Ortho by Dr Riwa Flashcards
Plexus Brachialis - Major Branches
- Musculocutaneus nerve ( C5, 6, 7) - M. Biceps brachii, brachialis,
- Axillary nerve (C5,6) M. deltoidius, regimental badge sign
- Median nerve (C5 -T1) - All flexors of the forearm except 1.5
- Radial nerve( C5-T1) - All extensors
- Ulnar nerve ( C8-T1) - 1.5 Flexors, all intrigate muscles of the hand
Median Nerve (C5-T1)- motor/sensory
- Motor
all flexors of the forarm except F.carpii ulnaris and half of F. digitotum proundus
Lateral two lumbriccals and thenar muscles except Adductor polices - Sensory:
supplies palmar aspect of the lateral 3.5 fingers
Median course
- *Anterior compartment of arm *
Anteromendial,
**with brachial artery ** - **Forearm **
all flexors exept F carpii ulnaris and F digitorum profundus - Hand* *
through Carpal Tunnel
supplies lateral two lumbricals - *Terminal branches *
* Anterior interosseous nerve
* palmar cutaneus branch
* recurrent branch - supplies thenar musles
Median Nerve Injury - Elbow (supracondylar fractur of the humerus)
Motor: All motor lost
Sensory: lost
Classical Sign: Hand of benediction( when pat makes a fist) and Thenar wasting
Symptoms worse with rotation (pronation) of forarm
Median Nerve Injury - Wrist
(Laceration, Carpal tunnel syndrom)
Motor: Lumbricalis and thenar lost - thenar wasting
Sensory: Similar to injury at elbow except no sensory loss over thenar muscle
Median nerve injury - test anterior interosseous nerve
- Ok-sign
Carpal tunnel syndrom - cause
- idiopatic -mc
- inflammatory - RA/OA
- posttraumatic
- pregnancy
- endocrine (Myxedema/Acromegaly)
- Gout
- repititive wrist movements
Carpal tunnel syndrom -S/S
- Hand and wrist pain
- Paraesthesia
- Hyposthesia
- Patient wakes up at night with burning/aching, has to shake hand to restore sensation- CLASSICAL-IMPORTANT FOR EXAM
- Late signs- Thenar atrophy and weakness of thumb
Carpal tunnel syndrom - Examination
- Thenar wasting
- Phalens sign ( flexion of the wrist produces symptomes)
- Tinel sign ( tapping of the wrist produces tingeling)
- NCS - BEST TEST
Carpal tunnel syndrom - MX
First : splint/wrist bands
If not working: steroid infections
Best: Surgery to relase the flexor retinaculum
Radial nerve ( C5-T1) - Motor supply
Most commonly injured nerve
best prognosis post injury.
Motor:
- Axilla : long head of triceps (first elbow extensor)
- Spiral groove : lateral and medial head of triceps, Anconeus
- After piercing the intermuscular septum : Extensor carpi radialis (first wrist extensor)
- divides into-Posterior interosseous nerve (major motor nerve) which extends thumb & fingers and a superficial branch
Radial nerve ( C5-T1) - Sensory supply
Radial nerve injury - Axilla
- Saturday night palsy/ crutch palsy
- all sensory & motor function loss
- Wrist drop classical seen
Radial nerve injury - Radial groove
- Fracture of the humerus
MOTOR
* Triceps retained
* Extension of fingers and wrist lost ( Wrist drop)
SENSORY
* Arm and forearm retained
* sensation lost on dorsal lateral 3.5 fingers
Radial nerve injury -forearm superficial branch
- Laceration/stabbing
MOTOR - none
SENSORY - sensation lost on dorsal lateral 3.5 fingers
Radial nerve injury - forearm deep branch
- Fracture of the radial head or posterior dislocation of the radius
MOTOR - Majority of muscles in posterior forarm efected
** NO wrist drop ** - Extensor carpi radialis not effected Posterior interosseous nerve
SENSORY
* none
Ulnar nerve injury - Compression Pisohammat ligament (eg cyst)
- loss of sensation over fingers and hypothenar muscle wasting.
- Sensations over hypothenar eminence are spared
Ulnar nerve ( C8-T1)- Sensory Supply
PATTERNS OF SENSORY LOSS
Mononeuropathies
localised sensory disturbance in the area supplied by the damaged nerve
Peripheral neuropathy
symmetrical sensory deficits in a ‘glove and stocking’ distribution in the peripheral limbs, m/c diabetes mellitus & chronic alcohol excess.
Radiculopathy
due to nerve root damage (e.g. compression by a herniated intervertebral disc), -sensory disturbancesin the associated dermatomes.
Spinal cord damage
sensory loss both at and below the level of involvement in a dermatomal pattern
Thalamic lesions (e.g. stroke)
contralateral sensory loss
Myopathies
symmetrical proximal muscle weakness
Nerve injury - Clavicular
Brachial Plexus - Subclavian artery
Nerve injury - anterior GH dislocation
N.axillaris
Nerve injury - Surgical neck of humerus
N.axillaris
Nerve injury - Midshaft humerus
N.radialis
Nerve injury - medial epicondyle
N.ulnaris
Nerve injury - greater tuberosity of the humerus
N.axillaris
Nerve injury - Supracondylar humerus
Median nerve - brachial artery
Nerve injury - Colles
N.median
Nerve injury - ERB
Brachial plexus – high: C5 – C6
Nerve injury - Klumpke
Brachial plexus – low: C8 – T1
Biceps reflex
C5/6
Supinator -Brachioradialis reflex
C5/6
Triceps reflex
C7
Injury Ulnar nerve - at wrist
Sensory
* numbness in the little and ring fingers
Motor
* weakness of abduction of his little finger
* weakness of flexion of the terminal
phalanx of his little and ring fingers
Lumbar Plexus
- formed by anterior rami L1-L4 and contributions of T12
- Important Obturator and Femoral nerve
Obdurator nerve (L2-4)
- innervates muscles of the medial thigh
- obturator externus, adductor longus,adductor brevis, adductor magnus and gracilis
Femoral nerve (L2-L4)
- innervates muscles of the anterior thigh
- the illiacus, pectineus, sartorius and quadriceps femoris
Sacral plexus
- anterior rami S1-S4 and L4-5
- Important Sciatic nerve
Sciatic nerve (L4,5, S1-3)
**Tibial portion **
* muscles in the posterior compartment of the
thigh (apart from the short head of the biceps femoris)
* hamstringcomponent of adductor magnus
* muscles in the posterior compartment of the leg and sole of the foot
Common fibular portion
* Short head of biceps femoris, all muscles in the
anterior and lateral compartments of the leg and extensor digitorum brevis
* Motor fn- dorsiflexion and eversion
Myotomes - upper limb
C4 = shoulder shrugs
C5 = Shoulder abduction and elbow flexion
C6 = Wrist extension
C7 = Elbow extension and wrist flexion
C8 = Thumb extension and fingers flexion
T1 = Finger abduction
Myotomes - lower limb
L2 = Hip flexion
L3 = Knee extension
L4 = ankle dorsiflexion
L5 = Big toe extension
S1 = Ankle plantar flexion
S4 = Bladder and rectum motor supply
Complication of fractures and fracture healing
- Osteomyelitis
- Haemorrhage – Mostly seen with pelvic fractures
- Vascular/Nerve injuries- Popliteal artery / common peroneal nerve
- Avascular Necrosis- NOF fractures/ scaphoid/ talus
- Malunion / Nonunion
- Compartment Syndrome
Compartment Syndrome
- Emergency
- High risk : fractures of elbow/forearm/proximal third of tibia/multiple fractures of hand or foot/ crush injuries / circumferential burns / tight plasters/ infection/ post surgery
- > 6h - severe irreversible myonecrosis - Volkmans ischemic contracture
Compartment Syndrome - Clinic
Pain out of proportion with injury
Paresthesia
Pallor ( may last symptom with Pulselessness)
Paralysis
Pulselessness
Compartment Syndrom - RX
- SIGN- passive stretch test
if toes/fingers are passively stretched it results in pain in calf or forearm - Confirmation- Measuring the inter compartmental pressure
- clinical diagnosis
Compartment Syndrom - Mx
- Fasciotomy
Clavicle Fracture
- Fall onto affected shoulder
- Pat is supporting arm which is in full adduction
Clavicle Fracture - Things to look for
- Careful NEUROVASCULAR examination
- skin integrity to r/o open fracture
- lung fields to r/o apical lung injury
Clavicle Fracture - Classification
- middle third
- lateral third
- medial third
Clavicle Fracture - Middle third
- 80%
- Defined by shortening/comminution/angulation
MX
* Broad arm sling to support limb for 2 weeks or untilcomfortable.Regular analgesia as required
Clavicle Fracture -Lateral third
- 15%
- Around and lateral to
coracoclavicular Ligaments
Mx
* If undisplaced,no reduction required
* If displaced,refer
* Broad arm sling to support limb for 2 weeks or until
comfortable
Regular analgesia as required
Clavicle Fracture -medial third
- 5%
- Bony injury alone associated with sternoclavicular
dislocation - look for vascular,injury/neurological injury
Mx
* If Undisplaced,no reduction required
* If displaced,urgent referral
* Broad arm sling to support limb
Clavicle Fracture -medial third
Brachial plexus injury
Subclavian vessel injury
Shortening of the shoulder arc
Stiffness of the shoulder joint
Cosmetic side effects
Shoulder disslocation - Types
- Anterior- m/c
- Posterior- seen in seizures or electric shock
- Inferior dislocation (luxatio erecta)
- Superior dislocation
Shoulder dislocation - Anterior Clinic
- most common of trauma indirect & direct
Clinic
* injured shoulder in slight abduction and
external rotation, SUPPORTED by the normal side
* Presents with pain/ discomfort and inability to move the affected shoulder.
* ALWAYS do a careful neurovascular examination (axillary nerve)
Shoulder dislocation - Anterior RX/Mx
Rx
* Xray AP
* CT/MRI post reduction
Mx
* reduction in trauma bay under anaestesia
Fracture proximal humerus - Pathopysiology
- common in elderly (osteoporosis) - outstreched arm (low energy)
- High energy - risk of soft tissue and neurovascular complications
- Nerve - axillaris injury M/C
- Aterial - uncommon, higher risk in elderly x
Fracture proximal humerus - Rx/Mx
Rx
* X-ray
Mx
* Nonsurgical: in minimal displaced, Sling immobalisation, Pain relief
* Surgical: if multiple part fracture, review by orthop team
Adhesive Capsulitis
- = frozen schoulder - functional loss of passiv and active shoulder motion due to inflammatory process
- unilateral/bilateral
- clinical diagnose
- increased in DM
Adhesive Capsulitis - Presentation
- Pain partricularly at night
- Stiffness
- Global reduction in movements
On Examination-
* Global tenderness
* Active movements restricted
* Passive movements-restricted
* Power- normal
* Sensations-normal
Adhesive Capsulitis - Management
- Rest during the acute phase
- Analgesics + physiotherapy
- if pain doesn’t subside, Imaging guided injection :
1 ml corticosteroid with 2-5 ml 1% lidocaine
(may be done to divide the thickened ligaments +/-
acromioplasty)
general approach :
* stiffness present along with pain = arthroscopy to divide adhesions
* Pain alone present = NSAIDS / Steroid injection.
Impingement/ Rotator cuff tear
- subacromial impingement M/C cause for shoulder pain ( 4% in <40y, >50% in over 60Y)
Impingement/ Rotator cuff tear - Stages
- Subacromial impingement = first stage of rotator cuff disease
- continuum of disease from
Impingement and bursitis
Partial to full-thickness tear
Massive rotator cuff tears
Rotator cuff tear arthropathy
Impingement- Symptoms
- Pain-insidious onset,exacerbated by overhead activities and lifting objects away from body.
- night pain
Impingement - Physical examination
- Strength-usually normal
- Painful Arc Test-pain with arm abducted in scapular plane from 60° to 120°
- Active and passive movements usually full
Impingement - Rx/Mx
Rx
* X-ray - initially
* US - Next
* MRI - Best
Mx
* Anagesics+ Physio- initial
* Trial of steroid injections- next
* Arthroscopic decompression - best
Rotator Cuff Tear
- one or more of the rotator cuff tendons is
torn –> tendon becomes partially or
completely detached from the head of the
humerus. - Most tears occur in the supraspinatus tendon
Cause :
* injury
* wear (degeneration).
Types
* Partial thickness tear
* Full thickness tear
Rotator Cuff Tear - Symptomes
- Pain at rest and at night, particularly if lying on the affected shoulder
- Pain with movement
- Weakness when lifting or rotating your arm
Rotator Cuff Tear - Examination
- Active movements weak
- Passive movements normal
- Impingement+ Power weak
- often supraspinatus weakness( Jobes test/empty cane)
Rotator Cuff Tear - Rx/Mx
Rx
* First-xray
* Next-usg
* Best-MRI
Mx
* Analgesics+ rest
* Steroid injection
* Surgery
Fracture Midshaft humerus
- common fracture caused by twisting force following a fall
Clinic
* Severe pain/ deformity +/- wrist drop
* Check for : radial nerve
Investigation:
* X-ray
Treatment:
* Undisplaced: reduce and place a U-Slab, always check for radial nerve post reduction
* Displaced: surgery
Fracture Supracondylar
- m/c fracture in children around the elbow
- FOOSH = Fall on outstreched hand
- Hyper extention
Fracture Supracondylar - Clinic
- pain/ deformity
- always check for the integrity of the triangle
- Check: median/ulnar/radial nerve and brachial artery
Fracture Supracondylar - Types
Fracture Supracondylar - Rx/Mx
Rx
* Xray
Mx
* Rx = hyperflexion of the elbow
* then apply collar and cuff
* Cast only if displacement
Biceps tendon rupture
- proximal ruptur more common (90%)
Cause:
* Injury
* overuse due to age or repetitive oberhead movement ( tennis / swimming)
Biceps tendon rupture - Clinic
- painful pop
- pain
- weakness especially in supination
Biceps tendon rupture - Examination
Distal rupture:
* varying degree of proximal retraction of the muscle belly-“reverse Popeye sign”
* change in contour of the muscle, proximally
* medial ecchymosis
Proximal
* popeye sign
* change in contour of the muscle, proximally
* medial ecchymosis
Rx
* mostly pysical exam
* Xray
* MRI
Mx
* Older, limited use - proximal -conservative( rice and Nsaids)
* young, athletes- proximal - surgical repair
Pulled elbow
- children 3-5
- subluxation/dislocation of the radial head ( not stable in ligaments)
- axial traction and pronation of hand ( lifted with their wrist)
Pulled elbow- clinic
- pain
- refusal to use affected arm
- affected arm in flexion and pronation
- child will refuse supination
Pulled elbow - Rx/Mx
Rx
* clinical
* may Xray for conformation
Mx
* Reduction = Elbow flexion and supination under analgesia
* Hyperpronation/supination and pronation alternation
Flow chart - Child not using upper limb
Lateral epicondylitis - Tennis Elbow
- wrist extensor ( externsor carpi radialis brevis)
- 40-60a
- carpenter, gardener, computer, vioinist, dentist
Lateral epicondylitis - Clinic
- pain - outer elbow
- Rest pain/night pain
- pain during gripping and hand movements
- lateral tenderness
- wrist extension by extend arm reproduces pain
Lateral epicondylitis - Mx
- 6-24 month self limiting
- lifestyle modifications
- Nsaids/rice
- brace ( counterforce)
- Physiotherapy
- Stereoids with severe pain
Medial epicondylitis
- golfers elbow, forehand tennis elbow
- flexor origin
- reverse dumbell eexercise
Fracture of the forearm
- Monteggia
- Galeazzi
Both requiere surgery
Montaggia Fracture
Fracture of the proximal
third of the ulna with fracture of the
radial head and dislocation of the
proximal radio-ulnar joint.
Galezzi Fracture
Fracture of the distal third of
the radius with dislocation of the DRUJ.
Greenstick Fracture - definition
- incomplete fracture, in which on cortex is broken and bending of the opsite side
- kids
Investigation
* Xray
Treatment:
* Closed reduction
* Suitable for local anaest, manipulation and plaster
* Plaster for 4-6 weeks
Fracture types distal radius
intrarticular : Bartons fracture
Extra- articular: Colles/ smith fracture
Colles fracture
*extraarticular
* distal end of the radius (2cm)
* commenly in postmenopausal women
* mechanism = FOOSH +wrist extension
Colles fracture - Management
Colles Cast
* below the elbow
* Hand is mid pronation and ulnar
deviation.
* wrist joint will be in palmar
flexion = HAND SHAKING CAST
- high displacement: K-wires/open reduction using plates
- repeated X-rays are recommended at 1, 2 and 6 weeks to verify proper healing.
1.
Colles fracture - Complication
- M/C stiffness of fingers.
- 2nd m/c dinner fork deformity.
- Others
- Damage to the median nerve
- Rupture of extensor pollicis longus tendon
- Non-union (extremely rare)
Colles vs Smith- Xray
Colles vs Smith
Smith - Fracture
- extra articular fracture
- Distal end of radius – volar / ventral displacement
- Mechanism of injury = FOOSH + wrist in flexion
- Deformity = Garden spade deformity
- Management – POP cast below elbow / Surgery using plate fixation.
Bartons fracture
- intra-articular fracture
- fragment can be dorsally or ventrally displaced
- Needs surgical management
Scaphoid Fracture
- Common after Foosh injury
- Blood supply from distal to proximal > any # in the waist can lead to AVN
Scaphoid Fracture - Clinic
- Pain/Tenderness in anatomical snuffbox
- Pain/tenderness on axial compression
Scaphoid Fracture - Rx/Mx
Rx
* X ray followed by Mri
Mx
* Thimb spica cast for 4-6 weeks
* If on initial Xray no # but symptoms apply cast and retest in 1 week
De Quervains Tendosynovitis
Cause
* Cumulated injuries/ overuse
Effected tendons
* Extensor pollicis brevis and Abductor pollicis longus
RX
* Finkelstein Test - Localize pain at the base of the thumb
MX
* Splinting of the hand at night
* NSAIDs
* Steroid injections
Mallet finger
Cause:
* injury to the finger extensor
* tear of tendon/ distal avulsion
* Hyperextension/hyperflexion injury
(Ball hits distal phalanx)
Mx
* Mallet finger splint (hyperflexion of the distal interphalangeal joint for 6 weeks)
Trigger finger
Epidermiology/Pathophysio
* problem of the flexor tendons-locking tendon in flexion with difficulty of extension
* f>m, older, more in DM
* Affected pully: A1
* m/c Flexor digitorum profundus, ring finger
**Cause **
* trauma/DM/ Autoimmune conditions like RH/SLE
**Examination **
* inflammation
Mx
* initial: Rest, splinting, Nsaids, steroid
* Corticosteroids
* surgical release
Pelvic Fractures - Unstable
Pelvic Fracture - Clinical evaluation
- follow Atls protocoll
- neurovasc status of limb
- pelvic instability - length discrepancy with internal or external rotation
- peritoneum for open injuries
- Rule out vaginal or rectum involvement
Pelvic fractures - Complications
- Massive hemorrhage due to rupture of the venous plexus in the posterior pelvis/ large vessel injury
- Neurological injury- damage to lumbosacral plexus /nerve roots
- Genitourinary/gastrointestinal injury
- DVT/PE/Fat embolism
Pelvic fractures - Rx/Mx
Rx
* Xray
Mx
* Stable: strict bed rest
* unstable: Aplly pelvic binder
* may require ex fix before surgical exploration
Coxa vara/ valga
Shoulder pain differentials
Common shoulder conditions
Evaluation of Subacromial Impingement/Cuff Pathology
Comparison of important causes of hip pain in chidren
L4 ( Motor/reflex/sensory)
Motor : ankkle dorsi flexion deficit ( tibialis ant)
Reflex: patella reflex defizit
Sensory: medial leg, medial big toe
L5 ( Motor/reflex/sensory)
Motor: big toe, dorsiflexion deficit
Reflex: ankle reflex
Sensory: dorsum foot, anteroir lower leg big toe
Osgood schlatter
- children who play active sport
Symptoms
* pain with physical activity
Signs
* palpable lump below the knee
* red inflammed skin over tibial tuberosity
* sometime quadriceps loose strenght and bulk
Osgood schlatter - Mx
- rest
- ice
- Physio
- Analgesics
Proximal femoral fracture - Epi/Pathothology
- M/c in elderly, rare in young( high energy trauma)
- displaced : non ambulatory, shortend leg + external rotation
- Impacted or stress fracture: my weight bearing, more groin pain/pain on axial compression
Proximal femoral fracture Rx/Mx
Rx
* Xray
Mx
* Surgery: DCS/DHS/Nailing/Hemi/THR
Knee injuries
ACL- Anatomy
- runs from posterior femur to anterior tibia. Has two bundles- AM/PL
- prevent anterior tibial translation and internal tibial rotation.
ACL - Injury
Contact : football, basketball, netball
non-contact: post a jump
ACL- Injury- Symptoms
- Pain/audible pop
- swelling
- Instability - esp when climbing down the stairs/running ets
- LAchmans test and anterior drawer test positiv
ACL Injury - Rx/Mx
RX
* MRI
MX
* rest
* ice
* Surgical repair
* Physio
Meniscal injury
Meniscal injury
- walking/squatting
- trauma( twisting while leg is bent)
- wear and tear (older people)
Meniscal injury - Symptoms
- pain
- Swelling, typical delayed
- catch/locking of the knee
- Instability or the knee “giving way”
- Restricted range of motion
- Mc Murry +
Meniscal injury - Rx/Mx
RX
*MRI
Mx
*depend on location and zone involed
*rest
*ice
*Physio
*Surgery
*
Genu varum/valgum
Ankle injury
- sprain or fracture
Ankle injury- Symptoms
- pain
- swelling
- sprain: can weight bear
- fracture: no weight bearing
- watch out for displaced fractures can lead to neurovascular injuries
Ankle injury
- sprain - rice
- Fracture - cast boot , if displaced surgery
Ottowa Rule
Bony tenderness:
- along distal 6 cm of the posterior edge of fibula or tip of lateral malleolus
- along distal 6 cm of the posterior edge of tibia/tip of medial malleolus
- at the base of 5th metatarsal
- at the navicular
- Inability to bear weight both immediately after injury and for 4 steps during an initial evaluation
Achilles tendon injury
- overuse injury
- strain/partial tear or complete tear
RF
* overuse
* history of previous injury
* obesity
* family history
* Muscle and tendon stiffness
Achilles tendon injury- Symptoms
Tendinopathy
* pain
* swelling
Tear
* shot feeling
* Thompson test - no plantar flexion of the foot being observed
Achilles tendon injury- Mx
Initial: RICE
Splinting with ankle in plantar flexion
Definitiv: surgery
Spine- Acute lower back pain
- injury
- overuse
Spine- Acute lower back pain- Symptoms
- pain
- tenderness
- inability to do daily task
- Can radiate- down legs or be associated with tingeling or numbness
Lower back pain - Red flags
Tumour
* History of cancer
* Weight loss
* Night pain
* Age >40 or <15 years
Fracture
* History of trauma
* Risk factors for fragility fracture
Infection
* Fever >38.0°C
* Night sweats/chills
* Immunosuppression
* Intravenous drugs
* Concomitant infection
Cauda equina syndrome
* Urinary retention
* Saddle anaesthesia
* Worsening neurology – flaccid paralysis
Lower back pain - Rx/Mx
- Unless red flags, no radiological evaluation
- if red flag: Xray, MRI
MX
* no red flags: Analgesics/continue normal activity/Physio
* First line analgesics: Paracetamol
* second line : Nsaids
* Third : codein
Cervical spondylosis
- natural degenerative process of the cervical motion segment –> cervical radiculopathy, cervical myelopathy, or axial neck pain.
RX
* plain radiographs of the cervical spine
Mx
* observation, medical management, or surgical management
* depending on the severity and chronicity of pain, presence of instability or,presence of neurological deficits
Classification of Back pain
1- Acute low back pain lasts less than 6 weeks.
2- Sub-acute low back pain lasts between 6 and 12 weeks.
3- Chronic low back pain persists for more than 12 weeks.
A chronic back pain persisting longer than 3 months, requires further investigations to exclude central canal stenosis and nerve root compression.
Sacroiliitis - Investigation
1-HLA-B27
2-Chlamydia and Gonorrhea serology
3-RA factor, anti-ccp to rule out Rheumatoid arthritis
4-Inflammatory markers such as ESR and C-reactive protein.
Vit D Level
75-250 nanomole/L
Specific test after knee injury
- ACL (anterior cruciate ligaments) rupture-Lachman and pivot shift tests.
- PCL (posterior cruciate ligament) injury-posterior draw test and posterior sag.
- Meniscal injury -McMurray test.
- Collateral ligament injury – varus and valgus stress tests.
- Patella dislocation – patellar apprehension test.
Paget
Osteoporosis - Riskfactors
– Menopause
– Age over 70
– Corticosteroid use longer than three months – Rheumatoid arthritis
– Alcoholism
– Smoking
– Anorexia nervosa.
– Inflammatory Bowel Disease
Ottawa knee rules
to see if a x ray is reqiered in a child
A knee X-ray is required when a child presents after an injury with:
– Isolated patellar tenderness.
– Tenderness at the head of the fibula.
– Inability to flex at 90 degrees.
– Inability to bear weight immediately after trauma and in an emergency.
- Age over 55
Autonomic Dysreflexia
- after spinal cord injury T6 or above
- parasympatic signal cant travel below injury
- Hypertension, bradycardia, flushing and sweating above
