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IPAP > Ortho 2.2 > Flashcards

Ortho 2.2 Flashcards

1
Q

OA Pts are more likely to report ? issue during a flare up

What would an OA joint effusion result look like?

What are the MC OA findings in the hand

A

Stiffness > Pain

Mild pleocytosis
Elevated protein
Normal viscosity

PIP- Bouchard
DIP- Heberden
First CMC

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2
Q

What are three common locations for OA to develop, especially in the foot?

What is the MC form of OA in the knee

If these Pts develop a Baker’s Cyst, it is due to the joint cavity communicating between ? two structures

A

First MTP joint
Calc/Talus/Navi articulation
Valgus/rigidus
Subtalar joint

Varus- bow legged

Gastroc/Semi-membrane

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3
Q

What will be seen on x-rays of OA

The severity of these findings are based on ? scale

What are the 4 grades

A

Lost joint space
Osterophytes
Sclerosis
Subchondral cysts

Kellgren Lawrence

0: none
1: doubt
2: minimal
3: moderate
4: severe

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4
Q

Non-pharm Tx of OA

Pharm Tx of OA

What opioids can be used for short-term relief w/ NSAIDs

A

Avoidance Reassure Education Weight-loss

NSAIDs, then Acetaminophen

Codeine Hydrocodone Oxy Tramadol

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5
Q

? COX-2 selective NSAID has s/e similar to Tylenol and used in Pts w/ no cardiac risk but are not achieving pain relief w/ Acetaminophen

What therapy can PTs utilize who are unable to tolerate weight bearing exercises

What are the indications surgical repair is needed for joints w/ OA

A

Celecoxib

Isometric exercises

Lost function
Pain at night
Non-surg failure

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6
Q

Define RA

What are common Sxs of RA

What joints are more commonly involved symmetrically

A

Chronic synovium inflammation causing erosion

2+ swollen joints in AM >1hr x 6wks or,
+RF/anti-CCPs

Feet Hands Ankle Wrist Knee

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7
Q

To receive an official Dx of RA, Pts need 6 out of 10 points based on ?

If they present w/ ? finding, they meet the definition

What joints are affected first and which ones are spared

A

Joint involvement
Acute phase reactants
Pt self report
Serology results

Characteristic erosive changes

First: hand/feet
Spared: DIP

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8
Q

Extra-articular Sxs of RA are more common in Pts w/ ?

These rarely occur in the absence of ?

? tendons can be ruptured by the Dz process

A

+RF

Clinical arthritis

EPL= no thumb extension

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9
Q

What are the predominant early PE findings of RA

What two findings are not predominant findings

? is an early result and what is a late result of the Dz process

A

Pain w/ pressure
Swelling
Dec ROM

Warmth, Erythema

Early: PIP
Late: joint deformity

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10
Q

? is the MC site for subcutaneous RA nodule

What is Rheumatoid Factor

What lab result is as sensitive and more specific

A

Elbow

IgM against Fc of IgG

Anti-CCP Abs

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11
Q

What lab result correlates to the degree of RA joint inflammation

? will CBC results look like

Which one correlates to Dz activity

A

ESR/CRP

Dec serum albumin
Inc ESR/CRP
Platelets

Albumin

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12
Q

What part of the body does Ankylosing Spondylitis affect?

What other conditions are associated with this Dx?

What is the Tx plan?

A

SI joint

Iritis Aoritis Carditis Enthesitis Uveitis

NSAIDs, Exercise

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13
Q

What parts of the body are affected by arthritis associated w/ IBS

What other conditions can be present w/ this Dx

What is the Tx

A

Asymmetric/oligoarticular
SI Ankle Knee

Crohns Enthesitis UColitis

NSAIDs

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14
Q

What parts of the body are involved w/ Psoriatic arthritis

What other conditions can also exist

What is the Tx

A

Wrist Ankle SI Hands

Dactylitis Iritis Nails Enthesitis Skin lesions

NSAIDs Biologics Methotrexate

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15
Q

What imaging results are seen in PTs w/ Ankylosing Spondylitis

What finding correlates to severity of Dz

What is different about this type of arthritis compared to other seronegative arthritis’?

A

Sacroiliitis, Kyphosis

Hip Ankle Shoulder

Less severe

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16
Q

What microbe pathogens can cause Retiers?

What are the 5 patterns of psoriatic arthritis

What differentiates one of these manifestations from RA

A

Clostridium Campylobacter Chlamydia Shigella Salmonella Yersinia

DIP
Arthritic mutilans
Asymmetric oligo
Symmetric poly
Sacroilitis

Symm Poly: DIP involvement w/ absent RA nodules

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17
Q

? form of IBDz is more likely to develop arthritis

? is the presenting Sx in all seronegative arthropathies

What do Pts w/ Reiters present w/

A

Crohns

Back pain

Conjunctivitis
Asymmetric oligoarthritis of LE large joints
Dactylitis
Urethritis
Enthesitis: Achilles, Plantar
Sacroilitis
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18
Q

What is the ‘usual’ clinical presentation of Psoriatic Arthritis

Pts w/ joint problems commonly have ? d/o

Pts w/ IBDz arthritis commonly have ? -itis’?

A

DIP pain
Scaly cutaneous lesions

Nail- Pits Oncolysis Ridging

Sacroillitis
Spondylitis
Knee/Ankle arthritis

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19
Q

IBDz associated arthritis has ? worsen during flare ups

What type of back measurement needs to be done for Pts w/ Ankylosing Sine?

What is the AKA name for this measurement’s starting point

A

Peripheral Sxs
Spondylitis Sxs remain same

Post Iliac Spine midline to upper lumbar

Dimples of Venus

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20
Q

? is a common x-ray finding of Psoriatic Arthritis in the hands

What causes the ‘bamboo/poker’ appearance on x-ray of ankylosing spondylitis

Which NSAID is particularly successful at controlling the Sxs from seronegative spondyloarthropathies

A

Proliferative bone reaction
Terminal phalanges resorption

Bamboo: anulus fibrosus enthesitis
Poker: ALL ossification, Facet autofusion

Indomethacin

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21
Q

What drugs are used for Sxs of AnkSpond not controlled by NSAIDs

What drug may be used for chronic reactive arthritis?

What is best for the Tx of Psoriatic Arthritis

A

TNF-a: Etanercept, Infliximab, Adalimumab

Sulfasalazine

DMARDs
Skin lesions: photo therapy

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22
Q

? type of gunshot wounds are particularly susceptible for compartment syndrome?

? are the MC compartments to be affected by

What are the 4 compartments of the leg

A

Prox tibia

Leg/Forearm

Ant/Lat/Sup-Deep posterior

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23
Q

What are the 3 compartments of the forearm

What are the 3 compartments of the thigh?

How long can muscles withstand compartmental pressure before beginning necrotic break down and what happens if relief is not achieved in that time?

A

Volar: flexor, pronator, supinator
Dorsal: extensors
Wad: radialis, extensors

Medial Ant Post

4hrs
6hrs- possible reversal
8hrs: irreversible necrosis

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24
Q

What are the seven Ps of Compartment Syndrome

? Sx is present at the onset of this condition

What is the most specific test to rule in Compartment syndrome and what are two are extremely late findings

A 
Pain Pallor Paresthesia Paresis Poikilothermia Pulselessness
#7: pressure

Altered sensation in effected compartments

PooP w/ passive stretch-
Pulseless
Paresis

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25
Q

CRPS is a clinical Dx composed of ?

What are the two types

? types of injuries can precipitate this Dx

A

Functional impairement
Autonomic dysfunction
Trophic changes
Pain

1: RSD/Algo- no lesion
2: causalgia- + nerve lesion

Distal radius Fx
Injury to infrapatellar branch

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26
Q

? is the most important step for CRPS prognosis outcomes

What is the exception to this rule

What happens after this exception

A

Early, appropriate Tx

Distal radius Fx w/ poor finger function 3mon after Fx

Algodystrophy after 10yrs

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27
Q

? prophylaxis Rx can be used after distal radius Fx to reduce chances of developing CRPS

What is first line Tx for Complex Regional Pain Syndrome

What off-label meds are used for pain control

A

Vitamin C 500 IU/d

Parenterals
Counseling
Sympatholytics
Therapy

CCB (a-2 agonists)
Anti-HTN/convulsants
TCA
Steroids

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28
Q

CRPS Tx therapy program utilizes PROM but ? is stressed more

? adaptive modalities are used for CRPS Tx

? medication is used for stellate blocks

A

AROM w/ stress loading

TENS Iontophoresis Contrast bath

Bupivacaine

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29
Q

Continue intrathecal administration of ? drugs are used for refractory CRPS Sxs

? are the possible sequelaes of CRPS

What are the possible s/e of stellate ganglion blocks for these Pts

A

Clonidine (a-2 agonsit) and Ziconotide (snail venom creates CCB)

Deformity
Neuromas
Contractures
Compression neuropathy

Seizures
Hoarseness
Arm numbness 
Weakness
PTHx
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30
Q

How is gout Tx

How is CPDD Tx

What are the 3 stages of urate crystal deposition

A

Indometha/Naproxin (Sx<48hrs)
Colchicine/Glucocorticoids
Allopurinol/Probenecid

Aspiration- Dx and Thx
Steroid injection- 1-2joints
NSAID/Colchicine if multiple joints during acute attack
3 or > attacks/year= Colchicine prophylaxis

Acute Interval Chronic

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31
Q

Gout affecting 1st MTP is AKA ?

What other areas can be affected

If Pt has gout in the back they have ? type

A

Podagra

Ankle Tarsal Knee

Tophaceous

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32
Q

After initial gout attack, Pts can expect to remain ASx for ? long

Where can tophi development occur

Define Chondrocalcinosis

A

2yrs

Hand tendon sheath
Olecranon
Forearm extensor
Achilles

MC in women >80y/o:
CPPD X-ray findings of punctate/linear calcifications of articular cartilage/internal joints

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33
Q

? joint is affected by CPPD more than half the time

What joint involvement come after this MC site

How can CPDD be differentiated from OA/RA

A

Knee

Wrist MCP Hip Shoulder Elbow SPine

OA: synovial fluid, x-ray
RA: no bony erosion or tenosynovitis

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34
Q

CPDD Pts w/ severe neuropathic joint Dz usually have ? two underlying conditions

What 4 metabolic d/os are associated w/ CPDD

What is a rare adverse outcome of the CPDD Dz process

A

DM
Tabes Dorsalis

Hyperparathyroid
Hemochromatosis
Hypophosphatasia
Hypothyroidism

End stage arthritis

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35
Q

? is the most preventable cause of death for in-hospital PTs and 3rd MC cause of death in PolyTrauma

Define Virchows Triad

? surgical positions increase DVT risk

A

PE

DVT identification:
Stasis
Damage
Hypercoagulable

Supine
Abduction
Internal rotation
Flexion

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36
Q

How does general anesthesia increase DVT risk

? bioactive chemicals are released during this time and can increase the risk further

Post-hip arthroplasty Pts have been noted to have decreased levels of ? putting them at DVT risk

A

Dilation, Stasis

Histamines
Leukotrienes

Anti-thrombin 3

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37
Q

? are classified as high risk surgeries for DVT development

Clinically, what two sings are indicative of DVTs

What post-op findings are indicative

A

Total joint arthroplasty
Internal fixation of hip fx
Polytrauma
Spinal cord injury

+ Homan
Edematous
Painful

Fever/Leukocytosis

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38
Q

Pts that die of PE do so w/in ? time frame

What are the current mainstays of prophylaxis

What is the FDA approved drug for VTE prevention

A

<30min

Fondaparinux
LMWH
ASA
Warfarin

Desirudin- hirudin derivative

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39
Q

Indirect inhibition of ? factors can help reduce DVT formation

What is the MC used DVT prophylaxis for hip/knee arthroplasty

What is this drugs s/e

A

2a 9a 10a

Enoxaparin

Renally cleared- swithc to heparin if dec renal clearance

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40
Q

? is the MC used anticoagulation w/ INR goal of ?

This MC is better at preventing ? clots for Pts having total hip arthroplasty

Mechanical prophylaxis reduces VTE Dzs secondary to ? and ?

A

PO Warfarin: INR 2-2.5

Proximal

Increased fibrinolysis
Decreases stasis

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41
Q

How long is DVT prophylaxis continued after hip/knee/plasty surgery continued

Spinal trauma Pts may need a IVC filter placed if ? 3 criteria are met

Why is Warfarin bridged w/ Heparin

A

7-10 days

Hx of VTE w/ prophylaxis
Prolonged immobilizaiton
Chemical anti-coag is c/i

Warfarin reduced Protein C/S causing Pt to be hypercoagulable

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42
Q

How long is Warfarin used for?

Therapeutic heparin is monitored w/ ? lab results

How is Enoxaparin monitoring achieved

A

3mon

Activated partial thromboplastin

Anti-factor 10a levels

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43
Q

What is the Tx for acute PEs

Oral anticoagulation is then recommended for ? long after first PE

What is an adverse outcome of Tx

A

Admit w/ heparin, O2 and then Warfarin

6mon

HIT Type 2 (AKA White Clot Syndrome)

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44
Q

DISH is predominant in ? Pt population

How do these Pts present

Since this condition can also lead to spinal fusion, how is this differentiated from Ankylosing

A

White male >60y/o

Spine stiffness in AM/PM
Red hip ROM
Knee arthritis

Normal posterior apophyseal/SI joints

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45
Q

What landmark does dish follow in the in the cervical region

What are the two MC causes of cervical myelopathy

What may be seen on x-rays of the pelvis and ribs

A

PLL

1st: cervical spondylosis
2nd: cervical DISH

Whiskering- shaggy hyperostotic bone

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46
Q

What are the two MC Dxs encountered by Rheumatologists

What are the two suspected etiologies for Fibromyalgia

What type of cardiac murmur may develop fibromyalgia

A

1st: RA
2nd: Fibromyalgia

Genetics
Environmental

MVP- mid-systolic click w/ late systolic murmur

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47
Q

How is FMS Tx per FDA recommendation

Why do these Pts need to be started at the lowest dose possible

? meds need to be avoided

A

Pregabalin Duloxetine Milnacipran

Usually have hypersensitivity to Rxs

Steroids

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48
Q

What two meds can be used at bedtime for fibromyalgia

What is recommened for use if Pt develops/has depression

What meds are good for sleep maintenance

A

Amytriptyline
Cyclobenzaprine

Fluoxetine

Initiatiion: Trazadone
Maintain: Gabapentin, Tiagabine

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49
Q

? meds are added for Fibromyalgia PTs w/ Restless Leg Syndrome or MVP?

What are the most beneficial injections for pain relief?

? type of fitness program is recommended for these pts

A

Clonazepam
Pramipexole

Lidocaine
Saline if allergic

Aerobic 20-30min/day x 5 days/wk

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50
Q

What is an adverse effect Pts w/ fibromyalgia can develop in response to long term Amytriptyline or Cyclobenzaprine usage

Where/how does osteomyelitis usually affect Peds/Adults

How can neonates present w/ this

A

Tachyphylaxis- decreased responses

Peds: Hematogenous to metaphysis of long bones (can lead to septic arthritis)
Adult: open Fx/post-ORIF

Pseudoparalysis

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51
Q

How does osteomyelitis present in adolscents/adults

What images can be used for Dx of osteomyelitis but what is the best method for Dx

What do lab results look like in cases of osteomyleitis

A

Post-op: drainage, failed/delayed healing

MRI
Open biopsy/aspiration

Acute- elevated leukocyte, ESR/CRP
Chronic/ImmSupp- normal
ESR/CRP- Dz process marker

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52
Q

What are the MC organism to cause osteomyelitis in Peds and adults

What is an indication of surgical site infection in Pt w/ AIDS

What is a rare adverse outcome if chronic osteomyelitis develops

A

Peds: Staph A > GBS > HInflu
Adults: Staph A, Pseudomonas

CD4 <200
Malnutrition (albumin <2.5g)

Marjolin Ulcer- SCC metaplasia

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53
Q

Since surgical debridment is required for osteomyelitis Tx, what type of ABX usage is recommended

What are the 3 methods of septic arthritis development

What microbe is the MC cause of septic arthritis in PTs >2y/o

A

Parenteral/impregnated methyl methacrylate beads after surgery

Direct
Hematogenous
Extension

Staph A

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54
Q

IV drug users can develop septic arthritis in ? unusual locations

? microbe is their culprit

Septic arthritis in kids is MC spread by ? route

A

Sternoclavicular
Sacroiliac

Pseudomonas

Hematogenous

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55
Q

? Pt populations are at increased risk for developing septic arthritis

? is a common scenario for Peds to present w/ that have a septic arthritis Dx

What will older children present w/

A

Systemic Lupus
ImmComp
RA

Previously ambulatory, no refusing to bear weight

Anorexia
Fever
Irritable
Tachy

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56
Q

What are the hallmark PE findings of septic arthritis

If the hip is affected, it will usually be held in ? position

? lab marker is used for monitoring response to therapy

A

Tenderness/Effusion/Erythema w/ painful PROM

Flexed, Abducted

CRP

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57
Q

What lab result of a native joint indicates Dx of septic arthritis

What if it’s a prosthetic joint

What will glucose/protein results look like

A

WBC >50K

> 1,100 w/ neutrophils >64%

Low glucose
High protein

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58
Q

When assessing septic arthritis, if ? 3 microbes are suspected, the lab needs pre-notification

? form of imaging is useful to identify the location of infection

What are the next best steps after Dx of septic joint has been made

A

H Influenza
Gonorrhoeae
Kingella

Tc-99

Synovial/blood culture
IV ABX
Surgical decompression/lavage

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59
Q

? is the cornerstone of successful Tx of septic joint

Once transitioned to PO AB, how long is the regiment continued

What microbe and type of microbe causes Lyme Dz

A

Emergent surgical decompression

4-6wks

Spirochete: Borrelia burgdorferi

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60
Q

Lyme Dz is the most ?

What types are endemic to Europe and Asia?

What are the 3 phases of Lyme Dz

A

Prevalent vector-borne illness in US

B afzelli
B garinii

Local: viral Sxs
Disseminated: cardiac/neuro- Meningitis Rediculopathy Cranial neuropathy
Late: arthritis/neuro- paresthesia encephalopathy radiculopathy joint pain

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61
Q

? is the most important non-op Tx for Lyme Dz

Lyme Dz risk remains low if tick is removed w/in ? time frame

How are these PTs Tx w/ ABX

A

Skin/Clothing checked for ticks

<36hrs

Doxy 100mg BID x 28days
Amox 500mg TID x 28 days
<8y/o: Amox 20mgg/kg

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62
Q

What are the 3 types of osteoporosis

What types of Fxs can Pts present w/ that indicate the type they have

Osteoporosis is usually unnoticed until Pts present complaining of ? four issues

A

Primary 1: post-menopausal (6x F>M)
Primary 2: senile (2x F>M)
Secondary: M>F steroid Hx, MM, OM, OI, hyperpara/thyroid

Type 1: compression vertebral, distal radial
Type 2: hip, pelvis
Type 3: men w/ low energy Fx

Back pain
Fx
Lost height >2”
Spine deformity

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63
Q

? is the 10yr Fx risk assessment for Osteoporosis and what two factors are as important as low bone density

What is the name of the thoracic kyphosis these PTs can develop

What are the two DEXA scores provided and what are the ranges

A

FRAX: bone density + RFs
Old age + prior low energy Fx

Dowagers Hump

Z: peers
T: healthy, young PTs

0- -1: normal

  • 1 - -2.5: osteopenia
  • 2.5 or more: osteoporosis
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64
Q

Where does DEXA scan measure density at

What is DEXA best used for ?

Who needs to have DEXA scans d/t RFs

A

Spine FemNeck Trochanter Femur

Monitoring osteoporosis Tx

Female >65y/o
Post-menopause <65y/o
Men w/ Hx low-trauma Fx/prostate Ca
Primary Hyperparathyroid

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65
Q

What are the two sub-types of osteoporosis

When does bone mass density reach peak levels during life

What recommendations are given to reduce risk for osteoporosis development

A

High-turnover: high NTx score
Low formatoin: low NTx score

<28y/o

Ca/Vit D
Avoid alcohol/tobacco
Impact loading- walk, strength, Tai Chi

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66
Q

How much Ca intake is recommended for osteoporosis prevention

What are the two main forms of Ca for ingestion

What is the difference in these two method of breaking down during metabolism

A

750-1000mg/day
(range 25-45)

Carbonate
Citrate

Carbonate reqs acid
Citrate dissolves at all pH levels w/ dec risk for stone development

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67
Q

How much Vitamin D is needed for proper Ca absorption

How much Vitamin D intake is recommended

Fx from fall can be avoided w/ as little as ? Vit D intake/day

A

> 15ng to avoid insufficiency
30 recommended

800-1200 IU/day
2-4K if Vit D deficient

800

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68
Q

What is the 3rd MC cause of delayed Fx healing

How is Osteoporosis Tx w/ Rx

A

Low Vit D

High NTx= antiresoptives (disphosphonates, -ate)
SERM: Denosumab
Low NTx: Anabolic (intermittent PTH)

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69
Q

? medication is used to increase spinal bone mass but doesn’t dec risk for hip Fxs but w/ ? s/e

? is used in Pts w/ dec renal function

? medication has mild spinal Fx protection and possible pain relief but w/ 2 s/e

A

Raloxifene- inc DVT risk and hot flash occurance

Denosumab- inhibits osteoclast formation

Calcitonin
No non-vertebral Fx protection
Inc Ca risk

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70
Q

When are anabolic agents recommended for use against osteoporosis

When is their use c/i

Prolonged diphosphonate usage is associated w/ ? 2 adverse outcomes

A

Pre-menopause
Impaired Fx healing
Diphosphonate failure
Low turnover

Radiation Hx
Paget Dz
Children

Atypical femur Fx
Jaw necrosis

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71
Q

What are the three parts assessed for overuse syndromes during PE

+ Phalen test means ? Dx

How are overuse syndromes Tx and what type of rehab program is useful in Tx

A

Inspect: Atrophy Pallor Erythema Swelling
Palpate: Point of max tenderness
Strength for pain w/ resistance

De Quervains (APL, EPL)

Protection Rest Ice NSAID Cream Eccentric

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72
Q

Sprains are uncommon in ? population

Instead of sprains, these Pts usually end up w/ ? Dx

What are the 3 degrees of Sprains

What are the 4 grades of Strains

A

Open growth plates

SALTR Harris Fx

1: partial w/ no instability
2: partial w/ laxity
3: complete w/ laxity

1: <10% muscle, intact fascia
2: 10-50% muscle, intact fascia
3: 50-100% muscle, intact fascia
4: 100% tear w/ disrupted fascia

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73
Q

What is assessed in strains or sprains during PE and what imaging modality is best

All sprain/strain need x-rays if pain is still present after ? days

How are Sp/trains Tx

A

Point of max tenderness
Sprain: joint stability
Strain: stretch injured muscle for defect
MRI: confirm/grade/rupture

7-10

PRICE- mainstay Cryotherapy NSAIDs
Minor sprain- compression, immobilize
Minor strain- immobilize w/ muscle stretched

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74
Q

When do sprain/strains need to be referred to Ortho

What are the 3 stages of benign tumors

What are 3 terms used for benign growths

A

Grade 4 strain, all Grade 3, Sev Grade 2

Latent Active Aggressive

Well-defined
Non-aggressive
W/out cortical destruction
W/out periosteal reaction

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75
Q

? Sx indicates a bone tumor has weakened the structural integrity

What is a critical part about evaluating bone tumors on x-ray?

Most benign tumors don’t weaken the underlying bone w/ ? exceptions

A

Sxs exacerbated w/ activity

Pattern recognition

Osteoid osteoma
Osteochondroma

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76
Q

What Sxs are absent in Pts w/ benign bone tumors

If these Sxs are present, ? Dx should be suspected

? is the MC scenario for bone tumors to be found

A

Constitutional Sxs

Mets Infection Lymphoma

Incidental finding

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77
Q

What is the best imaging modality for suspected bone tumor assessment

What other imaging modalities are used and what are the pros

What do bone scans use for imaging

A

Radiograph

MRI better: soft tissue/marrow
CT better: bone detail

Tc-99m: isotope bound to ligand methylene-diphosphonate

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78
Q

PTs >40y/o w/ aggressive bone lesions will probably have ? types of Ca

If a primary site can’t be located after detailed Hx/PE, what is the next step

What blood tests may be done to help w/ Dx in Pts >40y/o

A

Metastases
Myeloma

CT- chest abdomen pelvis

Light Immunoglobin Microglobulin Electrophoresis

Quant immunoglobin
Protein electrophoresis
Free light chain assay
B-2 microglobulin factor

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79
Q

What are the two MC methods for obtaining bone biopsies for suspected neoplasms

What type of benign tumors can cause pathological Fx and loss of function

These Pts are at risk for ? two things if they become immobile

A

Closed needle, Open bone

Active/Aggressive

HyperCa
Pneumonia

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80
Q

How are benign bone tumors Tx

? drug plays a vital role in managing established bone mets

What is the theorized etiology of growing pains in ? population MC

A

Active/Aggressive: surgery
Primary tumor, Peds: Chemo, Surgery
Mets: Rad/Chemo/Surgery

Disphosphonates

Over activity- muscle strain/fatigue
Boys 2-5y/o w/ ligamentous laxity

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81
Q

What may be found on PE in suspected growing pains

What part of the body is MC affected

what is done for management/Tx

A

Pain w/ deep pressure
Flexible flatfeet

Calves

Stretching Education Analgesics

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82
Q

Pt w/ suspected growing pains may need metabolic work up if ? two Dxs are possible

What is more common about CRPS in Peds

Where do these Pts MC have skin color changes

A

Leukemia
Endocrinopathy

Type 1: MC extremeties in Peds 9-15y/o

Ankle/Feet

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83
Q

What are the S/Sxs of long term CRPS in Peds

What two meds are used for Ped Pts that don’t respond to rehab

Most cases of child abuse occur in PTs ? old w/ ? populations at higher risk

A

Muscle wasting/contracture
Coarse hair, extremity
Thick nails

Amitriptyline
Gabapentin

<3y/o
First Handicapped Stepchildren Premature

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84
Q

Toddlers commonly have bruises located ?

What is the next step in evaluation if a child’s mental status is abnormal

What is the name and age criteria for the series of x-rays done for these suspected abuse cases

A

Brow Elbow Chin Knee Shin

Subdural hematoma
Retinal hemorrhage

Skeletal survey: <2y/o

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85
Q

Fx highly suspicious for abuse

Fx moderately suspicious for abuse

Bone scans can be used to assess for rib fxs in suspected abuse, what would be seen in healed Fxs

A 
Post ribs
Corner long bone metaphysis
Scapular
Process, spinal
Chip long bone metaphysis
Sternum
Multiple/Bilateral/Aged/ Fxs
Fingers
Epiphyseal separation
Vertebral body
Skull, complex

Fusiform thickening

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86
Q

How is the age of a Peds Fx assessed by imaging

How are Fxs older than 6wks best assessed

? type of wrist Fx is not associated w/ Fx

A

7-14d: new periosteal/callus
14-21d: lost Fx line, mature callus/trabecula
21-42d: dense callus
>42d: sublte fusiform sclerotic thickening

Eval for thickening by comparing to contralateral side

Buckle

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87
Q

What system is used to describe Peds Fxs involving the physis

? type of x-ray increases the ability to view these Fxs

What are the adverse outcomes from these types of Fxs

A

Salter-harris

Oblique

Premature growth arrest
Dec bone length

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88
Q

What are the Tx goals of Peds Salter-harris Fxs

How are these Fxs Tx

Mild displacement is allowed in ? gender that are ? age

A

Reduction/Avoiding arrest x 6wks

Type 1-2: closed reduction, cast immobilization
3-4: reduction w/ ORIF

Boys 15 and >
Girls 13 and >

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89
Q

Kids younger than 13y/o should not have any Fx older than ? reduced

Salter Fx Types 3-4 require surgery d/t ? structures involved

These require reduction to ensure congruent surfaces to prevent ? formation

A

> 7 days

Cartilage of growth plate and articular surface

Physeal bars

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90
Q

How long do Peds w/ Salter-harris Fxs need f/u

? types of Fxs require longer f/u process

How is JIA named differently in the US and Europe

A

12mon, less if they reach skeletal maturity before f/u appointment

Femur, Tibia

JRA: USA
JCA: Europe

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91
Q

There are at least seven types of JIA, but they all have ? two things in common

What are the types of facts of each

A

Chronic arthritis x 6wks
Pt is <16y/o

Systemic: Fever Arthritis Rash Adenopathy Hepa/Spleno-megaly Pericarditis

Oligoarticular: 4 or < joints, high risk ASx uveitis

RF neg-poly: RF-,, 5 or > joints

RF pos-poly: RF+, 5 or > joints

Psoritatic: first degree relative

Enthesitis: SI, enthesitis, HLA-B27

Udifferentiated: doesn’t fit elsewhere

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92
Q

What joint needs to be palpated when assessing suspected JIA in ASx Pts

What are adverse outcomes from this Dz

How is this Tx

A

TMJ

Joint arthritis/destruction
Blindness from un-Tx uveitis

NSAID- first line
Few joints: intra-articular CCS
Unless arthritis is mild, DMARD (Methotrexate) or a-TNF (Etanercept, A/I-umab)

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93
Q

What two meds are used for Ped PTs w/ refractory JIA uveitis

When would splinting be recommended

What is an adverse outcome to Tx for these Pts that are on a-TNF meds

A

Inflixiamab
Adalimumab

At night for contractures

Fungal/TB infection

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94
Q

Define Osteochondritis Dissecans

Where does this d/o MC occur and where can it occur

Where does it rarely develop

A

Osteonecrosis of subchondral bone

MC- posterolateral medial femoral condyle
Talus Humerus Elbow Femur

Patella

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95
Q

What do Pts w/ OCD in the knee report as a pain relieving maneuver

What test may be positive on PE for this condition

What is the goal of Tx and how are these Tx

A

Walking toe out

Wilson Test

Let lesion heal
Non-op: Peds w/ lesion <1cm, LLD, crutches, refractory due to noncompliance= immobilization
Surgery: mature/cartilage has separated or lesion >2cm

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96
Q

Why is hematogenous spread of microbes in Peds most likely to infect metaphysis of long bones

What is the sequence of infection progression

What is the difference between osteomyelitis sequestrate and involucrum

A

Circulation creates u-turn, slowing flow down

Canal, Cortex, Abscess formation

Seq: abscess inc pressure= bone fragment
Persistence leads to chronic osteomyelitis
Involucrum: periosteum remains, new bone growth

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97
Q

How does subacute osteomyeltits present in Peds and d/t ? microbes

X-rays of these Pts can show ? finding that can mimic ?

How do these Pts appear in clinic

A

Indolent- bacteria/TB

Lytic- aggressive appearance like a tumor

Pain Malaise
Warmth Erythema Swelling Tenderness

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98
Q

What is an early Sx of Ped osteomyelitis if the infection is in the pelvis or spine

What is seen if the upper extremity is involved

How does chronic osteomyelitis present

A

Refusal to walk/limp

Pseudoparalysis

Sepsis
Sinuses w/ chronic drainage

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99
Q

? is typical PE finding for Peds w/ Acute Hematogenous Osteomyelitis

What lab results will be elevated earliest during the Dz process

What are the MC joints involved

A

Fever >100.4
Tenderness over bone
Effusions

CRP, <8hrs of infection onset

Intra-articular:
Prox- Femur Humerus Radius
Distal-Fibula

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100
Q

How does subacute osteomyelitis appear on x-ray

How does AHO appear differently on x-ray

? is the imaging modality of choice for Dx AHO

A

Lytic lesions w/ thin sclerotic rim and crosses physis

Physis sparing

MRI

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101
Q

What are the next steps of Tx once a case of Peds osteomyelitis is suspected

? microbe is MC the cause

? other microbes need to be covered when considering ABX coverage

A

Culture/biopsy
IV ABX

Staph A

GBS
Neonate: enteric rods
6-48mon: H influenza

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102
Q

What special step is needed if Kingella kingae is the suspected culprit of Peds osteomyelitis

When are these Pts switched from IV to PO ABX

How long are ABX recommended

A

PCR and special culture media

7 days

6wks

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103
Q

What is almost always needed to Dx subacute osteomyelitis

? Tx step provides the best likelihood for Dz eradication

Why is immobilization recommended and for ? long

A

Biopsy from surgical debridment

Removal of all infected material

3-6wks
Dec pain
Reduces chance of pathological Fx

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104
Q

Septic arthritis in kids is usually d/t ? route and microbes

Septic joints will have ? lab results

What joints are most likely to be affected

A

Hematogenous seeding of synovium from:
Skin infections
Impetigo
Pneumonia

ESR >30
WBC >15K
Synovial WBC >50K

Knee Hip

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105
Q

Septic arthritis needs to be ID’d early in Peds and can be done so by ?

What signs may be present when this Pt arrives

If the hip/elbow/knee is involved, Pts hold it in ? position

A

Hyaline cartilage damage from lymphocytic enzymes <72hrs from inoculation

Guarding Fever Anorexia Malaise

Hip: Flex Abducted External rotation
Knee/Elbow: slight flexion

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106
Q

When assessing Peds Pt for septic arthritis, how is their presentation different if the underlying Dx is Transient Synovitis or Legg-Calves Dz

? lab marker is best for monitoring Ped Septic Arthritis

Septic joints will have ? lab results

A

TS/LC: discomfort instead of pain

CRP

ESR >30
WBC >15K
Synovial WBC >50K

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107
Q

How is Ped Septic Arthritis Tx

Pediatric Seronegative Spondyloarthropathies have ? 4 characteristics in common

? c/c presentation suggests a case of anklyosing spondylitis

A

Joint aspiration/drainage
IV ABX

HLA-B27
Inflammation of tendon/fascia/enthesitis
Pauciarticular arthritis in LE
Extra-articular inflammation

Asymmetric peri-articular arthritis of the lower extremeties in kids 9 or >

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108
Q

Peds Reiters Syndrome is a triad of ? three Dx

This conditions can be triggered by diarrhea caused by ? microbes

What can cause the non-gonorrhea urethritis in adolescents

A

Conjunctivitis Enthesitis Urethritis

Yersinia Campylobacter Salmonella Shigella

Trachoma
Chlamydia

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109
Q

Peds w/ Reiters in what two locations are particularly painful

How does Peds w/ Psoriatic arthritis tend to present

Peds IBDz arthritis usually presents prior to ? and ? prevelance is twice as common

A

Achilles or Plantar Fascia

Female <15y/o w/ skin problems before arthritis

<21y/o w/ arthralgia w/out effusion

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110
Q

What PE finding is a distinguishing feature of juvenile spondyloarthropathies

Peds w/ Ankylosing Spondylitis may have enthesitis in ? locations

What extra-articular Sxs do Peds w/ Reiters present w/

A

Purple discoloration around joint

Patellar Achilles Plantar

Conjunctivitis
Anterior uveitis
Photophobia

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111
Q

What is the most common manifestation for Peds w/ Psoriatic arthritis

Involvement of ? three locations is more common w/ Psoriatic than other Spondylonegatives

What lab result supports a Dx of juvenile Reiters Syndrome

A

Monoarticular knee

Digit tenosynovitis
UExtremity involvement
Nail pitting

Sterile pyuria

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112
Q

How are Peds w/ Spondyloarthropathies Tx

What is the name of the distal end of the spinal cord that ends at ? level

Anything below is AKA and if compressed presents as ?

A

Muscle strengthening
Orthoses
Activity modification
NSAIDs

Conus medullaris ending at L1-2

Cauda equina: L2-S4
Paralysis w/out spasticity

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113
Q

How does Cuada Equina present on PE

What special tests are done for suspected Cauda Equina Syndrome

How can Pts seen in the ER for back pain be mis-Dx w/ Cauda Equina

A

Bilateral radiculopathy
Incontinence
Foot drop
Stumbling gait

Inability to rise from chair (quad/extensor test)
Inability to walk on heels (ankle dorsiflexion, plantar flexion)

If given narcotic injection, causes acute urinary retention

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114
Q

How is Dx of Cauda Equina confirmed w/ imaging

What is a possible error that could be an adverse outcome to this Dz

What is the usual cause of cervical radiculopathy in young/older PTs

A

Compressed thecal sac on CT/Myelogram

Blame bladder Sxs as Cystocele/Prostatism w/out considering sphincter paralysis

Young: herniation traps root in foramen
Older: stenosis/arthritis

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115
Q

What will usually be seen on PE of cervical radiculopathy

Stenosis of the cervical spine commonly present w/ ? Sxs

Pts will report ability to relieve Sxs w/ ? maneuver

A

Radicular pain w/ UE numbness/paresthesia (deltoid to thumb)
Changed grip/handwriting

Trunk/leg dysfunction
Gait disturbance
Incontinence

Place hands on top of head

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116
Q

What type of neck malformation may be present and restrict movement in cervical radiculopathy

? motor/sensory tests need to be done for these PT

How is this Dx confirmed w/ imaging

A

Reduced cervical lordosis

C5-T1
UE reflexes

CT/Myelogram w/ contrast

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117
Q

How is Cervical Radiculopathy Tx

What two Txs are avoided in this population

Define Cervical Spondylosis

A

Most spontaneous x 8wks
NSAIDs + traction

Opioids
Manipulation

Degenerative disc dz of the cervical spine

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118
Q

What causes the Cervical Spondylosis dz process

What are the MC Sxs of Cervical Spondylosis

What Pt is morelikely to have spinal stenosis and myelopathy w/ this condition

A

Herniation
Osteophyte growth
Thick ligamentum flavum

Limited mobility
Pain worse w/ upright

Older men

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119
Q

What are 3 Sxs of early cervical mylopathy from cervical spondylosis

What PE findings will be abnormal

This type of abnormality suggests ? structure is involved

A

Palmar paresthesis
Altered gait (heel-toe)
Difficult dexterity

Lost vibration/proprioception in the feet

Posterior column

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120
Q

? sensory and motor function tests are needed for PTs w/ Cervical Spondylosis

What two special neuro tests may be positive in cervical spondylosis PTs

X-rays may reveal osteophytes originating from ? landmark

A

C5-T1 and L1-S1

Lhermitte sign
Hoffmann
Clonus
Hyper-reflexia
Babinksi

Zygoapophyseal joints

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121
Q

Where are cervical spondylosis/age-related degenerative findings MC seen

How is this Tx

What two meds can be used for sleep aids

A

C5-7

Cervical pillow
NSAIDs
Surgical decompression

Doxepin
Amitriptyline

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122
Q

What is the classic mechanism for whip-lash injury

What is the MC findings on PE

How are these Pts Tx

A

Stopped car that is rear ended= flexion/extension

Non-focal/radicular neck pain

NSAIDs
Soft collar
Muscle relaxants
Cervical pillows
Doxepin/Amitriptyline
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123
Q

What 3 x-rays are ordered for cervical strains and what is a normal measurement obtained

What is the next step and measurement if severe pain is present

What image should not be ordered until after eval by specialist

A

AP/Lat/Odontoid- pre-vertebral tissue width at C3 should be <1/3 width of C3

Vertebral body translation 3.5mm or more and/or 11* of angulation

Flex/Extension images

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124
Q

What type of rehab is recommended post-cervical strains

What is the most important x-ray obtained for multiple injury trauma Pt

What are the MC missed injuries

A

Walking early
Isometric exercises when tolerated

Cross-table lateral view of C1-T1

Injury to upper/lower C-spine

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125
Q

What type of x-ray is needed for trauma Pt to evaluate the cervical-thoracic junction

How are neck injured Pts Tx if cleared by imaging but pain persists

Flexion-distraction injuries of the T/L spine usually alos have ? injuries too

A

Swimmer view

Cervical collar x 7-10 days

Abdominal- bowel lac

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126
Q

What secondary issue can develop in Pts w/ lumbar spine Fxs

What are the hallmark PE findings of an unstable T/L flex-distract or burst Fx

Burst Fxs tend to involve ? column of the spine and best seen w/ ? image

A

Ileus- dec bowel motility

Hematoma w/ step off

Middle, CT

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127
Q

Any vertebral Fx other than ? requires additional imaging

Isolated transverse process Fxs need to be inspected for injury to ? and can be Tx w/ ? to dec Sxs

Compression Fxs w/ ? measurements are also tx the same method x 8wks

A

Single compression

Kidney, thoracolumbar corest

Wedging <20*
No posterior involvement

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128
Q

? is the MC cause of disability and lost time at work for Pts <45y/o

What causes the irritation process for this condition

What is used to monitor progress

A

Acute low back pain

Injury to anulus fibrosus= nucleus pulposus leak= irritation

Lumbar flexion
Ease of extension

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129
Q

Acute LBP that need x-rays need to have ? landmark in the picture

What are the two phases of Tx for acute lower back pain

When does this type of back pain become reclassified to chronic lower back pain

A

T10

Initial: Sx relief
Secondary: return to activity

Pain >3mon

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130
Q

All Pts w/ chronic lower back pain need to be evaluated by ? providers

Identifying ? underlying issue w/ Chronic LBP can help Sx resolution

Often there is ? sign seen on x-rays

A

GYN Internist FamMed Spine

Depression

Vacuum- Nitrogen in air space

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131
Q

What type of material is found in the nucleus pulposus

What are the 3 parts of the intervertebral disc

What two movements increase pressure on the nucleus pulposus

A

Collagen Type 2

Nucleus pulposus
Anulus fibrosus
Sup/Inferior end plates

Twisting
Lifting

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132
Q

Where do lumbar herniations MC occur

What nerve root is irritated

Herniations located in ? areas tend to NOT have radiculopathy below the knee and have ? Sx

A

L4-S1

L5-S1

L1-4, pain in anterior thigh

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133
Q

? PE test has high correlation to lumbar herniation

What test is even more specific though

When performing the supine straight leg raise, this maneuver pressures ? area

A

Seated leg raise

Crossed straight leg raise

L5-S1 is stretched

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134
Q

What will be seen in L3-4 herniation onto L4

What will be seen on L4-5 herniation onto L5

What will be seen on L5-S1 herniation onto S1

A

Weak anterior tibialis, asymmetric knee reflex

Great toe extensor weakness, numb dorsal foot/lateral calf

Unable to toe walk, lateral foot pain, asymmetric ankle relfex

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135
Q

When is an MRI ordered for suspected lumbar herniations

How many epidural injections can these PTs receive

When should the injections be avoided

A

Sxs >4wks

3 in 6mon

Substantial neuro deficit

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136
Q

Motor, Reflex and Sensation for L4 nerve root

Motor, Reflex and Sensation for L5 nerve root

Motor, Reflex and Sensation for S1 nerve root

A

Anterior tibialis / Patellar / Medial foot

Extensor hallucis longus / NONE / Dorsal foot

Gastroc soleus (toe raise) / Achilles / Lateral foot

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137
Q

Why would a PT younger than 60y/o experience lumbar stenosis

Where does stenosis typically develop

? type of movement tends to narrow the lumbar region

A

Achondroplasia

L2-5

Spine extension

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138
Q

What special tests should be done for suspected lumbar stenosis?

What is uncommon and ? area is rarely affected by this condition

Lateral x-ray views need to have ? landmark included

A

Proprioception/Romberg/Neurovascular

Leg muscle weakness
Uncommon sphincter tone decrease

T10

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139
Q

How is lumbar stenosis Tx non-op

When do these Pts become surgical candidates

What is the goal of Tx

A

Water exercise
Epidural injections

Non-ambulatory/Dec quality of life

Prevent progression

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140
Q

What type of malignant tumors of the spine are considered rare/common

Highest incidence of spinal carcinoma is d/t ? and via ?

How are Cas to the spinal column spread via hematogenous

A

Primary- rare
Metastatic- common

BLT KPC by hematogenous spread

Batson’s plexus- connects w/ inferior vena cava

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141
Q

Malignant tumors of the spine can present in ? ways

? is the MC presenting issue for these Pts

What is the first manifestation these appear as on x-ray

A

Pain as presenting c/c
Incidental
Neuro findings
Known primary tumor

Pain, usually from minor vertebral Fxs

Lost pedicle integrity (winking owl)

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142
Q

What is the best screening study for widespread mets after suspected spinal neoplasm

This test will usually be negative in Pts w/ ? Dx

What are the most severe sequelae of pathological Fxs induced by these mets

A

Tc-99m bone scan

Multiple myeloma

Quad/Paraplegia

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143
Q

How are ASx spinal neoplasms found during the search for mets Tx non-op

How are painful metastasis Tx

When is surgery indicated

A

Chemo/Rad/Hormones

Radiation if no deformity/neural compression

Pain w/ neurodeficit- decompression and stabilization w/ post-op radiation

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144
Q

What is a common adverse outcome after surgical decompression of spinal neoplasms?

Define Scoliosis

What is the MC presenting Sx

A

Wound complication if surgery is post-radiation/steroid

Coronal curvature of spine >10* using Cobb method

Pain in region of deformity

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145
Q

What is the MC overlapping condition seen w/ scoliosis

If these PTs have radiculopathy it’s because of ? compression

Neurological findings are rare but ? is the MC

A

Degenerative spondylosis

L4-5

Hallucis Longus

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146
Q

How is decompression in scoliosis assessed

How is adult scoliosis Tx

What are the red flags for referral in these Pts

A

Plum line- C7 to gluteal cleft

NSAIDs
Water/swimming therapy

Neuro deterioration
Can’t walk 2 blocks d/t pain
Respiratory dysfunction
Trunk exercise

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147
Q

Define Degenerative Spondylolisthesis

What is the opposite direction of slippage called

What nerve roots need to be evaluated

A

Female >40 L4-5 body slips fwd d/t deteriorated facets/disc leaving lamina/pars interarticularis intact

Retrolisthesis- posterior slippage

L1-S4

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148
Q

What neuro findings are seen in Pts w/ Degenerative Spondylolisthesis

Narrowing of ? two spaced in degenerative spondylolistesis causes ? types of pain

Where does pediatric isthmic spondylolisthesis usually develop

A

Dec knee reflexes, also seen in geriatrics
Weak toe/heel walking
Weak toe dorsiflexion

Lateral recess= radiculopathy
Central canal= claudication

L5-S1

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149
Q

Isthmic Spondylolisthesis develops at ? junction

This form of the condition is more likely to represent ? event

If only the defect is present, and no slippage has occurred? the PT has ? Dx

A

Lamina w/ pedicle (pars interarticularis)

Cyclic loading AKA- fatigue Fx that fails to heal

Spondylosis

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150
Q

? activities put Pts at higher risk for developing Isthmic Spondylolisthesis

How do Pts w/ isthmic spondylolisthesis present to clinic

What may be seen on PE

A

Gymnastic/Football

Posterior pain radiation below knees, worse w/ standing

Dec lordosis/flat buttocks
Vertebral step off
Hamstring spasm w/ forward extension/leg raise

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151
Q

What area of the lumbar spine can become compressed during Isthmic Spondylolisthesis

What is the x-ray finding name for this condition

Since Peds are considered skeletally immature, what imaging test is ordered to assess metabolic activity at site of defect

A

L5

Collar on scotty dog

Single Photon Emission Test- SPECT CT

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152
Q

How are cases of Isthmic Spondylolisthesis Tx

? is the MC cause of thoracic and lumbar pain in kids?

Spinal hyperextension loads posterior spine to test for ? while flexion loads anterior spine to test for ?

A

Metabolically active and skeletal immature= rigid brace
Surgery: refractory, high grade slip
Skeletal mature: no fixation, NSAID, exercise

Muscle strains

Extend: posterior- spondylolysis
Flex: ant- discitis, compression Fx

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153
Q

Abnormal abdominal reflexes may be the only sign Peds Pt has ? Dx

What is the initial imaging method of choice for Peds w/ back pain

Discitis and vertebral osteomyelitis in Peds are issues involving ? d/t ?

A

Syringomyella

Weight bearing PA/Lat x-ray

Discitis: MC Staph A in anterior spine in kids <5y/o
Osteo: Staph A in vertebral column in Pts >5y/o

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154
Q

Where is discitis MC seen in Peds

Other the MC microbe causing discitis, what other 3 microbes can cause this Dx

What special tests are performed and what is the imaging modality of choice

A

Low thoracic/Lumbar

Kingella E coli GAS

Percussion- localizes
Passive flex- pain due to anterior element compression
MRI

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155
Q

What provacative test can be done for Peds Pts w/ suspected discitis

? other Dx test should be considered in these populations

? abnormal lab results may be seen in Peds w/ discitis/vertebral osteomyelitis

A

Pick up- will avoid bending back to retrieve item

TB skin test

Normal WBC w/ inc ESR/CRP

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156
Q

What are common adverse outcomes in Peds w/ discitis/vertebral osteomyelitis

How are these PTs Tx by non-op methods

When is surgery/biopsy indicated

A

ASx persistent disk narrowing and spontaneous vertebral fusion

Empiric bed rest, LLD, analgesics
IV ABX x 2wks then PO x 4wks
Orthosis worn x 6wks

Non-responsive to empiric Txs

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157
Q

Define Kyphosis

What is the normal range for thoracic kyphosis and how is this measured

What are the two MC causes of hyperkyphosis and in seen in ? populations

A

Greek- humpback
Curve on saggital plane w/ apex more posterior

20-50* w/ Cobb angle between T3-T12
>50*= hyperkyphotic

Postural- female
Scheuermann dz- male

158
Q

How is Sheuermann Dz Dx on imaging

What are the names of the nodes seen in this Dz

Neuro findings are rare in these Pts except for ?

A

Wedgine >5* in three vertebraes

Schmorl- disc herniations through end plates

Congenital kyphosis

159
Q

How is hyperkyphosis assessed in clinic

How do the two different etiologies appear

What is a common neuro finding seen in pathlogical forms of hyperkyphosis

A

View from side w/ Adam fwd bend test

Scheuermann/pathologic- sharp apex angulation
Postural- gradual curvature

Hamstring spasm/contracture

160
Q

How is the magnitude of a hyperkyphosis angle measured

What are the adverse outcomes of this dz

What can complicate surgical Tx of this

A

Cobb angle: T5-12 w/ >50* being abnormal

Dec pulm function- >90-100*
Back pain
Neuro Sxs= congenital

Proximal junction kyphosis

161
Q

Define Scoliosis

What is the MC Dx

How is this MC scoliosis classified

A

Lateral curvature >10* w/ Cobb angle

Idiopathic

Age of onset:
Birth-3yrs: infantile
3-11yrs: juvenile
>11y/o: adolescent

162
Q

What is neuromuscular scoliosis associated w/ causing to be seen on PE

What is the predominant effect of Peds scoliosis

What is usually seen in PTs w/ neuromuscluar scoliosis

A

Flaccid weakness/spasticity

Loss of sitting balance
Impaired respiratory function

Long thora/lumbar curves

163
Q

Idiopathic neurological progression presents as ?

What findings on PE can solidify Dx of idiopathic scoliosis in Peds

What is the most sensitive test for screening and quantifying scoliosis in Peds

A

Lost sitting balance

Cafe au lait spots
Axillary freckles- neurofibromatosis
Lesions over spine= spinal d/o
Cavus feet- neuromuscular dz/cord anaomaly

Adam’s forward bend test
Cobb angle

164
Q

What are the indications for ordering MRI for Pt w/ Idiopathic Scoliosis

Pts w/ congenital spinal dyformities need ? additional images ordered

What is an adverse outcome for Pts w/ scoliosis

A

Age (infantile/juvenile)
Abnormal Hx/PE findings
Radiographic- (KREWL) Kyphosis Rib abnormals Erosive vertebrae Wide spinal canal Left sided thoracic curve

Renal US
Spine MRI
Echo

Curvatures >80*= dyspnea from restrictive pulm dz

165
Q

What/why does idipathic scoliosis have a reduced life expectancy

How are idiopathic scoliosis PTs Tx non-op

How are idiopathic scoliosis Pts Tx op

A

Cor pulmonale, MC infantile/juvenile and congenital cases

Skeletal immature w/ curve 25-45*- bracing
Neuromuscular scoliosis-
1) observation if sitting/function are normal
2) soft orthosis if progressive/Sxs

Immature >45*
Mature >50-60*

166
Q

How is neuromuscluar scoliosis Tx

What is the downside for the future in these Pts

How is congenital scoliosis Tx

A

No function/sitting impairement- observe
Progressive/Sx- soft orthosis

Post-op complication risk is higher

Premptive spinal fusion

167
Q

Define Spondylolysis

What causes this

What level is this MC seen

A

Defected pars interticularis

Stress Fx progresses into pseudoarthrosis

L5

168
Q

What can cause a higher grade slip to occur in spolylolisthesis

What is the MC Sx and what is the land mark it stops at

What may be the first sign of a stress reaction of spondylosis/listhesis and how is it reproduced on PE

A

lumbar kyphosis

Activity related radicluopathy stopping above knee

Hyperextension of spine

169
Q

How are Peds w/ stress reaction/early cases of spondylolysis Tx

When are these Tx w/ fusion/decompression surgery

A

LLD
NSAIDs
TLSO x 3-4mon

Immature Pts w/ slippage >50%
Chronic Sxs

170
Q

What are the 6 types of AC injuries

A

1- AC ligament sprain

2- AC ligaments torn, widening <100%, unstable in ant/post direction

3- 100% displace, CC disrupted here

4-6: periosteum, deltoid, traps are disrupted
4- Sup & Posterior displace
5- sup displaced clavicle
6- distal clavicle is in sub-acromial/coracoid space

171
Q

How are AC joint injuries confirmed w/ imaging

What is a type of weakness this type of injury can make PTs adopt

How are these injuries Tx

A

AP films- Type 2-6
Weight bilateral- Type 1-2

Weak pushing/benching

Type 1-2: sling
Most Type 3- Tx non-op
Surg: young/labor/Type 4-6

172
Q

What is the goal of rehab after AC injuries

How do Pts w/ shoulder arthritis present to clinic

Pts w/ shoulder arthirits and long standing rotator cuff tears may also develop ? issue

A

Reduce pain
Protect joint
Function

Diffuse/deep pain worse to posterior shoulder

High riding humeral head

173
Q

What will be seen on PE of shoulder arthritis

What x-ray findings help support a dx of shoulder arthritis

What would be seen if the actual underlying issue was RA?

A

Equally decreased A/PROM

Flattened humeral head
Inferior osteophyte
Posterior erosion of glenoid

Periarticular erosions
Osteopenia
Central wear of glenoid

174
Q

? is an adverse outcome for Pts w/ shoulder arthritis

How are these Tx non-op

What procedure is done for mil/mod cases w/ preserved ROM

A

Severe loss motor/strength even w/ -plasty

Heat/Ice
NSAIDs
Stretching exercises

Arthroscopy debridement and capsular release

175
Q

How does Transient Brachial Plexopathy develop

What is the corner stone of an accurate Dx of burner/stinger

How is a preganglionic burner to C8-T1 confirmed on exam

A
  • C5-7 stretch injury while neck tilts in opposite direction
  • Upper plexus between shoulder pad and scapula
  • C8-T1 stretched w/ arm abduction (usually pre)

Neuro Exam

Horner’s Syndrome:
Myosis Ptosis Enophthalmos Anhidrosis

176
Q

Dorsal scapular and long thoracic nerve may be injured during burners/stingers because of their origin ?

? muscles are assessed to see if these nerves have been injured

If these muscles are intact, the location of the burner/stinger is then ?

A

C5-7

Rhomboid
Serratus anterior

Post-ganglionic

177
Q

Recurrent episodes of burner Sxs may suggest ?

What findings on exam are required for an athlete to return to playing after a burner

What is the MC and associated RFs for developing idiopathic Frozen Shoulder

A

Cervical stenosis
Inc risk cord injury

Resolution of pain/neuro Sxs
Normal neuro exam
Full cervical ROM

DMT-1

178
Q

What PE finding is pathognemonic for frozen shoulder

Where is the most point tenderness elicited on exam

What imaging finding helps solidify the Dx of Frozen Shoulder

A

Contracted coracohumeral ligament

Deltoid insertion site
Subscapularis

Contracted capsule
Loss of inferior pouch

179
Q

What is the functional goal of rehab for frozen shoulders

? movement tends to be the most restricted for these Pts

During rehab Pts shouldn’t perform this restricted movement past ?

A

Inc ROM in scapula/glenohumeral joint

External rotation w/ arms in adduction

30-45* of abduction

180
Q

Frozen shoulder rehab that is too aggressive can result in ?

When do they need to be referred for further eval

What are the 4 muscles of the rotator cuff

A

Fx humerus

3mon w/out improvement of pain/motion

Supraspinatus
Infraspinatus
Teres minor
Subscapularis

181
Q

What part of the rotator cuff is susceptible to impingement syndrome under the coracoacromial arch and how is weakness here tested

What structures make up the corachromial arch

What is the characteristic presentation

A

Supraspinatus- 90 elevated and internal rotation

Coracoid process
Coracoacromial ligament
Acromion
Acromioclavicular joint

Gradual ant/lat pain worse w/ overhead activity from supraspinatus trauma from coracoacromial arch

182
Q

What two special tests are usually positive on impingement exam

Where will Pt have pain on PE

Once suspected, how is the Dx confirmed

A

Neers
Hawkins

W/ 90-120* abduction
W/ lowering arm

Suacromial injection- pain relief is Dx

183
Q

How are impingments/rotator tendonopathy Tx non-op

What is the goal of rehab

What can happen if more than 3 CCS injections are performed

A

Exercise x 3-4/day x 6wks
Then subacromial injection
Then stretching

Overhead activities w/out pain

Proximal bicep head tear

184
Q

What type of x-rays are used to assess rotator cuff isues

? is the Dx/pre-op image of choice

How are rotator cuff tears Tx non-op and op

A

30* caudal tilt- psurs from inferior acromion
Coracoacromial- outlet, hooked acromion

MRI

Non: CCS Avoidance NSAIDs
Strength/stretch rehab
Op: 6mon non-op failure, acute= <6wks of injury

185
Q

What are the goals of rotator cuff rehab

What is an adverse outcome of rotator cuff surgical Tx

What PT population usually have proximal bicep tendon ruptures

A

Pain ROM Strength Function

Large tears= high failure
Debridement may relive pain

Older adults w/ chronic shoulder pain d/t rotator cuff

186
Q

What are the landmarks that the long bicep tendon head is found in

What special test is done for assessing possible proximal bicep tendon ruptures

What is an adverse outcome for 10% of these Pts

A

Intertubercular groove, intrarticular for proximal 3cm

Ludington- put hand behind head and flex

Loss of elbow flexion/forearm supination (screw driver)

187
Q

When are proximal bicep tendon ruptures repaired w/ surgery

Instability is MC found in ? joint

Pts w/ this MC instability have recurrent episodes of ?

A

Young athletes
Adults <40y/o as laborers

Shoulder

Subluxation- humeral head slips out of socket MC in Anterior/Multi-directional

188
Q

Define TUBS

Define AMBRI

What type of forces cause a ant/posterior dislocation

A

Traumatic Unidirectional instability w/ Bankhart lesion best Tx w/ Surgery

Atraumatic, Multidiretional Bilateral signs of laxity, REhab as preferred Tx, and Inferior capsule shift

Post: Adduct w/ internal
Ant: Abduct, external

189
Q

What is a common but poor prognostic presentation in Pts w/ multidirectional instability

Pts w/ posterior dislocation present holding arm in ? position w/ ? movement impossible

What are 3 special tests performed for shoulder instability to isolate the direction of instability

A

Voluntary dislocation d/t psychological disturbance

Add, internal
External= impossible

Apprehension- anterior
Sulcus- inferior
Jerk- posterior

190
Q

What x-ray finding is clear evidence of an anterior dislocation

Posterior dislocations are missed on AP radiographs and axillary are impossible to obtain, ? image is needed

How are shoulder dislocations Tx non-op

A

Hill-Sachs lesion: compression Fx of posterior humeral head from pressing on anterior edge of glenoid

Trans-scapular

First anterior= immobilize 3wks
Rehab- subscapularis strength

191
Q

What types of shoudler instability are Tx non-op

When do these Pts need to be referred

TUBS also have a tear in the labrum located ?

A

Atraumatic/voluntary (AMBRI) instability

Failed reduction
2 or > dislocations/3mon w/ rehab
Multidirection instability

Anterior glenoid labrum

192
Q

SLAP tears are injuries to what 2 structures

What are the two mechanisms that cause tears

What special tests are done for suspected SLAP tears

A

Superior glenoid labrum
Bicep anchor complex

Fraying- natural degeneration
Frank tear- trauma

Crank test
Resisted supination/external rotation
Active compression (Obrien)
Clunk

193
Q

What image is needed for Dx of SLAP tear

How are SLAP lesions Tx non-op

What is the next step if non-op fails and Sxs persist

A

MRA= gold standard

NSAIDs
Rehab towards stabilization, stretch, strength x 6wks

Dx arthroscopy

194
Q

What is the goal of rehab for SLAP tears

What 3 exercises need to be avoided

? is the MC adverse outcome of SLAP lesions

A

Goal: reduce pain, protect joint

Bench press
Over head press
Bicep curls

Shoulder stiffness

195
Q

What causes Thoracic Outlet Syndrome

What three underlying congenital issues can cause Thoracic Outlet Syndrome

These Pts can present w/ Sxs mimicking ? d/t ?

A

Compressed brachial plexus/subclavian vessels between superior shoulder girdle and 1st rib

Fibrosed scalene muscle
Long C7 processes
Anomalous fibromuscular band
Cervical rib

Brachial plexus= ulnar entrapment

196
Q

When evaluating Thoracic Outlet Syndrome, evaluate ? area for masses

What is the simplest and most reproducible PE test

What x-rays are ordered for TOS and why are they ordered

A

Supraclavicular fossa

Raised arm stress test- shoulders abducted to 90*, open and close fist x 3min

AP: r/o cervical rib/C7 process
PA/Lat: r/o apical lung tumor/infection

197
Q

What are four adverse outcomes from thoracic outlet syndrome

What are two rare but possible outcomes

? is the MC cause of elbow joint destruction

A

Weakness
HAs
Inability to do overhead work
Coordination decrease

Raynauds
Ulcerations

RA

198
Q

Non-rheumatoid inflammatory arthritis of the elbow usually presents as ? condition

Elbow OA is usually seen in ? populations

How are elbows tested for the presence of osteophytes

A

Pseudo/gout

Manual laborers
Weight lifters

Jogging-
Extension= posterior
Flexion= anterior

199
Q

How is elbow arthritis Tx

Why are elbow arthroplasty’s avoided as much as possible

What muscle originates at the lateral/medial epicondyle of the humerus and inflamed during epicondylitis

A

RA: plasty
Non-Rheum: CCS, gout control
Post-trauma/OA: Stretch Analgesic Debridement

Prosthesis loosens/breaks

Lat: Extensor carpi radialis brevis
Med: flexor/pronator muscles

200
Q

What form of epicondylitis is more common

What makes pain of lateral/medial epicondylitis worse

What is the most consistent PE finding for lateral epidcondyltitis

A

Medial > Lateral

Lat: Wrist extension and grip
Med: Wrist flexion and pronation

Tenderness over extensor 1cm distal and anterior to lateral condyle

201
Q

What in office test can differ lateral/medial elbow Dxs

? is the MC adverse outcome from this condition

What is the most important non-op Tx step for elbow tendonitis

A

Lifting- pain w/ palm up= medial condyle

Pain

Avoidance
Persistent Sxs= CCS Debridement

202
Q

What are the 4 stages of Tx of humeral epicondylitis

What criteria can be used to determine if Pt is ready for early exercises

Surgical failure of these Pts can result in ? mids-Dx

A

Reduce pain/inflammation
Promote arm strength
Return pain free activity
Maintenance

Pain free hand shake

PIN w/ lateral epidcondylitis
Ulnar w/ medial epicondylitis

203
Q

Pts w/ pulmonary/breathing difficulty may present w/ ? abnormal c/c

What is done that is therapeutic and Dx

A

Olecranon bursitis

Aspiration

204
Q

How is olecranon bursitis Tx non-op

If septic olecranon bursitis is Dx by lab, IV ABX use needs to be broad enough to cover ? microbe followed by ?

When can PO ABX be used?

A

Small, mild= NSAIDs, LLD
Non-septic= compression bandage, Reassess 2-7days
Negative cultures, fluid re-accumulation= aspiration and CCS injection

PCN resistant Staph A
Surgical decompression
Daily aspiration

Septic bursitis Tx early and Pt not ImmComp

205
Q

Why are chronically inflamed olecranon bursitis’ rarely ever InD’d?

When do Pts need to be red flagged and referred?

Where can the ulnar nerve experience entrapment

A

Risk for chronically draining/infected sinus development

Septic/recurrent w/ 3 or > aspirations

10cm prox to elbow
5cm distal

206
Q

What are the two MC nerve entrapment in the upper extremity and what causes the compression

Define Cubitus Valgus

What can cause ulnar palsy

A

1st: carpal
2nd: ulnar, cubital tunnel or between humeral/ulnar heads and flexor carpi ulnaris muscle

Carrying angle >10* stretches nerve

Repetitive subluxation/dislocation w/ flexion

207
Q

Define Radial Tunnel Syndrome

What is the commonly mis-Dx as

How is it differentiated

A

Compressed PIN between supinator heads causing lateral elbow pain

Lateral epicondylitis

No sensory, innervates thumb/finger, carpi ulnaris extensors

208
Q

Define Pronator Syndrome

Why is this entrapment condition hard to find or is found late

What are early and late signs of ulnar compression

A

Muscular compression of median nerve in proximal forearm

Vague, few PE findings, high relation w/ worker’s comp

Early: aching elbow/numb fingers
Late: weak intrinsic muscles

209
Q

How is the location of Radial Tunnel Syndrome differ

What to Pts w/ Pronator Syndrome present w/ ? c/c

What activity can aggravate Sxs of pronator syndrome

A

Pain 4-5cm distal from lateral epicondylitis

Forearm aches w/ proximal radiation

Driving

210
Q

? is a provocative maneuver to test for ulnar compression

What are the first abnormals seen when assessing sensation/motor function

If two point discrimination is abnormal this means ?

A

Elbow flexion test

Light touch/vibration

Compression has progressed to degeneration

211
Q

? provocative test is done for radial tunnel syndrome

? is the most reliable PE test for pronator syndrome

Nerve conduction studies w/ a decrease of ? indicate ulnar nerve compression

A

Middle finger test- resisted extension causes forearm pain

Pain w/ direct pressure to pronator teres 4cm distal to antebrachial crease

30% or more

212
Q

What is the most important step in ulnar nerve compression Tx to prevent ? adverse outcome

When is surgical Tx considered

What is the adverse outcome of distal bicep tendon ruptures if not Tx in timely manner

A

Preventing flexion/pressure
Prevents permanent loss of strength/sensation

Ulnar: Sxs/weak x 3-4mon
Radial: discomfort after 3-6mon of rehab/non-op
Pronator: no relief after 3-6mon of rehab/non-op

Lost supination x 50%
Lost flexion strength x 15% (initial, but improves)

213
Q

W/ complete tears of distal bicep tendon, ? structure may remain intact

Resisted flexion, the muscle belly will migrate in ? direction

MRI is used to confirm Dx and distinguish between ? two things

A

Aponeurosis

Proximally

Tendon avulsion from radial tuberosity
Ruptured muscle-tendon junction (poor prognosis)

214
Q

What nerve can be damaged during surgical correction of distal bicep tendon repair

These need to be corrected w/in ? time frame

? structure is the primary valgus resistor in the arm and a tearing of this structure can present as ?

A

Radial

<2wks of injury

Ulnar collateral ligament
Medial paresthesia

215
Q

? maneuver is used to provoke valgus stress to UCL

What may be seen on x-rays in chronic UCL injuries

? imaging modality is used for Dx

A

Milking

Loos bodies
Ossification
Osteophytes
Marginal spurs

MRI w/ contrast

216
Q

What is the MC adverse outcomes of UCL injury

? is an indicator that non-op Tx will be successful for the Pt

When do ulnar collateral ligament tears need to be referred for surgical repair via ? procedure

A

Persistent pain w/ throwing

Main goal is pain relief

Competitive throwers
>3mon of non-op Txs
Tommy John surgery

217
Q

Arthritis of the wrist are MC from ? etiologies

How does wrist arthritis appear on exam depending on the cause

Define Caput ulnae

A

Trauma
RA

RA:
Wrist: radial deviation 
Finger: ulnar deviation
Dec grip w/ pain
OA:  Swelling Pain Dec ROM

Prominent ulna seen on PE

218
Q

When assessing wrist arthritis on x-rays, ? finding is indicative of early pseudogout

? random lab test may be needed during an abnormal work up

? is the MC compression neuropathy of the upper extremity

A

Calcificaiton of fibrocartilage complex

Lyme Dz

Carpal tunnel from compressed median nerve

219
Q

What are common precipitating conditions that can lead to Carpal Tunnel

? is the most useful PE test and what other test can be done

What abnormal PE finding may also be noted

A 
RA tenosynovitis
Tumor
Pregnancy
DM
Thyroid

Nerve compression test
Phalen

Failed two point discrimination <5mm

220
Q

? is the most useful confirmatory test for carpal tunnel

What is the purpose of non-op Tx

De quervain tenosynovitis is swelling/stenosis around sheath of ? tendons

A

Electrophysiologic

Dec pressure on median nerve

Abductor pollicis longus
Extensor pollicis brevis

221
Q

When is De quervain tenosynovitis commonly developed

How is it Dx

How is de quevains Tx

A

Post-partum w/ ulnar deviation during picking up child

Finklestein test

2 wks NSAIDs w/ spica splint
Persistent= CCS sheath injection
CCS failure= surgery

222
Q

? is an adverse outcome of surgical Tx for De Quervains

? are the MC soft tissue tumors of the hand in Pts 15-40y/o

What are the two types and how does their presentation tell the type

A

Injury to radial sensory nerve

Ganglion: cyst from joint capsule/synovial sheath deterioration

Sheath- tender w/ grasping, bump at base of finger (proximal flexion crease)
Mucus- dorsum finger swelling distal and lateral to DIP

223
Q

Where do wrist ganglions tend to develop

What are these called if they are located at base of a finger in a tendon sheath

Where do mucuous cysts develop and what effect do the exert

A

Wrist dorsum
Volar radial wrist
Base of finger at A1

Volar retinacular ganglia

Distal to DIP
Arthritic interphlangeal joint- press on germinal matrix causing nail pitting

224
Q

Dorsal ganglions of the wrist usually develop over ? joint

A volar radial ganglion is usually between ? structures

The volar growths may adhere to ? structure

A

Scapholunate joint

Flexor carpi radialis
Radial styloid

Radial artery

225
Q

Volar retinacular ganglions of the flexor tendon sheath MC develop on ? fingers

Mucus cysts tend to develop along ?

Mucus cysts are the only growths that can cause ? x-rays changes

A

Long/Ring

One side of extensor tendon of DIP

Degeneration
Spurs from dorsum of DIP

226
Q

Why is aspiration/rupture of a mucous cyst not recommended

If this adverse outcome does occur, how it it Tx

Define Kienbock Dz and these PTs present to clinic

A

Infecting DIP joint

1s generation Cephalosporin

Osteonecrosis of carpal lunate in men 20-40y/o unable to grasp heavy objects

227
Q

As the Kienbock Dz progresses, what is the final result

How does Kienbock Dz appear on x-rays and how is Dz staging accomplished w/ imaging

Radiographic classification uses ? method

A

End stage arthritis of wrist

Early: inc density
Later: fragment/collapse

MRI

Lichtman/Weiss and Assoc.

228
Q

How is Kienbock Dz Tx non-op

X-rays are obtained w/ arm in ? position

Why is this positioning needed

A

Normal/sclerotic- splint, NSAIDs x 3wks

Shoulder abducted to 90
Elbow flexed to 90

Eval ulnar variance- difference between ulnar and radius

229
Q

Ganglias are the MC benign soft tissue tumors

? are the MC benign and malignant neoplasms of hand bones

? is the MC malignant neoplasm of hand

Most hand tumors are painless w/ ? exception

A

2nd: Giant cell tumor
3rd: EIC

B: enchondromas
M: chondrosarcomas

SCC

Glomus- pressure/cold sensitive

230
Q

How are hand/wrist tumors evaluated and what does their location indicated

A

EIC- digit/amputated stump end, non-transillumination w/ light

Giant: multi-nodular, firm and non-tender at thumb/index/long finger’s interphalangeal joint

Lipoma- thenar emminence

231
Q

Recurrent paronychia infections and chronic nail deformities can be caused by underlying ?

AIDs Pts w/ skin nodules w/ red/brown plaques have ?

Symptomatic enchondroma is usually tender along ?

A

SCC

Kaposi sarcoma

Proximal phalanx

232
Q

Define Carpal Boss

These are sometimes associated w/ ?

What color d/c come from mucous/EICs?

A

Dorsal prominence at base of 2nd/3rd carpal

Ganglions

EIC: white/cream
Mucous: clear

233
Q

Hand tumors usually need ? imaging for max info

? can cause Pts to develop ulnar tunnel syndrome

What are the 3 zones of ulnar tunnel syndrome

A

MRI

Wrist entrapment (mass/lesion)
Trauma- jack hammer, base of hammer hammering

1: motor and sensory Sxs (pisiform)
2: motor deficits
3: sensory (hook of hamate)

234
Q

Pts w/ ulnar tunnel syndrome originating at the elbow will almost all have ? Sx

What can happen if this condition goes untreated

Animal bites to the hand MC occur in ?

A

Sensory and Motor changes

Sensory loss
Atrophy
Clawed ring/little finger

Dominant hand of kids

235
Q

What are the two MC animal bites and which one is more likely to become infected

What are the MC microbes infected after animal bites

Outside of the US, ? is the MC vector for rabies

A

Dog, Cat
Cat > Dog

Dog/Cat- Pasteurella multocida
Dog- AHStrep, Bacteroides, Fusobacterium Staph A

Dogs
In US= bat skunk fox raccoon

236
Q

Animal bite w/ purulent drainage suggests wound is at least ? old

What ABX are used for Tx

What are the two MC causes of arthritis in the hand/wrist

A

> 10hrs

PO Augmentin 875mg
IV Amp-Sulbactam
PCN Allergy= Tetracycline

OA
Secondary degenerative joint dz

237
Q

All deformities and destruction in hand/wrist arthritis from RA are due to ? pathological

What joints are MC involved in OA/RA of the hand processes

What is the difference between the two when assessing pain

A

Synovial hypertrophy
Inflammation

OA: DIP PIP, thumb CMC
RA: wrist, MCP, tenosynovitis

RA: pain w/ acivity
OA: pain w/ palpation

238
Q

What two deformities can develop in RA of the hands

OA involving the DIP forms ? nodules and can have ? other growth on them

Involvement of ? joint is more rare w/ OA so it’s presence usually indicates ?

A

PIP contracture- boutoniierre
Hyper-extended PIP, DIP flexed- swan neck

Heberden w/ mucous cysts

MCP, Hx of trauma

239
Q

How is RA of the hands Tx

? tendons can rupture in these Pts

Idiopathic degenerative arthritis of the thumb’s CMC MC affects ? Pt populations and caused by ?

A

NSAIDs
Etanercept/Infliximab

Little Ring Thumb

Female 40-70y/o
Joint configuration/laxicity

240
Q

What is the MC Sx and hallmark of arthritis of the thumb CMC joint

? tunnel syndrome may co-exist or be mimicked

What test is performed on PE to Dx thumb CMC arthritis

A

MC: Pain w/ grip/pinch
Hallmark: Tenderness over palmar/radial aspects of joint region

Carpal

Grind test

241
Q

How is thumb CMC arthritis managed non-op

Define Boutonniere Deformity

What PE test is done for Dx confirmation

A

Thumb spica splint w/ NSAIDs
Splint failure= injections

Extensor tendon ruputres from insertion on middle phalanx, PIP is flexed unopposed

Joint in flexion, extend PIP
Lack of 15-20* PIP extension= rupture

242
Q

What will be seen on x-rays of Pseudo-Boutonniere deformities

How are Boutonniere’s Tx non-op

Define Dupuytren Contracture and who is more likely to develop this condition

A

PIP flexion= calcification on lateral view of PIP

Splint in extension x 6wks (young Pt) or 3wks (old Pt)

Thick/contracted palmar fascia in Pts w/ dominant genetics of Northern European men >50y/o

243
Q

What are the associated RFs for Dupuytren’s development

? finger is MC affected during Dupuvtren Contractures in descending order

What non-Tx step can be done to help slow the Dz progression

A

Pulmonary Dz, Alcohol/smoking, Vibration trauma, Epilepsy, DM

Ring Little Long Thumb Index

Night splinting
Collagen injection (+FDA)
244
Q

? procedure may be done to Tx Dupuytrens w/ isolated cord involvement

When does Dupuytren’s become surgical candidates

What are the two types of finger tip infections and what is the MC microbe to cause both types

A

Aponeurotomy

30* fixed flexion of MCP
10* deformity at PIP

Felon- thumb/index tip from puncture
Paronychia- tissue around nail; post-manicure/deformity
Staph A

245
Q

Why do Herpetic Whitlows and Felons need to be carefully differentiated

What happens if felons are left untreated

How are paronychias Tx non-op

A

HL- clear fluid vesicle around finger tip; don’t I&D
Felon- I&d for Tx; tender, red

Distal phalynx osteomyelitis
Septic flexor tenosynovitis

Warm/moist soak x 10min Q6h w/ PO ABX x 5days
(1st Gen- Cephalexin/Dicloxacillin)
MRSA risk- Sulfameth/Trimeth/Clinda
Sev infection= nail removal

246
Q

What are the two types of incisions that include the puncture site for felon Tx

What is the most important part of Tx

What type of closure is used

A

Central volar longitude (visible pus)
Dorsal mid-axial (no pus visible)

Using curved hemostat to break up septae

Secondary, never suture

247
Q

When suturing finger tips back in place on Peds, what type of materials are used

When is this replantation method an option

Complete laceration of what two structures will result in immediate loss of flexion at PIP and DIP

A

Absorbable: 4O/5O chromic or plain gut

Thumb: at/prox to IP
Finger: prox to middle of middle phalanx or multiple amputations

Flexor Digit Sublimis- mid
Flexor Digit Profundus- distal

248
Q

? finger tendon is most likely to be injured during sporting activities

What type of neuro examination needs to be done to finger trauma

When testing fingers after traumatic lacerations, what is tested during flexion ROM

A

Profundus of ring finger

Two-point discrimination

1st: active
2nd: strength

249
Q

Most Pts can’t move pinky finger independently d/t joint connectivity preventing independent movement of ? muscle

How are these tendonous injuries initially treated

A

Sublimis

Clean/splint
Surgery <7days

250
Q

What are the 4 Kanavels Signs of finger tendon/sheath infection

Flexor tendon sheaths extend from ? to ? and have ? plates

How do tendon/sheath infections present and once ID’d are Tx w/ ?

A

Sausage digit
Passive flexion/extension pain
Percussion/palpation pain

Distal palm to DIP
A1-5
C1-4

Puncture w/ swelling <48hrs
Anti-Staph/Strep IV ABX
PO ABX x 7-14days
Non-responsive- surgical drainage

251
Q

What kind of microbe can infect hand wounds from human bites

These injuries can be Tx out[Pt if Tx is sought out w/in ? time frame

How are these Tx non-op

A

AHS/Staph A- MC
Eikenella corrodens

<8hrs

Arthrotomy wash out w/ PCN/1st Gen Cephalosporin
PCN Allergy- Tetracylcine

252
Q

What is the f/u instructions after medical Tx for human fist bite

What causes a mallet finger to develop

These may present w/out pain if they are older than ?

A

F/u 24hrs then,
Daily whirpool or dressing change Q12hrs

Extensor tendon avulsion from distal phalanx

14days

253
Q

How long are mallet fingers splinted for Tx

How long after splinting do skin checks need to be done

What is the next step if Pt is unable to fully extend finger by second f/u appointment

A

Acute: 6-8wks
>3mon old: 8wks

4-5 days

Refer for surgical pinning

254
Q

? type of mallet finger may need further evaluation

What do fingernail avulsions in infants need to be assessed for?

How are painful subungual hematomas decompressed

A

Volar subluxation of distal phalanx
Bony fragment >1/3 of joint surface

Physeal injury= referral

Battery-operated microcautery or 18g needle

255
Q

? type of suture material is used to keep nail in place on nail bed

Any injury to the nail fold should be repaired w/ ? material

Post-nail avulsions need to be wrapped in ? 5 things

A

6.0-7.0 bioabsorbable gut

5.0 gut/nylon or monofilament
Kids- absorbable

Anti-bacterial ointment
Non-adherent gauze
Sterile gauze
Outer wrap
Splint
256
Q

What structures keep flexor tendons from bow stringing

Define Trigger Finger

? fingers are MC affected by trigger finger

A

4 annular
3 cruciform

Thick flexor tendon or first annular pulley

Long and Ring
Kids= thumb, other finger involved suspect metabolic d/o

257
Q

Trigger finger is commonly seen in Pts w/ ? other comorbidity

Higher prevalence is seen in PTs w/ ? two comorbidity

Where do PTs point pain located to ? but the issue lies at the ?

A

RA DM Hypothyroid

Carpal tunnel
De Quervains

Pain at PIP
Source at MCP

258
Q

How are Trigger Fingers Tx non-op

Peds elbow pain is usually d/t overuse activity placing ? stress on the elbow

When imaging Pediatric elbows, the head of the radius should be pointing in ? direction

A

CCS injection x 2
Failure= surgical release

Valgus

Towards capitellum

259
Q

Posterior fat pad in Peds means high likely hood of occult Fx and need repeat images in ?

What kind of cast are the placed in for in between appointments

What is the next step if at f/u appointment no tenderness is appreciated on exam

A

2-3wks

Posterior long arm

Immobilization not needed

260
Q

If peds dislocate their elbow, it’s usually in ? direction

Why are elbow sprains rare/unlikely in Peds

How are elbow sprains Tx

A

Posterior

Bones are the weak link

Short term immobilization

261
Q

? is the MC elbow injury in kids <5y/o

What are the only two PE findings consistent w/ this MC injury

How can Nursemaid Elbows be reduced

A

Pulled/Nursemaid elbow- subluxation of radial head d/t elbow extension w/ forearm pronated

Tenderness on radial head
Resisted supination

Thumb over radial head
Fully supinate forearm
No reduction= flex elbow
Alt: forearm pronation w/ elbow extended/flexed

262
Q

When reducing Nurse Maid’s elbow, what structure moves and makes a noise

Kids will immediately be able to resume activity w/ arm except for ?

? is the compression and tension side of Peds humerus

A

Annular ligament moves

Presentation 1-2 days after injury

Medial= tension (avulsion Fx, LLE)
Lateral= compression (capitellum osteonecrosis)
263
Q

Osteonecrosis of lateral elbow in Peds is AKA ? depending on their age

What are the 4 MC congenital deficiencies of the Peds Upper Arm

Any type of surgical correction for these are not considered until ? age

A

<10y/o- Panner Dz
>10y/o- osteochondritis dissecans

Thumb Radial Ulnar Transverse deficiencies

6-18mon

264
Q

? other d/os are commonly seen w/ Hypoplasia of the Thumb

They can have ? type of anemia

When is surgery an option and by ? procedure

A

Holt-Oram Syndrome (congenital heart dz)
Craniofaical abnormals
VATER

Fanconi

Adequate size of thumb
CMC joint is stable
Index Pollicization- index finger transfered to thumb

265
Q

What blood d/o is seen in Peds w/ Radial Deficiency

Why is this dificiency abnormal

Ulnar deficiency may present w/ ? abnormal coalition

A

Thrombocytopenia w/ absent radius

Normal thumb is present

Radiohumeral synostosis

266
Q

How is ulnar deficiency unlike radial and thumb deficiencies

Instead these Pts are more likely to have ? issues

Transverse deficiency maintain ? function but are more likely to have ? issues

A

Not associated w/ abnormalities of other organ systems

Tibial deficiency
Proximal femoral deficiency

Elbow flexion
Congenital constriction band sydrome

267
Q

Define Syndactyly

What other syndromes are these PTs more likely to have

Define Polydactyly

A

Lack of separation between finger/toes

Apert/Poland syndrome

Extra digit in hand/foot (thumb/great toe- preaxial)
Little finger (post-axial)
268
Q

Define Congenital Radioulnar Synostosis

Define Congenital dislocaiton of radial head

? PE finding suggests prognosis predictor for surgical Tx

A

Ulnar/radial proximal ends don’t separate= no pronation/supination

Presenting issue of elbow deformity d/t posterior dislocation

Concavity- traumatic dislocation, surgical candidate
Convex- congenital, poor surgical outcome

269
Q

LLE includes terms that are different by side of elbow, what are the lateral/medial Dxs

What two subsequent issues can develop from LLE depending on the Pts age

What is a more common sequelae of untreated LLE

A

Traction/Tension: apophysitis of medial epicondyle, UCL strain, olecranaon avulsion
Compression: OCD, Panners

Fragment: 8-12y/o
Avulsion: 12-14y/o

Delayed/failed olecranon fusion

270
Q

LLE OCD usually occurs in Pts older than ? after ? structure has ossified

? is the Dx if the Pt is under this age

? is the MC PE finding of LLE

A

> 12 y/o after capitellum ossifies

<12y/o= Panners

TTP
Flexion contracture

271
Q

How is LLE Tx non-op

How is OCD Tx non-op

A

Rest x 3-6mon

Rest x 12mon

272
Q

What is the MC type of Obstretric Palsy

What is the two other types of Obstetric Palsy

A

Erbs- motor and sensory deficit of C5-6 causing Waiter’s Tip (weak elbow flexion, weak should Abd, Flex and External rotation)

Klumpke- lesion to C8-T1 affecting hand/wrist

Panplexus palsy- entire plexus involvement

273
Q

If Peds Pt recovers atigravity strength in under ? months, prognosis is good

What is a poor prognostic factor

What are 3 other poor prognostic factors

A

2mon

Return of bicep function after 3mon

Entire plexus
Horner Syndrome
Nerve root avulsion

274
Q

? is the MC observed clinical Sx of Obstetric Palsy

? reflexes may be impaired

These Pts may exhibit tenderness located ? for first few weeks after birth

A

Reduced spontaneous movement- pseudoparalysis

Moro
A/Symmetric tonic neck reflex

Supraclavicular triangle

275
Q

What is the position of Waiter’s tip in words

What PE findings are consistent w/ a preganglionic avulsion injury of sympathetic chain

A

Forearm pronated
Elbow extended
Wrist flexed
Shoulder adduct, internal rotated

Horners Syndrome
Phrenic nerve palsy
Nerve involvement- long thoracic, dorsal scapular, suprascapular, thoracodorsal

276
Q

Erb’s Pts w/ progressive internal shoulder rotation are at risk for ? for the first two years

What is considered the best non-op Tx for Obstetric Palsy

What is the cornerstone of Tx

A

Shoulder subluxation/dislocation

Supervised at home exercise program

Assessment and monitoring neuro function/recovery

277
Q

What two Dx are suspected in infants w/ sudden loss of function in part that was mobile at birth

What causes Congenital Muscular Torticollis and what does it look like

How is Congenital Muscle Torticollis differentiated from AARD

A

Sepsis, Abuse

Unilateral contracture of SCM= head to affected, rotate to unaffected
Contracture of left SCM= tilt to left, rotate to right, left side facial/mandibular flattening, right side occipital flattening

AARD- SCM spasm occurs on opposite side of tilt

278
Q

Infantile Torticollis can present mimicking ? syndrome

CMT is commonly associated w/ ? two PE findings

What lower extremity issues may also be noted

A

Klippel-Feil Syndrom- congenital fusion of two or more cervical sections causing dec ROM/head tilts

Plagiocephaly
Facial assymetry

Metatarsus adductus
Calcaneovalgus
Hip dysplasia

279
Q

Pts w/ CMT hold their head in ? termed position

What does an optic exam need to be conducted for acquired torticollis

How can these findings be resolved on PE

A

Cock-robin

Superior oblique palsy= nystagmus causing torticolis

Close eyes/block vision

280
Q

? are the neuro causes of Torticollis

AARD affects ? part of the spine

AARD can also develop after ? inflammatory d/o causing ? syndrome

A

Posterior fossa tumor
Cervical spine tumor
Syringomyelia

C1-2

Grisel- inflammation of pharynx

281
Q

? image is needed when assessing suspected AARD torticollis

? are the adverse outcomes of this Dz process

How is CMT Tx non-op

A

Odontoid

Malaligned atlantoaxial joint
Klippel-Feil syndrome are at risk for spinal cord injuries

Rehab stretching exercise
Position beds/table to make baby look away from affected side

282
Q

If CTM has to be Tx w/ surgery, what are the time frames

How is AARD initially Tx non-op

? is the MC bony Fx and MC/LC location

A

Problems lasting >12mon= SCM release after 4y/o

Soft collar w/ analgesics and Benzos
Persistent >7d= cervical traction w/ analgesia and relaxers
Persistent= halo traction
Persistent >1mon= cervical fusion

Clavicle
MC- middle
LC: proximal

283
Q

What types of images are needed for clavicle Fxs

When are clavicular Fxs referred to Ortho

When is surgical correction indicated

A

AP w/ 10* cephalic lift
CT if high suspicion for Fx/dislocation of medial end

Painful nonunion after 4mon

Ipsilateral rib Fx/flailing
Open
Neurovascular compromise
Shortened
Fx of distal 1/3 medial to coracoclavicular ligament, imedial part of clavicle superiorly displaced
284
Q

How are mid-clavicle Fxs Tx non-op by age

Regardless of age, when is gentle shoulder exercises supposed to begin

? type of clavicle Fxs are more likely to result in nonunion

A

Figure 8
<12y/o- support x 3-4wks
Adult- support x 6-8wks

2-3wks

Displaced lateral or midshaft lateral to coracoclaviculr ligament
Segmental Fxs

285
Q

? type of neuro injury usually accompanies humeral shaft Fxs

Most humerus shaft Fxs are Tx non-op w/ how much acceptance

What type of Tx is used for humeral shaft Fxs w/ <2cm of shortening

A

Radial x6mon- dec wrist/finger extension w/ lost sensation to dorsal web space

20* apex ant/lateral

U-shaped coaptation x 2wks

286
Q

Humeral Fxs w/ radial nerve dysfunction need EMG/NCV studies after ? long

What are the 4 segments that proximal humeral Fxs can be classified as w/ ? method

What muscles attach to the different humeral tuberosity

A

6wks

Neer
Greater/Lesser tuberosity
Humeral head
Shaft

Greater- Supra Infra TM
Lesser- Subscap

287
Q

What is the MC two-part humerus Fx

What image is obtained if an axillary view is impossible

What is the most common error that occurs when assessing proximal humeral Fxs

A

Surgical neck

Transcapular- scapular y-view

Shoulder dislocation- AP images alone are not enough

288
Q

How are proximal humerus Fxs w/ <1cm displacement Tx

When can the sling be removed and worn PRN

Why are two part Fxs of the greater tuberosity w/ >0.5cm displacement Tx w/ surgery

A

Sling w/ pendulums after 3wks
Deltoid/rotator isometrics after 6wks

3wks

Restore rotator cuff muscles

289
Q

What types of displaced humeral Fxs need to have surgical Tx

What types of humeral Fx usually has disrupted blood flow requiring prosthetic replacement

Two part proximal humerus shaft Fxs where lesser tuberosity is also Fx’d may also have ? abnormal injury

A

Two part humeral neck
All 3/4 part Fxs

Displaced 4 part

Posterior shoulder dislocation

290
Q

What is the MC associated injury to accompany scapular Fxs

If Pt is able to sit for images, ? is the best for Dx

Axillary view is better for revealing Fxs in ? two locations

A

Rib Fxs

Transcapular lateral/oblique

Acromial/Coracoid

291
Q

Any scapular Fx where the glenoid is poorly viewed needs ? next step image

? is a common adverse outcome from these injuries

? is are two rare outcome

A

CT

ASx malunion

Suprascap nerve injury
Impingement syndrome

292
Q

How are scapular Fxs Tx non-op

What are the operative red flags for these Fxs

? is the MC dislocated joint in kids and in ? direction

A

Sling w/ motion as tolerated after 1wk

Glenoid displace >2mm
Acromion w/ impingement
Scapular neck >30* deformity

Elbow; posteriolateral w/ damage to UCL being universal

293
Q

What is a ‘perched’ elbow dislocation

What is the terrible triad in adults

What is the terrible triad in kids

A

Subluxated w/ trochlea resting on coronoid

Elbow dislocation, Radial head fx, Coronoid fx

Elbow dislocation, Radial head fx, medial epicondyle Fx

294
Q

What imaging is needed after reducing elbow dislocation

Define a simple dislocation

While under conscious sedation for elbow reduction, if Pt develops muscle spasms or marked swelling, ? is the next step

A

CT

No associated Fx

General anesthesia

295
Q

How are elbows positioned for max stability after reduction

How are these splinted post-reduction

How long after elbow Fx/Reduction should motion be restarted

A

Elbow flexed, forearm pronated

Elbow flexed at 90* w/ extension block x 4wks

5-7 days and progress over 3-6wks

296
Q

How are distal humerus Fxs Tx non-op

How is a Fx olecranon Tx non-op

When is protected ROM recommended to return

A

Splint x 10 days w/ protected ROM

Posterior splint w/ eblow at 45* flexion
F/u x-ray at day 7-10
Rubber ball squeeze daily

2-3wks

297
Q

Since most olecranon Fxs need to be surgically Tx, what is a common adverse outcome of Tx

What is the classification methods of radial head Fxs

What types of radial head Fxs can have mechanical blocks with them

A

Implant irritation requiring implant removal

Modified Mason:
1- non/minimal displacement
2- >2mm displacement, angulated neck/mechanical block
3- severely comminuted

Types 2 and 3

298
Q

Define Essex-Lopresti Fx

What type of imaging is needed for radial head Fx

What is a common adverse outcome of radial head Fxs

A

Radial head Fx w/ injury to forearm

Greenspan

Loss of last 10* of extension

299
Q

How are radial Fxs Tx

What types are red flags

Define Bennett Fx

Define Rolando Fx

A

Type 1- move as tolerated
Type 2/3- surgical ORIF

Type 2 w/ rotation block
Type 3
Fx w/ elbow dislocation/instability

Oblique thumb base Fx enters CMC joint

Less common than Bennett, y-shaped intra-articular Fx

300
Q

What is the goal of Tx for Fxs at base of thumbs

How are Fxs at the base of thumb Tx non-op and w/ surgery

What types of x-rays are needed to view a hook of hamate Fx

A

Restore axial length, put metacarpal fragment against smaller volar fragment

Thumb spica-cast x 4wks
Bennett- ORIF

Semi-supinated
Carpal tunnel view

301
Q

What happens if Hook Of Hamate Fxs are left un-Tx

How are these Tx non-op

A

Non-union
Tendon rupture, little finger

Wrist immobilization in neutral position

302
Q

MC type of distal radius Fx seen in adults

? is the name of the Fx that is opposite of the MC

Define Barton Fx

A

Colles- Fx tilts dorsal w/ Fx of ulnar styloid

Smith- Fx fragment tilts volar

Intra-articular carpus Fx w/ subluxation of carpus and displaced radius fragment

303
Q

Define Chauffeurs Fx

What is an adverse outcome from wrist Fxs

How are these Tx non-op

A

Oblique radial styloid Fx

Compartment syndrome

Sugar tong x 3 wks
Short arm cast x 3wks

304
Q

What PE finding of distal radius Fxs suggests open Fx

Most of these Fx’s are Tx non-op w/ ?

How much angulation is acceptable for wrist Fxs

A

Fat droplets in blood

Sugar tong splint x 2-3 wks

Lateral- <5* of dorsal angulation
AP- no less than 15* radial inclination
>2mm step off = reduce

305
Q

Distal radius Fxs that have low levels of Vit D can have ? much supplemented

What is used during distal radial Fxs to decrease risk of CRPS development

? is the MC Fx of the hand and when is surgical Tx needed

A

1-2K IU/day

Vit C 500mg/day

Boxer Fx- distal > proximal > middle
>40* angulation
+ extensor lag

306
Q

? is the MC phalangeal Fx in adults

Phalangeal Fxs are more common in ? expecially ? phalanx

Most Fxs of the phalanx are non-op Tx by?

A

Distal, Proximal then Middle

Peds, little

Splint x 3-4wks
Rpt x-rays at 1wks
Resume activity at 3wks

307
Q

MC adverse outcome after hand Fxs

MC carpal bone Fx in men

Why are these Fxs associated w/ so much osteonecrosis

A

Joint stiffness

Mid-pole scaphoid

Blood supply enters at distal third at dorsal side

308
Q

What are the Snuff Box landmarks

? x-ray view may be needed to view Fx

+ Sunff Box tenderness and normal x-rays are Tx w/ ?

A

Top: EPL
Bottom: EPB

Oblique

Forearm base thumb spica
Cast w/ thumb IP free x 6wks
F/u 7-14 days, pain= MRI

309
Q

How long do scaphoid Fxs in different areas take to heal

? type of x-ray is used to show scaphoid-lunate disassociation

Finger sprains are characterized by injury to ? structures

A

Distal: 6-8wks
Middle: 8-12wks
Prox: 12-24wks

Clenched fist

Torn collateral ligament and/or volar capsule ligament

310
Q

Almost all sprains of the finger can be Tx non-op w/ ? type as the exception

Most dislocations of the hand are MC in ? and due to ? injuries

A complex dislocation of the MCP joint can cause ? structure to become entrapped to the dorsal carpal head

A

Unstable, complete UCL rupture in thumb MCP

PIP
Hyperextension tearing the volar capsule

FDP

311
Q

DIP dislocations usually are in ? direction

PIP splints allow ? movement and block ? movement

What type of Peds elbow Fx has a high incidence of neurovascular problems

A

Dorsal

Flexion
Block last 20-30* of extension of volar plate

Supracondylar- AIN palsy

312
Q

What are the MC elbow Fx in kids 2-12y/o

What is the 2nd MC type of Fx

What is the 3rd MC type of Fx

What type of Fx is uncommon

A

Supracondylar Fxs of distal humerus

Lateral condole Fx of distal humerus

Medial epicondyle Fx

Lateral epicondyle

313
Q

Why are Peds w/ condylar Fxs serious

Transphyseal Fx across distal humerus are uncommon and MC seen where?

? is the weak point of the radius in kids

A

Growth plate of distal humerus and articular surface of elbow are involved

Infants from abuse

Metaphysis of radial neck

314
Q

The valgus force that causes an adult radial head Fx will cause ? Fx in kids

PE tests for radial, median and ulnar nerve

Supracondylar Fx causing brachial artery to be injured in Peds that is not ID’d can result in ? type of contracture

A

Radial neck

R: thumb up
M: ok sign
U: criss-cross finger

Volar forearm compartment syndrome= Volkman ischemic contracture

315
Q

How are Peds condylar Fxs Tx

Radial neck Fx’s w/ ? angles can be Tx w/ cast immobilization

Metaphysical Fx of proximal humerus typically occur in ? age groups while physeal Fxs tend to occur in ?

A

Rpt x-ray day 3-5

30-45* in Pts < 10y/o

Meta: 5-12y/o
Phys: 13-16y/o

316
Q

Newborns w/ Fx of clavicle or proximal humerus may present w/ ?

? are the MC physeal Fx

How are proximal humerus Fxs in Peds Tx

A

Pseudoparalysis

Salter Type 2

Non-surg, best w/ sling:
70* <5y/o
40-70 5-12y/o
<40 in >12y/o

317
Q

Clavicle Fx w/ shortening more than ?needs surgery

? is the MC location for Fxs in kids

Kids younger than 4y/o are more likely to have ? types of Fx

A

2cm
>30-40* angluation
Fragment >50% apposition

Distal 1/3 of forearm

Torus- buckled cortex, least complex forearm Fx
Greenstick- disrupted cortex on tension side, buckled on compression side

318
Q

? is the MC torus Fx in Peds

Define Galeazzi Fx

Define Monteggia Fx

To minimize physeal damage, reduction attempts shouldn’t be made after ? days

A

Dorsal surface of distal radius

Displaced distal radius w/ dislocation of ulna

Radial head dislocation (anterior) w/ Fx of ulna

5

319
Q

How are prox/middle forearm Fx in Peds Tx

A

Surgery:
>10*
All Monteggia: closed reduction w/ 6-10wk immobile

320
Q

C5 M/R/S

C6 M/R/S

C7 M/R/S

C8 M/R/S

A

Deltoid/Bicep flexion
Bicep
Lateral upper arm

Wrist extension
Brachioradialis
Lateral lower arm

Wrist flexion, Finger extend
Tricep tendon
Middle finger, thenar

Finger flexion
None
Medial lower arm

321
Q

T1 M/R/S

L4 M/R/S

L5 M/R/S

S1 M/R/S

A

Interosseous
None
Medial elbow

Anterior tibialis/patellar/medial foot

Extensor digit longus/non/dorsal foot

Peroneus longus/brevis/achilles/lateral foot

322
Q

Intra-articular hip pathology is classically associated w/ ? c/c

What ‘sign’ may be used by Pts to pin point pain and what movement makes pain worse

What provocative PE test is positive for hip impingement

A

Groin pain

C-sign, worse w/ rotational movement

FADDIR- Fixed Adduction Internal Rotation

323
Q

Define Pure Femoral Cam Impingement

Define Pincer Impingement

A normal acetebulum has ? morphology

A

Femoral neck loses concave anatomy tears anterosuperior labrum w/ flexion

Focal-over: focal retroversion
Global-over: coxa profunda/protrusio

Anteverted- posterior rim more lateral than anterior rim

324
Q

What is the adverse outcome of hip impingement?

How are these Tx non-op

How does Tx change if there is a long Hx of Dx or tendinitis

A

Etiology of 80% of hip OA

NSAID
LLD
ROM/Strength

Deep massage
Active release

325
Q

? is Dx and Therapeutic for hip impingements and is the most accurate test to determine ? issues

? do hip impingement PTs need for post-op rehab

Systemic d/os may first present w/ ? c/c and what two are the MC causes

A

Fluoroscopical intra-articular injection
Intra-articular etiology for hip pain

CPM device
Stationary bike

Hip pain/Sxs
Lupus/AS

326
Q

? types of gait do inflammatory arthritis of the hip have depending on the length of Dz

What are the early/late signs seen on x-rays

How is non-infectious fnflammatory hip arthritis Tx

A

Antalgic- early in Dz
Trendelenburg- lost cartilage

Early: osteopenia/effusion
Late: symmetric narrowing/periarticular erosions

NSAID
DMARD
Tylenol
Cane on contra-lateral side
TxOC: arthroplasy
327
Q

Where is the lateral femoral cutaneous nerve most susceptible to compression and what ? type of innervation does it provide

What is a rare cause of this nerve compression

what can Pts present w/ if condition is uncommon or acute?

A

Exiting pelvis, medial to ASIS
Sensory only

Cecal tumor

Uncommon: Groin ache
Acute= pain radiating to SI joint

328
Q

What is the MC spot to reproduce hypo/dysesthesia Sxs of lateral femoral cutaneous nerve entrapment

If Pt is a jogger, what do they describe pain as ?

Rarely is surgical release needed for Tx unless ?

A

Superior and Lateral knee- MC w/ burning

Electric jab w/ hip extension

Persistent burning dysethesia

329
Q

When obtaining Hx for hip OA, what early life issues can indicate secondary issues may be present

What part of the OA Dz process causes Pts to alter gait

How are young/active Pts w/ this condition Tx w/ surgery

A

Infant/toddler= dysplasia
Small child- Legg Calve Dz
Adolescent- SCFE

Flexion contracture= increased lumbar extension

Realignment osteotomy
Arthroplasty metal-on-metal
Hip fusion: young labor/vigorous lifestyle

330
Q

What risk factors can lead to osteonecrosis of the hip?

How will these PT present and

? type of gait will they have depending on the duratino of Dz

A

Steroid Lupus Alcohol Trauma RA Sickle

30-50y/o w/ bilateral Pain, Dec ROM, + straight leg

Early: atalgic
Late: trendelenburg

331
Q

What is seen on x-ray of hip osteonecrosis

what is a beneficial next step if unilateral findings are noted

How is osteonecrosis Tx if femoral collapse has/not occurred

A

White crescent sign= subchondral Fx

MRI contralateral hip to eval ASx condition

Not:
Core decompression
Vascular/Osteochondral grafts to relieve pressure
Has:
Core decompression= short term relief
Arthroplasty
332
Q

What is an unique adverse outcome of core decompression Tx for osteonecrosis

What are the three etiologies of Snapping Hip

Where do Pts w/ trochanter bursitis induced from ITB snapping hip describe their pain as?

A

Femur shaft fx if core biopsy is placed below lesser trochanter

MC: ITB over greater trochanter
Iliopsoas over pectineal eminence of pelvis
Intra-articular labrum tears

Pain in AM/PM, or laying on affected side

333
Q

Snapping from subluxation of iliopsoas tendon is described and located as ?

? type of snapping is more debilitating and causes Pt to reach for support

What two etiolgoies of snapping may benefit from CCS injection to bursa

A

Groin pain w/ hip extension from flexed (rising from chair)

Intrarticular origin

ITB into trochanteric bursa
Psoas tendon

ITB: rotate hip w/ leg in adduction
Ilio: hip extension from flexed position

334
Q

Hip strains can encompass what 5 muscles?

What is the usual mechanism of injury for hip strains?

? is a common etiology in general for all hip strains

A

Abdominals
Flexors- Sartorius Iliopsoas Rectus
Adductors

Contraction w/ muscle stretched- kicking ball but leg blocked causes iliopsoas strain

Over use

335
Q

? type of MRI image is used for hip strain Dx

How is a strained adductor isolated on PE?

How is a rectus, iliopsoas or sartorius strains isolated on exam?

A

Short Tae Inversion Recovery

Groin pain w/ passive abduction/resisted strength test

RF: Inc pain w/ muscle stretch
Ill: deep groin/inner thigh pain
Sar: superficial, lateral pain

336
Q

What are the 5 phases of hip strain rehab

What are the typical MRI findings for transient osteoporosis of the hip

Stretching ? two muscles in particular may help w/ greater trochnater bursitis rehab

A

48-72hrs; RICE, protected weight w/ crutches

2: 72hrs-7d; PROM, heat, stimulation
3: 7d+: isometric exercises, inc strength/flexibility

Femoral neck edema= T1 decreased/T2 increased

Piriformis
Tensor fascia latae

337
Q

What non-leg sourced issues can lead to trochanteric bursitis?

Where can this pain radiate to?

How do Pts describe pain

A

Lumbar spine dz

Leg, butt, or knee, NOT to foot

Worse when rising, improves, worse <30min
Unable to lie on affected side

338
Q

? is the essential finding on PE for Dx trochanteric bursitis and what movement makes pain worse

How is this Dx different from gluteus medius tendonitis and what movement makes pain worse

What mechanisms usually cause ACL tears and what will Pt report for activity after event

A

Pain to palpation on lateral greater trochanter- worse w/ hip abduction

GMT- tenderness above greater trochanter, worse w/ ab/adduction and rotation

Twist/hyperextension force during non-contact event
Pt unable to continue game

339
Q

? other 3 structures are possibly torn along w/ an ACL tear in descending order

Multiple ligamentous injuries need to have ? life threatening issue r/o?

Lateral Capsular Sign seen on lateral tibia is AKA ?

A

Meniscal > MCL > L/PCL

Popliteal disruption

Segond Fx

340
Q

ACL injuries w/ tibial eminence Fxs are more common in ? Pts

Chronic ACL insufficiency leaves ? structure prone to injury and why?

? muscle rehab is used for stability improvement

A

Open physes

Posterior horn of medial maniscus; secondary stabilizer to anterior tibial translation

Hamstring* curl
Isometric quad flex
Leg raise

341
Q

? ranges of motion need to be avoided during ACL rehab due to excessive stress on damaged area

? anatomical deviations can make Pts susceptible to ACL damage

? adverse outcome can occur post-op if full ROM was not restored prior to surgery

A

Extension 30-10* and varus/valgus stress

Foot pronation
Large Q-angle
Anteverted hip
Genu recurvatum/valgum

Arthrofibrosis w/ loss of motion

342
Q

Isolated patellofemoral OA can exist in ? 3 populations

If RA is the cause of the knee OA, what compartment is affected

OA knee w/ effusion can extend past joint line into ? structure

A

MC- Tibiofemoral OA
Patellar subluxation
Patellar baja

Valgum d/t ligamentous laxicity (more dec ROM)

Pes anserinus

343
Q

What is the characteristic x-ray results for Pts w/ degenerative arthritis from OA

What is the hallmark x-ray finding of inflammatory arthritis

What types of images may be obtained after weight bearing x-rays

A

Sclerosis
Osteophytes
Asymmetric joint narrowing
Periarticlar cysts

Symmetric joint narrowing
Osteopenia
Bony erosion at margins

Lateral: Merchant
Axial: Sunrise

344
Q

Why would weight bearing AP x-rays w/ OA knee in 40* flexion be used preferably

What non-surg Tx is used for knee OA PTs that have Varus Gonarthrosis

? type of management is not recommended for Pts w/ advanced knee OA cases

A

More sensitive for early arthritis, expecially when posterior femoral condyle is involved

Lateral heel wedge- unloads medial compartment

Arthroscopic

345
Q

What procedures may be effective for correcting alignment and reducing pain in mild-mod knee OA w/ deformity cases?

This may have expected relief for ?yrs until ? definitive step is warranted

Pes anserinus is the insertion site for ? 3 muscles and commonly develops in PTs w/ ? Dx

A

Unloading tibial/femoral osteotomy

5-10yrs, Knee replacement

Sartorious
Gracillus
Semi-tendon
Early OA in medial compartment

346
Q

? nerve can become compressed during pes anserinus bursitis

Septic bursitis presents w/ ? 3 Sxs

Non-infectious traumatic bursitis presents w/ ? and w/out ?

A

Saphenous and infrapatellar branch

Pain Erythema Warm

+ Warm, - pain/erythematous

347
Q

How are bursitis and septic arthritis of the knee differentiated on x-ray

What therapeutic modality may help bursitis here

Early onset, mild septic bursitis of the knee can be managed by ? exception

A

Burs: diffuse pre-patellar swelling
SA: suprapatellar pouch swelling

US/phonophoresis

PO ABX

348
Q

What causes and what are the S/Sxs of neurological claudication

What are the causes and what are the S/Sxs of vascular claudication

A

Spinal stenosis= ischemia of cauda equina:
Pain in butt, spreads to legs
Walking downhill inc pain
Prox to distal
Slowly improves w/ sit/supine/stationary bike over time

Secondary to peripheral vascular dz, screen w/ ABI:
Immediate relief w/ cessation of movement
Worse w/ stationary bike distal to proximal

349
Q

? type of injury causes MCL/LCL tears

What injury can occur to the lateral knee at the same time a MCL injury is sustained and how

How are MCL and LCL best palpated

A

MCL: Valgus/abudction- football clipping
LCL: Varus/adduction

Lateral femoral condyle presses against lateral tibial plateau= lateral meniscus tears

MCL: slight knee flexion
PCL: figure-4

350
Q

Laxity measurements of ? much can indicate the grade of sprain

Why are varus/valgus stresses to test for MCL/LCL integrity best done w/ 30* of knee flexion

What is suspected if valgus/varus laxity is noted w/ full extension and how are these then classified prompting ? to be assessed

A

<5mm- Grade 1, insterstitial
5-10mm- Grade 2, partial
>10mm- Grade 3, complete

Ligaments/posterior capsule are relaxed

ACL/PCL injury w/ disrupted posterior capsule
Knee dislocation w/ spont reduction; neurovasc w/ ABI

351
Q

How are MCL/LCL sprains managed

What types need surgical correction

What types need surgical correction

A

<5mm- Grade 1, insterstitial
5-10mm- Grade 2, partial
>10mm- Grade 3, complete

Grade 1-2: RICE, NSAID, Crutches
Begin playing at 1mon in hinged brace, w/ Sx resolution
Grade 3 MCL proximal and in midsubstance: non-op w/ hinged brace, inc weight bearing 4-6wks, brace x 3-4mon

Grade 3 LCL d/t capsule/tendon/
Tibial MCL avulsions, repair <7days

352
Q

? PROM ca also help identify what compartment is involved in acute compartment syndromes

Chronic/exertional compartment syndrome may have ? c/c and MC involves ? compartment

What compartments of the lower leg are involved by compartment syndrome it Pt reports numbness in dorsal/plantar regions?

A

EHL by moving great toe- anterior
Peroneus brevis/longus by foot inversion- lateral
Extending great toe- deep posterior
Dorsiflex ankle- superficial posterior

First web dorsum paresthesia
Weak dorsiflexion
MC anterior compartment

Dorsal foot- ant/lat compartment
Plantar aspect- deep posterior compartment

353
Q

Define Myositis Ossificans Traumatics and ? is this a sub-category of ?

? type of strengthening therapy is recommended for thigh contusions and ? therapeutic step can be taken for severe quad contusions to speed up time to returning to game

What are 3 anatomic RFs placing PTs at risk for developing ITB inflammation

A

MC thigh contusion causing calcified mass via heterotropic ossification

Heel raises
Elastic wrap w/ knee in hyperflexion
RICE/ROM

Rum, genu
Internal tibial rotation
Pronation of foot

354
Q

? functional test on PE confirms present of ITB syndrome

How are cases of Tennis Leg Tx non-op

What is the goal of this non-op Tx

A

One legged hop w/ flexed knee= pain

NSAID RICE
Cam w/ .5” lift
Crutches until pain free ambulation

Control inflamm/pain w/ RICE

355
Q

When can medial Gastroc tears begin early movement exercises

? is the MC PE finding of meniscal tears

Young Pts w/ meniscal tears that cause large effusions/hemarthrosis indicates tear is located ?

A

7-21 days later w/ PROM

Tenderness on joint lines

<5mm of meniscal attachment sites

356
Q

Meniscal tears located ? tend to have small/no effusions associated with them

Peripheral meniscal tears that are near ? location may be able to self-heal

? PE test is used for meniscus test and what type of force does this test cause

A

Degenerative/near central body of meniscus

Meniscocapsular junction

McMurray= Appley + Thessaly
Forced flexion circumduction

357
Q

When is arthroscopic debridment preferred for meniscal Tx

Initial Tx consists of ? and early ? is done to improve mobility and reduce pain

? is the MC site of the femur to develop osteonecrosis

A

Younger PT w/ substantial tear
Locked knee
Older Pt non-op failure

RICE
Controlled movement

Weight bearing medial condyle

358
Q

What can cause femur osteonecrosis

Chronic osteonecrosis will present w/ ? c/c

? are early and late radiographic signs that femoral osteonecrosis is occurring

A 
MC: female +60y/o
Renal transplant
Sickle cell
Gaucher Dz
Steroids

ASx

Early: Sclerosis, Flat condyle
Late: Narrowed spacing, Osteophytes

359
Q

? imaging is used to Dx femoral osteonecrosis

How are these Tx surgicall

? is the hallmark Sx Extensor Mechanism Tendinitis

A

MRI, Bone scan

Debridement
Osteotomy
Replacement

Anterior Knee pain

360
Q

Long standing Jumper’s knee can cause ? muscle to atrophy

What images are needed

How long should these PTs be LLD

A

Vastus medialis obliquus

Oblique x-ray= enthesophytes: calcification of tendinous insertions

3days-6wks

361
Q

What are the 3 phases of Tx for Patella/Quad tendonitis

What is the MC adverse outcome of Tx

Tears need to be repaired w/in ? days

A

1: NSAID Immobilizer LLD (rest, pain control)
2: Strength Flexibility ROM PRP (pain free motion) Debridement
3: Resume activities (resume: heat prior, ice after)

Persistent functional impairment, even w/ surgery

<7days

362
Q

What type of force causes a quad/patellar tendon rupture

If simultaneous, bilateral Quad/Patellar ruptures occur and the demographic criteria are not met, what two issues need to be r/o

What will usually be absent in their Hx

A

Fall on knee that is partially flexed

Endocrinopathy
FQN usage

Quad/Patella tendinitis

363
Q

? PE finding is pathgnemonic for leg extensor disruption?

What is the hallmark of clinically substantial extensor tear

Why are knee tendon ruptures assessed w/ lateral views w/ 30* of knee flexion?

A

Large effusion w/ palpable defect

Inability to extend knee against gravity/perofrom straight leg raise

Inferior patella in line w/ Blumensaat line

364
Q

? triad presentation suggests Quad/patella tendon rupture and need surgical correction w/in ? days

What RFs place Pts at risk for patella dislocaiton/maltracking

Knee dislocations mimic ? other Dx

A

Palpable defect
Unable to extend knee
Patella alta/baja
<7 days

Patella alta
Shallow trochlear groove
Flat patella under surface
Excessive anterior femoral neck anterior version
Externally rotated tibia 
Ligament laxity

ACL tear

365
Q

What is the c/c of Symptomatic Malalignment present

What two PE findings can contribute to lateral patellar instability

What are the two axial patellofemoral views used to assess knee alignment

A

Retropatellar pain d/t Genu Valgum alignment

Patella alta
Pos J sign

Merchant/Laurin

366
Q

What is the initial Tx for acute patellar subluxation/dislocation

Total time of immobilization shouldn’t exceed ? long

? is the initial Tx for chronic, recurrent maltracking/instability

A

Brace/immobile in extension x 4wks
Modified weight bearing
Pain meds
Ice

> 4wks

Quad strength/flexible
Lateral butress brace
Electrical stim/K-tape

367
Q

? term shouldn’t be used for describing patellofemoral syndrome

What key item is usually missing from their Hx of presentation

Gait is assessed for ? finding

A

Chondromalacia

No swelling

Patellar winking- inc femoral anteversion/weak glut medias

368
Q

When assesing patellofemoral syndrome, w/ knee at 30* flexion, how much meidal/lateral movment should be seen w/ patella manipualtion

What is the hallmark of Tx

Of the five plicas, what 3 are most palpable

A

1 quad medially
2 quad lateral

Pain free PT without full-arc and open chain quad exercises

Supra: under quad tendon to medial/lat capsule
Medial: medial capsule to medial anterior fat pad
Infra: Ligamentum Mucosa; anterior covering of ACL

369
Q

Why do plica structures become bothersome when inflamed

? plica is most likely to become symptomatic and what is found on PE if this plica is inflamed

Baker Cysts are associated w/ ? knee issues

A

Bowstring over femoral condyles

Medial- knee at 90* flexion w/ pop at 60* of flexion

Degenerative meniscal tear
RA

370
Q

In whom do Baker’s Cysts rupture in more often

Most cysts are located between ?

Rarely this will become large enough to impinge on ? nerve, but if they ruputre it can mimic ?

A

> 40 w/ degenerative arthritis

Gastroc/Semi-tendon

Tibial nerve: plantar surface numbness
DVT

371
Q

How are ruputres Baker’s Cysts Tx non-op

? four injury mechanisms can suggest issues w/ PCL

? is most sensitive test for PCL damage

A

Analgesic Rest Elevation

Dashboard injury
Fall on flexed knee w/ foot plantar flexed
Pure hyperflexion injury
Hyperextension after ACL= dislocated knee

Posterior drawer

372
Q

How are PCLs Tx non-op

What movement needs to be avoided

Any suspected PCL tear needs ? test done during assessment

A

Resolve swelling/Restore motion x 1-5 days, then:
Strength w/ emphasis on short arc terminal extension 30-0* of flexion

Hamstring curls

ABI

373
Q

Shin splint pain is localized to the distal third of tibia which is the origin of ? muscle and presents w/ ? foot shape

? is the hallmark PE finding for shin splints and

What movement may also ellicit pain

A

Tibialis posterior
Pes planus

Tenderness along posterior medial crest

Pain w/ plantar flexion

374
Q

Pts w/ shin splints should research ? type of orthotic

Congenital deficiencies of the lower leg Tx are based off of ? two things

Surgical Txs won’t be offered until ? age

A

Anti-pronation

Foot functional?
Anticipated limb length discrepancy?

9-12mon

375
Q

Define Longitudinal Deficiency of Fibula

All of these PTs need ? Tx

What is the classification method

A

MC long bone deficiency, absence of fibula

Limg length discrepancy

Kalamchi:
1A- minimal shortening
1B- partially present
2- absent

376
Q

What other d/os are assoicated w/ Tibial Deficiency

1/3 of these PTs will also have ?

What position does leg adopt if there is deficient femur present

A 
Congenital Heart Dz
Cleft palate
Imperforate anus
Hypospadias
Hernia
Gonad malformation

Hand anomalies

Flexed thigh, Abducted, Externally rotated
FABER’d

377
Q

What is better about a deficient femur Dx compared to deficient tibia Dx

? is MC cause of anterior knee pain in kids

What is an uncommon cause and where in the structure is the deformity located and associated w/ the same located pain

A

Less organ anomaly involvement

Patellar mal-tracking

Bipartite patella- superolateral corner

378
Q

Peds PFS can be improved w/ ? rehab

What two RFs are strongest w/ developmental dysplasia of the hip

What are the two maneuvers done to r/o this Dx

A

Strengthening medial head of quad

FamHx
Female gender

Barlow- provocative; attempt to displace femur head posterior
Ortolani- relocates dislocation

379
Q

? PE finding indicates femoral shortening in Peds

Degrees of varus allowed in Peds

When are x-rays of Varum needed if Ped is <2y/o

A

Galeazzi sign

10-15 at birth
Straight/Neutral at 18mon
Valugs after 2y/o
10-15 valgus at 3-4
5-7 by 11

Below 25th percentile

380
Q

? Dz process can cause Peds leg Varus and needs Tx

If Surgical Tx is needed, surgical realignment via osteotomy is best if done by ? age

A

Blount Dz- abnormal growth between posterior and medial tibial physes

4y/o

381
Q

AC injection

A

PT seated

Neviaser portal (posterior clavicle, anterior scapula)

Supralateral to inferomedial direction

382
Q

Posterior Shoulder Injection/Aspiration

A

Pt seated

Palpate coracoid

2cm medial, cm inferior to posterior acromion corner

Thumb on posterior soft spot

Aim for coracoid tip

383
Q

Subacromial Bursa Injection

A

Pt seated w/ arm in lap

Posterior- lateral corner of acromion

1cm inferior, 1cm medial

Needle angle 20-30*

384
Q

Elbow Joint Injection/Aspiration

A

Pt supine

Arm against chest w/ 90* flexion

Soft-spot portal:
Lateral epicondyle
Radial head
Olecranon tip

Over anconeus muscle

385
Q

Tennis Elbow Injection

A

Arm against chest w/ elbow flexed at 90*

Inject at point of max tenderness

Inject through Extensor Carpi Radialis Brevis muscle

386
Q

MCP/PIP injection site

Thumb CMC injectio site

Wrist aspiration/injection site

A

Dorsolateral

Between CMC and Trapezium

1cm distal to Lister’s, 1cm distal to radius
Divot= radiocarpal joint
Needle angle 10-11* distal to prox

387
Q

Carpal Tunnel Injection

De Quervains injection

A

Volar insertion 1cm proximal to flexor crease in line w/ ring finger
Needle 30-45*

45* to skin
Thumb paresthesia= sensory branch of radial nerve has been depolarized; reposition 2-3mm dorsal/volar

388
Q

Hook removal technique for Right Hand

Trigger Finger Injection site

Trochanteric Bursitis Injection

A

Press and retrace entrance path
Incision w/ 15blade

Distal palmar crease

Pt on unaffected side w/ pillow between legs
Insert until hit bone, withdraw 2mm

389
Q

Knee Injection/Aspiration

Pes Anserine Bursa Injection

A

Pt supine
Lateral knee entry- 1cm lateral, 1cm superior to superiolateral patella

Bursa: between Gracili/Semi-tendon and MCL
Hit bone, withdraw 1-2mm

390
Q

Ankle Joint Injection

Where do the sensory nerves travel in the foot

A

1cm prox to medial malleolus

Plantar side of tarsal

391
Q

Mortin Neuroma injection

Plantar Fasciitis injection site

Chronic Stress Fx of foot are more likely to develop ?

A

1-2cm proximal to toe web

Medial calcaneus, 2cm from plantar surface

Jones
Navicular

IPAP (212 decks)

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