knee XR
496
Management for tibial tuberosity fx
RICE immobilize and ortho f/u for incomplete/small; RICE immobilizer, 24-48 hour ortho f/u if complete avulsion
497
Tibial shaft fx
Most common long bone fracture, usually assoc with fibular fx
498
Presentation of tibial shaft fx
NWB, Swelling pain, Compartment syndrome, check for NV compromise
499
Dx for tibial shaft fx
XR CT to eval further complexity
500
Management of tibial shaft fracture
Rest, analgesic, Splint, emergent consult for open, tib/fib, NV compromise, compartment syndrome, closed reduction if displaced long leg posterior splint with stirrup for displacement, consult ortho in 1 week
501
Stirrup splint
Prevents ankle eversion and inversion, origin 2 inches below fibular head, inserted on plantar surface of the foot, ankle at 90 degrees, patient prone to prevente achilles tendon shortening
502
Fibular fracture
Uncommon to be isolated direct blow or twisting - point tenderness and weight bearing
503
Maisonneuve fracture
Proxima fibular fracture with medial malleolar fracture
504
Dx for fib fracture
XR with knee and ankle as well
505
Fib racture management
RICE, analgesices, Long posterior leg splint, refer to ortho
506
Emergent fib fracture indications
Open fx, tib/fib, NV compromise, crush injury, compartment syndrome
507
Tx for fibular head/neck fracture
Knee immobilizer splint or long leg posterior splint
508
Tx for distal fibular fx
Stirrup splint or air cast splint, ortho within 1 week
509
3 lateral ankle ligaments
Posterior talofibular ligament, Calcaneofibular ligament, anterior talofibular ligament
510
Ligaments of medial ankle
Deltoid ligament with four parts - less common to sprain
511
Pes cauvs
High arch of foot
512
Pes planus
Flat foot
513
Normal ankle ROM - flexion
Plantar - 0-50, Dorsi 0-20
514
Formal ROM eversion/Inversion of foot
In - 0-35 Out - 0-25
515
Toes ROM normal
Flex - 0-30 Extend - 0-80
516
Posterior tibialis
Resist as patient inverts and plantar flexes
517
Anterior tibialis
Resist as patient inverts and dorsiflexes
518
Peroneus longus and brevis
Resist eversion
519
Extensor hallucis longus
Resist dorsiflexion of great toe
520
Floexor hallucis longus
Resist plantar flexion of great toe
521
Anterior drawer andkle test
Pull mfoot forward to test anterior talofibular ligament
522
Talar tilt test
Tests integrity of calcaneofibular, deltoid, and anterior and posterior talofibular ligaments - use inversion, eversion, plantarflexion+inversion, and dorsiflexion+inversion for each respectively
523
Thompson's test
Compression of calf in prone position produces plantar flexion in intact achilles tendon
524
Mortise view of ankle
Better than AP and lateral - Look diagonally down from the front towards the ankle
525
Ottowa ankle rules
Radiograph if 1 present - pain at amlleoli, inability to bear weight 4 steps, tenderness posteriorly or inferiorly at malleoli
526
3 XR views for foot
AP, Lat, Oblique
527
Ottowa foot rules
Radiograph if 1 present - pain at amlleoli, inability to bear weight 4 steps, tenderness posteriorly or inferiorly at malleoli
528
Achilles tendon injury
Usually 5 cm above insertion - Blow or forced dorsiflexion, can also get microtears at insertion site
529
Presentation of achilles tendon injury/rupture
Pop and severe pain, palapavle defect, positive thompson test, weak active plantar flexion
530
Management for achilles tendon injury
RICE, Surgery for young rupture, Controlled ankle mostion boot for tear but not rupture
531
Achilles tendonitis presentation
Burning pain and stiffness 2-6 cm above calcaneus, Negative Thompson test, ROM normal, calcaneal spur, worse with activity, better with rest
532
Management for achilles tendonitis
Rest, ICE, NSAIDs for 7-10 days, PT if no improvement
533
High ankle sprain
Damage to the tibiofibular syndesmosis due to severe inversion
534
Grades of ankle sprain
I - Stretch and small tears, II-Larger but incomplete tear III - Complete tear
535
Presentation of ankle sprain
Fell, stepped off curb, tenderness over involve ligament, Sqeeze test, Talar tilt and anterior drawer to assess stability
536
Phase 1 of ankle sprain management
RICE with NSAID, Aircast splint, crutches if needed
537
Phase 2 of ankle sprain management
Initiate once weight bearing without pain
538
Phase 3 Ankle sprain management
After a month, wean from ankle brace, more challenging exercises - send to PT if continued pain, send to ortho for frequent sprains
539
Bimaleolar fx
Both malleoli fractured
540
Trimaleolar fracture
Both malleoli fractured as well as posterior tibial fx
541
Management for ankle fracture
Long leg splint /cast NWB for unstable WB splint /cast for non-displaced, Short leg splint for suspected occult fracture with repeat XR in 10-14 days
542
Calcaneal fracture
Usually due to axial load - fall and land on heal - can be assoc with vertebral injuries - MC tarsal fx
543
Presentation og calcaneal fx
NWB, Swelling, Check cap refill and lumbar spine
544
Management for calcaneal fx
RICE, posterior short leg splint with lots of padding, urgent ortho referral, NWB
545
Talar fx
High force plantarflexion, risk of AVN, 2nd MC tarsal fx
546
Presentation and tx for talar fracture
Similar to calcaneal fx - need imaging to differentiate, NWB and padded support with ortho referral
547
Ankle dislocation
MC - Posterior d/t force on plantar flexed foot, inversion for lateral, highly unstable
548
Presentation of ankle dislocation
Gross deformity, locked in plantar flexure - check NV status and fix before imaging
549
Management for ankle dislocation
Sedate and reduce, grasp heel and downward traction - splint, post reduction films and ortho consult
550
Metatarsal fx presentation
D/t drop on foot etc., pain with difficult ambulation - may just be tender
551
Jone's fx
Fifth metatarsal fx
552
Management for metatarsal fx
Single - Short leg posterior cast, If multiple or displaced consult ortho for surgery
553
Tarsometatarsal injury
Disruption of tarsometatarsal joint/Lisfranc injury, often fx associated, bending, rotation, compression or loading of plantar flexed foot
554
Presentation of tarsometatarsal injury
Can barely walk - painful, assess for compartment syndrome, deformity, swelling and eccymosis, midfoot pain
555
Management for nondisplaced lisfranc injury
Non weightbearing splint/cast for 6-8 weeks; If complicated - refer to ortho for surgery
556
MC phalangeal fx
5th phalanx (foot)
557
MC foot phalanx dislocation
MTP of the 1st joint
558
Management for foot phalangeal injury
Often buddy tape, digital block with reduction for dislocation
559
Hallux valgus
Bunion, big toe bent towards others - over 15 degrees angulation of big toe
560
Management of hallux valgus
Patient ed and shoe wear modifications, wide toed shoes avoid high heels, Surgery for patients who fail conservative therapy
561
Morton's neuroma
Perineural fibrosis of common digital nerve of foot - MC between base of third and fourth toes - often d/t tight shoes
562
Presentation of Morton's neuroma
Plantar pain in forefoot - MC, burning in nature, aggravated by activity and tight shoes, better with rest, walking on a marble feeling
563
Interdigital neuroma test
Applyqdirect plantar pressure to interspace - squeeze metatarsal - pain is a positive test for Morton neuroma
564
Management for Morton neuroma
Education, Steroids, Surgery for severe
565
Plantar fasciitis
Idiopathic - linked to frequent standing, obesity
566
Presentation of plantar fasciitis
Heel pain that is worse when the start to walk and then gets worse again towards the end of the day, tenderness over medial calcaneal tuberosity and along plantar fascia, pain with passive dorsiflexion
567
Management of plantar fasciitis
Orthotics and stretching (heel lift pad), Avoid barefoot and flat shoes, ice and NSAIDs may take 6-12 months to resolve - Steroid, surgery of custom orthotic may be considered
568
Valgus Stress Test
20 degree flexion with pressure the lateral aspect of the elbow
