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Clin Med III > MSK Exam 1 > Flashcards

MSK Exam 1 Flashcards

1
Q

Type of tissue causing catching or locking

A

Typically cartilage issue

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2
Q

Type of issue causing instability of joints

A

Ligament issue

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3
Q

5 things to expect for in MSK exam

A

Swelling
Erythema
Atrophy
Deformity
Scars/Skin

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4
Q

Quantitative way to measure swelling

A

Measure it

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5
Q

Place to locate with palpation

A

Point of MAXIMAL tenderness

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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

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7
Q

Two ranges of motion

A

Active and passive - Take both!!

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8
Q

Goniometer

A

Measures angles of joints, hard to do for hip and shoulder

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9
Q

Muscle testing grade 5

A

Full ROM even with full resistance

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10
Q

Muscle strength grade 4

A

Full ROM with some resistance

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11
Q

Muscle strength grade 3

A

Against gravity but not resistance

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12
Q

Muscle strength grade 2

A

Only when not against gravity

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13
Q

Muscle strength grade 1

A

See muscles twitching but can’t move limb

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14
Q

Muscle strength grade 0

A

No movement

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15
Q

What should a long bone x ray include

A

Joint above and joint below

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16
Q

How many planes should be obtained

A

2 planes/views always

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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

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18
Q

Highest bony detail imaging

A

CT scan

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19
Q

When do you need contrast for a CT

A

When looking as soft tissue

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20
Q

MRI Uses

A

Good for soft tissue
Bone death
Osteomyelitis
Stress fractures(harder to see on Xray)

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21
Q

Ultrasound in MSK

A

Need a skilled tech
Soft tissues and bursae

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22
Q

Bone scan

A

Scintigraphy
Looks at metabolic activity of bone rather than tissue (pet scan)

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23
Q

Myelography

A

Dye injected to look at the spinal cord
Used for spinal cord imaging when we cannot take an MRI

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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

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25
Q

Arthrocentesis

A

Can use an ultrasound to guide
Draw off and analyze fluid

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26
Q

Muscle biopsy purpose

A

Differentiate between myopathy or neuropathy
VERY painful

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27
Q

Indications for emergent MSK referral

A

Pain out of proportion
Paresthesia
Pulselessness
Pallor
Paralysis
Open/Unstable fracture

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28
Q

Urgent MSK complaints

A

Stable fracture
Reduced joint dislocation
Locked joint
Tumor
Get in within a week

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29
Q

Strain v. Sprain

A

Strain muscle
Sprain ligaments

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30
Q

Muscle sprain

A

Usually distal, wheere the muscle attaches to the tendon
MC in muscle attached to two joints
Forceful eccentric loading

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31
Q

Ligament sprain

A

Joint is overextended and the ligament is damaged
Bone can evulse instead

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32
Q

Clinical presentation of strain/sprain

A

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

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33
Q

Muscle strain categories

A

1-4 More muscle fibers torn as we go up - muscle fascia is torn in 4

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34
Q

Grades of ligament sprain

A

1-3 - 3 is a complete tear of the ligament

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35
Q

Dx for sprain/strain

A

Usually a clinical diagnosis
X ray for fracture if not healing or if they meet criteria to suspect a break - Ottoawa ankle rules

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36
Q

4 phase healing process for strains and sprains

A

Hemostasis - clot forms, skin blanches
Inflammatory destructive phase - days 1-3 with swelling
Proliferative - Scar formation occures
Maturation phase - Remodeling

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37
Q

Over time management of strains and sprains

A

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

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38
Q

PRICE Inflammation stage management

A

Protection
Rest Ice
Compress
Elevation

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39
Q

Ice recommendations for sprain/strain

A

NO HEAT
15-20 minutes every 2-3 hours

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40
Q

Surgical repair for sprain/strain

A

Indicated with complete tear

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41
Q

Pain management for strain/sprain

A

NSAIDs

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42
Q

Presentation of overuse syndrome

A

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

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43
Q

Management for overuse syndrome

A

Avoidance of activity
Ice/Heat/NSAID
Steroid injections
PT

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44
Q

Periosteum

A

Thick outer bone layer
Nerve and vessel rich

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45
Q

Endostium

A

Lines marrow cavity

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46
Q

Epiphysis

A

Growth plate area - very prone to infection or fracture

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47
Q

Metaphysis

A

End of the bone in adults, where the growth plate was, succeptible to compression fractures

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48
Q

Diaphysis

A

Long part of the bone - structural support

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49
Q

Fracture

A

Any broken bone

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50
Q

Pathologic fracture

A

Bone cancer or osteoporosis cause a fracture that normally would not occur

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51
Q

H&P for fracture

A

Palpate above and below the joint
Palpate
Assess neurovascular status!!

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52
Q

Imaging for fractures

A

X ray is first line
MRI/CT for complicated cases or for surgical planning

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53
Q

Open fracture grades

A

Grades I-IIIC
Determines how we use abx for the fracture

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54
Q

Gustilo and Anderson Grade I

A

Low energy injury with open wound under 10cm and no evidence of contamination

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55
Q

A&G Grade II

A

Moderate injury with comminution of the fracture and a 1-10 cm wound with some contamination

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56
Q

G&A grade IIIA

A

High energy fracture pattern with wound over 10cm and gross contamination

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57
Q

G&A Grade IIIB

A

High energy fracture with over 10cm contaminated wound exposure and exposed bone

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58
Q

G&A grade IIIC

A

Grade IIIB with vascular involvement

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59
Q

Transverse fracture

A

Straight across fracture

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60
Q

Oblique fracture

A

Diagonal fracture

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61
Q

Spiral fracture

A

Multiplanar and complex fracture line - red flag for child abuse!!

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62
Q

Comminuted fracture

A

Two or more fracture fragments

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63
Q

Segmental fracture

A

2 fracture lines isolating a segment of bone

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64
Q

Avulsed fracture

A

Detached bone fragment that results from excess pulling of a ligament, tendon, or joint capsule from its point of attachment

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65
Q

Compression fracture

A

Often spinal and osteoporosis
Can cross joints

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66
Q

Displacement

A

Distal fragment is out of alignment - direction that the distal bone has gone relative to proximal bone

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67
Q

Distraction

A

Segments of bone have been pulled away from each other - measured in mm

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68
Q

Angulation

A

Distal bone is rotated relative to its proximal half

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69
Q

Description of broken bone displacement and angulation

A

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

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70
Q

Shortening

A

Fractured ends of the bone slide past each other - causing shortening
Distal and proximal segments overlap describe in mm

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71
Q

Rotational deformity

A

Bone has rotated on itself, usually visible on PE
(Foot is pointing the wrong way)

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72
Q

Buckle fracture

A

Incomplete fracture line at the metaphysis
Need to look at multiple views
MC in distal radius

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73
Q

Greenstick fracture

A

A fracture that doesn’t extend through the entire periosteum
More splintery

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74
Q

Salter Harris classification

A

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

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75
Q

3 phases of bone healing

A

1 - Inflammatory
2 - Reparative w/ neovascularization, laying down collagen callous
3 -Remodeling phase - Imaature bone becomes hardened can take 6-10 weeks

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76
Q

Closed fracture meneagment

A

Reduce the fracture - refer if you cannot

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77
Q

Open fracture

A

Emergent for infection or compartment syndrome - immediate ortho referral

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78
Q

Abx for I or II open fracture

A

Cefazolin

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79
Q

Abx for type III fracture

A

Cefazolin AND Gentamycin

Add Flagyl if at risk for an anaerobic infection
Update Td if needed

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80
Q

Fracture risk factors

A

Intra articular
Older
Oblique or comminuted

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81
Q

Malunion

A

Poo alignment of bone - have to rebreak

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82
Q

Nonunion

A

No healing in 6 months or no progress in 3 months
May require surgical fixation or bone graft

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83
Q

Risk factors for nonunion

A

Smoking, Infection, NSAID overuse, malnutrition, inadequate immobilization

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84
Q

Stress fracture

A

Combined load over time creates a small break in the bone - runners, athletes, etc.

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85
Q

Risk factors for stress fractures

A

Acceleration of physical fitness
Prior stress fracture
Low calcium/Vitamin D
Eating disorder
Female
Poor biomechanics

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86
Q

Presentation of stress fracture

A

Don’t do much activity and get pain that is severe

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87
Q

Imaging for stress fracture

A

Not healing with conservative therapy

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88
Q

Management of stress fracture

A

Let it heal in its own usually unless in
Patella
Femoral head
Medial malleolus
etc.

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89
Q

Casting pearls

A

Always check neurovascular status
Use X ray to check for healing

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90
Q

Clinical presentation of osteomyleitis

A

Fever, bone pain and tenderness
Blood cultures

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91
Q

Imaging for osteomyelitis

A

Takes weeks to see changes on XR
CT might be helpful early on -expensive!!
US may also be helpful

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92
Q

Labs for Osteomyelitis

A

CRP and ESR more useful than CBC w/Diff for chronic osteomyelitis

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93
Q

Common sources of hematogenous osteomyelitis

A

UTI, Skin, Intravascular, Dental, Catheter, endocardium

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94
Q

MC osteomyelitis organisms and infection site in children

A

Metaphysis of long bones (more common in males)
S aureus, Salmonella, Strep, E. coli

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95
Q

Sites and sources of hematogenous osteomyelitis common in adults

A

More common in vertebral column - usually lumbar spine
IVDU, DIabetes, Catheters
Staph MC or pseudomonas for IVDU
Tenderness of spinal cord percussion

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96
Q

Continuous spread osteomyelitis

A

Often polymicrobial from diabetic foot ulcer, etc.
Find precipitating event
Fevers and rigours, tenderness, warmth, erythema

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97
Q

Probing for bone

A

Put cotton applicator into wound to see if it touches the bone
May be painless in diabetics

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98
Q

Dx for osteomyelitis

A

Blood cultures + in 60% of cases
Cultures from wounds NOT reliable
Left shift on CBC=Acute
ESR and CRP
Bone biopsy may be useful

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99
Q

X ray in osteomyelitis

A

Takes TIME to happen
May see swelling first
Eventually see scalloping or onion skinning
Moth eaten appearance of bone

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100
Q

Bone biopsy in osteomyelitis

A

When we have radiologic evidence of osteomyeltis without positive blood cultures
Do not delay for abx
Must be collected through an uninfected site

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101
Q

Management for osteomyelitis

A

COnsult ID and Ortho
Vanc AND a 3 or 4 gen cephalosporin (triaxone, tazidime, cefipime)
Tailor after C&S results

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102
Q

IV therapy for osteomyelitis

A

MAX dose for 4 weeks at least
Vanc for MRSA
Cephalosporin for MSSA
Monitor trough levels

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103
Q

Abx for S aureus osteomyelitis oral therapy

A

Need IV first, will need PO combo
Use a PO FQ and rifampin

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104
Q

Indication for debridement in osteomyelitis

A

Infection related to open fx or surgical hardware
Extensive disease
Concomitant joint infection
Recurrent or persistent

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105
Q

Monitoring for abx therapy for osteomyelitis

A

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

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106
Q

Sequestrium

A

Dead bone stuck in healthy bone with a cloaca seeping out of the bone
May need to remove and put in a rod

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107
Q

Involcrum

A

New bone is layed down over lesion to make the bone stronger

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108
Q

Chronic osteomyelitis workup

A

Same but no leukocytosis
Very long term tx
Pathologic fractures
Extensive debridement or amputation

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109
Q

Pathophys of compartment syndrome

A

Pressure in muscle is greater than BP
Muscle death

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110
Q

Normal compartment pressure

A

10mmHg (20mmHg is intolerable

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111
Q

Reversibility of compartment syndrome

A

2-4 hours = reversible may loose nerve conduction
6 hours - Variable damage
8 hours - Irreversible damage
12 hours - Myocyte death

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112
Q

5 P’s of ischemia

A

Pain out of proportion
Pulseless
Pallor
Paresthesia
Paralysis

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113
Q

Compartment pressure requiring decompression

A

Anything over 45mmHg or within 30 points of DBP for hypotensive patients
Take two readings with a manometer to measure

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114
Q

Management for fasciotomy

A

Remove cast or tourniquet
Fasciotimy with open sutures
Delayed closure
CI in patients whose symptoms began over 24 hours ago - observe

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115
Q

Rhabdomyolysis presentation

A

Crush injury, drugs can be overexertion
Electrolyte abnormalities with kidney failure - ATN from purine crystals
Aches with low grade fever

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116
Q

Dx for rhabdomyolysis

A

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

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117
Q

Tx for rhabdomyolysis

A

LOTS of fluids
Measure I/O with foley
Give bicarbonate to help with process
Consult nephro

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118
Q

Monitoring for rhabdomyolysis

A

Monitor electrolytes and EKG
CK should drop

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119
Q

3 complications of rhabdomyolysis

A

AKI
Compartment syndrome
Disseminated Intravscular Coagulopathy

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120
Q

Fibromyalgia presentation

A

Widespread MSK pain in different trigger points with no clear cause 3+ months
Fatigue and aching
Thought to be overactive nerves
Joints UNAFFECTED!!

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121
Q

Dx for fibromyalgia

A

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

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122
Q

Management of fibromyalgia

A

Difficult to treat - chronic condition
CBT and Low aerobic activity ie. yoga or swimming, weight loss

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123
Q

Pharm for fibromyalgia

A

Cymbalta - fatigue or anxiety, Cyclobenzaprine - MC first line, Lyrica/Neurontin - sleep disturbance, Tramadol - An opioid is NOT sustainable because of length of tx

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124
Q

FDA approved fibromyalgia drugs

A

Duloxetine
Milnacipram
Gabapentin (Neurontin)
Pregabalin (Lyrica)

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125
Q

Charcot foot

A

Neurogenic arthropathy
Arch of the foot drops with destruction of soft tissue
Rocker bottom foot

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126
Q

Presentation for charcot foot

A

Rocker bottom
Less pain than expected
May look like/result from infection

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127
Q

Dx for charcot foot

A

Weight bearing XR - Yellow angle measurement
MRI if XR is negative and need to r/o osteomyelitis

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128
Q

Stage 0 charcot foot

A

Early inflammatory stage with little change on XR

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129
Q

Stage 1 charcot foot

A

Swelling, redness and warmth persist
Bony fracture, subluxation, etc. seen

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130
Q

Stage 2 charcot foot

A

Clinical signs of inflammation decerase
Fracture healing, debris resorption and new bone formation

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131
Q

Stage 3 charcot foot

A

No signs of inflammation with bony deformity
Fracture callus is present

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132
Q

Charcot 0-2 management

A

Avoid weight bearing
Boot!!
Grdaul progression back to exercise

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133
Q

Charcot 3 treatment

A

consider surgery

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134
Q

Raynauds phenomenon

A

Abnormal vasculature at finger tips
Turns cyanotic or white in the cold, then red inside
Primary or secondary to autoimmune condition

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135
Q

Presentation of raynauds phenomenon

A

Attacks of ischemia - white or blue
Followed by painful reperfusion of digits
Sclerodactyly (calcified tendons from calcinosis), or digital ulcers

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136
Q

Dx for raynauds phenomenon

A

Ophthalmascope shows corkscrew blood vessels in nail beds
Usually clinical dx

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137
Q

Tx for raynauds phenomenon

A

Educate!!! - keep fingers warm, etc.
CCB - first line pharm
Viagra
Treat underlying conditions
Decongestants
Smoking cessation

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138
Q

Presentation of Marfans syndrome

A

Wingspan greater than height
Scoliosis
Pectus excavatum
May have aortic or eye issues - Myopia, MVP
Long-spidery fingers

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139
Q

Thumb sign for Marfans

A

Thumb sticks out the other side of the fist

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140
Q

Genetics for Marfan

A

Mutation in Fibrillin gene
Autosomal dominant

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141
Q

Management for Marfan’s syndrome

A

BB - Atenolol or Atenolol for aortic root disorders
Limit exercise
Ortho, Ophtho, and Cardio consult

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142
Q

Complication of undiagnosed Marfans

A

Aortic dissection is a common cause of death in undiagnosed Marfans

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143
Q

4 rotator cuff muscles

A

Supraspinatus
Infraspinatus
Subscapularis
Teres minor

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144
Q

Shoulder injuries common under 30

A

Usually trauma
Dislocation or separation
RC tears in athletes

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145
Q

More common shoulder dislocation

A

Anterior rather than posterior

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146
Q

Subluxation

A

Joint slides out and in

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147
Q

PE for shoulder complaint

A

Start at sternoclavicular joint
Shirt off and standing

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148
Q

Deltoid muscle testing

A

Stabilized at shoulder, abduct to 90 degrees, bend elbows
Patient able to resist downward pressure

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149
Q

Supraspinatus test

A

Empty can test
90 degree abduction with 30 degree forward flexion and thumbs down
Push down with resistance
Weakness is a positive sign

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150
Q

Hornblowers test

A

Support flexed elbow and attempt external rotation
Evaluates infraspinatus and teres minor

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151
Q

Gerber lift off test

A

Subscapularis
Patient places hands behind their back palms facing wawy from back
Lift hands against resistance

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152
Q

Serratus anterior test

A

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

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153
Q

Rhomboid test

A

Pot arm on back with palm facing away from back
Push up with the elbow

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154
Q

Neer Impingement sign

A

Depress scapula with one hand and elevate the arm with the other
Checks for rotator cuff tear or impingement syndrome

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155
Q

Hawkins-Kennedy test

A

Forward flex shoulder to 90 and elbow at 90
Internally rotate shoulder (push forearm down)
Pain indicates supraspinatus impingement

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156
Q

Crossover test

A

Stabilize shoulder and cross arm over body
Pain suggests arthritis or AC joint pathology

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157
Q

Apprehension sign

A

Place arm supine
90 abduction and 90 flexions
Crank forearm towards head
Indicates anterior shoulder instability

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158
Q

Sulcus sign

A

Pull down arm and see simple in the shoulder
Indicates inferior instability

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159
Q

Jerk test

A

For posterior instability
90 flexion
Max internal rotation with elbow flexed
Adduct arm with pushing the humerus

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160
Q

Shoulder diagnostics

A

Imaging 1st line
AP, Scapular, and Axillary views possible

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161
Q

Point of rotator cuff muscles

A

Stabilization

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162
Q

Progression of rotator cuff injuries

A

Overuse
Edema
Inflammation
Fibrosis
Microscopic tear
Partial thickness tear
Full thickness tear

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163
Q

Impingement syndrome

A

Precursor for tear
Due to repetitive use of rotator cuff

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164
Q

Impingement presentation

A

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

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165
Q

Diagnostics of impingement syndrome

A

XR to r/o fracture, check for spurs
MRI - more definitive
Can inject lidocaine or steroids - will improve ROM

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166
Q

Tx for impingement

A

Rest and NSAIDs - Topical
Gradual exercise with PT
Red flag for tear if worsening
Steroids if failing conservative therapy

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167
Q

Rotator cuff tendonitis

A

Next step after impingement
Throwing athletes and diabetic patients or hyperlipidemia
Painters and stockers

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168
Q

Presentation of rotator cuff tendonitis

A

Worsening from an ache
Can’t throw as far, can’t wash hair, get things out of cabinets
Pain and no active ROM

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169
Q

Dx and Treatment for rotator cuff tendonitis

A

Shoulder XR, MSK US if good tech - thickened tendon, MRI
Rest - Stage I
Rest and refer to PT - Stage II

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170
Q

Rotator cuff tears

A

Uncommon in persons under 40
Supraspinatus is most common torn
d/t degeneration, mechanichal impingement, altered blood flow

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171
Q

Presentation of rotator cuff tear

A

Chronic shoulder pain
Crepitus and catching
Can’t put shirt on or put on bra

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172
Q

Drop arm test

A

Take patient through pass ive range of motion and let it go - it will drop - can’t hold it up

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173
Q

Tests for rotator cuff injury

A

Empty can, Neer’s, Hawkins-Kennedy
Passive ROM okay but inhibited Active ROM

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174
Q

Dx for rotator cuff tear

A

XR to rule out other pathologies
US
MRI - best to see tear
Arthography

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175
Q

Management for rotator cuff tear

A

Rest
NSAIDs
PT - 6 weeks at least
Steroids - once every 3 months

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176
Q

Adehsive capsulitis

A

Frozen shoulder
Both active and passive ROM are affected
Idiopathic inflammation
Women 40-60
DM I is common cause

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177
Q

Presentation of adhesive capititis

A

Freezing phase - loss of ROM (active AND passive)
Thawing phase - gradual improvement
Tender at deltoid insertion

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178
Q

Imaging for adhesive capsulitis

A

XR - Normal
Get an MRI - Absent axillary recess

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179
Q

Management for adhesive capsulitis

A

NSAIDs
Stretching - conservative takes years to work
Surgery after three months with failed treatment - followed by PT

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180
Q

MC shoulder dislocation

A

Anterior

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181
Q

Mechanism of anterior shoulder dislocation

A

Blow to abducted, externally rotated, extended arm
ie. blocking a basketball shot

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182
Q

Clinical presentation of anterior shoulder dislocation

A

Arm abducted and externally rotated
Prominent acromion
Loss of shoulder rounding
No ROM
Feel humeral head on PE

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183
Q

Posterior dislocation cause

A

Axial loading of an adducted internally rotated arm
Seizure, anterior blow, arm gets pulled

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184
Q

Posterior dislocation presentation

A

Arm is adducted and internally rotated
No ROM
Shoulder prominence posteriorly

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185
Q

Inferior shoulder dislocation

A

Uncommon - can’t put their arm down - often have neurovascular compromise

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186
Q

Multidirectional instability

A

Can voluntarily dislocate shoulder
Poor prognosis for surgery and treatment

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187
Q

PE tests for joint instability

A

Apprehension - Anterior
Jerk - Posterior
Sulcus - Inferior

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188
Q

Complications of shoulder instability

A

Damage to brachial plexus - numbness over arm
Vascular issue

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189
Q

Hill sachs lesion

A

Fracture of humeral head - can be seen on XR
We don’t care if they have no pulse

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190
Q

Bankart lesion

A

Tearing of labrum - (meniscus of the shoulder
Complication of shoulder dislocation

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191
Q

Dx for shoulder instability/dislocation

A

XR - AP, Y, and Axillary views
CT if XR unclear
MRI post reduction for Bankart lesion under 30 or RC tear under 40

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192
Q

Posterior v. Anterior shoulder dislocation on XR

A

Anterior will be down and turned away

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193
Q

Management for anterior shoulder instability

A

Stimson - Hanging weight from arm
or Longitudinal traction method
Sedate and informed consent

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194
Q

Inferior dislocation management

A

Axial traction - traction and counter traction
Sedate and informed consent

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195
Q

Post relocation management

A

Assess neurovascular status
Post reduction films
Immobilize for 3 weeks
PT and Ortho referral

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196
Q

Type one AC injury

A

Just a sprain - no deformity
No separation

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197
Q

Type two AC injury

A

Acromioclavicular ligaments disrupted
Coracoclavicular ligaments intact

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198
Q

Type three AC joint injury

A

Acromioclavicular and coracoclavicular ligaments disrupted

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199
Q

Type 4-6 AC joint injury

A

Acromial end of the clavicle is moved out of place with increasing severity

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200
Q

Presentation of AC joint injury

A

Pain in the AC joint on abduction
Deformities in grades III-VI
Tenderness over AC joint
Supports arm adducted
Asess NV statues

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201
Q

Imaging of AC joint

A

Zanca veiw - from below XR
Greater gap with greater separation

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202
Q

Grade 1-2 AC injury management

A

Ice compress
NSAIDs
Sling for 2-3 days
ROM exercises for 2-4 weeks before return to sports

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203
Q

Management of grade 3 AC injury

A

Conserative as in 1 and 2
Surgery if career impacted
6-12 weeks to return to activity
Deformity w/o surgery - can be acceptable

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204
Q

Management of grade IV-VI AC injury

A

Refer to ortho for surgery - emergent if NV compromise
Deformity if no intervention

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205
Q

MOI fo sternoclavicular injuries

A

Crushing or rolling movement on chest
Can be sprained or dislocated

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206
Q

Presentation of sternoclavicular sprain

A

Mild to moderate swelling and tenderness with no change in joint structure

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207
Q

Presentation of sternoclavicular dislocation

A

Severe pain, swelling, and ecchymosis
Prominent medial clavicle for anterior dislocation
Less visible for posterior - hoarseness, dysphagia, dyspnea, upper extremity paresthesia possible

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208
Q

Diagnostics of sternoclavicular injury

A

XR not sensitive
CT of chest considering contrast

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209
Q

Management for sternoclavicular injury

A

Sling
May want to relocate
Figure eight or sling and swath brace
Surgery for posterior dislocation

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210
Q

MC site of clavicle fracture

A

Middle clavicle
Distal is least severe

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211
Q

Presentation of clavicle fracture

A

Pain, swelling, deformity
Skin tenting
Tenderness along fracture site
Grinding during ROM

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212
Q

Imaging for clavicle fracture

A

XR helpful
The more medial or proximal the fracture is the more you need a CT

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213
Q

Management for clavicle fracture

A

Sling only for uncomplicated 6-8 weeks with gentle ROM for 2-3 weeks after
Surgery for any reduction, rotation, medial fracture

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214
Q

Biceps tendinopathy

A

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

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215
Q

PE test for biceps tendinopathy

A

Yergason’s test - Flex elbow at 90 degrees pronate arm and have patient supinate against resistance
Pain is a positive test

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216
Q

Presentation of biceps tendinopathy

A

Tenderness along the bicipital groove
Pain with active AND passive ROM

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217
Q

Management for biceps tendinopathy

A

Rest, ICE, NSAIDs
May inject steroids or do surgery

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218
Q

Biceps tendon rupture

A

Most often proximal head
Bulge and bruising on tednon
XR to r/o evulsion
MRI to r/o rotator cuff

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219
Q

Management ofr biceps tenson rupture

A

Only fix surgically in young patients - need to do it sooner rather than later
Can leave as is and it will be okay

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220
Q

Proximal humeral fracture

A

Generally from direct blow for Fall on outstreched hand (FOOSH)
Proximal, midshaft, or distal

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221
Q

Presentation of humeral fractures and PE

A

Pain swelling and ecchymosis
Tenderness over fracture site
Limited ROM
Assess NV status

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222
Q

NV status assessment for humeral fracture

A

Check axillary for proximal
Check radial for shaft

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223
Q

Treatment for hymeral fracture

A

Sling if not displaced
Reduction and fixation if complicated
May need a replacement for a fractured humeral head

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224
Q

Splint for humeral shaft fracture

A

If angulation under 20% - U shaped or sugar tong splint for 2 weeks followed by humeral fracture brace

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225
Q

Indications for surgery in humeral fracture

A

Open fracture
NV compromise
Pathologic
Ipsilateral forearm fracture

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226
Q

Capitulum articulation

A

Articulates with the radius (rad cap)

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227
Q

Flexors location

A

Ventral aspect of forearm

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228
Q

Extensors location

A

Posterior aspect of the forearm

229
Q

3 Elbow imaging views

A

AP, Lateral and oblique views (Oblique best for radial head)

230
Q

What a lateral view of the elbow joint should look like

A

Anterior humeral line bisects the middle third of the capitulum; radiocapitellar line passes through the center of the capitulum

231
Q

Normal ROM for elbow: Flexion, Hyperextension, Sup/Pronation

A

Flexion: 0-150; Hyperextension: 10-15; Supination/Pronation: 80

232
Q

Innervation of Bicep

A

C5 and C6, also control pronation and supination

233
Q

Innervation of Tricep and extensors

A

C7-C8

234
Q

Innervation of pronation

A

Median nerve and C6-C7

235
Q

Varus stress test

A

20 degree flexion of elbow with pressure on medial aspect - test radial collateral ligament

236
Q

Test for radial and ulnar collateral ligament

A

Valgus and Vaus stress tests

237
Q

Distal humeral fracture

A

Generally from direct trauma; usually supracondylar in kids

238
Q

Type A,B, and C fractures for distal humerus

A

A - Above both condyles, B - One condyle involved C - Both condyles involved

239
Q

Presentation of distal humeral fractures

A

Pain, tenderness, swelling, eccymosis, crepitus; Limited ROM of elbow

240
Q

PE for supracondylar distal humeral fracture

A

Radial artery and median nerve affected

241
Q

PE for epicondylar distal humeral fracture

A

Ulnar and radial nerves affected

242
Q

XR for distal humeral fracture

A

Sail sign from pushed out fat pad due to intrarticular bleeding - posterior fat pad is pathologic always

243
Q

Supracondylar fracture management

A

If not displaced or angulated - can use just a cast - surgery if more complex

244
Q

Epicondylar fracture management

A

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
Q

Olecranon fractures

A

From a fall on the elbow or tricep evulsion from falling with flexed arm

246
Q

Prsentation of olecranon process fracture

A

Limited ROM, Swelling, Ulnar nerve dist. Affected

247
Q

XR for olecranon fracture

A

AP and radiocapitular view if needed for better management

248
Q

Tx for nondisplaced olecranon fracture

A

Posterior long arm splint, monitor for vasc compromise, squeezing of ball, put in a degree of flexion

249
Q

Tx for displaced olecranon fracture

A

Splint and ORIF, Admit for IV abx for open fracture

250
Q

ORIF

A

Open reduction and Internal Fixation

251
Q

MCC of radial head and neck fractures

A

Fall on outstretched hand

252
Q

Mason type I radial head fracture

A

Under 2mm displacement

253
Q

Mason type II radial head fracture

A

Displaced over 2mm

254
Q

Mason type III radial head fracture

A

Comminuted

255
Q

Mason type IV radial head fracture

A

Radial head fracture with elbow dislocation

256
Q

Presentation of radial head/neck fracture

A

Tenderness along lateral aspect og elbow; pain with supination/pronation, effusion and ecchymosis

257
Q

XR for radial head fracture

A

AP and Lateral views; Fracture line and posterior fat pad sign, may need an oblique view

258
Q

Management for radiakl head and neck fracture

A

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
Q

Radial head subluxation

A

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
Q

Presentation of radial head subluxation

A

Mechanism followed by crying - flexed, adducted, and pronated arm. Tenderness alone

261
Q

Management for radial head subluxation

A

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
Q

Hyperpronation

A

Better for nursemaids elbow for reduction

263
Q

Failed reduction of radial head subluxation

A

XR for fracture/other issues

264
Q

Epicondylitis

A

Tennis lateral, Medial golfers. Chronic repetetive use resulting in tendon trauma

265
Q

Presentation of lateral epicondylitis - Tennis elbow

A

Tenderness a cm distally to the epicondyle, shaking hands and difficulty opening jars. Pain with ROM against resistance

266
Q

Presentation of medial epicondylitis - Golfers

A

Pain with pronation and wrist flexion, Point tenderness 1 cm distal to the epicondyke, Pain with ROM against resistance

267
Q

Dx for epicondylitis

A

Clinical dx, imaging not needed

268
Q

Management for epicondylitis

A

Activity modification, NSAID, Ice, PT, Counterforce brace, Steroid injection 3 max per year

269
Q

Olecranon bursitis

A

Direct trauma or chronic inflammation - can also be part of autoimmune

270
Q

Presentation og olecranon bursitis

A

Swelling of bursa, may or may not have pain, Limited ROM. Redness and warmth if acute/infectious

271
Q

Diagnostics of olecranon bursitis

A

Aspirate if large and symptomatic - CBC, gram stain, C&S, Crystals. XR if hx of trauma

272
Q

Treatment for olecranon bursitis

A

Control swelling with activity mod and NSAIDs, Aspirate and apply compression bandage, reculture if continues, steroids if all cultures are negative

273
Q

Tx for septic bursitis

A

Bactrim or Keflex in non-immune compromised

274
Q

Tx for severe septic bursitis

A

IV vanc

275
Q

Tx for severe septic bursitis associated with trauma

A

Cipro or Zosyn for pseudomonas coverage

276
Q

Usual forearm imaging

A

AP and Lateral

277
Q

Usual wrist, hand, finger

A

AP, Lateral, Oblique

278
Q

Monteggia fracture

A

Ulnar fracture with dislocated radial head, proximal break

279
Q

Galeazi fracture

A

Radius fracture with dislocation of the distal radioulnar joint

280
Q

Mneumonic for Forearm fractures

A

MUGR - A is proximal, Z is distal

281
Q

Presentation of forearm fracture

A

Deformity, swelling, point tenderness, Limited ROM

282
Q

Diagnosis of forearm fracture

A

XR to diagnose

283
Q

Emergent forearm fracture

A

Arterial compromise or open fracture, ortho referral in under an hour

284
Q

Urgent forearm fracture

A

Under 50% opposition or over 10 degrees angulation, ulno-radial joint instability, peripheral nerve injury, both bone fx with displacement

285
Q

Priority forearm fracture

A

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
Q

Management for simple isolated forearm fracture

A

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
Q

Follow up XR for simple isolated forearm fracture

A

At 1 week then Q4 weeks

288
Q

Long arm posterior splint

A

Double sugar tong, flexes elbow at 90 degrees both fold around the elbow

289
Q

Colles wrist fracture

A

Dorsal wrist displacement - looks like a dinner fork, usually a FOOSH with palm DOWN

290
Q

Smith’s fracture

A

Anterior wrist displacement - looks like a garden spade, usually a FOOSH with palm UP

291
Q

Management for wrist fracture

A

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
Q

Follow up XR for Smith’s/Colles fx

A

Each week for two weeks

293
Q

MOI for scaphoid fracture

A

Hyperextension of wrist/ Fall on outstretched hand

294
Q

Palpation for scaphoid fracture

A

Anatomic snuff box

295
Q

Presentation of scaphoid fracture

A

Snuffbox tenderness, decreased wrist ROM

296
Q

XR for scaphoid fracture

A

Sacaphoid/Navicular view - put in Ulnar deviation for XR. CT or MRI if neg with high suspiscion

297
Q

Management for scaphoid fracture

A

Thumb spica cast or splint, repeat XR in 1-2 weeks if initially negative, Pins or ORIF if displaced

298
Q

Thumb spica cast

A

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
Q

Indications for a thumb spica cast

A

Scaphoid, lunate, trapezium, thumb fractures, UCL tear

300
Q

Risk factors for carpal tunnel syndrome

A

Sedentary, repetetive hand movement, multiple systemic issues

301
Q

Presentation of carpal tunnel syndrome

A

Burning, tingling, pain over median nerve distribution (hand of benediction) worse at night. Tadiates to elbow and shoulder

302
Q

PE for carpal tunnel

A

Positive Tinel, Phalen, Carpal compression, hand elevation, thenar atrophy

303
Q

Tinel’s sign

A

Tap on carpal tunnel to elicit pain

304
Q

Phalen sign

A

Praying hands for CTS

305
Q

Dx for CTS

A

EMG/NCS

306
Q

Management for CTS

A

Activity modification, Cock up wrist splint, Steroid injection, Refer to ortho for realease if 3+ months of conservative therapy fail

307
Q

Boxer’s fracture

A

Fracture of the fifth metacarpal, most likely to be malrotated

308
Q

Phalangeal fractures

A

MC in children, usually distal in adults

309
Q

Presentation of metacarpal/phalangeal fractures

A

Hx of trauma, Local tenderness, swelling, deformity, decreased ROM and knuckle definition

310
Q

Managemeng of metacarpal neck fracture

A

Open or close reduction for any fracture with over 30 degree angulation

311
Q

Management for metacarpal phalangeal fractures with under 30 degrees of angulation

A

Metacarpals 4-5 = Ulnar Gutter spliont Metacarpals 2-3 = Radial gutter splint

312
Q

Gutter splint

A

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
Q

Management for non displaced fractures of metacarpal/phalangeal shafts of 2-5

A

Splint 3-4 weeks, Gutter for metacarpal, Buddy splint/Tape for phalanx

314
Q

Thumb fracture management

A

Thumb spica with 30 degree wrist extension

315
Q

Management for angulate, displaced or articulat phalangeal fractures

A

Refer to ortho - may need reduction

316
Q

Buddy taping

A

Tape fingers together or single finger splint

317
Q

Game keepers tumb

A

Rupture UCL of 1st MCP joint also known as Skier’s thumb d/t forced radial abduction

318
Q

Presentation of gamekeepers thumb

A

Pain, swelling, and tenderness along the medial 1st MCP joint

319
Q

Presentation of gamekeepers thumb

A

Pain, swelling and tenderness along 1st MCP joint, weak pincer function (opposition) Dx via stress test or XR

320
Q

Management for gamekeepers thumb

A

Thumb spica splint, refer to rotho for repair

321
Q

Mallet finger

A

Rupture, evulsion, or laceration of the extensor tendon at the distal phalanx d/t DIP hyper extension

322
Q

Presentation of mallet finger

A

DIP flexed at 40 degrees, PROM intact, Tenderness over DIP, finger like a mallet, swan neck deformity

323
Q

Management of mallet finger

A

Finger splint for 4-8 weeks, splint CANNOT be removed - results in swan neck deformity

324
Q

Boutinierre deformity

A

Rupture of the central slip of the extensor tendon where it inserts on the middle phalanx d/t forced plexion of the PIP

325
Q

Presentation of Boutoniere deformity

A

Finger partially flexed at PIP with PROM but no AROM, Swelling apin and point tenderness

326
Q

Management for Boutonierre deformity

A

Finger series to tule out evulsion fx, Splint PIP in extension leaving DIP free for 4-8 weeks

327
Q

Indications for Boutinierre deformity ortho referral

A

Conservative therapy failure, Irreducible PIP dislocation, Open fracture

328
Q

DeQ Tendinosynovitis

A

Inflammation of tendon sheeth covering extensor/ abductors, an overuse syndrome

329
Q

Presentation of DeQ Tendinosynovitis

A

Aching pain and point tenderness, positive finklesteign test, Thickened 1st dorsal compartment creating prominence at radial styloid

330
Q

Finkelstein test

A

For Dequervain Tenosynovitis, hold thumb in fist and ulnar deviate. Positive if painful

331
Q

Management for DeQ Tenosynovitis

A

Thumb spica splint, Activity modification, NSAIDs, Refer to ortho if conservative therapy fails for surgery/steroids

332
Q

Ganglion cyst

A

Outpouching of fluid from joint capsule MC in dorsal wrist

333
Q

Presentation og ganglion cyst

A

Rubbery to palpation, Cyst that can be transluminated - clear fluid filled. XR not needed if non-concerning (nontender, stable)

334
Q

Management for ganglion cyst

A

Most will regress spontaneously, Aspiration with or w/o steroid, Surgery also an option, Smashing generally not effective

335
Q

Trigger finger

A

Idiopathic dysfunction of the flexore tendon - gets sticky, MC in Digits 3-4

336
Q

Presentation of trigger finger

A

Catching, snapping or locking of finger in a flexed position, Pain and dysfunction with a painful palm nodule

337
Q

Management for trigger finger

A

NSAID and steroids, surgery if no results after 2nd injection

338
Q

Second steroid injection for trigger finger

A

Not done in RA patients, surgical release if fails, done 3-4 weeks after 1st injection

339
Q

Dupuytren cotnracture

A

Fibrosis of palmar fascia, can’t extend fingers, MC in men 50+ 4th finger MC

340
Q

Presentation of DP Contracture

A

Non-tender, thickening nodule, flexion is normal but extension is limited, nodules thicken to a cord

341
Q

Dx for DP contracture

A

Clinical dx, imaging not needed

342
Q

Management of DP contracture

A

Night splinting to skow progression, Surgery indicated for 30+ degrees of flexion. Excision of thickened tissue bands

343
Q

Superior BP trunk

A

C5-6

344
Q

Middle BP trunk

A

C7

345
Q

Inferior BP trunk

A

C*-T1

346
Q

Lateral brachial plexus cord

A

Middle and superior trunks

347
Q

Posterior BP Cord

A

All three trunks

348
Q

Medial BP cord

A

Inferior trunk only

349
Q

Musculocutaneous nerve origin

A

Lateral BP cord

350
Q

Axillary nerve origin

A

Posterior cord

351
Q

Median nerve origin

A

Lateral and Medial cords

352
Q

Radial nerve origin

A

Posterior cord

353
Q

Ulnar nerve origin

A

Medial cord only

354
Q

MOI of BP injury

A

Traction/Stretching focrse, side bening of head

355
Q

Presentation of BP injury

A

Sharp, burning pain with radiculopathy in the effected nerve root distribution, Weakness is common

356
Q

Associated symptom with C8-T1 lesion

A

Horner’s syndrome!!

357
Q

C5 functions

A

Elbow flexion and shoulder abduction

358
Q

C6 function

A

Elbow flexion, wrist extension, thumb and radial hand sensation

359
Q

C7 function

A

Elbow extension, wrist flexion, finger extension

360
Q

C8 function

A

Finger flexion

361
Q

T1 function

A

Abduction of the fingers

362
Q

Dx for brachial plexus injury

A

XR, CT of C spine - MRI is best. May get an EMG

363
Q

Management of BP injury

A

Conservative woth PROM and stretching, strengthening, no participation in sports until complete resolution of symptoms

364
Q

Thoracic outlet syndrome

A

Compression of SC artery and BP

365
Q

Presentation of thoracic outlet syndrome

A

Fatigue, aching, weakness of extremity, worsens when arm lifted above head

366
Q

PE for thoracic outlet syndrome

A

Check for mass, check pulses, swelling and discoloration

367
Q

Elevated arm test for TOS

A

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
Q

Dx for TOS

A

r/o tumor, PA and Lateral CXR, may want to look at spine

369
Q

Management of TOS

A

Home exercise program, avoidance of heavy shoulder bags, NSAIDs, Muscle relaxers - Surgery usually not required

370
Q

Normal hip ROM

A

0-110 or 130 degree range

371
Q

Normal range for hip extension

A

20-30 degrees

372
Q

Normal hip abduction/adduction

A

AB - 35-50 degrees; AD 25-35 degrees

373
Q

Internal and external rotation hip ROM

A

25-35 degrees

374
Q

Thomas test

A

Look at tight hip flexor, contralateral leg comes up when knee is brought to chest

375
Q

Trendelenburg test

A

Patient stand on one leg, opposite hip with drop - looks at abductors - weakness

376
Q

FABER test

A

Flexion, abduction, external rotation test (figure of four) press on knee; ipsilateral pain = hip problem contralateral pain = sacroiliac dysfunction

377
Q

Leg length measurement

A

Measure from ASIS to Medial malleolus, 3+ cm difference can lead to hip prblems; send to podiatry and r/o fracture

378
Q

Log roll test

A

For osteonecrosis, roll leg in and out to put pressure on the femoral head

379
Q

Piriformis test

A

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
Q

Positive piriformis test

A

Pain in the buttock or down the leg indicates impingement of sciatic nerve by the piriformis

381
Q

Scouring test

A

Pushing the femoral head into acetabulum - look for crepitus of damaged cartlidge, may also have pain

382
Q

Specialty views of the hip

A

Frog leg - from below - better for the femoral head and neck Oburator - Helps to look at the pelvic floor

383
Q

MOI of posterior hip dislocation

A

More common. MVA knee to dashboard, hard fall on knee, posterior force to flexed knee

384
Q

MOI of anterior hip dislocation

A

Hyperextension against an abductedleg or anterior force on posterior femoral head

385
Q

Hip dislocation more likely to have NV complications

A

Posterior dislocation

386
Q

Presentation of any hip dislocation

A

Severe pain, unable to move leg, paresthesias, deformity, NV status changes

387
Q

Posterior hip dislocation presentation

A

Leg is shortened, adducted, and internally rotated

388
Q

Presentation of anterior hip dislocation

A

External rotation and flexion of the hip - Inferior or Superior depending on degree of flexion

389
Q

Dx for hip dislocation

A

Stat XR - CT scan if uncertain

390
Q

Management of hip dislocation

A

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
Q

Post reduction immobilization for hip dislocation

A

Triangular abduction pillow or knee immobilizer

392
Q

Allis procedure

A

Requires two people, one to hold pelvid and one to push on knee

393
Q

Post reduction care for hip dislocation

A

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
Q

Traction bed

A

For complicated hip dislocation - hilds up the leg

395
Q

Intracapsular Hip Fracture

A

Femoral head or femoral neck

396
Q

Extracapsular Hip Fractures

A

Intertrocanteric or Subtrochanteric

397
Q

Risk factors for hip fracture

A

Elderly, smoking, Psych meds, alcohol, dementia, female

398
Q

Presentation of hip fracture

A

Groin pain!! Externally rotated, abducted, shortened leg, pain even with tiny movement, inability to ambulate

399
Q

Dx for hip fx,

A

Hip XR with other images as needed, CT or MRI if uncertain with shortened leg

400
Q

Management for Hip Fx

A

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
Q

Contraindications for surgery in hip fx

A

Medically unstable, patients who were non ambulatory, dementia patient with minimal pain during transfers

402
Q

Complication of Hip Fx

A

Infection, DVT, Pneumonia, Ulcer, Avascular necrosis

403
Q

Greater trochanteric bursitis

A

Due to repetitive trauma/walking, greater trochanter is prominent bone of the hip

404
Q

Presentation of greater trochanteric bursitis

A

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
Q

Dx for GT Bursitis

A

R/O trauma

406
Q

Management of GT Bursitis

A

NSAIDs, activity modification, ice, Cate in opposite hand, heat 15 then stretch, then ice for 20, local anesthetic/steroid injection

407
Q

Avascular necrosis

A

Bone infarction in the hip, can be d/t steroids!! Smoking, transplant, trauma

408
Q

Presentation of avascular necrosis

A

Extreme pain during cell death - becomes dull and aching. Crescent sign on XR - patchy white infiltate around femoral head

409
Q

Management for AVN

A

Avoid weight bearing, NSAID and opiates for breakthrough pain, Ortho - may do surgical intervention - only way to reverse

410
Q

Emergent concern for femoral shaft fracture

A

Bleeding from femoral artery

411
Q

Cause and presentation for femoral shaft fracture

A

High energy trauma, Pain swelling, tenderness, NV status must assess

412
Q

Femoral shaft fracture complications

A

Blood loss, Compartment syndrome, Multi-system injuries

413
Q

Management of femoral shaft fx

A

Pain management, fluids for blood loss, Stabilization, ortho for surgery

414
Q

Knee muscles

A

Quads - Extend, Hamstings - flex

415
Q

Valgus deformity

A

Knock knee - come together (gum sticking together)

416
Q

Weak abductor location in a trendelenberg gait

A

Contralateral to hip drop

417
Q

Gaits to watch for

A

Antalgic, wide, wddle, trnedelenburg

418
Q

PE for knee

A

Squat, gait, inspect

419
Q

Joint space palpation of the knee

A

Can ONLY be done on a flexed knee!!

420
Q

Bulge sign

A

Milking the patella - superior on medial knee and inferior on the lateral side - wave is positive for an effusion

421
Q

Normal knee ROM

A

0-145 degrees flexion

422
Q

Patellar tracking

A

Patellar does not travel directly up and down - watch patella during flexion/extension

423
Q

Patellar aprehension sign

A

Supine with 30 degree knee flexion, displace patella, aphrehension d/t pain or quad contraction (knee extension) is positive

424
Q

3 indication for patellar aprehension sign

A

Patellofemoral syndrome, patellar subluxation, patellar dislocation

425
Q

Patellar grind test

A

For chonromalacia patella - assess for cartilage degeneratin, fully extend knee push patella inferiorly and feel crepitus if positive sign

426
Q

Valgus stress test

A

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
Q

McMurray test

A

For mensical injury - valgus or varus depending on which meniscus is being tested

428
Q

McMurray test for medial meniscus

A

MEG - Exteral rotation with valgus stress and slowly extending knee

429
Q

McMurray test for lateral meniscus

A

LIR - Internal rotation with varus stress and slow knee extension

430
Q

Positive McMurray test

A

Pain, popping or clicking is notede

431
Q

Lachman test

A

BEST test for ACL tear - stabilize femur and pull up on the tibia - shoulod see NO translation

432
Q

Most sensitive test for ACL

A

Lachmans

433
Q

Anterior drawer test

A

For ACL tear - Pull forward on tibia - foot stabilized on table

434
Q

Pivot shift test

A

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
Q

Posterior drawer test

A

Push tibia backwards to evaluate for PCL tear

436
Q

Noble’s test

A

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
Q

Valgus stress test

A

Apply force to lateral aspect of knee

438
Q

Ober’s test

A

Asess for tight IT band and tensor fascia latae

439
Q

Procedure for Ober’s test

A

Patient lies on unaffected side with affected knee at 90 degrees of flexion, abduct and extend ipsilateral hip while stabilizing the pelvis

440
Q

Positive Ober’s test

A

Extremity cannot drop below horizontal - tight fascia or IT band

441
Q

Knee XR options

A

Sunrise view in addition to AP and LAT

442
Q

Iliotibial band syndrome

A

Feel IT band when flexing/extending, common in runners/cyclist

443
Q

IT band syndrome presentation

A

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
Q

Management and Dx of ITBS

A

Clinical dx, Knee XR, NSAID, rest, Ice, modify exercise and refer if no improvement (last resort to surgically lengthen IT band)

445
Q

Distal femur fracture

A

Easier to sustain - fall on knee can affect any potion of the joint - red flag for infection with open wound - need IV abx

446
Q

Dx for distal fem fracture

A

XR conventional, CT, MRI, CTA for vascular and other sructure assessment

447
Q

Management of distal femoral fracture

A

Splint if non-displaced, surgery if displaced (ORIF), emergent ortho consult for comp. syndrome, open fx, vasc compromise

448
Q

Patellar fracture

A

Fall, direct blow, forceful quad contraction

449
Q

Presentation of patellar fx

A

Localized tenderness and swelling, palpable defect, lack of extensor mechanism

450
Q

Dx for patellar fx

A

Sunrise XR view

451
Q

Management for patellar fx

A

Long leg splint with immobilization, surgery for displaced or complex fx, ortho referral - LONG Recovery

452
Q

Patellar dislocation

A

Usually a lateral dislocation, may have a bloody effusion and positive apprehension test

453
Q

Dx for patellar dislocation

A

Sunrise XR view

454
Q

Management for patellar dislocation

A

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
Q

Patellofemoral syndrome

A

Overuse syndrome in runners - have to rest it. Can result from and angular dysalignment

456
Q

Q angle

A

Angle between femur and tibia should be 15-20 degrees or LESS

457
Q

Presentation of patellofemoral syndrome

A

Diffuse aching and pain “behind the knee cap” with running, walkingm squats, etc.

458
Q

PE for patellofemoral syndro,e

A

Gait shows patellar squinting, instability on apprehension test, positive grind test, trendelenbuerg sign, longer sitting = more pain on getting up

459
Q

Patellar squinting

A

Kneecaps rotated inwards risk of patellofemoral syndrome

460
Q

Dx for patellofemoral syndrome

A

Clinical, XR to r/o trauma, MRI for surgical planning if severe

461
Q

Management for patellofemoral syndrome

A

Rest, ICE, NSAID, Weight loss, PT is mainstay quad and hamstring stretch ortho if no improvement

462
Q

Prepatellar bursitis

A

Chronic compression - praying, kneeling, wrestling - can become septic if punctured

463
Q

Presentation of prepatellar bursitis

A

Early on pain only with activity, localized swelling over the knee, lack of patellar differentiation, erythema, warmth pain

464
Q

Dx for prepatellar bursitis

A

XR, Aspirate if septic bursitis is suspected C&S

465
Q

Tx for inflammatory NON-Septic bursitis

A

NSAID, Ice, Activity, Corticosteroid injection

466
Q

Tx for septic bursitis

A

Oral abx for mild Keflex for MSSA Bacrtim or Clinda for MRSA IV rocephin for MSSA inpatient IV vanc for MRSA inpatient

467
Q

Ottowa knee rules (5 criteria)

A

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
Q

ACL tear MOI

A

ACL keeps femur from moving forward - quick stop, hyperextension of the knee, popping sound

469
Q

Presentation of ACL tear

A

Sudden pain and knee giving way with pop, Swelling of joint, limited weight bearing and ROM

470
Q

3 PE tests for ACL tear

A

Lachman (best), Anterior drawer, Pivot shift (only on sedated pt)

471
Q

Diagnostics for ACLE tear

A

May see an avulsion fracture of the lateral capsular magin of the tibia; Tunnle view XR, Cloudy joint effusion seen

472
Q

Management of ACL tear

A

Rest, Ice, Compression, Immobilize, Acetominophen before NSAID, Aspirate effusion if needed, Graft for young pt’s PT for older pts

473
Q

Sequeklae to ACL tear

A

Medial meniscus tear

474
Q

MOI of PCL tear

A

Direct blow to tibia, MVA, Extreme hyperextension (with an ACL tear

475
Q

Presentation of PCL tear

A

Same as ACL with a positive posterior drawer test, assess NV status

476
Q

Management of PCL tear

A

Rest, ICE, etc.ROM after 1-5 days, PT followed by reconstruction if failure for PCL only; Reconstruction if multiple ligaments affected

477
Q

Collacteral ligament knee tear

A

MCL more common - blow to the side of the knee

478
Q

Presentation of collateral ligament tear

A

Localized pain/tenderness worsens over 6-8 hours, may be able to walk, eccymosis, positive valgus/varus stress test

479
Q

Dx of collateral ligament tear knee

A

Lack straight line on side of knee on MRI

480
Q

Tx for collateral ligament tear

A

Rice and knee brace for sprain or partial tear; Ortho with potential repair for complete rupture

481
Q

MOI of meniscal injury

A

Rotational force to the knee, less intentse MOI in older patients

482
Q

Presentation of meniscal knee tear

A

Can walk but with stiffness, locking, catching, or popping sensation, tenderness along flexed joint line, effusion (bigger in lateral tear, positive McMurray test

483
Q

XR for meniscal tear

A

Do weight bearing and flexed XRs in over 40. Knee MRI

484
Q

Management for meniscal injury

A

RICE, NSAID, Ortho for repair in Young patients, patients who fail conservative therapy, mechanical sympom pts, unstable patients, otherwise PT

485
Q

Knee dislocation

A

Not common - MVA, Martial arts. Obese, trampoline falls - define by where the tibia is in relation to the femur

486
Q

Presentation of knee dislocation

A

Severe pain - spont. Reduction in 50%, swelling, check NV status, knee may be very unstable, hyperextension indicates ligament injuries

487
Q

Imaging for knee dislocation

A

2 view XR, CT for occult fracture, MRI for soft tissue injuries

488
Q

Management for knee dislocation

A

Sedation and reduction with longitudinal traction, repeat NV status check and imaging, immobilize at 20 degree flexion, Admit for observation

489
Q

Tibial plateu fracture

A

Due to a valgus stress - a lateral plateu fracture, usually high energy trauma

490
Q

Presentation of tibial plateau fracture

A

Sudden onset, NWB after trauma, may be deformed, limited ROM, Effusion of joint

491
Q

Imaging for tibial plateau fracture

A

AP, lateral maybe oblique XR - CTA/MRI for soft tissue and NV compromise

492
Q

Management for tibial plateau fracture

A

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
Q

Tibial tubercle fracture

A

Due to sudden force to flexed knee - avulsion fracture of the patellar tendon

494
Q

Presentation of tibial tubercle fracture

A

Pain, tenderness and swelling over tibial tuberosity, superior displacement of the patella, loss of ROM

495
Q

Dx for tibial tubercle fracture

A

2 views knee XR

496
Q

Management for tibial tuberosity fx

A

RICE immobilize and ortho f/u for incomplete/small; RICE immobilizer, 24-48 hour ortho f/u if complete avulsion

497
Q

Tibial shaft fx

A

Most common long bone fracture, usually assoc with fibular fx

498
Q

Presentation of tibial shaft fx

A

NWB, Swelling pain, Compartment syndrome, check for NV compromise

499
Q

Dx for tibial shaft fx

A

XR CT to eval further complexity

500
Q

Management of tibial shaft fracture

A

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
Q

Stirrup splint

A

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
Q

Fibular fracture

A

Uncommon to be isolated direct blow or twisting - point tenderness and weight bearing

503
Q

Maisonneuve fracture

A

Proxima fibular fracture with medial malleolar fracture

504
Q

Dx for fib fracture

A

XR with knee and ankle as well

505
Q

Fib racture management

A

RICE, analgesices, Long posterior leg splint, refer to ortho

506
Q

Emergent fib fracture indications

A

Open fx, tib/fib, NV compromise, crush injury, compartment syndrome

507
Q

Tx for fibular head/neck fracture

A

Knee immobilizer splint or long leg posterior splint

508
Q

Tx for distal fibular fx

A

Stirrup splint or air cast splint, ortho within 1 week

509
Q

3 lateral ankle ligaments

A

Posterior talofibular ligament, Calcaneofibular ligament, anterior talofibular ligament

510
Q

Ligaments of medial ankle

A

Deltoid ligament with four parts - less common to sprain

511
Q

Pes cauvs

A

High arch of foot

512
Q

Pes planus

A

Flat foot

513
Q

Normal ankle ROM - flexion

A

Plantar - 0-50, Dorsi 0-20

514
Q

Formal ROM eversion/Inversion of foot

A

In - 0-35 Out - 0-25

515
Q

Toes ROM normal

A

Flex - 0-30 Extend - 0-80

516
Q

Posterior tibialis

A

Resist as patient inverts and plantar flexes

517
Q

Anterior tibialis

A

Resist as patient inverts and dorsiflexes

518
Q

Peroneus longus and brevis

A

Resist eversion

519
Q

Extensor hallucis longus

A

Resist dorsiflexion of great toe

520
Q

Floexor hallucis longus

A

Resist plantar flexion of great toe

521
Q

Anterior drawer andkle test

A

Pull mfoot forward to test anterior talofibular ligament

522
Q

Talar tilt test

A

Tests integrity of calcaneofibular, deltoid, and anterior and posterior talofibular ligaments - use inversion, eversion, plantarflexion+inversion, and dorsiflexion+inversion for each respectively

523
Q

Thompson’s test

A

Compression of calf in prone position produces plantar flexion in intact achilles tendon

524
Q

Mortise view of ankle

A

Better than AP and lateral - Look diagonally down from the front towards the ankle

525
Q

Ottowa ankle rules

A

Radiograph if 1 present - pain at amlleoli, inability to bear weight 4 steps, tenderness posteriorly or inferiorly at malleoli

526
Q

3 XR views for foot

A

AP, Lat, Oblique

527
Q

Ottowa foot rules

A

Radiograph if 1 present - pain at amlleoli, inability to bear weight 4 steps, tenderness posteriorly or inferiorly at malleoli

528
Q

Achilles tendon injury

A

Usually 5 cm above insertion - Blow or forced dorsiflexion, can also get microtears at insertion site

529
Q

Presentation of achilles tendon injury/rupture

A

Pop and severe pain, palapavle defect, positive thompson test, weak active plantar flexion

530
Q

Management for achilles tendon injury

A

RICE, Surgery for young rupture, Controlled ankle mostion boot for tear but not rupture

531
Q

Achilles tendonitis presentation

A

Burning pain and stiffness 2-6 cm above calcaneus, Negative Thompson test, ROM normal, calcaneal spur, worse with activity, better with rest

532
Q

Management for achilles tendonitis

A

Rest, ICE, NSAIDs for 7-10 days, PT if no improvement

533
Q

High ankle sprain

A

Damage to the tibiofibular syndesmosis due to severe inversion

534
Q

Grades of ankle sprain

A

I - Stretch and small tears, II-Larger but incomplete tear III - Complete tear

535
Q

Presentation of ankle sprain

A

Fell, stepped off curb, tenderness over involve ligament, Sqeeze test, Talar tilt and anterior drawer to assess stability

536
Q

Phase 1 of ankle sprain management

A

RICE with NSAID, Aircast splint, crutches if needed

537
Q

Phase 2 of ankle sprain management

A

Initiate once weight bearing without pain

538
Q

Phase 3 Ankle sprain management

A

After a month, wean from ankle brace, more challenging exercises - send to PT if continued pain, send to ortho for frequent sprains

539
Q

Bimaleolar fx

A

Both malleoli fractured

540
Q

Trimaleolar fracture

A

Both malleoli fractured as well as posterior tibial fx

541
Q

Management for ankle fracture

A

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
Q

Calcaneal fracture

A

Usually due to axial load - fall and land on heal - can be assoc with vertebral injuries - MC tarsal fx

543
Q

Presentation og calcaneal fx

A

NWB, Swelling, Check cap refill and lumbar spine

544
Q

Management for calcaneal fx

A

RICE, posterior short leg splint with lots of padding, urgent ortho referral, NWB

545
Q

Talar fx

A

High force plantarflexion, risk of AVN, 2nd MC tarsal fx

546
Q

Presentation and tx for talar fracture

A

Similar to calcaneal fx - need imaging to differentiate, NWB and padded support with ortho referral

547
Q

Ankle dislocation

A

MC - Posterior d/t force on plantar flexed foot, inversion for lateral, highly unstable

548
Q

Presentation of ankle dislocation

A

Gross deformity, locked in plantar flexure - check NV status and fix before imaging

549
Q

Management for ankle dislocation

A

Sedate and reduce, grasp heel and downward traction - splint, post reduction films and ortho consult

550
Q

Metatarsal fx presentation

A

D/t drop on foot etc., pain with difficult ambulation - may just be tender

551
Q

Jone’s fx

A

Fifth metatarsal fx

552
Q

Management for metatarsal fx

A

Single - Short leg posterior cast, If multiple or displaced consult ortho for surgery

553
Q

Tarsometatarsal injury

A

Disruption of tarsometatarsal joint/Lisfranc injury, often fx associated, bending, rotation, compression or loading of plantar flexed foot

554
Q

Presentation of tarsometatarsal injury

A

Can barely walk - painful, assess for compartment syndrome, deformity, swelling and eccymosis, midfoot pain

555
Q

Management for nondisplaced lisfranc injury

A

Non weightbearing splint/cast for 6-8 weeks; If complicated - refer to ortho for surgery

556
Q

MC phalangeal fx

A

5th phalanx (foot)

557
Q

MC foot phalanx dislocation

A

MTP of the 1st joint

558
Q

Management for foot phalangeal injury

A

Often buddy tape, digital block with reduction for dislocation

559
Q

Hallux valgus

A

Bunion, big toe bent towards others - over 15 degrees angulation of big toe

560
Q

Management of hallux valgus

A

Patient ed and shoe wear modifications, wide toed shoes avoid high heels, Surgery for patients who fail conservative therapy

561
Q

Morton’s neuroma

A

Perineural fibrosis of common digital nerve of foot - MC between base of third and fourth toes - often d/t tight shoes

562
Q

Presentation of Morton’s neuroma

A

Plantar pain in forefoot - MC, burning in nature, aggravated by activity and tight shoes, better with rest, walking on a marble feeling

563
Q

Interdigital neuroma test

A

Applyqdirect plantar pressure to interspace - squeeze metatarsal - pain is a positive test for Morton neuroma

564
Q

Management for Morton neuroma

A

Education, Steroids, Surgery for severe

565
Q

Plantar fasciitis

A

Idiopathic - linked to frequent standing, obesity

566
Q

Presentation of plantar fasciitis

A

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
Q

Management of plantar fasciitis

A

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
Q

Valgus Stress Test

A

20 degree flexion with pressure the lateral aspect of the elbow

Clin Med III (4 decks)

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