ortho Flashcards
anterior glenohumeral shoulder dislocation
abducted arm and externally rotated squared off shoulder axillary and y view hill sachs: groove on humeral head bankarlesion: glenoid inferior rim fracture
posterior shoulder dislocation
MC associated with seizures electric shock
adducted internally rotated
rotator cuff injuries
SITS: supraspinatus, infraspinatus, teres minor, subscapularis)
common in athelese with repetitive overhead movements
supraspinatus is MC
anteroir deltoid pain with decreased ROM especially with overhead activities, external rotation or abduction
empty can test: supraspinatus strength test
rotator cuff impingement tests
hawkin’s test: elbow/shoulder flexed at 90 degrees with sharp anterior shoulder pain with internal rotation
drop arm test: can’t hold arm above shoudler level or severe pain when slowly lowering the arm
neer test: arm fully pronated and thumbs downwith pain during forward flexion)
acromioclavicular joint dislocation
pain with lifting arm, unable to lift arm at shoulder, +dformity at ac joint
type I: just ac joint weakneed
type 2: ac rupture
type 3: ac rrupture and coracoclavicular lig ruptured too
humeral head fractures or proximal humeral fractures
CHECk DELTOID SENSATION- to rule out brachial plexus or axillary nerve injuries
Humeral SHAFT fractures
must rule out radial nerve injury- this injury may cause wirst drop
clavicle fracutre
tenting of skin, most common fractured bone in children adolescends and newborns during birth
figure of eight sling in children
proximal 1/3 –> ortho consult
adhesive capsulitis
frozen shoulders
(DM and hypothyroid)
shoudler pain/stiff for more than 18.24 months- decreased ROM especially external rotation, SIFF-pain cycle- pain worse at night
RHEAB, antiinflammatories, surgery
thoracic outlet syndroem
idiopathic copressions of brachial plexus, s
loss of radial pulse with head rotated to affected side
supracondylar huermus fracture
swelling, tenderness at the elbow, mc in children
displaced anterior fat pad sign or posterior fat pad sign
in children if psoterior or anterior fat pad- radial head fracture
complications: MEDIAN NERVE AND BRACHIAL ARTERY INJURY- volkmann ischemic contracture
RADIAL NERVE INJURY!
if displaced: ORIF!!
radial head fractures
inability to fully extend the elbow FOOSH posterior fat pad sign or displaced anterior fat pad sling, long arm if non-dsplaced if displaced- orif
suppurative flexor tenosynovitis
staph aureus MC- infection of the flexor tendon synovial sheath of the finger finger held in flexon lenght of tendon sheath is tender enlarged finger extension of finger causes pain
olectranon fracture
ulnar nerve dysfunction- inability to extend the elbow
ulnar shaft
nightstick fracture
nondistal 1/3— short arm cast
nondisplaced mid proximal 1/3: long arm cast
dispalaced: ORIF
monteggia fracutrue
proximal ulnar shaft fracture with an anterior RADIAL HEAD DISLOCATION!!!
RADIAL NERVE INJURY!!!
ORIF!
galeazzi
mid-distal radial shaft fracutre with DISLOCATION of DRUJ (distal radioulnar joint)- FOOSH
unstable- needS ORIF
nursemaid’s elbow
pessure on radial head with supination and flexion
lateral epicondyltisis- tennis elbow
lateral elbow pain - wrist extension and FORARM pronation against resistance- gives pain!!
medial epicondylitis
golfers elbow: WRIST flexion against RESISTANCE
elbow dislocation
posterior is MC type
r.o brachial artery, median, ulnar, radial nerve injury
scaphoid fracture
foosh anatomical snuffbox tenderness incidence of avascular necrosis if you miss this!! thumb spica!! displaced: ORIF
colles fracture
FOOSH With wrist extension-dinner form deofrmity - on ap colles and smith look same
EPL tendon rupture MC
sugar tong splint//cast!
dorsa/posterior angulation
smith fracture
ventral/anterior angulation- mc foosh with wrist FLEXION
lunate dislocation
lunate doesn’t articulate with both the capitate or the RADIUS!- emergent consult
piece of pie sign
spilled teacup sign
needs ORIF
complx regional pain syndrome
autonomic dysfunction following bone or soft tissue injuries
pain out of proprotion to injury
auto symptoms: swelling, extremity color changes, nail and hair growth increased
NSAIDS initial treatment
vitamin C prophylaxis after fracture- to prevent
mallet finger( baseball)
inability to straighten the distal finger (flexed @DIP)
tx: splint the DIP in EXTENSION X 6 weeks
boutonnier deformity
finger flexed @ pip join and hyperextended @DIP joint
swan neck
finger flexed @ DIP and hyper extended at pip joint
skiier’s thumb
ulnar collateral ligament of the thumb sprain or tear: instability of MCP joint of the thumb!!!
forced abduction of the thumb is mechanism
fracture at the base of the proximal phalanx
thumb spica!!!! it affects pincer function!!
boxer’s fracture
fracture at the neck of 5th metacarpal!!!
rotational deformity
ULNAR GUTTER SPLINT!!!!!!!!!!
bennett/rolando
orif
thumb spica
fracture of base of 1st MCP bone
SALTRE HARRIS
type I: growth plate fracture
type II: growth plate fracture and fracture of the METAPHYSIS!!! (good prognosis- MC)!!!!
type III: growth plate plus epiphysis
type Iv: extending through all
type V: growth plate compression: worst type
dequervian tenosynovitis
AP AND EPB
pain at the radial styloid,
+finkelstein test
thumb spica
carpal tunnel syndrmoe
volar splint and nsaids, palmar 1st 3 and 1/2 of 4th esp at night- paresthesais and pain
thenar muscle wasting- advanced
tinnel, phalens.
hip disloctations
posterior is MC
leg shortened and internally located and adducted
hip fracture
shortened leg, eternally rotated and abducted!!
high incidence of avascular necrosis with femoral neck fracturs
legg-calve perthes disease (ISCHEMIA)!!!!
idiopathic avascular osteonecrosis of the femoral head in children!!
ischemia of cpaital femoral epipphysis in children
PAINLESS LIMPING X weeks-
observation - self limiting within 2 years usually.
slipped capital femoral epiphysis (Slip)
african american male- obese young child- during growth spurt
hip, thigh, or knee pain with LIMP
ORIF!!!
MCL knee injury
valgus stress with rotation
LCL knee injury
VARUS STRESS!
ACL injuries
MC ligament knee- pop, swelling, hemarthrosis aND KNEE BUCKLING!!- inability to bear weight
lachmans’ -most sensitive test
atnerior drawer test
tibia slides in front of femur in lachman’s
meniscal tear
medial! most common
LOCKING, popping, giving away, effusion after activities
MCMURRAY’s sign (pop or click while the tibia is externally and internally rotated)
nsaid
patellar fracture
sunrise view radiographs
patellar dislocation
mc laterally!!
+apprhension test!
tibial-femoral dislocations
complication: popliteal artery injury!!!
or pernoeal or tibial nerve injury
pernoeal nerve injuries
check 1st web space
osgood shclatter disease
chronic knee pain in young, active adolescents
growth spurts!- atheletes
painful lump below knee
tenderness to the anterior tibial tubercle
Quad stretching, rice, nsaids
chondromalacia (patellafemoral syndrome)
MC in runners
anterior kne pain behind or around the patella worsened with knee hyperflexion (after prolonged sitting)
+apprehension test
nsaids, rest, rehab- strengthen the vastus medialis and quads
ankle dislocations
posterior MC
ankle sprains
anterior talofibular mc- is the main stabilizer during inversions
POP, swelling, pain, inability to bear weight
ottawa ankles
pain along lateral malleolus pain along medial malleolus nvicular pain 5th metatarsal pain inabiilty to walk more than 4 steps at time of injury
achiles tendon rupture
increased risk with fluroquinole use
sudden heel pain pain after push off movement- pop, sudden sharp calf pain
thompson test: waek , absent plantar flexion when gastrocnemius is squeezed
stress (march) freactures
military, 3rd metatarsal mc
plantar fasciitis
heel pain, tenderness at the plantar fascia of medial foot, pain worse after period of rest!!- first few steps in the moring are most painful- then decrease over tiem
tarsal tunnel syndrome
posterior tibial nerve compression
bunion - hallux valgus
deformity of the bursa over teh 1st metatarsal
1st metatarsal LATERAL deviation!!
charcot’s
diabetic foot
result of peripheral neuropathy from DM- joint damage and destruction
obliteration of joint space!
mc affects midfoot
morton’s neuroma
painful mass near the tarsal head
3rd metatarsall head MC
glucocorticoid injection
jones fracture
transverse fracture thrugh the diaphysis of the 5th metatarsal
psuedojones
transverse avulsion fracture at base of 5th metatarsal
herniated disc
mc in L5-S1
l4
A- anterior thigh pain, sensory loss to medial ankle, ankle dorsiflexion weak, loss of knee jerk
l5
L- lateral thighleg, hip groin pain, beetween first and second toes sensory loss, dorsum of footbig toe dorsiflexion!!! walking on heels more diff than on toes
loss of ankle jerk
s1
P- posterior thigh , plantar surface of the foot, plantarflexion, loss of ankle jerk`
Scoliosis
more than 10 degree curvature- maybe associated with kyphosis (humphback)- forward bending test: cobb’s angle measured on ap/lateral firlms- observation mostly
Bracing if 20-40 degrees
surgery if 40
spondylolysis
pars interarticularis defect
spondylolisthesis
forward slipping of a vertebrae on another
osteomyletitsi
mc in children- staph arueus mc
salmonella- for sickle cell disease
acute hematogenous spread: mc route in children
pain over the involved bone
ESR will be elevated
BONE aspiration: gold standard
periostial reaction- lucent areas of cortical destruction
acute osteo
group b strep in newborns- naficillin or oxacillin
4 months old MSSA- staph aureusa: naficillin or oxacillin or cafzolin
mrsa: vanco
salmonella: 3rd gen cephalo or fq
puncture wound;: pseudomans: cipro
septic arthritis
MC: s. aruesu
neisseria gonrehea: sexually active young adults
neonates: group b strep
joint is single, swollen, warm, painful joint, tender, knee MC
feve
join fluid aspiration with lots of wbc, primary pmns, gram stain and culture
gram positive cocci: naficillin, or vanco
gram negative cocci: ceftraixone (gonorrhea)
gram neg rods: ceftriaxone or antispeudo: gentamicin
osteosarcoma
mc bone malignancy- mostly in adolescents
90% in metaphysis of the long bones- femur, tibia, humerus
mc mets to the LUNGS
hair on end or sunray/burst apperance on radiograph, codmans’
ewing sarcoma
mc in males young- femur and pelvis- periosteal reaction (onion skin) apperance, codman’s
chondrosarcoma
cancer of caritlage- MC seen in aDULTS!
punctate or ring and arc appearnce
osteochondroma
benign!- mc in young males
pedunculated, grows away from growth plate and involves medullary tissue
SLE
young females, sun exposure, estrogen
drug induced: procainamide, hydralazine, inh, quinidine
joint pain, fever, malar butterfly rash, pericarditis, pleuritis,
discoid: annular patch on face and scalp- heals with scarring
glomerulonephritis, retinitis, oral ulcers, alopecia
ANA best test initially
Anti double-stranded DNA and anti SMITH
antiphospholipid ab syndrome- arterial and venous thrombosis
tx: sun protection, hydroxychloroquine, nsaids or aceaminophen for pain
scloroderma
tight, shiny , thickened skin CREST calcinosis, raynauds, esophageal motility disorder and sclerodactyly- spares trunk, face and neck affected, ANTI CENTROMERE AB DMARDS!, corticosteroids
sjogren’s syndrome
attacks exocrine glands- salivary glands, dry mouth, dry eyes, partoid enlargemet
high incidence of non-hodgkin lymphma
ANTI-RO, anti LA
pilocarpine- cholinergic drug that increase lacrimation and salivation
fibromyalgia
widespread muscular pain, extreme fatigue, sleep disturbances, poor sleep/memory
difuse pain in 11 out of 18 triggerpoints for more than 3 months,
muscle biopsy: moth eaten appearance
TCA, duloxetine, ssri, neurontin is TX
polymyalgia rheumatica
proximal joints - shoulder, hip neck
giant cell arteritis- closely associated
bilateral proximal join aching/STIFFNESS, pelvic, neck and shoulder girdle!!
low dose corticosteroids
polymyositis
progressive symmetrical proximal muscle weakness- usually painless-
increased muscle enzymes
anti-jo 1
high dose corticosteroids
dermatomyositis
heliotrope, gottron’s papules, muscleenzymes increased- aldolas, creatine kinase.
aspirin
increases serum uric acid
junvenile idopathic arthirtis
children less than 16 years with mono or polyarthritis
oligoarticular: less than 5 joints, anterior uveitis
polyarticular: more than 5 small joints- most similar to adult rheumatoid arthritis
osteoarthritis
articular cartilage damage and degeneration
MC in weight bearing joints!!!
OSTEOPHYTE formation
evening joint stiffness- worsens throughout the dya!!
heberden’s node: dip,
bouchard’s :pip
ACETAMINOPHEN!- initially
nsaids- more effective- but secondly line for mod disease
rheumatoid
t-cell mediated destruction
pannus: granulation tissue that erodes into cartilage and bone
small joint stiffness: mcp, wrist, pip) worse with rest
morning joint stiffness- improves later in day
swollen tender erythematous, boggy joint
swan neck deformity
ulnar deviation at mcp joint
rheumatoid factor: best initial test
Anti-cyclic citrullinated peptide antibodies: most specific
narrowed joint space (osteopenia and erosions(
DMARDS:- reduces permanent joint dmaage: methotreate
nsaids for pain
DMARDS for reducing progression of RA
non biologic: : methotrexate, hydroxychlorquine- plaquenil (retinal tox), sulfasalazine
biologic: etanercept, inflixmab, adalimumab,
dif between RA and osteo
rheum: wrists, mcp, pip (Dip spared)
osteo: dip , thumb
r: morning stiff
Osteo: evening stiffness
r: osteopenia, symmetric joint narrowing
o: assymetric joint narrowing, osteophytes
GCA
headache, scal tenderness, jaw claudication, fever, visual changes
increased ESR!!!
temporal artery biopsy: def diagnosis
kawasaki
medium and small vessel necrotizing vasculitis- including CORONARY arteries
conjunctivites, RASH, extremity changes (erythema of palms and soles, desquation ,), fever, adenopathy, lip, swelling fissures and strawberry tongue, arthritis
coronary artery aneurysm, MI
INTRAVENOUS IMMUNE GLOBULIN AND ASPIRIN
polyarteritis nodosa
association with hep B
microaneurysms with rupture- hemorrahge- thrombosis-organi ischemia or infarction
renal: htn, renail failure, lungs usually spared, CNS neuropathy,
increased ESR- ANCA NEGATIVE!
CORTICOSTEROIDS!- tx
renal or mesenteric angiography shows: microaneurysms with abrupt cut off of small arteries
NO GRANULOMA
wegener’s
GRANULOMATOUS small vessel vasculitis - nose, lungs, kidney
upper resp /nose symptoms
lower respiratory tract symptoms
glomerulonephritis
saddle nose deformity, sinusitis, affects lungs wiht pulmonary hemorrhage, glomerulonephritis
+c-anca
corticosteroids and cyclophosphamide
goodpasture’s diase
IGG antibodies against collagen of alveoli and glomerular basement
Good pastures: Glomerulonephritis and pulmonary heomorrhage
linear IGG deposits in biopsy!
coticosteroids and cyclophosphamide
takayasu arteries
most common in asian young woman
aorta and aortic arch affected- affects large vessel
TIA, CVA, MI,
high dose steroids
microscopic polyangitis
non granulomatous, capillaries, arteries, veins
P-anca positive
steroids and cyclophosphaide
psoriatic arthritis
penicil in cup deformity, hla-b27, incresed esr,
sausage digits, assymettric arthritis!!- signs of psoriasis- pitting of nail
NSAIDS- DMARDS-TNf-inhibitors
ankylosing spondylitis
axial skeeton and sacroilliac joint and progressive stiffness
morning stiffness, back stiffness decrese with exercise and activity
sacroilitis
HLA-b27, increased ESR
bamboo spine
reactive arthritis (reiter’s syndrome)
autoimmune response to an infection in another part of the body
arthritis: asymmetric inflamation, conjunctivities, urethritis
can’t see, cant pee, can’t climb trees
chlamydia- most common cause, gonoreeha, salm, shigella,
HLA B27
NSAIDS
hyperexxtension injurry of knee
acl
osteogenesis imperfecta
Osteogenesis imperfecta, or “brittle bone disease,” is a group of hereditary conditions characterized by abnormal development of type I collagen leading to weak bones. In addition, patients have blue tinted sclera secondary to decreased collagen.
volar splint
for carpal tunnel syndrome
transient synovitis
comes after viral infection
acromonioclavicular joint separation
An acromioclavicular joint (ACJ) separation is classically described by the mechanism of action of falling on the tip of the shoulder with the arm tucked (adducted). Patients with ACJ injuries will have restricted range of motion secondary to pain, especially with overhead movement and axial traction applied to the arm. The most reliable physical examination test for acromioclavicular joint pathology is the cross-body adduction test.
most common cause of bone cancer
METS!
acrominoclavicular joint separation
Acromioclavicular joint injuries are common, and range from a mild sprain to complete disruption of the acromioclavicular joint (ACJ), with injury to the surrounding structures. The mechanism of injury usually involves either a direct blow, or a fall onto the shoulder with an adducted arm. Physical examination finding include pain, swelling, prominence of the clavicle, and point tenderness over the ACJ.
bicipital tendonitis
Yergason’s test is used to evaluate for a biceps tendon injury. It involves applying resistence to arm supination with the elbow flexed. Pain of the long head of the biceps is a positive test.
axial loading with rotation (MENISCAL )
. Axial loading with rotation
Catching and locking of the knee, with a positive McMurray’s test suggest that this patient has a meniscal injury. The most common mechanism causing this type of injury is axial loading with rotation, in which the patient twists on a weight-bearing knee. It is common in football, soccer, and basketball players.
A 3 year old boy is brought to the clinic by his mother. Up to this point he has been developmentally normal, but is now having trouble rising from the floor. Physical exam shows hip girdle weakness, enlargement of the distal muscles of the leg, and atrophy of the proximal thigh muscles. Lab studies reveal an elevated serum creatinine kinase. Which of the following is this boy’s most likely diagnosis?
Duchenne’s muscular dystrophy
motor test for median nerve
thumb opposition
bicipital tendonitis
E. Bicipital tendonitis
The Yergason test is done to evaluate for bicipital tendonitis. The test is done by having the patient flex their elbow to 90 degrees, the examiner then applies downward pressure on the patients forearm. The patient is then instructed to attempt to supinate against resistance. Eliciting pain with this movement is indicative of bicipital tendonitis.
jefferson fracture
C1
hangman’s
c2
if sciatica less than 4 weeks
observation is treatment.
