Ortho 2.2 Flashcards
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
Stiffness > Pain
Mild pleocytosis
Elevated protein
Normal viscosity
PIP- Bouchard
DIP- Heberden
First CMC
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
First MTP joint
Calc/Talus/Navi articulation
Valgus/rigidus
Subtalar joint
Varus- bow legged
Gastroc/Semi-membrane
What will be seen on x-rays of OA
The severity of these findings are based on ? scale
What are the 4 grades
Lost joint space
Osterophytes
Sclerosis
Subchondral cysts
Kellgren Lawrence
0: none
1: doubt
2: minimal
3: moderate
4: severe
Non-pharm Tx of OA
Pharm Tx of OA
What opioids can be used for short-term relief w/ NSAIDs
Avoidance Reassure Education Weight-loss
NSAIDs, then Acetaminophen
Codeine Hydrocodone Oxy Tramadol
? 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
Celecoxib
Isometric exercises
Lost function
Pain at night
Non-surg failure
Define RA
What are common Sxs of RA
What joints are more commonly involved symmetrically
Chronic synovium inflammation causing erosion
2+ swollen joints in AM >1hr x 6wks or,
+RF/anti-CCPs
Feet Hands Ankle Wrist Knee
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
Joint involvement
Acute phase reactants
Pt self report
Serology results
Characteristic erosive changes
First: hand/feet
Spared: DIP
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
+RF
Clinical arthritis
EPL= no thumb extension
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
Pain w/ pressure
Swelling
Dec ROM
Warmth, Erythema
Early: PIP
Late: joint deformity
? is the MC site for subcutaneous RA nodule
What is Rheumatoid Factor
What lab result is as sensitive and more specific
Elbow
IgM against Fc of IgG
Anti-CCP Abs
What lab result correlates to the degree of RA joint inflammation
? will CBC results look like
Which one correlates to Dz activity
ESR/CRP
Dec serum albumin
Inc ESR/CRP
Platelets
Albumin
What part of the body does Ankylosing Spondylitis affect?
What other conditions are associated with this Dx?
What is the Tx plan?
SI joint
Iritis Aoritis Carditis Enthesitis Uveitis
NSAIDs, Exercise
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
Asymmetric/oligoarticular
SI Ankle Knee
Crohns Enthesitis UColitis
NSAIDs
What parts of the body are involved w/ Psoriatic arthritis
What other conditions can also exist
What is the Tx
Wrist Ankle SI Hands
Dactylitis Iritis Nails Enthesitis Skin lesions
NSAIDs Biologics Methotrexate
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’?
Sacroiliitis, Kyphosis
Hip Ankle Shoulder
Less severe
What microbe pathogens can cause Retiers?
What are the 5 patterns of psoriatic arthritis
What differentiates one of these manifestations from RA
Clostridium Campylobacter Chlamydia Shigella Salmonella Yersinia
DIP Arthritic mutilans Asymmetric oligo Symmetric poly Sacroilitis
Symm Poly: DIP involvement w/ absent RA nodules
? form of IBDz is more likely to develop arthritis
? is the presenting Sx in all seronegative arthropathies
What do Pts w/ Reiters present w/
Crohns
Back pain
Conjunctivitis Asymmetric oligoarthritis of LE large joints Dactylitis Urethritis Enthesitis: Achilles, Plantar Sacroilitis
What is the ‘usual’ clinical presentation of Psoriatic Arthritis
Pts w/ joint problems commonly have ? d/o
Pts w/ IBDz arthritis commonly have ? -itis’?
DIP pain
Scaly cutaneous lesions
Nail- Pits Oncolysis Ridging
Sacroillitis
Spondylitis
Knee/Ankle arthritis
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
Peripheral Sxs
Spondylitis Sxs remain same
Post Iliac Spine midline to upper lumbar
Dimples of Venus
? 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
Proliferative bone reaction
Terminal phalanges resorption
Bamboo: anulus fibrosus enthesitis
Poker: ALL ossification, Facet autofusion
Indomethacin
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
TNF-a: Etanercept, Infliximab, Adalimumab
Sulfasalazine
DMARDs
Skin lesions: photo therapy
? 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
Prox tibia
Leg/Forearm
Ant/Lat/Sup-Deep posterior
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?
Volar: flexor, pronator, supinator
Dorsal: extensors
Wad: radialis, extensors
Medial Ant Post
4hrs
6hrs- possible reversal
8hrs: irreversible necrosis
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
Pain Pallor Paresthesia Paresis Poikilothermia Pulselessness #7: pressure
Altered sensation in effected compartments
PooP w/ passive stretch-
Pulseless
Paresis
CRPS is a clinical Dx composed of ?
What are the two types
? types of injuries can precipitate this Dx
Functional impairement
Autonomic dysfunction
Trophic changes
Pain
1: RSD/Algo- no lesion
2: causalgia- + nerve lesion
Distal radius Fx
Injury to infrapatellar branch
? is the most important step for CRPS prognosis outcomes
What is the exception to this rule
What happens after this exception
Early, appropriate Tx
Distal radius Fx w/ poor finger function 3mon after Fx
Algodystrophy after 10yrs
? 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
Vitamin C 500 IU/d
Parenterals
Counseling
Sympatholytics
Therapy
CCB (a-2 agonists)
Anti-HTN/convulsants
TCA
Steroids
CRPS Tx therapy program utilizes PROM but ? is stressed more
? adaptive modalities are used for CRPS Tx
? medication is used for stellate blocks
AROM w/ stress loading
TENS Iontophoresis Contrast bath
Bupivacaine
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
Clonidine (a-2 agonsit) and Ziconotide (snail venom creates CCB)
Deformity
Neuromas
Contractures
Compression neuropathy
Seizures Hoarseness Arm numbness Weakness PTHx
How is gout Tx
How is CPDD Tx
What are the 3 stages of urate crystal deposition
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
Gout affecting 1st MTP is AKA ?
What other areas can be affected
If Pt has gout in the back they have ? type
Podagra
Ankle Tarsal Knee
Tophaceous
After initial gout attack, Pts can expect to remain ASx for ? long
Where can tophi development occur
Define Chondrocalcinosis
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
? 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
Knee
Wrist MCP Hip Shoulder Elbow SPine
OA: synovial fluid, x-ray
RA: no bony erosion or tenosynovitis
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
DM
Tabes Dorsalis
Hyperparathyroid
Hemochromatosis
Hypophosphatasia
Hypothyroidism
End stage arthritis
? 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
PE
DVT identification:
Stasis
Damage
Hypercoagulable
Supine
Abduction
Internal rotation
Flexion
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
Dilation, Stasis
Histamines
Leukotrienes
Anti-thrombin 3
? are classified as high risk surgeries for DVT development
Clinically, what two sings are indicative of DVTs
What post-op findings are indicative
Total joint arthroplasty
Internal fixation of hip fx
Polytrauma
Spinal cord injury
+ Homan
Edematous
Painful
Fever/Leukocytosis
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
<30min
Fondaparinux
LMWH
ASA
Warfarin
Desirudin- hirudin derivative
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
2a 9a 10a
Enoxaparin
Renally cleared- swithc to heparin if dec renal clearance
? 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 ?
PO Warfarin: INR 2-2.5
Proximal
Increased fibrinolysis
Decreases stasis
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
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
How long is Warfarin used for?
Therapeutic heparin is monitored w/ ? lab results
How is Enoxaparin monitoring achieved
3mon
Activated partial thromboplastin
Anti-factor 10a levels
What is the Tx for acute PEs
Oral anticoagulation is then recommended for ? long after first PE
What is an adverse outcome of Tx
Admit w/ heparin, O2 and then Warfarin
6mon
HIT Type 2 (AKA White Clot Syndrome)
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
White male >60y/o
Spine stiffness in AM/PM
Red hip ROM
Knee arthritis
Normal posterior apophyseal/SI joints
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
PLL
1st: cervical spondylosis
2nd: cervical DISH
Whiskering- shaggy hyperostotic bone
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
1st: RA
2nd: Fibromyalgia
Genetics
Environmental
MVP- mid-systolic click w/ late systolic murmur
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
Pregabalin Duloxetine Milnacipran
Usually have hypersensitivity to Rxs
Steroids
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
Amytriptyline
Cyclobenzaprine
Fluoxetine
Initiatiion: Trazadone
Maintain: Gabapentin, Tiagabine
? 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
Clonazepam
Pramipexole
Lidocaine
Saline if allergic
Aerobic 20-30min/day x 5 days/wk
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
Tachyphylaxis- decreased responses
Peds: Hematogenous to metaphysis of long bones (can lead to septic arthritis)
Adult: open Fx/post-ORIF
Pseudoparalysis
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
Post-op: drainage, failed/delayed healing
MRI
Open biopsy/aspiration
Acute- elevated leukocyte, ESR/CRP
Chronic/ImmSupp- normal
ESR/CRP- Dz process marker
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
Peds: Staph A > GBS > HInflu
Adults: Staph A, Pseudomonas
CD4 <200
Malnutrition (albumin <2.5g)
Marjolin Ulcer- SCC metaplasia
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
Parenteral/impregnated methyl methacrylate beads after surgery
Direct
Hematogenous
Extension
Staph A
IV drug users can develop septic arthritis in ? unusual locations
? microbe is their culprit
Septic arthritis in kids is MC spread by ? route
Sternoclavicular
Sacroiliac
Pseudomonas
Hematogenous
? 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/
Systemic Lupus
ImmComp
RA
Previously ambulatory, no refusing to bear weight
Anorexia
Fever
Irritable
Tachy
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
Tenderness/Effusion/Erythema w/ painful PROM
Flexed, Abducted
CRP
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
WBC >50K
> 1,100 w/ neutrophils >64%
Low glucose
High protein
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
H Influenza
Gonorrhoeae
Kingella
Tc-99
Synovial/blood culture
IV ABX
Surgical decompression/lavage
? 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
Emergent surgical decompression
4-6wks
Spirochete: Borrelia burgdorferi
Lyme Dz is the most ?
What types are endemic to Europe and Asia?
What are the 3 phases of Lyme Dz
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
? 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
Skin/Clothing checked for ticks
<36hrs
Doxy 100mg BID x 28days
Amox 500mg TID x 28 days
<8y/o: Amox 20mgg/kg
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
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
? 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
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
Where does DEXA scan measure density at
What is DEXA best used for ?
Who needs to have DEXA scans d/t RFs
Spine FemNeck Trochanter Femur
Monitoring osteoporosis Tx
Female >65y/o
Post-menopause <65y/o
Men w/ Hx low-trauma Fx/prostate Ca
Primary Hyperparathyroid
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
High-turnover: high NTx score
Low formatoin: low NTx score
<28y/o
Ca/Vit D
Avoid alcohol/tobacco
Impact loading- walk, strength, Tai Chi
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
750-1000mg/day
(range 25-45)
Carbonate
Citrate
Carbonate reqs acid
Citrate dissolves at all pH levels w/ dec risk for stone development
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
> 15ng to avoid insufficiency
30 recommended
800-1200 IU/day
2-4K if Vit D deficient
800
What is the 3rd MC cause of delayed Fx healing
How is Osteoporosis Tx w/ Rx
Low Vit D
High NTx= antiresoptives (disphosphonates, -ate)
SERM: Denosumab
Low NTx: Anabolic (intermittent PTH)
? 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
Raloxifene- inc DVT risk and hot flash occurance
Denosumab- inhibits osteoclast formation
Calcitonin
No non-vertebral Fx protection
Inc Ca risk
When are anabolic agents recommended for use against osteoporosis
When is their use c/i
Prolonged diphosphonate usage is associated w/ ? 2 adverse outcomes
Pre-menopause
Impaired Fx healing
Diphosphonate failure
Low turnover
Radiation Hx
Paget Dz
Children
Atypical femur Fx
Jaw necrosis
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
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
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
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
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
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
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
Grade 4 strain, all Grade 3, Sev Grade 2
Latent Active Aggressive
Well-defined
Non-aggressive
W/out cortical destruction
W/out periosteal reaction
? 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
Sxs exacerbated w/ activity
Pattern recognition
Osteoid osteoma
Osteochondroma
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
Constitutional Sxs
Mets Infection Lymphoma
Incidental finding
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
Radiograph
MRI better: soft tissue/marrow
CT better: bone detail
Tc-99m: isotope bound to ligand methylene-diphosphonate
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
Metastases
Myeloma
CT- chest abdomen pelvis
Light Immunoglobin Microglobulin Electrophoresis
Quant immunoglobin
Protein electrophoresis
Free light chain assay
B-2 microglobulin factor
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
Closed needle, Open bone
Active/Aggressive
HyperCa
Pneumonia
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
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
What may be found on PE in suspected growing pains
What part of the body is MC affected
what is done for management/Tx
Pain w/ deep pressure
Flexible flatfeet
Calves
Stretching Education Analgesics
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
Leukemia
Endocrinopathy
Type 1: MC extremeties in Peds 9-15y/o
Ankle/Feet
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
Muscle wasting/contracture
Coarse hair, extremity
Thick nails
Amitriptyline
Gabapentin
<3y/o
First Handicapped Stepchildren Premature
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
Brow Elbow Chin Knee Shin
Subdural hematoma
Retinal hemorrhage
Skeletal survey: <2y/o
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
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
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
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
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
Salter-harris
Oblique
Premature growth arrest
Dec bone length
What are the Tx goals of Peds Salter-harris Fxs
How are these Fxs Tx
Mild displacement is allowed in ? gender that are ? age
Reduction/Avoiding arrest x 6wks
Type 1-2: closed reduction, cast immobilization
3-4: reduction w/ ORIF
Boys 15 and >
Girls 13 and >
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
> 7 days
Cartilage of growth plate and articular surface
Physeal bars
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
12mon, less if they reach skeletal maturity before f/u appointment
Femur, Tibia
JRA: USA
JCA: Europe
There are at least seven types of JIA, but they all have ? two things in common
What are the types of facts of each
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
What joint needs to be palpated when assessing suspected JIA in ASx Pts
What are adverse outcomes from this Dz
How is this Tx
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)
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
Inflixiamab
Adalimumab
At night for contractures
Fungal/TB infection
Define Osteochondritis Dissecans
Where does this d/o MC occur and where can it occur
Where does it rarely develop
Osteonecrosis of subchondral bone
MC- posterolateral medial femoral condyle
Talus Humerus Elbow Femur
Patella
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
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
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
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
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
Indolent- bacteria/TB
Lytic- aggressive appearance like a tumor
Pain Malaise
Warmth Erythema Swelling Tenderness
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
Refusal to walk/limp
Pseudoparalysis
Sepsis
Sinuses w/ chronic drainage
? 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
Fever >100.4
Tenderness over bone
Effusions
CRP, <8hrs of infection onset
Intra-articular:
Prox- Femur Humerus Radius
Distal-Fibula
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
Lytic lesions w/ thin sclerotic rim and crosses physis
Physis sparing
MRI
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
Culture/biopsy
IV ABX
Staph A
GBS
Neonate: enteric rods
6-48mon: H influenza
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
PCR and special culture media
7 days
6wks
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
Biopsy from surgical debridment
Removal of all infected material
3-6wks
Dec pain
Reduces chance of pathological Fx
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
Hematogenous seeding of synovium from:
Skin infections
Impetigo
Pneumonia
ESR >30
WBC >15K
Synovial WBC >50K
Knee Hip
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
Hyaline cartilage damage from lymphocytic enzymes <72hrs from inoculation
Guarding Fever Anorexia Malaise
Hip: Flex Abducted External rotation
Knee/Elbow: slight flexion
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
TS/LC: discomfort instead of pain
CRP
ESR >30
WBC >15K
Synovial WBC >50K
How is Ped Septic Arthritis Tx
Pediatric Seronegative Spondyloarthropathies have ? 4 characteristics in common
? c/c presentation suggests a case of anklyosing spondylitis
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 >
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
Conjunctivitis Enthesitis Urethritis
Yersinia Campylobacter Salmonella Shigella
Trachoma
Chlamydia
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
Achilles or Plantar Fascia
Female <15y/o w/ skin problems before arthritis
<21y/o w/ arthralgia w/out effusion
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/
Purple discoloration around joint
Patellar Achilles Plantar
Conjunctivitis
Anterior uveitis
Photophobia
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
Monoarticular knee
Digit tenosynovitis
UExtremity involvement
Nail pitting
Sterile pyuria
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 ?
Muscle strengthening
Orthoses
Activity modification
NSAIDs
Conus medullaris ending at L1-2
Cauda equina: L2-S4
Paralysis w/out spasticity
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
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
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
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
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
Radicular pain w/ UE numbness/paresthesia (deltoid to thumb)
Changed grip/handwriting
Trunk/leg dysfunction
Gait disturbance
Incontinence
Place hands on top of head
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
Reduced cervical lordosis
C5-T1
UE reflexes
CT/Myelogram w/ contrast
How is Cervical Radiculopathy Tx
What two Txs are avoided in this population
Define Cervical Spondylosis
Most spontaneous x 8wks
NSAIDs + traction
Opioids
Manipulation
Degenerative disc dz of the cervical spine
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
Herniation
Osteophyte growth
Thick ligamentum flavum
Limited mobility
Pain worse w/ upright
Older men
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
Palmar paresthesis
Altered gait (heel-toe)
Difficult dexterity
Lost vibration/proprioception in the feet
Posterior column
? 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
C5-T1 and L1-S1
Lhermitte sign Hoffmann Clonus Hyper-reflexia Babinksi
Zygoapophyseal joints
Where are cervical spondylosis/age-related degenerative findings MC seen
How is this Tx
What two meds can be used for sleep aids
C5-7
Cervical pillow
NSAIDs
Surgical decompression
Doxepin
Amitriptyline
What is the classic mechanism for whip-lash injury
What is the MC findings on PE
How are these Pts Tx
Stopped car that is rear ended= flexion/extension
Non-focal/radicular neck pain
NSAIDs Soft collar Muscle relaxants Cervical pillows Doxepin/Amitriptyline
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
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
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
Walking early
Isometric exercises when tolerated
Cross-table lateral view of C1-T1
Injury to upper/lower C-spine
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
Swimmer view
Cervical collar x 7-10 days
Abdominal- bowel lac
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
Ileus- dec bowel motility
Hematoma w/ step off
Middle, CT
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
Single compression
Kidney, thoracolumbar corest
Wedging <20*
No posterior involvement
? 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
Acute low back pain
Injury to anulus fibrosus= nucleus pulposus leak= irritation
Lumbar flexion
Ease of extension
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
T10
Initial: Sx relief
Secondary: return to activity
Pain >3mon
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
GYN Internist FamMed Spine
Depression
Vacuum- Nitrogen in air space
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
Collagen Type 2
Nucleus pulposus
Anulus fibrosus
Sup/Inferior end plates
Twisting
Lifting
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
L4-S1
L5-S1
L1-4, pain in anterior thigh
? 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
Seated leg raise
Crossed straight leg raise
L5-S1 is stretched
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
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
When is an MRI ordered for suspected lumbar herniations
How many epidural injections can these PTs receive
When should the injections be avoided
Sxs >4wks
3 in 6mon
Substantial neuro deficit
Motor, Reflex and Sensation for L4 nerve root
Motor, Reflex and Sensation for L5 nerve root
Motor, Reflex and Sensation for S1 nerve root
Anterior tibialis / Patellar / Medial foot
Extensor hallucis longus / NONE / Dorsal foot
Gastroc soleus (toe raise) / Achilles / Lateral foot
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
Achondroplasia
L2-5
Spine extension
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
Proprioception/Romberg/Neurovascular
Leg muscle weakness
Uncommon sphincter tone decrease
T10
How is lumbar stenosis Tx non-op
When do these Pts become surgical candidates
What is the goal of Tx
Water exercise
Epidural injections
Non-ambulatory/Dec quality of life
Prevent progression
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
Primary- rare
Metastatic- common
BLT KPC by hematogenous spread
Batson’s plexus- connects w/ inferior vena cava
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
Pain as presenting c/c
Incidental
Neuro findings
Known primary tumor
Pain, usually from minor vertebral Fxs
Lost pedicle integrity (winking owl)
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
Tc-99m bone scan
Multiple myeloma
Quad/Paraplegia
How are ASx spinal neoplasms found during the search for mets Tx non-op
How are painful metastasis Tx
When is surgery indicated
Chemo/Rad/Hormones
Radiation if no deformity/neural compression
Pain w/ neurodeficit- decompression and stabilization w/ post-op radiation
What is a common adverse outcome after surgical decompression of spinal neoplasms?
Define Scoliosis
What is the MC presenting Sx
Wound complication if surgery is post-radiation/steroid
Coronal curvature of spine >10* using Cobb method
Pain in region of deformity
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
Degenerative spondylosis
L4-5
Hallucis Longus
How is decompression in scoliosis assessed
How is adult scoliosis Tx
What are the red flags for referral in these Pts
Plum line- C7 to gluteal cleft
NSAIDs
Water/swimming therapy
Neuro deterioration
Can’t walk 2 blocks d/t pain
Respiratory dysfunction
Trunk exercise
Define Degenerative Spondylolisthesis
What is the opposite direction of slippage called
What nerve roots need to be evaluated
Female >40 L4-5 body slips fwd d/t deteriorated facets/disc leaving lamina/pars interarticularis intact
Retrolisthesis- posterior slippage
L1-S4
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
Dec knee reflexes, also seen in geriatrics
Weak toe/heel walking
Weak toe dorsiflexion
Lateral recess= radiculopathy
Central canal= claudication
L5-S1
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
Lamina w/ pedicle (pars interarticularis)
Cyclic loading AKA- fatigue Fx that fails to heal
Spondylosis
? 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
Gymnastic/Football
Posterior pain radiation below knees, worse w/ standing
Dec lordosis/flat buttocks
Vertebral step off
Hamstring spasm w/ forward extension/leg raise
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
L5
Collar on scotty dog
Single Photon Emission Test- SPECT CT
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 ?
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
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 ?
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
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
Low thoracic/Lumbar
Kingella E coli GAS
Percussion- localizes
Passive flex- pain due to anterior element compression
MRI
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
Pick up- will avoid bending back to retrieve item
TB skin test
Normal WBC w/ inc ESR/CRP
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
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
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
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
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 ?
Wedgine >5* in three vertebraes
Schmorl- disc herniations through end plates
Congenital kyphosis
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
View from side w/ Adam fwd bend test
Scheuermann/pathologic- sharp apex angulation
Postural- gradual curvature
Hamstring spasm/contracture
How is the magnitude of a hyperkyphosis angle measured
What are the adverse outcomes of this dz
What can complicate surgical Tx of this
Cobb angle: T5-12 w/ >50* being abnormal
Dec pulm function- >90-100*
Back pain
Neuro Sxs= congenital
Proximal junction kyphosis
Define Scoliosis
What is the MC Dx
How is this MC scoliosis classified
Lateral curvature >10* w/ Cobb angle
Idiopathic
Age of onset:
Birth-3yrs: infantile
3-11yrs: juvenile
>11y/o: adolescent
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
Flaccid weakness/spasticity
Loss of sitting balance
Impaired respiratory function
Long thora/lumbar curves
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
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
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
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
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
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*
How is neuromuscluar scoliosis Tx
What is the downside for the future in these Pts
How is congenital scoliosis Tx
No function/sitting impairement- observe
Progressive/Sx- soft orthosis
Post-op complication risk is higher
Premptive spinal fusion
Define Spondylolysis
What causes this
What level is this MC seen
Defected pars interticularis
Stress Fx progresses into pseudoarthrosis
L5
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
lumbar kyphosis
Activity related radicluopathy stopping above knee
Hyperextension of spine
How are Peds w/ stress reaction/early cases of spondylolysis Tx
When are these Tx w/ fusion/decompression surgery
LLD
NSAIDs
TLSO x 3-4mon
Immature Pts w/ slippage >50%
Chronic Sxs
What are the 6 types of AC injuries
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
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
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
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
Reduce pain
Protect joint
Function
Diffuse/deep pain worse to posterior shoulder
High riding humeral head
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?
Equally decreased A/PROM
Flattened humeral head
Inferior osteophyte
Posterior erosion of glenoid
Periarticular erosions
Osteopenia
Central wear of glenoid
? 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
Severe loss motor/strength even w/ -plasty
Heat/Ice
NSAIDs
Stretching exercises
Arthroscopy debridement and capsular release
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
- 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
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 ?
C5-7
Rhomboid
Serratus anterior
Post-ganglionic
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
Cervical stenosis
Inc risk cord injury
Resolution of pain/neuro Sxs
Normal neuro exam
Full cervical ROM
DMT-1
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
Contracted coracohumeral ligament
Deltoid insertion site
Subscapularis
Contracted capsule
Loss of inferior pouch
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 ?
Inc ROM in scapula/glenohumeral joint
External rotation w/ arms in adduction
30-45* of abduction
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
Fx humerus
3mon w/out improvement of pain/motion
Supraspinatus
Infraspinatus
Teres minor
Subscapularis
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
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
What two special tests are usually positive on impingement exam
Where will Pt have pain on PE
Once suspected, how is the Dx confirmed
Neers
Hawkins
W/ 90-120* abduction
W/ lowering arm
Suacromial injection- pain relief is Dx
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
Exercise x 3-4/day x 6wks
Then subacromial injection
Then stretching
Overhead activities w/out pain
Proximal bicep head tear
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
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
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
Pain ROM Strength Function
Large tears= high failure
Debridement may relive pain
Older adults w/ chronic shoulder pain d/t rotator cuff
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
Intertubercular groove, intrarticular for proximal 3cm
Ludington- put hand behind head and flex
Loss of elbow flexion/forearm supination (screw driver)
When are proximal bicep tendon ruptures repaired w/ surgery
Instability is MC found in ? joint
Pts w/ this MC instability have recurrent episodes of ?
Young athletes
Adults <40y/o as laborers
Shoulder
Subluxation- humeral head slips out of socket MC in Anterior/Multi-directional
Define TUBS
Define AMBRI
What type of forces cause a ant/posterior dislocation
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
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
Voluntary dislocation d/t psychological disturbance
Add, internal
External= impossible
Apprehension- anterior
Sulcus- inferior
Jerk- posterior
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
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
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 ?
Atraumatic/voluntary (AMBRI) instability
Failed reduction
2 or > dislocations/3mon w/ rehab
Multidirection instability
Anterior glenoid labrum
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
Superior glenoid labrum
Bicep anchor complex
Fraying- natural degeneration
Frank tear- trauma
Crank test
Resisted supination/external rotation
Active compression (Obrien)
Clunk
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
MRA= gold standard
NSAIDs
Rehab towards stabilization, stretch, strength x 6wks
Dx arthroscopy
What is the goal of rehab for SLAP tears
What 3 exercises need to be avoided
? is the MC adverse outcome of SLAP lesions
Goal: reduce pain, protect joint
Bench press
Over head press
Bicep curls
Shoulder stiffness
What causes Thoracic Outlet Syndrome
What three underlying congenital issues can cause Thoracic Outlet Syndrome
These Pts can present w/ Sxs mimicking ? d/t ?
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
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
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
What are four adverse outcomes from thoracic outlet syndrome
What are two rare but possible outcomes
? is the MC cause of elbow joint destruction
Weakness
HAs
Inability to do overhead work
Coordination decrease
Raynauds
Ulcerations
RA
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
Pseudo/gout
Manual laborers
Weight lifters
Jogging-
Extension= posterior
Flexion= anterior
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
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
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
Medial > Lateral
Lat: Wrist extension and grip
Med: Wrist flexion and pronation
Tenderness over extensor 1cm distal and anterior to lateral condyle
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
Lifting- pain w/ palm up= medial condyle
Pain
Avoidance
Persistent Sxs= CCS Debridement
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
Reduce pain/inflammation
Promote arm strength
Return pain free activity
Maintenance
Pain free hand shake
PIN w/ lateral epidcondylitis
Ulnar w/ medial epicondylitis
Pts w/ pulmonary/breathing difficulty may present w/ ? abnormal c/c
What is done that is therapeutic and Dx
Olecranon bursitis
Aspiration
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?
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
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
Risk for chronically draining/infected sinus development
Septic/recurrent w/ 3 or > aspirations
10cm prox to elbow
5cm distal
What are the two MC nerve entrapment in the upper extremity and what causes the compression
Define Cubitus Valgus
What can cause ulnar palsy
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
Define Radial Tunnel Syndrome
What is the commonly mis-Dx as
How is it differentiated
Compressed PIN between supinator heads causing lateral elbow pain
Lateral epicondylitis
No sensory, innervates thumb/finger, carpi ulnaris extensors
Define Pronator Syndrome
Why is this entrapment condition hard to find or is found late
What are early and late signs of ulnar compression
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
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
Pain 4-5cm distal from lateral epicondylitis
Forearm aches w/ proximal radiation
Driving
? 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 ?
Elbow flexion test
Light touch/vibration
Compression has progressed to degeneration
? 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
Middle finger test- resisted extension causes forearm pain
Pain w/ direct pressure to pronator teres 4cm distal to antebrachial crease
30% or more
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
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)
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
Aponeurosis
Proximally
Tendon avulsion from radial tuberosity
Ruptured muscle-tendon junction (poor prognosis)
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 ?
Radial
<2wks of injury
Ulnar collateral ligament
Medial paresthesia
? 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
Milking
Loos bodies
Ossification
Osteophytes
Marginal spurs
MRI w/ contrast
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
Persistent pain w/ throwing
Main goal is pain relief
Competitive throwers
>3mon of non-op Txs
Tommy John surgery
Arthritis of the wrist are MC from ? etiologies
How does wrist arthritis appear on exam depending on the cause
Define Caput ulnae
Trauma
RA
RA: Wrist: radial deviation Finger: ulnar deviation Dec grip w/ pain OA: Swelling Pain Dec ROM
Prominent ulna seen on PE
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
Calcificaiton of fibrocartilage complex
Lyme Dz
Carpal tunnel from compressed median nerve
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
RA tenosynovitis Tumor Pregnancy DM Thyroid
Nerve compression test
Phalen
Failed two point discrimination <5mm
? 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
Electrophysiologic
Dec pressure on median nerve
Abductor pollicis longus
Extensor pollicis brevis
When is De quervain tenosynovitis commonly developed
How is it Dx
How is de quevains Tx
Post-partum w/ ulnar deviation during picking up child
Finklestein test
2 wks NSAIDs w/ spica splint
Persistent= CCS sheath injection
CCS failure= surgery
? 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
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
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
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
Dorsal ganglions of the wrist usually develop over ? joint
A volar radial ganglion is usually between ? structures
The volar growths may adhere to ? structure
Scapholunate joint
Flexor carpi radialis
Radial styloid
Radial artery
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
Long/Ring
One side of extensor tendon of DIP
Degeneration
Spurs from dorsum of DIP
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
Infecting DIP joint
1s generation Cephalosporin
Osteonecrosis of carpal lunate in men 20-40y/o unable to grasp heavy objects
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
End stage arthritis of wrist
Early: inc density
Later: fragment/collapse
MRI
Lichtman/Weiss and Assoc.
How is Kienbock Dz Tx non-op
X-rays are obtained w/ arm in ? position
Why is this positioning needed
Normal/sclerotic- splint, NSAIDs x 3wks
Shoulder abducted to 90
Elbow flexed to 90
Eval ulnar variance- difference between ulnar and radius
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
2nd: Giant cell tumor
3rd: EIC
B: enchondromas
M: chondrosarcomas
SCC
Glomus- pressure/cold sensitive
How are hand/wrist tumors evaluated and what does their location indicated
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
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 ?
SCC
Kaposi sarcoma
Proximal phalanx
Define Carpal Boss
These are sometimes associated w/ ?
What color d/c come from mucous/EICs?
Dorsal prominence at base of 2nd/3rd carpal
Ganglions
EIC: white/cream
Mucous: clear
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
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)
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 ?
Sensory and Motor changes
Sensory loss
Atrophy
Clawed ring/little finger
Dominant hand of kids
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
Dog, Cat
Cat > Dog
Dog/Cat- Pasteurella multocida
Dog- AHStrep, Bacteroides, Fusobacterium Staph A
Dogs
In US= bat skunk fox raccoon
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
> 10hrs
PO Augmentin 875mg
IV Amp-Sulbactam
PCN Allergy= Tetracycline
OA
Secondary degenerative joint dz
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
Synovial hypertrophy
Inflammation
OA: DIP PIP, thumb CMC
RA: wrist, MCP, tenosynovitis
RA: pain w/ acivity
OA: pain w/ palpation
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 ?
PIP contracture- boutoniierre
Hyper-extended PIP, DIP flexed- swan neck
Heberden w/ mucous cysts
MCP, Hx of trauma
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 ?
NSAIDs
Etanercept/Infliximab
Little Ring Thumb
Female 40-70y/o
Joint configuration/laxicity
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
MC: Pain w/ grip/pinch
Hallmark: Tenderness over palmar/radial aspects of joint region
Carpal
Grind test
How is thumb CMC arthritis managed non-op
Define Boutonniere Deformity
What PE test is done for Dx confirmation
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
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
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
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
Pulmonary Dz, Alcohol/smoking, Vibration trauma, Epilepsy, DM
Ring Little Long Thumb Index
Night splinting Collagen injection (+FDA)
? 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
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
Why do Herpetic Whitlows and Felons need to be carefully differentiated
What happens if felons are left untreated
How are paronychias Tx non-op
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
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
Central volar longitude (visible pus)
Dorsal mid-axial (no pus visible)
Using curved hemostat to break up septae
Secondary, never suture
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
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
? 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
Profundus of ring finger
Two-point discrimination
1st: active
2nd: strength
Most Pts can’t move pinky finger independently d/t joint connectivity preventing independent movement of ? muscle
How are these tendonous injuries initially treated
Sublimis
Clean/splint
Surgery <7days
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/ ?
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
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
AHS/Staph A- MC
Eikenella corrodens
<8hrs
Arthrotomy wash out w/ PCN/1st Gen Cephalosporin
PCN Allergy- Tetracylcine
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 ?
F/u 24hrs then,
Daily whirpool or dressing change Q12hrs
Extensor tendon avulsion from distal phalanx
14days
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
Acute: 6-8wks
>3mon old: 8wks
4-5 days
Refer for surgical pinning
? 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
Volar subluxation of distal phalanx
Bony fragment >1/3 of joint surface
Physeal injury= referral
Battery-operated microcautery or 18g needle
? 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
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
What structures keep flexor tendons from bow stringing
Define Trigger Finger
? fingers are MC affected by trigger finger
4 annular
3 cruciform
Thick flexor tendon or first annular pulley
Long and Ring
Kids= thumb, other finger involved suspect metabolic d/o
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 ?
RA DM Hypothyroid
Carpal tunnel
De Quervains
Pain at PIP
Source at MCP
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
CCS injection x 2
Failure= surgical release
Valgus
Towards capitellum
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
2-3wks
Posterior long arm
Immobilization not needed
If peds dislocate their elbow, it’s usually in ? direction
Why are elbow sprains rare/unlikely in Peds
How are elbow sprains Tx
Posterior
Bones are the weak link
Short term immobilization
? 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
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
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
Annular ligament moves
Presentation 1-2 days after injury
Medial= tension (avulsion Fx, LLE) Lateral= compression (capitellum osteonecrosis)
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
<10y/o- Panner Dz
>10y/o- osteochondritis dissecans
Thumb Radial Ulnar Transverse deficiencies
6-18mon
? 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
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
What blood d/o is seen in Peds w/ Radial Deficiency
Why is this dificiency abnormal
Ulnar deficiency may present w/ ? abnormal coalition
Thrombocytopenia w/ absent radius
Normal thumb is present
Radiohumeral synostosis
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
Not associated w/ abnormalities of other organ systems
Tibial deficiency
Proximal femoral deficiency
Elbow flexion
Congenital constriction band sydrome
Define Syndactyly
What other syndromes are these PTs more likely to have
Define Polydactyly
Lack of separation between finger/toes
Apert/Poland syndrome
Extra digit in hand/foot (thumb/great toe- preaxial) Little finger (post-axial)
Define Congenital Radioulnar Synostosis
Define Congenital dislocaiton of radial head
? PE finding suggests prognosis predictor for surgical Tx
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
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
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
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
> 12 y/o after capitellum ossifies
<12y/o= Panners
TTP
Flexion contracture
How is LLE Tx non-op
How is OCD Tx non-op
Rest x 3-6mon
Rest x 12mon
What is the MC type of Obstretric Palsy
What is the two other types of Obstetric Palsy
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
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
2mon
Return of bicep function after 3mon
Entire plexus
Horner Syndrome
Nerve root avulsion
? 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
Reduced spontaneous movement- pseudoparalysis
Moro
A/Symmetric tonic neck reflex
Supraclavicular triangle
What is the position of Waiter’s tip in words
What PE findings are consistent w/ a preganglionic avulsion injury of sympathetic chain
Forearm pronated
Elbow extended
Wrist flexed
Shoulder adduct, internal rotated
Horners Syndrome
Phrenic nerve palsy
Nerve involvement- long thoracic, dorsal scapular, suprascapular, thoracodorsal
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
Shoulder subluxation/dislocation
Supervised at home exercise program
Assessment and monitoring neuro function/recovery
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
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
Infantile Torticollis can present mimicking ? syndrome
CMT is commonly associated w/ ? two PE findings
What lower extremity issues may also be noted
Klippel-Feil Syndrom- congenital fusion of two or more cervical sections causing dec ROM/head tilts
Plagiocephaly
Facial assymetry
Metatarsus adductus
Calcaneovalgus
Hip dysplasia
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
Cock-robin
Superior oblique palsy= nystagmus causing torticolis
Close eyes/block vision
? are the neuro causes of Torticollis
AARD affects ? part of the spine
AARD can also develop after ? inflammatory d/o causing ? syndrome
Posterior fossa tumor
Cervical spine tumor
Syringomyelia
C1-2
Grisel- inflammation of pharynx
? image is needed when assessing suspected AARD torticollis
? are the adverse outcomes of this Dz process
How is CMT Tx non-op
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
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
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
What types of images are needed for clavicle Fxs
When are clavicular Fxs referred to Ortho
When is surgical correction indicated
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
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
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
? 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
Radial x6mon- dec wrist/finger extension w/ lost sensation to dorsal web space
20* apex ant/lateral
U-shaped coaptation x 2wks
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
6wks
Neer
Greater/Lesser tuberosity
Humeral head
Shaft
Greater- Supra Infra TM
Lesser- Subscap
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
Surgical neck
Transcapular- scapular y-view
Shoulder dislocation- AP images alone are not enough
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
Sling w/ pendulums after 3wks
Deltoid/rotator isometrics after 6wks
3wks
Restore rotator cuff muscles
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
Two part humeral neck
All 3/4 part Fxs
Displaced 4 part
Posterior shoulder dislocation
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
Rib Fxs
Transcapular lateral/oblique
Acromial/Coracoid
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
CT
ASx malunion
Suprascap nerve injury
Impingement syndrome
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
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
What is a ‘perched’ elbow dislocation
What is the terrible triad in adults
What is the terrible triad in kids
Subluxated w/ trochlea resting on coronoid
Elbow dislocation, Radial head fx, Coronoid fx
Elbow dislocation, Radial head fx, medial epicondyle Fx
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
CT
No associated Fx
General anesthesia
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
Elbow flexed, forearm pronated
Elbow flexed at 90* w/ extension block x 4wks
5-7 days and progress over 3-6wks
How are distal humerus Fxs Tx non-op
How is a Fx olecranon Tx non-op
When is protected ROM recommended to return
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
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
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
Define Essex-Lopresti Fx
What type of imaging is needed for radial head Fx
What is a common adverse outcome of radial head Fxs
Radial head Fx w/ injury to forearm
Greenspan
Loss of last 10* of extension
How are radial Fxs Tx
What types are red flags
Define Bennett Fx
Define Rolando Fx
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
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
Restore axial length, put metacarpal fragment against smaller volar fragment
Thumb spica-cast x 4wks
Bennett- ORIF
Semi-supinated
Carpal tunnel view
What happens if Hook Of Hamate Fxs are left un-Tx
How are these Tx non-op
Non-union
Tendon rupture, little finger
Wrist immobilization in neutral position
MC type of distal radius Fx seen in adults
? is the name of the Fx that is opposite of the MC
Define Barton Fx
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
Define Chauffeurs Fx
What is an adverse outcome from wrist Fxs
How are these Tx non-op
Oblique radial styloid Fx
Compartment syndrome
Sugar tong x 3 wks
Short arm cast x 3wks
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
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
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
1-2K IU/day
Vit C 500mg/day
Boxer Fx- distal > proximal > middle
>40* angulation
+ extensor lag
? 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?
Distal, Proximal then Middle
Peds, little
Splint x 3-4wks
Rpt x-rays at 1wks
Resume activity at 3wks
MC adverse outcome after hand Fxs
MC carpal bone Fx in men
Why are these Fxs associated w/ so much osteonecrosis
Joint stiffness
Mid-pole scaphoid
Blood supply enters at distal third at dorsal side
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/ ?
Top: EPL
Bottom: EPB
Oblique
Forearm base thumb spica
Cast w/ thumb IP free x 6wks
F/u 7-14 days, pain= MRI
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
Distal: 6-8wks
Middle: 8-12wks
Prox: 12-24wks
Clenched fist
Torn collateral ligament and/or volar capsule ligament
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
Unstable, complete UCL rupture in thumb MCP
PIP
Hyperextension tearing the volar capsule
FDP
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
Dorsal
Flexion
Block last 20-30* of extension of volar plate
Supracondylar- AIN palsy
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
Supracondylar Fxs of distal humerus
Lateral condole Fx of distal humerus
Medial epicondyle Fx
Lateral epicondyle
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
Growth plate of distal humerus and articular surface of elbow are involved
Infants from abuse
Metaphysis of radial neck
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
Radial neck
R: thumb up
M: ok sign
U: criss-cross finger
Volar forearm compartment syndrome= Volkman ischemic contracture
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 ?
Rpt x-ray day 3-5
30-45* in Pts < 10y/o
Meta: 5-12y/o
Phys: 13-16y/o
Newborns w/ Fx of clavicle or proximal humerus may present w/ ?
? are the MC physeal Fx
How are proximal humerus Fxs in Peds Tx
Pseudoparalysis
Salter Type 2
Non-surg, best w/ sling:
70* <5y/o
40-70 5-12y/o
<40 in >12y/o
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
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
? 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
Dorsal surface of distal radius
Displaced distal radius w/ dislocation of ulna
Radial head dislocation (anterior) w/ Fx of ulna
5
How are prox/middle forearm Fx in Peds Tx
Surgery:
>10*
All Monteggia: closed reduction w/ 6-10wk immobile
C5 M/R/S
C6 M/R/S
C7 M/R/S
C8 M/R/S
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
T1 M/R/S
L4 M/R/S
L5 M/R/S
S1 M/R/S
Interosseous
None
Medial elbow
Anterior tibialis/patellar/medial foot
Extensor digit longus/non/dorsal foot
Peroneus longus/brevis/achilles/lateral foot
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
Groin pain
C-sign, worse w/ rotational movement
FADDIR- Fixed Adduction Internal Rotation
Define Pure Femoral Cam Impingement
Define Pincer Impingement
A normal acetebulum has ? morphology
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
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
Etiology of 80% of hip OA
NSAID
LLD
ROM/Strength
Deep massage
Active release
? 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
Fluoroscopical intra-articular injection
Intra-articular etiology for hip pain
CPM device
Stationary bike
Hip pain/Sxs
Lupus/AS
? 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
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
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?
Exiting pelvis, medial to ASIS
Sensory only
Cecal tumor
Uncommon: Groin ache
Acute= pain radiating to SI joint
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 ?
Superior and Lateral knee- MC w/ burning
Electric jab w/ hip extension
Persistent burning dysethesia
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
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
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
Steroid Lupus Alcohol Trauma RA Sickle
30-50y/o w/ bilateral Pain, Dec ROM, + straight leg
Early: atalgic
Late: trendelenburg
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
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
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?
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
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
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
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
Abdominals
Flexors- Sartorius Iliopsoas Rectus
Adductors
Contraction w/ muscle stretched- kicking ball but leg blocked causes iliopsoas strain
Over use
? 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?
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
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
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
What non-leg sourced issues can lead to trochanteric bursitis?
Where can this pain radiate to?
How do Pts describe pain
Lumbar spine dz
Leg, butt, or knee, NOT to foot
Worse when rising, improves, worse <30min
Unable to lie on affected side
? 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
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
? 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 ?
Meniscal > MCL > L/PCL
Popliteal disruption
Segond Fx
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
Open physes
Posterior horn of medial maniscus; secondary stabilizer to anterior tibial translation
Hamstring* curl
Isometric quad flex
Leg raise
? 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
Extension 30-10* and varus/valgus stress
Foot pronation
Large Q-angle
Anteverted hip
Genu recurvatum/valgum
Arthrofibrosis w/ loss of motion
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
MC- Tibiofemoral OA
Patellar subluxation
Patellar baja
Valgum d/t ligamentous laxicity (more dec ROM)
Pes anserinus
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
Sclerosis
Osteophytes
Asymmetric joint narrowing
Periarticlar cysts
Symmetric joint narrowing
Osteopenia
Bony erosion at margins
Lateral: Merchant
Axial: Sunrise
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
More sensitive for early arthritis, expecially when posterior femoral condyle is involved
Lateral heel wedge- unloads medial compartment
Arthroscopic
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
Unloading tibial/femoral osteotomy
5-10yrs, Knee replacement
Sartorious
Gracillus
Semi-tendon
Early OA in medial compartment
? nerve can become compressed during pes anserinus bursitis
Septic bursitis presents w/ ? 3 Sxs
Non-infectious traumatic bursitis presents w/ ? and w/out ?
Saphenous and infrapatellar branch
Pain Erythema Warm
+ Warm, - pain/erythematous
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
Burs: diffuse pre-patellar swelling
SA: suprapatellar pouch swelling
US/phonophoresis
PO ABX
What causes and what are the S/Sxs of neurological claudication
What are the causes and what are the S/Sxs of vascular claudication
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
? 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
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
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
<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
How are MCL/LCL sprains managed
What types need surgical correction
What types need surgical correction
<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
? 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?
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
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
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
? 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
One legged hop w/ flexed knee= pain
NSAID RICE
Cam w/ .5” lift
Crutches until pain free ambulation
Control inflamm/pain w/ RICE
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 ?
7-21 days later w/ PROM
Tenderness on joint lines
<5mm of meniscal attachment sites
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
Degenerative/near central body of meniscus
Meniscocapsular junction
McMurray= Appley + Thessaly
Forced flexion circumduction
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
Younger PT w/ substantial tear
Locked knee
Older Pt non-op failure
RICE
Controlled movement
Weight bearing medial condyle
What can cause femur osteonecrosis
Chronic osteonecrosis will present w/ ? c/c
? are early and late radiographic signs that femoral osteonecrosis is occurring
MC: female +60y/o Renal transplant Sickle cell Gaucher Dz Steroids
ASx
Early: Sclerosis, Flat condyle
Late: Narrowed spacing, Osteophytes
? imaging is used to Dx femoral osteonecrosis
How are these Tx surgicall
? is the hallmark Sx Extensor Mechanism Tendinitis
MRI, Bone scan
Debridement
Osteotomy
Replacement
Anterior Knee pain
Long standing Jumper’s knee can cause ? muscle to atrophy
What images are needed
How long should these PTs be LLD
Vastus medialis obliquus
Oblique x-ray= enthesophytes: calcification of tendinous insertions
3days-6wks
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
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
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
Fall on knee that is partially flexed
Endocrinopathy
FQN usage
Quad/Patella tendinitis
? 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?
Large effusion w/ palpable defect
Inability to extend knee against gravity/perofrom straight leg raise
Inferior patella in line w/ Blumensaat line
? 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
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
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
Retropatellar pain d/t Genu Valgum alignment
Patella alta
Pos J sign
Merchant/Laurin
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
Brace/immobile in extension x 4wks
Modified weight bearing
Pain meds
Ice
> 4wks
Quad strength/flexible
Lateral butress brace
Electrical stim/K-tape
? 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
Chondromalacia
No swelling
Patellar winking- inc femoral anteversion/weak glut medias
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
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
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
Bowstring over femoral condyles
Medial- knee at 90* flexion w/ pop at 60* of flexion
Degenerative meniscal tear
RA
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 ?
> 40 w/ degenerative arthritis
Gastroc/Semi-tendon
Tibial nerve: plantar surface numbness
DVT
How are ruputres Baker’s Cysts Tx non-op
? four injury mechanisms can suggest issues w/ PCL
? is most sensitive test for PCL damage
Analgesic Rest Elevation
Dashboard injury
Fall on flexed knee w/ foot plantar flexed
Pure hyperflexion injury
Hyperextension after ACL= dislocated knee
Posterior drawer
How are PCLs Tx non-op
What movement needs to be avoided
Any suspected PCL tear needs ? test done during assessment
Resolve swelling/Restore motion x 1-5 days, then:
Strength w/ emphasis on short arc terminal extension 30-0* of flexion
Hamstring curls
ABI
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
Tibialis posterior
Pes planus
Tenderness along posterior medial crest
Pain w/ plantar flexion
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
Anti-pronation
Foot functional?
Anticipated limb length discrepancy?
9-12mon
Define Longitudinal Deficiency of Fibula
All of these PTs need ? Tx
What is the classification method
MC long bone deficiency, absence of fibula
Limg length discrepancy
Kalamchi:
1A- minimal shortening
1B- partially present
2- absent
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
Congenital Heart Dz Cleft palate Imperforate anus Hypospadias Hernia Gonad malformation
Hand anomalies
Flexed thigh, Abducted, Externally rotated
FABER’d
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
Less organ anomaly involvement
Patellar mal-tracking
Bipartite patella- superolateral corner
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
Strengthening medial head of quad
FamHx
Female gender
Barlow- provocative; attempt to displace femur head posterior
Ortolani- relocates dislocation
? 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
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
? 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
Blount Dz- abnormal growth between posterior and medial tibial physes
4y/o
AC injection
PT seated
Neviaser portal (posterior clavicle, anterior scapula)
Supralateral to inferomedial direction
Posterior Shoulder Injection/Aspiration
Pt seated
Palpate coracoid
2cm medial, cm inferior to posterior acromion corner
Thumb on posterior soft spot
Aim for coracoid tip
Subacromial Bursa Injection
Pt seated w/ arm in lap
Posterior- lateral corner of acromion
1cm inferior, 1cm medial
Needle angle 20-30*
Elbow Joint Injection/Aspiration
Pt supine
Arm against chest w/ 90* flexion
Soft-spot portal:
Lateral epicondyle
Radial head
Olecranon tip
Over anconeus muscle
Tennis Elbow Injection
Arm against chest w/ elbow flexed at 90*
Inject at point of max tenderness
Inject through Extensor Carpi Radialis Brevis muscle
MCP/PIP injection site
Thumb CMC injectio site
Wrist aspiration/injection site
Dorsolateral
Between CMC and Trapezium
1cm distal to Lister’s, 1cm distal to radius
Divot= radiocarpal joint
Needle angle 10-11* distal to prox
Carpal Tunnel Injection
De Quervains injection
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
Hook removal technique for Right Hand
Trigger Finger Injection site
Trochanteric Bursitis Injection
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
Knee Injection/Aspiration
Pes Anserine Bursa Injection
Pt supine
Lateral knee entry- 1cm lateral, 1cm superior to superiolateral patella
Bursa: between Gracili/Semi-tendon and MCL
Hit bone, withdraw 1-2mm
Ankle Joint Injection
Where do the sensory nerves travel in the foot
1cm prox to medial malleolus
Plantar side of tarsal
Mortin Neuroma injection
Plantar Fasciitis injection site
Chronic Stress Fx of foot are more likely to develop ?
1-2cm proximal to toe web
Medial calcaneus, 2cm from plantar surface
Jones
Navicular
