Ortho Block 2 Cram Flashcards
Define the 6 types of AC joint sprains
1- ligament sprain
2- joint widening w/ less than 100% elevation of AC joint
3- 100% superior displacement clavicle w/ inc CC interspace
4- superior and posterior clavicle displacement
5- 100-300% superior displacement clavicle w/ increased CC interspace
6- distal clavicle is in subacromial/subcoracoid space from arm abduction during injury causing clavicle to get stuck under short head of bicep
What images are ordered for AC joint injuries?
What are the adverse outcomes of this injury?
Bilateral AP to confirm Type 2-6
Weighted bilateral for Type 1-2
Deformity
Weakness
Pain
Numbness
What are the 4 types of shoulder arthritis?
Primary- age w/out trauma/Fx
Secondary- Hx of trauma/Fx
Rhematoid- bilateral, multiple joints across midline
Crystaloid- unicorn of shoulder
Define Shoulder arthritis
What type of ostephyte is associated w/ shoulder arthritis?
Destruction of joint cartilage w/ pain, loss of space and function
Goats beard- inferior spur in glenoidhumeral ligament
What will be seen on x-rays of shoulder arthritis?
Superior migration of the humeral head develops in associated w/ ? which leads to ?
Flattened humeral head
Inferior osteophyte
Posterior glenoid erosion
Superior migration
Rotator cuff tears
Causes loading of glenoid leading to rotator arthropathy
What would be seen on x-ray of RA in the shoulder?
How are shoulder arthritis cases Tx non-surgically?
Periarticular lesions
Osteopenia
Central glenoid wear
RICE, NSAID, Heat/Ice
CCS injection w/ posterior approach, max of 3
What are adverse outcomes of shoulder arthritis surgical Tx?
When are they referred to Ortho?
Thrombophlebitis
Emoblus
Intolerable pain
Dec functional range of motion after 3mon of non-surg Tx
What is the most common MOIs of transient brachial plexy?
Upper/middle trunks (C5-7): Traction force on shoulder w/ head tilted to opposite direction
Post-ganglionic
Lower trunks (C8-T1):
Nerves stretched w/ arm abducted/ hanging
Pre-ganglionic, poor prognosis
What is a unique finding of pre-ganglionic brachial plexy?
What is the cornerstone of an accurate diagnosis of Burners/Stingers?
Horners- ipsilateral myosis, anhidrosis, enophthalmos
Neuro exam
What type of images are ordered for burners/stingers?
What unique presenting Sxs can post-ganglionic burner PTs present w/ ?
X-rays of C-spine and shoulder girdle
Painful rhomboids and anterior serratus muscles
What is the first step to management of PTs w/ burners presenting with bilateral upper/lower extremity radicular Sxs?
What are 4 things required prior to a person returning to sports/duty after having a burner?
Treat as spinal cord injury until proven otherwise
Resolution of pain/neuro Sxs
Normal neuro exam
Full cervical ROM
How are brachial plexus burners Tx non-surgical
What additional study could be ordered to assess nerve function?
Strength/stretch
Splint to maintain PROM
Nerve conduction study:
Electromyogram- motor function
Velocity- tests speed of signals
What do recurrent episodes of burners/stingers suggest?
What are the adverse outcomes of this condition?
Cervical stenosis
Inc risk for spinal cord injury
Pain
Sensation loss
Weakness
Amputation
What is an indication to refer a PT w/ a burner/stinger to Ortho?
Frozen shoulder is AKA ? and defined as ?
Worsening neuro Sxs
Adhesive capsulitis
Idiopathic (non-traumatic) loss of A/PROM
What is the are most common risks of adhesive capsulitis?
Where is the pain located for these PTs?
Type 1 DM
Hypothyroid
Dupuytren Dz
At deltoid insertion
How is Frozen Shoulder movement limitations different than arthritis limitations?
What term is pathognomonic of this condition?
Worse w/ external rotation
Contracture of coracohumeral ligament which limits external rotation
What findings would be see on MRI of a frozen shoulder?
How are these cases Tx nonsurgically?
Contracted capsule
Loss of inferior pouch
NSAID, heat, stretching
How are frozen shoulders Tx w/ surgery?
How long does it take for a shoulder to freeze and release?
Arthroscopic capsule release
Freeze in 48hrs
Thaw in 6-24mon
What happens to frozen shoulder PTs who take therapy too aggressively?
When do these PTs need to be referred?
Fx of humerus
No pain/movement improvement after 3mon
What muscle is the primary raiser of the arm?
This muscle is pulled under what structure during movement?
Supraspinatus
Under coracoacromial arch
What are the two causes impingement?
Where do these PTs have their pain localized to?
Loss of blood supply and mechanical damage
Lateral shoulder under acromium
Worse w/ abduction between 90-120* and lowering arm
PTs with impingement usually have what 3 positive tests during PE?
These 3 tests only indicated there’s an issue where?
Neers, Hawkins, Jobes
Supraspinatus
What tests are done during PE to differentiate between impingement, rotator cuff or AC joint origin?
What is the goal of PT for these PTs?
Drop arm- r/o rotator
Cross arm- r/o AC joint
Perform overhead movements w/out pain
What is the non-traumatic trifecta leading to rotator cuff tears?
What type of motion changes will be seen?
Degeneration, impingement, dec blood supply
Normal PROM, dec AROM
How quickly do traumatic rotator tears need to be surgically repaired?
PTs w/ rotator cuff tears will have pain localized where?
W/in 6wks
Insertion of supraspinatus on lateral arm
What are the goals of PT for rotator cuff tears?
The term ‘torn rotator cuff’ includes a tear to what 2 muscles?
Reduce pain
Inc strength, ROM
Restore function
Supra and Infraspinatus
Acute roator tears are often associated with a ? tear
When are these PTs referred to Ortho for surgery?
Splitting- parallel to tendon fibers
Acute tears, less than 6wks
What type of PT is more likely to have a proximal bicep tear?
Where will these PTs have TTP?
Older w/ rotator cuff dz
Over bicep groove
What movement can be done to accentuate proximal bicep tendon tears?
What is an adverse outcome of this condition?
Ludington test
Loss of 10% of elbow flexion/forearm supination (screwdriver)
When are PTs with proximal bicep tendon tears considered for surgery?
Which head of bicep is the long/short head?
Under 40y/o athletes
Older PT w/ concomitant rotator tear and persistent Sxs
Lateral- long
Medial- short, attaches to coracoid
What image is ordered after a + Lundington test?
Where is a ruptured proximal bicep tendon screwed back into the arm during surgery?
MRI ASAP
Distal to surgical neck of humerus
What are the most common directions of shoulder dislocation?
What does TUBS and AMBRI stand for?
Anterior and Multidirectional
Traumatic Unidirectional Bankart lesion Tx w/ surgery
Atraumatic, Multidirectional, Bilateral, Rehab preferred, Infierior capsule shift
Bankart lesion is a tear of ?
How is the arm placed in order for a posterior dislocation to occur?
Anterior glenoid labrum
Adduction and internally rotated
PTs that can voluntarily dislocate shoulders are indicative of ?
Subluxation of the shoulder is more associated w/ ?
Multidirectional instability
Poor surgical Tx prognosis
AMBRI
What nerve needs to be assess before and after shoulder dislocation/reductions?
What type of force creates a Hill-Sachs lesion?
Axillary- assessed for deltoid dysfunction and lateral arm numbness
Compression Fx from posterior humeral head pressing on anterior edge of glenoid
Ant, Post, Inf disloactions are associated w/ ?
What are the adverse outcomes from this type of injury and who is more likely to have this outcome?
Ant- most common
Inf- multi-directional instability
Post- seizure, shock
Axillary dysfunction
Osteoarthritis
Persistant dislocation- younger PT or w/ multiple episodes
What kind of x-rays are ordered to assess shoulder dislocations?
First time dislocations are Tx ?
Scapular Y-views
3wk immobilization in neutral rotation
PT w/ supraspinatus strengthening
How should PTs w/ AMBRI be Tx?
When do these PTs need to be referred to Ortho?
Nonsurgical w/ aggravation avoidance
Two or more dislocations inside of 3mon of shoulder rehab program
Intolerable multi-directional Sxs
What makes the bicep anchor?
What tests are done during PE for suspected SLAP tears?
Long head tendon confluency w/ labrum at superior glenoid labrum
Speeds
Resisted Supin/Rotation
What is the gold standard for viewing SLAP tears?
How are they Tx non-surgically?
MRA w/ gadolinium
NSAID
Rotator/periscapular stabilization
Capsule stretches
Strengthening
What is the only surgical option for SLAP tears that don’t respond to non-surgical Tx?
What is the most common outcome of Tx?
Dx shoulder arthroscopy
Shoulder stiffness
What can cause TOS?
This can present mimicking ?
Compression of brachial plexus/subclacian vessels from cervical rib, large C7 transverse process, anomalous fibromuscular band
Ulnar nerve entrapment w/ paresthesia of little/ring finger
What images are ordered for TOS?
What are two rare outcomes of this syndrome?
AP/Lat- assess ribs/processes
PA/Lat- r/o apical tumor/infxn
Ulcers
Raynaud’s
What types of activities need to be avoided when Tx TOS at home?
What are the 4 types of arthritis in the elbow?
Avoid overhead activities
Strenuous aerobics
Sleeping on affected side
Primary OA- age
Secondary OA- trauma/Fx
Rheumatoid- most common cause of elbow destruction
Crystaloid- gout/pseudogout
Most PTs with rheumatoid elbow arthritis will also have ?
Which one will present with swelling and warmth?
Bilateral shoulder, wrist, and hand in 90% of PTs
Non-rheumatoid inflammatory arthritis
If effusions are present in elbow arthritis, what are they aspirated and tested for?
How is RA of the elbow Tx?
WBC, Culture, Gram, Crystals
DMARDs
CCS injections
Rehab/Surgery
What will be seen on x-ray of Primary OA in the elbow?
What will be seen x-ray of RA in the elbow?
What will be seen in crystaline arthropathy?
Narrowed joint space
Sub- chondral cyst
Articular bone spur
Osteopenia
Erosion at bone margins at synovium
Sub-chondral erosion
Peripheral bone spurs
What are the primary reasons to refer elbow arthritis PTs to Ortho?
What muscle originates at the site of Lateral Epicondylitis?
Loss of ability to self care/daily activity completion
Extensor Carpi Radialis Brevis
How do PTs w/ lateral epidcondylitis present?
How do PTs present w/ medial epicondylitis?
Pain in lateral elbow with gripping and wrist extension
Pain in medial elbow w/ wrist flexion and forearm pronation
What are the non-surgical Tx options for epicondylitis?
What mis-diagnosed nerve entrapment syndromes can lead to surgical Tx failures of epicondylitis?
Modify/stop movement is most important
Protein Rich Plasma injection w/ buffy layer
Dry needling
PIN w/ lateral
Ulnar w/ medial
What are the 4 stages of humeral epicondylitis Tx?
What is the most common adverse outcome of surgical Tx?
Reduction of overload
Promotion of strength
Return to activity
Maintenance
Incomplete pain relief
What is the difference in Tx of Medial and Lateral epicondylitis?
Why is the olecrananon easily irritated and inflamed?
Medial Txs done by Ortho
Superficially located on extensor side of elbow
How are different size olecranon bursitis cases Tx?
Small/mild Sxs- NSAID, activity modification
Sxs- aspiration for Dx and therapeutic relief
Non-septic- elastic compression bandage
Septic- ABX w/ PCN resistant Staph A coverage and decompression
When do olecranon bursitis cases need to be referred?
Define the Cubital Tunnel
Recurrence w/ 3 or more drainage
Passage of the ulnar nerve on the posterior side of medial epicondyle between humeral and ulnar heads of flexor carpi ulnaris muscle
Define the Radial tunnel
Define Pronator Syndrome
Spit of radial nerve at lateral elbow, most common is PIN compression
Compression of median nerve at elbow
What are the top two most common nerve entrapments of the upper extremity?
What can cause ulnar palsy?
Carpal tunnel syndrome
Ulnar nerve compression
Repetitive subluxation or dislocation of ulnar nerve on elbow flexion
PIN causes ? Sx and is commonly mis-Dx as ?
What does the PIN innervate?
Lateral elbow pain
Lateral epicondylitis
Thumb, finger, extensor carpi ulnaris
Where is the PIN most commonly compressed and what usually compresses it?
What causes Pronator syndrome to be Dx late?
Fibrous bands between supinator muscle heads of radial tunnel
Vague Sxs
Frequently w/ workers com claims
What is the most common cause of Cubital Tunnel Syndrome?
What are two common causes?
Hyperflexion of elbows
Sleeping on elbows
Resting arm while driving for long periods
How is radial compression Sxs different than lateral epicondylitis Sxs?
What is a late Dz issue?
Radial compression TTP distal to condyle
Weak extension of fingers
What tests are done when evaluating median nerve compression?
What Sxs will not be associated w/ this compression syndrome?
Pronation movements
Nerve is motor only, no numbness/tingling
What special tests are done for nerve compression syndromes of the elbow?
What further studies can help differentiate these?
Tinels
Elbow flexion test
Middle finger resistance test for radial tunnel
Electromyographic/conduction study
What is the most important step of elbow nerve compression syndrome Tx?
When are PTs w/ ulnar compression syndrome referred for surgery?
Modifying activities/reducing pressure
Bothersome Sxs after 3-4mon of non-surgical Tx
When are PTs w/ radial/pronator compression syndromes referred for surgery?
What are the red flags for referral of the compression syndromes?
Discomfort after 3-6mon of non-surgical Tx
Weakness/atrophy of intrinsic muscles
Inc numbness
Persistent/debilitating Sxs
What are the adverse outcomes of a distal bicep tendon rupture?
What PTs are not Tx w/ surgery?
15% loss of strength
50% loss of supination
Older/sedentary lifestyle not requiring flexor/supinator strength
What are the adverse outcomes of distal bicep tendon rupture surgical Tx?
How quickly does surgical repair have to be done?
Damaged radial nerve
Hetertropic ossification
Chronic pain
1-2wks from injury
What is the primary elbow structure that resists valgus stress?
What is a common Sx seen?
Ulnar collateral ligament
Paresthesia along ulnar nerve during throwing motion
What PE finding during assessing ulnar collateral ligament tear can mislead to a Dx of Primary Ulnar Neuritis?
What imaging is used for Dx?
+ ulnar nerve Tinel sign
MRI w/ contrast
What is a rare adverse outcome of an ulnar collateral ligament?
What Otho Tx step needs to be avoided?
Hindered daily living
UCL tear
What is the name of the procedure used to correct a torn UCL?
What is the most common cause of wrist arthritis?
Tommy John
Previous trauma- Fx
RA
Typical OA findings of wrist arthritis
What would be seen w/ RA?
Joint narrowing, subchondral sclerosis, bone spurs
Osteopenia, Erosion at capsule
What is a unique lab ordered when working up wrist arthritis depending on geography?
What lab tests are done to test for RA in the wrist?
Lyme Dz titer
ESR, Rheumatoid factor, Anti-nuclear Abs, Uric acid
When are wrist arthritis PTs surgical candidates?
When are these PTs referred for red flags?
Dec hand function
Unstable joint
Failed non-surgical Tx
Infection in wrist
Advanced Dzs
Non-surgical Tx failure
What is the most common compression neuropathy of the upper extremity?
What are common precipitating issues that can lead to this common syndrome?
Carpal tunnel syndrome
Tenosynovitis of adjacent flexor tendons
Pregnancy (bilateral)
DM
Thyroid dysfunction
How do PTs w/ carpal tunnel present?
What is the most useful Dx test but is rarely used?
Numbness in thumb, index, long finger
Pain worse at night
Thenar atrophy
Electophysiologic testing
What tests can be done during PE for carpal tunnel?
Define de Quervain tenosynovitis
Reverse/Phalen test
Carpal compression test
Tinel’s
Swelling of sheath around abductor pollicis longus and extensor pollicis brevis
How is de Quervain tenosynovitis Dx’d?
What images need to be done?
+ Finklestein test
PA/Lat x-ray to r/o radial styloid deformity
How is de Quervain tenosynovitis Tx non-surgically?
What is the most common soft tissue tumor of the hand?
Splint- forearm/thumb spica
NSAID
CCS injection- max of 3
Wrist ganglion
What type of fluid is inside of ganglion cysts?
What is a key factor to distinguish a ganglion from other soft tissue tumors?
Thick, clear, mucinous identical to joint fluid
Variation in size
Where do mucus cysts usually grow?
What is the most common site for ganglions to grow?
Extensor tendon at DIP
Palmar side near A1 pulley near MCP joint
When is a MRI ordered for ganglion cysts?
Define Kienbeck Dz
Volar cyst near radial nerve/artery and prior to surgery
Osteonecrosis of lunate, usually in men 20-40y/o
What type of ganglion cyst should never be aspirated?
How do PTs w/ Kienbeck Dz present?
Dorsal cysts on fingers
Inability to grasp heavy objects
Stiffness/swelling
What will be seen on x-rays early/late in Kienbock Dz?
What imaging is usually used to stage the Dz?
Early- inc density (white)
Late- fragmentation/collapse of bone
MRI
When are Kienbock wrists splinted for Tx?
What is the top 3 most common benign soft tissue tumors?
Normal radiograph/significant sclerosis w/ NSAIDs
Ganglia, Giant Cell tumor, Epidermal inclusion cyst
What is the most common benign neoplasm of the hand bones?
What is the most common malignant neoplasm of the hand?
Enchondroma- cartilage didn’t change into bone development
Squamous cell carcinoma
What are the most common primary malignant bone tumor of the hand?
Where/why are malignant melanomas seen?
Chondrosarcomas
Upper arm from sun exposure
Most tumors of the hand are painless w/ ? exception?
How can you differentiate ganglions, inclusion, giant, glomus cysts on PE?
Glomus tumor- pain w/ pressure or cold
Ganglion- transilluminate
Inclusion- swelling/white tuft at end of finger
Giant- firm, non-tender at IP joint of first 3 fingers
Glomus- finger nail changes
Where are lipomas most commonly seen?
Where are enchondromas most commonly seen?
Thenar emminence
Proximal phalynx associated w/ patholgical Fx
Where would a carpal boss be seen?
What types of x-rays need to be ordered for hand/finger masses?
Immovable mass on dorsal hand
PA/Lat- finger
PA/Lat/Oblique- hand
When do PTs w/ hand masses need to be referred?
What usually causes ulnar entrapment of the hand?
Painful/expanding mass
Interferes w/ function
Pigmented subungual lesion
Lipoma, ganglion, ulnar artery aneurysm or muscle anomaly
What is the path of the ulnar nerve through the hand?
What is innervated from this nerve?
Wrist, past psiform, under hamate hook and branches to senosry/motor branch
Sensor- to pinkly
Motor- thenar muscles
What special test is done during PE of ulnar nerve entrapment?
What are the most common animal bites but which ones are more likely to cause infection?
Allen’s test
Dog, then cat
Cat causes more infection due to deeper/sharper injury
What type of microbe is most commonly associated with dog/cat bite infection?
What are the other microbes that can cause an infection?
Pasteurella multocida
A-hemolytic strep
Staph A
Anaerobics- Bacteroides and Fusobacterium
If an animal bite presents w/ purulent drainage, this indicates the bite is at least ?hrs old
What makes dog or cat bites characteristic?
10-12hrs
Dogs grab and tear
Cats puncture and let go
Red streaks seen days after an animal bite indicate ?
What lab tests are usually ordered for animal bites?
Lymphangitis
CBC, ESR, CRP, Gram stain, Culture
How are animal bites that don’t have nerve, tendon or bone injury managed?
How are bites on a finger managed?
Debridment, Irrigate w/ 500-1000mL NS, out patient ABX
Anesthetic block for debridement
How are animal bites on the back of a hand managed?
What is the standard ABX for animal bites?
3-10mL of anesthetic infiltrated into the wound
Amoxicillin-Clavulanate 875mg PO BID
What IV ABX are used for infected animal bites?
When are PTs w/ animal bites referred?
Empiric IV ampicillin sulbactam 1.5-3g q6hrs
Tendon, nerve, joint capsule or Fx
What are the most common causes of arthritis of the hand and wrist?
What would be seen on on x-ray for the 2 major ones?
2* OA from FxHx
RA
Pseudogout
1* OA- dec ROM, pain, swelling
OA- Narrowing, Spurs, Sclerosis
RA- Osteopenia, erosion @ capsule/bone margin
When are wrist arthritis PTs T non-surgical and surgical/red flag referred?
What lab tests can be done to confirm a Dx of hand arthritis?
Non Surg= splint
Surg- dec function, unstable joint, non-surg failure
Red- infection, advanced degeneration, splint/NSAID Tx failure
ESR, CRP, RF, Anti-nuclear Ab, Anti-cyclic Citrulinated peptide Ab
What meds can be used for hand RA?
What joints are more likely impacted by OA and RA?
NSAID
Etanercept/Infliximab
CCS injections
OA: DIP, PIP, CMC
RA: wrist, MCP
What PT population is more likely to have thumb CMC arthritis?
What is the most common Sx they present with?
Female 40-70y/o
Opposition: pain at base of thumb w/ grip/pinch activities
What is the hallmark of thumb CMC arthritis?
What test can be done during PE for this?
Tenderness over palmar/radial joint aspects
Grind test- palm facing up and back of hand on table, thumb is pushed down with other joints extended
How are thumb CMC cases Tx non-surgically?
Define Boutonniere deformity
NSAID
Spica cast
OT
Central portion of extensor tendon rupture at insertion in middle phalynx causing PIP to extend/DIP hyperflex
What PE finding is indicative of a rupture of the central slip of the extensor tendon?
What movement will accentuate/worsen the deformity
PT lacking 15-20* extension at PIP
Palm closer to volar surface (wrist flexion)
What is the adverse outcome of an untreated Boutonniere?
How are these Tx non-surgically?
Flexion contracture of PIP and extension of DIP joints
Young PT- splint extended x 6wks
Older PT- splint extended x 3wks
Define Dupuytren contracture
Since this is usually a dominant genetic issue, who is it seen in?
Nodular thickening/contraction of palmar fascia
Northern European men +50y/o in the ring finger
What are the associated risk factors with a Dupuytren contracture?
How are they Tx?
DM, Epilepsy, Pulmonary Dz, Alcoholism, Vibration trauma
Splints will slow progression
Collagenese injections is FDA approved Tx
When are Dupuytren cases considered for surgery?
What are the 3 fingertip infections?
30* flexion of MCP towards palm
10* deformity of PIP
Both in pulp of finger:
Felon- bacteria infxn
Whitlow- viral infxn
Paronychia- either side of nail
What usually causes fingertip infections?
Why is correctly identifying felons/whitlows important?
Staph Aureus
Whitlow- HSV
I&D of whitlows are c/i
I&D of felons is recommended
What preceding factor usually causes the development of a paronchyia?
Felons and paronchyia usually have what 3 Sxs with them?
Manicure or hangnail
Tender, Red, Fluctuance
Felons and paronchyia usually stop at the distal digit crease, but if they pass that crease what issue is considered?
Felons can be drained w/ block and tourniquet through what 2 types of incisions?
Infectious flexor tenosynovitis
Central volar longitudinal
Dorsal midaxial
UNLESS- puncture causing the felon is in the finger pulp, then incision includes puncture hole
How are finger amputations in kids under 6y/o managed?
When is replantation a consideration?
Composite grafting w/ 4 or 5 chromic/plain gut sutures
Thumb amputation at/proximal to IP joint
Amputation proximal to middle of middle phalanx
Multiple fingers amputated
What two injuries immediately cause a loss of flexion in PIP and DIP?
Where doe the flexor tendons of the fingers insert and what kind of movement is allowed if one is cut?
Flexor digitorum sublimis
Flexor digitorum profundus
FDP in distal phalanx
FDS in middle phalanx
Cut FDP= PIP, MCP flexion
Cut FDS= DIP, PIP, MCP flexion
What happens in the traumatic rupture of the FDP in a finger?
These ruptures are often missed because they resemble ?
Ring finger caught and profundus tendon avulses from insertion
Jammed finger
What is the first and second test done during assessment of a flexor tendon injury?
Flexor tendons of the fingers are enclosed in sheath that extends from ? to ?
Active flexion
Strength of flexion
Distal palm
DIP
What tracking method is used for flexor tendon infections?
Kanavel signs 1- swollen finger (sausage digit) 2- held in passive flexion 3- pain to percussion/palpation of sheath 4- pain w/ passive extension
What kind of ABX are used for flexor tendon infections?
What microbe is most common in human bite infections?
Staph and Strep coverage
Eikenella corrodens
A-hemolytic strep
Staph A
If drainage is present in a human bite wound, what needs to be collected for lab?
What procedure is done if there is a possibility of joint infection?
A/naerobic cultures, WBC, ESR, CRP
Arthrotomy to irrigate
What type of ABXs should be sued for human bite infections?
Define Mallet Finger
PCN, 1st Gen Cephalosporins
Deformity of insertion of extensor tendon at base of distal phalynx causing PT to present w/ resting in flexed position and lack of extension
When are Pts w/ mallet finger referred to Ortho?
Subluxation of joint, suggesting collateral ligament involvement
Avulsion Fx larger than 1/3 of surface area of distal phalynx
How are subungual hematoma, nail bed lacerations and nail avulsions Tx?
Subungual- decompression
Bed- only remove nail if it’s floating and ready for removal
Avulsion- replace and suture in place through poximal fold to pull nail bed through
When do nail bed injuries need to be sent to ortho?
Trigger finger is AKA ?
Complex lacerations, Loss of tissue, Injury to germinal matrix, Open Fx
Stenosing tenosynovitis of flexor tendons
What causes trigger finger?
What are these often seen in conjunction with?
Thickening of flexor tendon near A1 pulley most commonly of long/ring finger
Middle aged women w/ RA*, DM, Hypothyroid
Higher association w/ Carpal tunnel and De quervains
What finger do kids develop trigger finger?
If they develop trigger finger anywhere other than this finger it’s usually due to ?
Thumb
Metabolic d/o
What happens during the creation of a nurse maid elbow?
What is done during PE?
Axial pull on radius
Radius head pulled out from annular ligament
Annular ligament becomes trapped in radiocapitellar joint
Neurovascular
Pronation/supination
TTP
How are nurse maid elbows reset?
Define Congenital Deficiency
Define Congenital Deformity
Full supination
Push on radial head medial
Flex hand to head
Ficiency- missing parts (hypoplasia, congenital d/os)
Formity- psindactyle,
Define Little League elbow
Define Osteochondritis dissecans
Traction apophysitis of medial epicondyle/olecrenon
Osteonecrosis of capitellum, rarely the radial head
Define Panner Dz
What imaging modality is used to confirm OCD, Panner or UCL injuries?
Under 12y/o w/ focal avascular lesion of capitellum
MRI
Neonatal brachial plexus palsy is AKA and what is the most common pattern?
What type of movement issues are seen?
Obstetric palsy
C5-6 Erbs Palsy
Weak elbow flexion, shoulder abduction, flexion and external rotation
Define Klumpke Palsy
PTs with this have poor prognostic factors that include ?
Neonate brachial palsy at C8-T1
Entire plexus
Horner (preganglionic, sympathetic)
Root avulsions
What happens during Torticollis?
What can cause ocular torticollis?
SCM contraction pulls head to affected side and rotated to unaffected side
Mandibular flattening on affected side
Occipital flattening on unaffected side
Nystagmus
Superior oblique palsy
What is the most common bony injury?
What type of x-ray is needed to confirm this?
Clavicle Fx
AP and 10* cephalic
What type of image is needed to confirm Fx/dislocations of the medial end of clavicles?
How are most midshaft clavicle Fx treated?
CT
Non-surgically
What type of PT exercises are started with clavicle Fx?
When are these Fxs referred for surgery?
Pendulum swings at 2wks
Shortened
Open
Neurovascular compromise
Painful nonunion at 4mon
What nerve is injured with Fx of humerus?
How many degrees of angulation is acceptable for non-surgical Tx?
Radial- inability to extend wrist/fingers, loss of sensation on back of hand at first dorsal web space
Less than 20* of apex anterior/lateral angulation
Less than 2cm of shortening w/ U-shaped coaptation splint
Define Floating Elbow
PTs in a Sarmiento Splint need to have what education piece upon release?
Distal humerus Fx
Proximal forearm Fx
Sleep upright, will feel sensation of suffocation if not upright
When are humeral Fxs referred to ortho?
What are the 4 segments of a proximal humerus Fx?
Non-union at 3mon
Greater tuberosity- supra, infra, teres minor
Lesser tuberosity- subscapularis attachment
Humeral head
Shaft
What is the most common Fx of the proximal humerus?
How does these Fx usually occur?
Two part Fx of the surgical neck, distal to tuberosities
Motion w/ torsion
What unique view of x-ray is needed for proximal humerus Fx?
How are these type of Fxs Tx?
Scapular Y-view
Sling for full 6wk healing period
ROM at 3wks
When are proximal humerus Fxs Tx non-surgical?
When are these Tx w/ surgery?
Less than 1cm displaced
> 1cm of displacement
45* of angulation
When are proximal humerus Fxs referred to ortho?
What are scapula Fxs associated w/?
Displaced 2 part Fxs
All 3 and 4 part Fxs
Polytrauma due to high energy MOI
Injuries to the Superior/Lateral aspect of the scapula need to go to ? for assessment?
How are they Tx?
CT
Sling and ROM at 1wk
What type of scapula Fx has the PT admitted for observation?
When are scapula Fxs Tx w/ surgery?
Body Fx
Displaced >2mm of articular step off
Neck of scapula w/ >30* angulation
Acromiom Fx w/ impingement
What are the most common elbow dislocations?
What structure is always torn?
Posterolateral
LCL
What is the terrible triad of the elbow?
What is the MOI for these injuries?
Radial collateral ligament
Dislocation
Coronoid/radial head Fx
FOOSH w/ elbow partially bent
What step must be done after elbow dislocation reduction?
What position are these arms splinted in after reduction?
CT to assess coronoid
Elbow 90* w/ arm fully pronated
If there are no Fxs/Terrible Triad, how long after elbow dislocations can they start PT?
When are these PTs referred to Ortho?
1wk
Terrible triad
Instability
Neurovascular injury
What are the 3 landmarks of the lateral elbow for introducing needles?
Which bone is screwed when surgically correcting a Terrible Triad?
Radial head
Lateral epicondyle
Tip of olecranon
Coronoid
What is a bad type of elbow Fx to occur in Peds?
How is this Fx assessed and cleared?
Supracondylar Fx
Bilateral x-rays w/ normal arm used for assessment
What step do all PTs w/ distal humerus and olecranon Fxs receive?
What is the MOI for olecranon Fxs?
Refer to Ortho
Fall onto flexed elbow
PTs w/ olecranon Fxs will get repeat x-rays to assess the amount of tricep pull every ? days?
How are these PTs Tx non-surgically?
1-2
Splinted w/ elbow at 45*
ROM at 2-3wks
What is the classification system used for Fx of radial head?
Mason
1- non displaced
2- >2mm displaced or angled enough to create mechanical block
3- severely comminuted Fxs of radial head and neck
Define a Lessex Lopresti Fx
What x-ray view is used to view the radial head?
Proximal radial head Fx dislocation down interosseous membrane to distal radial/ulnar joint w/ medial ulnar dislocation/deviation
Greenspan
When are radial head Fxs referred for surgery?
Define a Bennett Fx
Define a Rolando Fx
Mechanical block
>2mm step off at articular surface
B: oblique Fx of thumb metacarpal as it enters CMC joint w/ one small and one large piece
R: Y shaped intra-articluar Fx at base of thumb metacarpal
What is the primary concern of Bennet/Rolondo Fxs?
What causes Hook of Hamate Fx?
Secondary CMC OA
Holding objects and forces hitting the object
What PE finding is seen w/ Hook of Hamate Fxs?
What view is used on x-ray to assess the bones?
Ulnar compression Sxs
Carpal tunnel view
What type of cast are used on hamate Fx?
Define Colles Fx
Short arm cast (no thumb component) x 6wks
Most common Fx of distal radius when distal radisu Fx fragment tilts dorsally
Define Smith Fx
Define a Barton Fx
Opposite of Colles Fx
Distal radius Fx fragment tilted volarly
Fx of intra articular Fx associated w/ subluxation of carpus w/ displaced fragment of radius
Define Chauffeurs Fx
Define a Die-Punch Fx
Oblique Fx through base of radial styloid
Depressed Fx of articular surface opposite the lunate/scaphoid bone
When are Fxs of the distal radius sent for surgery?
> 5* dorsal angulation
15* radial angulation
2mm articular step off
Define Boxers Fx
What Fx is this the most common of?
Fx of distal end of 5th metacarpal
MC Fx of hand
What type of phalangeal Fx is the most commonly injured?
When are Boxer’s Fxs sent to surgery?
Distal
> 40* angulation
When are metacarpal Fxs sent to surgery?
Multiple Fxs
Shortening
Intra-articular Fx >1mm
>40% of articular surface involved
Where are the 3 scaphoid Fxs more likely to occur?
This is the most common ? Fx
60%- waist/middle
20% at proximal/distal pole
Carpal Fx
Since scaphoid Fxs are usually occult, when do they f/u?
What is done if they’re f/u is normal but w/ pain?
7-10 days for x-rays
Spica thumb cast
What is Gamekeeper’s Thumb
What is it AKA?
Torn thumb ulnar collateral ligament from hyper extension
Skier thumb
How are hand collateral ligement injuries Tx?
How are volar plate injuries Tx?
Splint/thumb spica cast x 6wks
Refer to ortho
What is the 4 most common elbow Fxs in kids?
What bone connects w/ the radius in the elbow?
Supracondylar
Lateral condyle
Medial epicondyle
Capitellum
What finding is useful for pediatric occult elbow Fxs?
When can peds elbow Fxs be treated w/ casts?
Posterior fat pad- hemearthrosis indication
Radial neck Fx w/ less than 30-45* angulation and kid is under 10y/o
What type of pediatric elbow Fx requires repeat x-rays?
What is the most common type of proximal humerus Fx in peds?
Condylar
SALTAR 2
How are neonatal clavicle Fxs treated?
How are proximal humerus Fxs Tx?
Left alone
Swath and pinned
How are young kids w/ clavicle/proximal humerus Fxs treated?
How are adolsecents Tx?
Under 5, <70*
5-12, 40-70*
+12, <40*
More than 2cm shortening= surgery
Humerus angulation 30-40* w/ <50% apposition
Define Galeazzi Fx
Define Torus/Greenstick Fx
Distal radius Fx w/ ulnar dislocation
Fx of distal forearm
Define Monteggia Fx
Radial head dislocation w/ Fx of ulna
How are replaced finger nails post-sutures wrapped and wound cared?
Flexor tendons of the fingers glide under ? annular and ? cruciform pulleys which keep them from ?
Ointment, non-adhesive gauze, sterile gauze, splint
4A, 3C
Keep tendons from bowstringing
What digits are more likely to be affected by trigger finger?
In pediatric UE x-rays, the radial head should be directed towards the ? on all views?
Ring, long
Capitellum
What type of x-ray can be useful when searching for subtle Fxs of the UE in a Peds PT?
Kids who have a positive posterior fat pad but no evidence of a Fx only have a ?% chance of having a bony injury and need ? support
Comparison view of uninjured elbow
80%
Posterior long arm splint/long arm cast
What is the most common elbow injury to kids under 5?
What can happen to the medial epicondyle in kids 8-12 compared to what can happen when they’re 12-14y/o?
Nurse maid’s elbow
Fragmentation: 8-12
Avulsion: 12-14
In Peds UEs, the medial side of the humerus is AKA the ? side and the lateral side is AKA the ? side?
What is the most common physical finding in little league elbow?
Medial- tension
Lateral- compression
TTP
Babies w/ brachial plexus palsy tend to have a poor prognosis if what 3 findings are seen?
What are signs that Erb’s palsy occurred at a pre-ganglionic location?
Panplexus palsy
Horner syndrome
Nerve root avulsion
Horner Syndrome
Phrenic nerve paralysis
Long thoracic, Dorsal scapular, Suprascapular, Thoracodorsal nerve involvement (TDSL)
What is the cornerstone of neonatal brachial plxus palsy treatment?
What must be suspected in infants that present with sudden loss of function in an extremity that was functioning at birth?
Assessment and monitoring
Sepsis
Abuse
What is the most common error when assessing a Fx of the proximal hymerus?
How are these types of Fx Tx non-surgically?
Missed Dx of shoulder dislocation
Less than 1cm displaced w/ sling and PT at 3wks
When do proximal humeral Fxs need surgical repair?
More than 0.5cm separation of tuberosity
2 parts through humeral neck
All 3 and 4 part Fxs
What do 4 part proximal humeral Fxs need surgery?
Interrupted blood supply, need prosthetic replacement
