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Ortho: Phase 2 Flashcards

1
Q

Difference between amputation and disarticulation

What 3 disease processes account are the cause for 2/3 of amputations?

Define Ray Resection

A

Amp- through bone
Disart- through joint

Majority: DM, Infection, PVDz
Remaining: Trauma Tumors Congenital

Toe and all/part of metatarsal

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2
Q

Mid-foot amputations are performed through what level?

What are two common adverse outcomes of hindfoot amputations

Define Syme Disarticulation

A

Trans/Tarso-metatarsal

Dec function
Poor prosthetic management

Foot disarticulated at ankle, heel pad covers site

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3
Q

Below the knee amputation is AKA ?

Above the knee amputation is AKA ?

? is the initial step for prosthetic pain/pressure issues?

A

Transtibial amputation

Transfemoral amputation

Socket modification

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4
Q

What are 4 possible etiologies of amputation site pain if socket modification fails to relieve Sxs?

If ulcer/infections develop on residual limbs, how are they managed?

A

Bone spurs
Pressure/bruise
Heterotopic bone
Symptomatic neuromas

Socket mod, non-bulky dressings

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5
Q

OA is the MC type of arthritis, which is the leading cause of ? and can be attributed to ?

What are the common Sxs of OA

This rarely occurs in ? locations but overall ? causes PTs to seek medical care

A

Impaired elderly mobility
Genetics Obesity Age Trauma

Pain Stiff Deformity

Ankle Wrist Elbow
Joint pain

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6
Q

What would an OA joint effusion result look like?

? is a common finding on PE and what is this due to

What are the MC OA findings in the hand

A

Mild pleocytosis
Elevated protein
Normal viscosity

Joint crepitus- softening of articular cartilage

DIP- Heberden
PIP- Bouchard

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7
Q

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

? is an early sign of RA

What are the predominant findings on PE of early RA

A

First CMC joint
Articulation of Calcaneus Talus Navicular
Hallux valgus/rigidus
Subtalar joint

PIP swelling

Pain w/ pressure
Swelling
Dec ROM

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8
Q

What is the MC form of OA in the knee

What type of abnormal growth can occur

How do PTs w/ OA of the hip present

A

Varus- bow legged

Baker cyst between gastroc/semimembranosus

Toe out, externally rotated, dec internal rotation
Abudctor lurch: Tilts to affected side

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9
Q

What will be seen on x-rays of OA

Non-pharm Tx of OA

Pharm Tx of OA

A

Lost joint space
Osterophytes
Sclerosis
Subchondral cysts

Avoidance Weight Education

NSAIDs, then Acetaminophen

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10
Q

What Tx method is not recommended for joints w/ OA

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

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

A

Viscosupplementation

Isometric exercises

Lost function
Pain at night/unresponsive to non-surg Tx

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11
Q

What 4 joints are effectively corrected with arthrodesis

Define RA

What are common Sxs of RA and what joints are more commonly involved symmetrically

A

Hip Ankle Knee Shoulder

Chronic inflammation of synovium

2+ swollen joints stiff in AM >1hr x 6wks or,
+RF/anti-CCPs
Feet Hands Ankle Wrist Knee

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12
Q

Extra-articular manifestations and Sxs of RA in Pulmonary System

Extra-articular manifestations of RA in CV System

Extra-articular manifestations of RA in MSK System

Extra-articular manifestations of RA in Ocular System

A

M: Fibrosis, Nodules
Sx: pleurisy, effusion

M: vasculitis, pericarditis
Sxs: digital infarcts, ischemic mononeuropathy

M: nodules, tenosynovitis
Sx: Carpal/Tarsal tunnel, trigger finger

M: Keratoconjunctivitis, scleritis
Sx: dry eyes, corneal ulcer, scleritis

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13
Q

How does RA appear on x-rays

What part of the spine may become unstable as Dz progresses

What is Rheumatoid Factor but what lab result is as sensitive and more specific

A

Periarticular osteopenia
Bony erosions

C1-2

IgM against Fc portion of IgG
Anti-CCP Abs

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14
Q

? RA lab result correlates w/ degree of joint inflammation along w/ ? CBC result will be elevated

What are the two adverse outcomes of RA

What are the 4 seronegative spondyloarthropathies and why are these called seronegative?

A

Inc ESR/CRP; Dec serum albumin
Platelets

Osteoporosis
Dec immune function from DMARDs

Psoriatic Ankylosing IBS Reactive/Reiters
- RF and ANA (antinuclear antibodies)

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15
Q

What are 3 system manifestations that are commonly seen in the SeroNegative along w/ ? type of inflammation

What imaging results are seen in PTs w/ Ankylosing Spondylitis

What finding correlates to severity of Dz

A

GI Ocular Derm
Enthesitis- inflammed insertion site

Sacroiliitis, Kyphosis

Peripheral joint involvement (ankle hip shoulder)

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16
Q

What part of the body does Ankylosing Spondylitis affect?

What other conditions are associated with this Dx?

What is the Tx plan?

A

Sacroiliac joint, rarely involved peripheral joints

Iritis Aoritis Carditis Enthesitis Uveitis

NSAIDs, Exercise

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17
Q

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

What other conditions can be present w/ this Dx

What is the Tx

A

Asymmetric/oligoarticular involvement of SI, ankle, knee

Crohns Enthesitis Uveitis

NSAIDs

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18
Q

What parts of the body are involved w/ Psoriatic arthritis

What other conditions can also exist

What is the Tx

A

Erosion of wrist ankle SI hands

Dactylitis Iritis Nails Enthesitis Skin lesions

NSAIDs Methotrexate Biologics

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19
Q

What parts of the body are involved in Reiter Syndrome

What other conditions can co-exist with this Dx

What is the Tx?

A

Asymmetric oligoarticular of SI, ankle, knee

Urethritis Dactylitis Iritis Enthesitis

Infection Tx, NSAIDs

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20
Q

What microbe pathogens can cause Retiers?

What are the 5 patterns of psoriatic arthritis

A

Chlamydia Shigella Salmonella Yersinia Clostridium Campylobacter

Asymmetric oligoarthritis
Symmetric polyarthritis
Sacroiliitis
Arthritic mutilans
DIP
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21
Q

How are PTs w/ symmetric polyarthritis differentiated from RA?

What are common x-ray findings of Psoriatic Arthritis

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

A

DIP involvement w/out rheumatoid nodules

Terminal phalange reabsorption
Proliferative bone reaction

Bamboo: Enthesitis of anulus fibrosus
Poker: ALL ossification, Facet autofusion

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22
Q

What will lab results look like for ankylosing spondylitis

What is more important to Dx than these lab results?

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

A

Usually HLA-B27 pos
Inc ESR/CRP
Negative RF and ANA Abs

PE/Hx

Indomethacin

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23
Q

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

What drug may be used for chronic reactive arthritis?

What is best for the Tx of Psoriatic Arthritis

A

TNF-a: Etanercept, Infliximab, Adalimumab

Sulfasalazine

Non/DMARDs
Photo therapy for skin lesions

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24
Q

When do PTs w/ seronegative spondyloarthropathies need to be referred to Ortho?

Compartment syndrome develops when ? and is above ? pressure

Acute Syndromes are MC caused by ?

A

Kyphosis
Pain at rest/night
Eye/Skin/Pulm manifestations

Intercompartmental > perfusion= ischemia
35mmHg= Dx

Trauma

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25
What are the 6 Ps of Compartment Syndrome ? Sx is present at the onset of this condition What two are extremely late findings
Pain Pallor Paresthesia Paresis Poikilothermia Pulselessness Altered sensation in effected compartments Pulseless Paresis
26
What are the criteria to Dx Chronic Compartment Syndrome Acute syndromes are best confirmed by ? but ? will happen to extremities if issues go untreated How does CRPS present
Ant/Lat resting pressure of 15mmHg 30mmHg after 1min of exercise 20mmHg after 5min of exercise Hx/PE Fingers/toes/wrist flex and claw ``` Functional impairment Autonomic dysfunction Trophic changes Pain Type 1: RSD/Alygodystrophy- no nerve injury Type 2: Causalgia- nerve lesions ```
27
What is first line Tx for Complex Regional Pain Syndrome Therapy program utilize PROM but ? is stressed more
PO sympatholytics PT/OT AROM w/ stress loading
28
? adaptive modalities are used for CRPS Tx Pain an swelling of gout is caused by ? What causes the development of uric acid crystals and cause PTs to be placed into what two categories?
TENS Iontophoresis Contrast bath Lysis of PMN cells from crystal ingestion Purine metabolism (over producers, under excretors)
29
What causes the inflammation process of gout? What are the three end results of urate crystal accumulation within the body? ? is the MC manifestation of gout
Excess monosodium urate crystal deposits Tophi Nephrolithiasis Nephropathy Recurrent attacks of acute inflammatory arthritis
30
When x-rays show most PTs w/ CPPD are ? but can cause ? issues Gout crystals have ? microscopic appearance, appear in ? joints and are Tx w/ ?
ASx, Pseudogout Negative birefringence First MTP Ankle Knee Indomethacin Colchicine Allopurinol NSAIDs
31
Pseudogout crystal s of ? microscopic appearance, affect ? joints and are Tx w/ ? What are the 3 stages of urate crystal deposition Define Chondrocalcinosis
Pos rhomboid birefringence Knee Wrist Aspiration Intra-articular steroids NSAIDs Acute arthritis- years of ASx hyperuricemia Interval gout Chronic tophaceous gout CPPD X-ray findings of punctate/linear calcifications of articular cartilage/internal joints
32
What are the 4 metabolic d/os associated w/ CPPD What will PTs expect to develop who let chronic hyperuricemia go untreated
Hyperparathyroid Hemochromatosis Hypophosphatasia Hypothyroidism Nephropathy Renal stones
33
How is gout Tx How is CPDD Tx What is the goal of long term Tx for gout
1st: Indomethacin, Naproxex 2nd: Colchicine (acute arthritis), PO glucocorticoids, CCS injections ``` Aspiration CCS injection (1 or 2 joints involved) NSAID/Colchicine- acute attacks if multiple joints involved 3 or more attacks= Colchicine prophylaxis ``` Limit hyperuricemia: Probenecid- inc urinary excretion Allopurinol- xanthine oxidase inhibitor= dec purine
34
? is the most preventable cause of death for in-hospital PTs and 3rd MC cause of death in PolyTrauma Define Virchows Triad ? anticoagulation prophylaxis is used for hip/knee arthroplasty and long bone Fxs
PE DVT identification: Venous stasis Venous damage Hypercoagulable Enoxaparin- renally cleared LMWH for renal insufficiency
35
? is the standard diagnostic test for DVT if Pt has endematous limb ? is the MC used anticoagulation w/ INR goal of ? This MC is better at preventing ? clots for Pts having total hip arthroplasty
Venography PO Warfarin: INR 2-2.5 Proximal
36
Mechanical prophylaxis reduces VTE Dzs secondary to ? and ? Define Diffuse Idiopathic Skeletal Hyperstosis Osteophytes of DISH follow ? anatomical landmarks and present w/ ? principal Sx
Increased fibrinolysis Decreases stasis Striking osteophytes on 3+ discs/4+ vertebral bodies ALL/peripheral disk margins Spine stiffness in AM/PM (cervical spine= PLL, dysphagia)
37
DISH of the cervical spine is the 2nd MC cause of ? after ? as the first What is an adverse outcome of the Dz How is DISH Tx non-op but ? is an adverse outcome if these Pts have hip arthroplastys
1st: Cervical spondylosis 2nd: Cervical myelopathy Stiffness w/ single segment becoming unstable/painful Initial: walking/exercise then NSAIDs Heterotropic ossification
38
# Define Fibromyalgia Syndrome Criteria needed for Dx What is the name of the tool used for pressure testing in Dx of FMS
Pain, fatigue, tender soft tissue Wax/wane pain in 4 quadrants x 3mon (lumbar pain= pain below waist) Pain at 11/18 sites w/ 4kg of pressure Dolorimeter- exerts 4kg, as much pressure as turning nail bed white
39
How is FMS Tx per FDA recommendation What meds can be used w/ needling for Tx Where does osteomyeltitis usually occur in Peds or Adults?
Pregabalin Duloxetine Milnacipran Lidocaine (Saline if allergic) Peds- hematogenous spread to long bone metaphysis Adult- open Fx, surgical fixation
40
How does osteomyelitis appear in clinic What images can be used for Dx of osteomyelitis What do lab results look like in cases of osteomyleitis
Acute: pain, fever Post-op: drainage, failed/delayed healing MRI NucMed (high sensitivity, low spec) Acute- elevated leukocyte, ESR/CRP Chronic/ImmSupp- normal ESR/CRP- markers for Dz process
41
What are the two most common organism to cause osteomyelitis in Peds and adults ? type of ABX therapy is used after the required and necessary debridement procedure
Peds: Staph A > GBS > HInfluenza Adults: Staph A, Pseudomonas ABX impregnanted methyl methacrylate beads
42
What are the 3 methods of septic arthritis development What microbe is the MC cause of septic arthritis in PTs >2y/o Septic arthritis in kids is MC spread by ? route
Direct Hematogenous Extension Staph A Hematogenous
43
What are the hallmark signs of septic arthritis What lab result of a native joint indicates Dx of septic arthritis What are the two most serious/feared outcomes of septic arthritis
Tenderness/Effusion/Erythema w/ painful PROM WBC > 50K Sepsis, Death
44
What are the next best steps after Dx of septic arthrits has been made What microbe and type of microbe causes Lyme Dz What is the name of the microbes carrier
Synovial fluid/blood culture IV ABX Surgical decompression/lavage Spirochete: Borrelia burgdorferi Deer Tick- Ixodes Dammini
45
What are the 3 phases of Lyme Dz What is the MC neurolgoical manifestation of the Dz What is the name of the characteristic marking of lyme dz and what needs to be investigated for once this is ID'd
Local: viral Sxs Disseminated: cardiac/neuro- meningitis, cranial neuropathy, rediculopathy Late: arthritis/neuro- paresthesia encephalopathy radiculopathy joint pain Bells Palsy during disseminated phase Erythema migrans Synovitis/Restricted joint pain
46
? 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
47
What are the 3 types of osteoporosis Osteoporosis is usually unnoticed until Pts present complaining of ? four issues ? is the 10yr Fx risk assessment for Osteoporosis and what two factors are as important as low bone density
Primary 1: post-menopausal (6x F>M) Primary 2: senile osteoporosis (2x F>M) Secondary: M>F long steroid use, MM, OM, OI, hyperpara/thyroid Back pain Fx Lost height Spine deformity FRAX: bone density + RFs Old age + prior low energy Fx
48
What is the reference standard for assessing osteoporosis related bone mineral density and monitoring Tx results What are the two scores provided DEXA scans measure the lowest value at ? four locations and what are the ranges for results
DEXA Z/T= SDs lower than comparison group Z: peers T: healthy, young PTs Spine FemNeck Trochanter Femur 0- -1: normal -1 - -2.5: osteopenia -2.5 or more: osteoporosis
49
When does bone mass density reach peak levels during life What recommendations are given to reduce risk for osteoporosis development
<28y/o Ca/Vit D Avoid alcohol/tobacco Impact loading- walk, strength, Tai Chi
50
Overuse syndromes are usually secondary to ? and can produce ? two results Reactive/acute inflammatory overuse syndromes produce ? effects and are AKA ? What physiological process is occurring during this Dx
Repetitive microtrauma= acute inflammation, chronic degeneration Fatigue and inflammation Tendinitis Infiltration of tendon/epitenon by inflammatory cells and mediators
51
# Define Tendinosis Where does this occur and what causes the degeneration process to begin and is associated w/ ? RF Skeletally immature PTs that participate in high stress loading/repetitive trauma can lead to what two issues
Chronic degeneration w/out inflammation from microtrauma Areas w/ dec blood flow d/t age Apophysitis- inflammation of growth plate Opiphysiolysis- traumatic widened physis
52
What are the three parts assessed for overuse syndromes during PE How are overuse syndromes Tx What type of rehab program is useful in Tx of tendinitis
Inspect: Atrophy Pallor Erythema Swelling Palpate: Point of max tenderness Strength for pain w/ resistance Protection Rest Ice Cream/NSAIDs Eccentric strengthening
53
What are the 3 degrees of Sprains What are the 4 grades of Strains What is assessed in strains or sprains during PE and what imaging modality is best
1: partial w/ no instability 2: partial w/ laxity 3: complete w/ laxity 1: <10% muscle tear, intact fascia 2: 10-50% muscle tear, intact fascia 3: 50-100% muscle tear, intact fascia 4: 100% tear w/ disrupted fascia Palpate for point of max tenderness Sprain: joint stability Strain: stretch injured muscle for defect MRI: confirmation/grading/ruptures
54
How are Sp/trains Tx When do sprain/strains need to be referred to Ortho What is the best imaging modality for suspected bone tumor assessment
PRICE- mainstay Cryotherapy NSAIDs Minor sprain- compression, immobilize Minor strain- immobilize w/ muscle stretched Grade 4 strain, all Grade 3, Sev Grade 2 X-ray most valuable for lesions MRI better: soft tissue/marrow CT better: bone detail
55
PTs >40y/o w/ aggressive bone lesions will probably have ? types of Ca What blood tests may be done to help w/ Dx in Pts >40y/o
Metastases Myeloma Serum/urine protein electrophoresis Quant serum immunoglobin levels Serum free light chain assay B-2 microglobulin factor
56
What are the two MC methods for obtaining bone biopsies for suspected neoplasms What is the theorized etiology of growing pains in ? population MC What may be found on PE in suspected growing pains and what is done for management/Tx
Closed needle, Open bone Over activity- muscle strain/fatigue Boys 2-5y/o w/ ligamentous laxity Pain w/ deep pressure Stretching Education Analgesics
57
Most cases of child abuse occur in PTs ? old w/ ? populations at higher risk Fx highly suspicious for abuse What imaging is used to assess for rib fxs in suspected child abuse and what would be seen in healed Fxs
<3y/o First Premature Stepchildren Handicapped Post ribs Corner long bone metaphysis Scapular Process, spinal Chip long bone metaphysis Sternum Bone scan Fusiform thickening
58
Fx moderately suspicious for abuse How is the age of a Fx assessed by imaging
``` Multiple/Bilateral/Aged/ Fxs Epiphyseal separation Vertebral body Fingers Skull, complex ``` 7-14d: new periosteal and callus formation 14-21d: loss of Fx line, mature callus/trabecular formation 21-42d: dense callus >42d: sublte fusiform sclerotic thickening
59
What is the name of bone imaging done for suspected child abuse in kids <2y/o Define Toddler's Fx
Skeletal survey: long, hand, feet, spine, chest, skull Tib/Femur spiral Fx in walking kid 1-3y/o
60
Salter-Harris Fx classifications Where will the most pain be found during PE What are the two adverse outcomes of Salter Harris Fxs
1: slipped 2: above/away from joint 3: lower 4: through/transverse 5: ruined/rammed Over growth plate Limb length inequality Angular deformity
61
What are the 3 goals of non-operative Tx How are Salter Harris Fxs casted Kids younger than 13y/o should not have any Fx older than ? reduced How does the acceptance of minimally displaced Fx Tx by immobilization change by age and gender
Reduction Maintenance Avoiding arrest 1-2: closed reduction, cast immobilization Minimal displacement= immobilization 7days 15 and > boys 13 and > girls
62
Salter Harris Fx 3-4 require anatomic reduction due to ? structures being involved These also required correction in attempts to prevent ? development especially after ? Fxs There are seven types of Juvenile Idiopathic Arthritis but ? trait is common and used for Dx criteria
Cartilage of growth plate and articular surface ``` Physeal bar (bone bridge) Open types 3-4 (ORIF) ``` Chronic arthritis x 6wks that are <16y/o JRA: USA JCA: Europe
63
What labs are ordered during work up for Juvenile Idiopathic Arthritis How is Juvenile Idiopathic Arthritis Tx What two meds are used for PTs w/ refractory uveitis
HLA UA RF Ferritin ANA CBC w/ Diff ESR/CRP First- NSAIDs DMARDs- Methotrexate A-TNF- Etanercept, Infliximab, Adalimumab Inflixiamab Adalimumab
64
When do PTs w/ Juvenile Idiopathic Arthritis need to be referred to Ortho Define Osteochondritis Dissecans Where does this d/o MC occur and where can it occur
Refusal to bear weight Unexplained fever Severe pain Osteonecrosis of subchondral bone MC- posterolateral medial femoral condyle Talus Elbow Distal humerus/femur Uncommon- patella
65
What is the etiology of Osteochondritis Dissecans How is this Dz searched for on PE and imaging What is the goal of Tx for Osteochondritis Dissecans
Repetitive small stress to subchondral bone= bone separated by fibrous tissue Medial femoral condyle pain w/ 90* flexion X-ray Lat/tunnel MRI- view cartilage/stage lesion Allow lesion to heal
66
What are the non-surgical Tx options for Osteochondritis Dissecans These Pts become surgical candidates after ? two criteria are met When do Peds w/ Osteochondritis Dissecans need to be referred
Non-Surg: LLD until Sxs are relieved Avoid running/jumping Immobilize refractory Sxs/non-compliant PTs <1cm wide- nonsurgical Txs Peds: articular cartilage separation Skeletal maturity >2cm wide- develop progressive problems
67
How does Osteomyelitis infections usually spread/develop but are rarely d/t ? What is the difference between osteomyelitis sequestrate and involucrum What imaging modality is used to assess acute hematogenous osteomyelitis or any time an infection or tumor is suspected
Hematogenous spread of Staph A: canal to cortex= abscess Rarely from open Fx/puncture Seq: abscess inc pressure= bone fragment Persistence leads to chronic osteomyelitis Involucrum: periosteum remains, new bone growth MRI w/ contrast
68
? is typical PE finding for Peds w/ Acute Hematogenous Osteomyelitis Septic arthritis in kids is usually d/t ? route and microbes Septic joints will have ? lab results
Fever >100.4 Tenderness over bone Hematogenous seeding of synovium from: Skin infections Impetigo Pneumonia ESR >30 WBC >15K Synovial WBC >50K
69
What are the clinical Sxs of pediatric septic arthritis What is the initial Dx method and Tx of choice Pediatric Seronegative Spondyloarthropathies have ? 4 characteristics in common
Guarding Malaise Lost appetite Fever Joint aspiration for analysis then, Joint drainage, IV ABX HLA-B27 Inflammation of tendon/fascia/enthesitis Pauciarticular arthritis in LE Extra-articular inflammation
70
What PE finding is a distinguishing feature of juvenile spondyloarthropathies What two lab results supports a Dx of juvenile ankylosing spondylitis and they're more likely to have ? In adolescents, nongonococcal urethritis can be secondary to ? two microbes causing excessive pain in ? two locaitons
Purple discoloration around joint + HLA-B27 and FamHx Lower extremity involvement Chlamydia/Trachom in Achilles or Plantar Fascia
71
Reiters Syndrome is a triad of ? three Dx What lab result supports a Dx of juvenile Reiters Syndrome How are these Tx
Conjunctivitis Enthesitis Urethritis Sterile pyuria Counseling Rehab Orthoses NSAIDs
72
Psoriatic arthritis in Peds is more likely in ? kids/age and presents in ? sequence Peds IBDz arthritis usually presents prior to ? and ? prevelance is twice as common What is the name of the distal end of the spinal cord that ends at ? level, meaning anything below is AKA ?
Female before 15y/o Arthritis before skin problems <21y/o w/ arthralgia w/out effusion Conus medullaris ending at L1-2 Cauda eqeina: L2-S4 roots
73
What happens if PTs cauda equina region is compressed What can cause Cauda Equina Syndrome to occur How does Cuada Equina present on PE
Paralysis w/out spasticity Retropulsed burst Fx Abscess Herniation Hematoma Bilateral radiculopathy Incontinence Foot drop Stumbling gait
74
? PE finding is typical for most PTs w/ cauda equina syndrome What special tests are done for suspected Cauda Equina Syndrome If not caught early, what two adverse outcomes can develop
Perineal numbness in saddle distribution Inability to rise from chair (quad/extensor test) Inability to walk on heels (ankle dorsiflexion, plantar flexion) Paralysis, Incontinence
75
? MRI findings confirm a Dx of Cauda Equina What is the usual cause of cervical radiculopathy in young/older PTs What will usually be seen on PE
Compressed thecal sac Young: herniation traps root in foramen Older: foramen narrowing/uncovertebral arthritis Neck/Radicular pain w/ UE numbness/paresthesia (deltoid to thumb) Changed grip/handwriting
76
What type of neck malformation may be present and restrict movement in cervical radiculopathy What ROM/sensation tests need to be done What imaging is done for Dx confirmation How is cervical radiculopathy Tx non-surgically and by avoiding ?
Reduced cervical lordosis Extension/axial rotation- pain Motor/sensory of C5-T1 Myelogram (intrathecal contrast) Anti-inflammatory w/ cervical traction Avoid narcotics/manipulation
77
# Define Cervical Spondylosis What causes this dz process What are the MC Sxs of Cervical Spondylosis
Degenerative disc dz of the cervical spine Herniation Osteophyte growth Thick/Buckled ligamentum flavum Limited mobility Chronic pain worsened w/ upright activity
78
What are 3 Sxs of early cervical mylopathy from cervical spondylosis What neuro changes may be seen in cervical spondylosis PTs What findings on lateral neck x-rays can be seen in cervical spondylosis
Palmar paresthesis Altered gait (heel-toe) Difficult dexterity Lhermitte sign- flexion= shock in neck/arms Hoffmann-middle nail flick, thumb/index twitch Clonus/Hyper-reflexia/Babinksi Degeneration MC to C5-7 End plate changes Anterior osteophytes
79
What Tx step needs to be avoided in cervical spondylosis PTs What non-surgical Tx options are available What type of mechanism causes a whip-lash injury
Narcotics Cervical pillow/roll and rehab MC MVC accel/decel causing flex/extension
80
How can whiplash injuries present on PE What is the MC finding on PE What may be seen on c-spine films following a whip-lash injury
Spasms, paraspinal Occipital HA Pain w/ motion Nonradicular/focal pain: skull to CT junction Anterior displaced pharyngeal shadow- possible spinal Fx/disc/ALL injury
81
What extra step is done when assessing these films if Pt is in extreme pain? What Tx steps are taken for neck strains? If a gap or step off is appreciated on exam, what structure is injured?
Examine for instability- translation of vertebral body >3.5mm and/or >11* angulation to adjacent vertebrae NSAIDs w/ soft collar Muscle relaxants if spasms present Manipulation is c/i Posterior ligementous complex= unstable
82
What is the most valuable image that can be obtained on Pts w/ suspected cervical Fxs PTs that suffer neck injuries, are evaluated and cleared but have persistent pain should be managed how? What type of spinal Fxs are generally considered stable and highly unstable
Lateral view C1-T1 C-collar x 7-10 days Simple compressed anterior half of column Burst Fxs compressed posterior 1/3 vertebral body Unstable: flex-distraction
83
What other injuries are usually present at the same time as spinal column Fxs ? are the hallmark PE findings of Pts w/ unstable flexion-distraction or burst Fx injuries ? imaging modality offers the most and best info for need of surgical stabilization
``` Abdominal injury (bowel lac) Lumbar Fx= ileus ``` Hematoma and forward shift step off/gap between spinous processes CT w/ recon
84
How are compression Fxs of the spinal column managed non-op? What type of rehab do these Pts get recommended What type of process causes atraumatic lower back pain to develop
<20* wedge, no posterior vertebral involvement= Thoracolumbosacral orthosis x 10wks Walking Trunk flexor/extensor strengthening after bracing Ligamentous injury to anulus fibrosus= nucleus pulposus leak= irritation
85
What are the parameters used for evaluating ROM progress in lower back pain Pts What are the two phases of Tx for acute lower back pain and when does this type of back pain become reclassified to chronic lower back pain Once this new Dx is given, what other issues need to be r/o?
Degree of lumbar flexion Ease of lumbar extension Initial: Sx relief Secondary: return to activity Pain >3mon Ca Stenosis Deformity Osteoporosis Infection Abdominal aneurysm/ulcer/tumor
86
What is the hallmark, predominant, and commonly seen Sx of Chronic Lower Back Pain ? age appropriate x-ray results may be seen
Hallmark- pain radiating down buttock (hallmark) Predominant- discomfort worse w/ activity Common- tenderness Anterior osteophytes Dec disk space
87
All Pts w/ chronic lower back pain need to be evaluated by ? providers Motor, Reflex and Sensation for L4 nerve root Motor, Reflex and Sensation for L5 nerve root Motor, Reflex and Sensation for S1 nerve root
GYN Internist FamMed Spine Anterior tibialis / Patellar / Medial foot Extensor hallucis longus / NONE / Dorsal foot Gastroc soleus (toe raise) / Achilles / Lateral foot
88
What physiological process allows for lumbar disc herniations to develop? This development leads to ? syndrome0 Where do these herniations occur MC
Posterolateral anulus fibrosus weakens/fissures Herniated disc syndrome- sciatica L4-S1 w/ irritation to L5, S1 roots
89
What special tests are performed for suspected lumbar disc herniation When is MRI imaging warranted How are lumbar herniations Tx non-operatively
Seated straight leg raise Pre-op, Neuro deficit, Sxs >4wks NSAIDs w/ LLD Aggravation avoidance Three epidural injection w/in 6mon
90
Where does lumbar stenosis MC develop What is the common presentation for lumbar stenosis What special tests should be done?
L2-5 Neurogenic claudication w/ radicular Sxs Proprioception/Romberg/Neurovascular
91
How is lumbar stenosis Tx non-op When do these Pts become surgical candidates What type of malignant tumors of the spine are considered rare/common
``` Water exercise (elder, deconditioned, mild Sxs) Epidural injections ``` Non-ambulatory/Dec quality of life Primary- rare Metastatic- common
92
Highest incidence of spinal carcinoma is d/t ? and via ? How are Cas to the spinal column spread via hematogenous What are the 4 possible presentations of metastatic dz
BLT KPC by hematogenous spread Batson's plexus- connects w/ inferior vena cava Pain as primary presenting Sx Incidental finding Neuro finding Known primary tumor
93
How do neoplasms of the spine usually present on PE What is the first manifestation these appear as on x-ray What is the best screening study for widespread mets
Pain w/ weight bearing (sit/stand) Relief w/ laying down Pain at night Lost pedicle integrity (winking owl) Tc-99m bone scan
94
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
95
What is a common adverse outcome after surgical decompression of spinal neoplasms? When do Pts w/ spinal pain/neoplasms need to be referred d/t red flags
Wound complication if surgery is post-radiation/steroid Malignancy Hx Intractable pain Trivial trauma causes spine Fx, even w/ osteoporosis Spinal Sxs
96
# Define Scoliosis These Pts may develop radicular pain MC d/t ? What special tests are done for Pts w/ scoliosis
Coronal curvature of spine >10* using Cobb method Compression of L4-5= Ext Hallucis Longus d/t: asymmetric facet hypertrophy/disc degeneration rotator subluxation Spine palpation while standing Decompensation- plumb line from C7 to R/L gluteal cleft
97
What images should be ordered for scoliosis How is adult scoliosis Tx What are the red flags for referral in these Pts
Weight bearing, full length PA and lateral on 36" cassette NSAIDs Water/swimming therapy Neuro deterioration Inability to walk >2 blocks d/t pain Respiratory dysfunction Trunk exercise
98
# Define Degenerative Spondylolisthesis What needs to be evaluated on PE for Pts w/ degenerative spondylolisthesis Since these Pts usually have a normal motor exam, what strength issues can present
L4-5 body slips fwd d/t deteriorated facets/disc Lamina/pars interarticularis remain intact L1-S4 nerve roots Dec patellar/ankle DTRs (also present in geriatrics) Weak toe/heel walking Weak toe dorsiflexion
99
Narrowing of ? two spaced in degenerative spondylolistesis causes ? types of pain How is degenerative spondylolisthesis Tx non-op What are the red flags for referral for these Pts
Lateral recess= radiculopathy Central canal= claudication NSAIDs and exercise Weight loss Neuro claudication after walking <2 blocks Cauda equina syndrome
100
Where does pediatric isthmic spondylolisthesis usually develop This form of the condition is more likely to represent ? event ? activities put Pts at higher risk for developing this condition
L5-S1 Cyclic loading AKA- fatigue Fx that fails to heal Gymnastic/Football
101
How do peds w/ isthmic spondylolisthesis present to clinic What may be seen on PE What is usually seen on x-ray in Peds w/ isthmic spondylolisthesis
Posterior pain radiation below knees, worse w/ standing Dec lordosis/flat buttocks Vertebral step off Hamstring spasm w/ forward extension/leg raise Defect of pars interarticularis (collar on scotty dog) L5 anterior to S1
102
Since Peds are considered skeletally immature, what imaging test is ordered to assess metabolic activity at site of defect How are peds w/ isthmic spondylolisthesis Tx non-op When do these Pts become surgical candidates
Single Photon Emission Test- CT SPECT Immature= rigid bracing Mature- no fixation, NSAIDs and exercise Refractory Sxs High grade slips
103
? 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 ? ? is the initial imaging study of choice for kids w/ back pain and what are the initial Txs
Muscle strains Post- spondylolysis Ant- discitis, compression Fx Weight bearing PA/Lat of entire spine LLD w/ analgesics x 6wks, re-eval is Sxs remain
104
Discitis and vertebral osteomyelitis in Peds are issues involving ? d/t ? 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
Discitis: MC Staph A in anterior spine in kids <5y/o Osteo: Staph A in vertebral column in Pts >5y/o Kingella E coli GAS Spinal percussion- localizes Passive flexion- pain MRI
105
? abnormal lab results may be seen in Peds w/ discitis/vertebral osteomyelitis What are common adverse outcomes in Peds w/ discitis/vertebral osteomyelitis How are these PTs Tx by non-op methods
Normal WBC w/ inc ESR/CRP 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
106
Pts w/ discitis/vertebral osteomyelitis rarely develop neuro Sxs, but if they present are usually d/t? 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
Epidural abscess 20-50* w/ Cobb angle between T3-T12 >50*= hyperkyphotic Postural- female Scheuermann dz- male
107
How is hyperkyphosis assessed in clinic How do the two different etiologies appear How is hyperkyphosis viewed w/ imaging
View from side w/ Adam fwd bend test Scheuermann/pathologic- sharp apex angulation Postural- gradual curvature AP/Lat of entire spine while standing
108
What are the adverse outcomes of this dz How is hyperkyphosis Tx non-op and w/ surgery What type of hyperkyphosis is almost always Tx by surgical methods
Dec pulm function- curve 90-100* Back pain Neuro Sxs= congenital Posture- exercise Sheuermann- immature= Milwaukee brace full time >70*- fusion Congenital
109
Peds scoliosis can be accompanied by ? other abnormalities of the spine How is idiopathic scoliosis classified What is neuromuscular scoliosis associated w/?
Abnormal sagittal- excessive kyphosis/lordosis Age of onset: Birth-3yrs: infantile 3-11yrs: juvenile >11y/o: adolescent Dzs causing flaccid weakness/spasticity
110
What is the predominant effect of Peds scoliosis Congenital scoliosis is a result of ? What are two Sxs rarely seen in Peds w/ scoliosis
Loss of sitting balance Impaired respiratory function Failed formation/segmentation Mixed anomalies common Pain Neuro Sxs
111
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 What are the indications for ordering MRI
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 Age (infantile/juvenile) Abnormal Hx/PE findings Radiographic- (KREWL) Kyphosis Rib abnormals Erosive vertebrae Wide spinal canal Left sided thoracic curve
112
What is an adverse outcome for Pts w/ scoliosis How are these PTs Tx non-op How are these Pts Tx op
Curvatures >80*= dyspnea from restrictive pulm dz 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*
113
# Define Peds Spondylosis Where does Peds Spondylolisthesis MC occur How do Pts w/ spondylosis present in clinic on PE and imaging
Defected pars interarticularis- bone between sup/inf articular facets L5-S1 Hip/knee flexion compensates backward tilt Flattened lumbar lordosis Oblique x-ray w/ collared Scotty Dog
114
How are Peds w/ stress reaction/early cases of spondylolysis Tx When are these Tx w/ fusion/decompression surgery How are AC joint injuries confirmed w/ imaging
LLD NSAIDs TLSO x 3-4mon Immature Pts w/ slippage >50% Chronic Sxs AP films- Type 2-6 Weight bilateral- Type 1-2
115
What are the 6 types of AC injuries What are five possible adverse outcomes of injuries to AC joint How are these injuries Tx
``` 1- ligament sprain 2- widening <100% 3- 100% displace 4- Sup & Posterior displace 5- sup displaced clavicle 6- something in spaced ``` Pain Deformity Arthritis Weak Numb Type 1-2: sling Most Type 3- Tx non-op Surg: young/labor/Type 4-6
116
What is the goal of rehab after AC injuries When do these injuries need to be referred Define Shoulder Arthritis
Reduce pain Protect joint Function Type 4-6 Athletes/labor w/ Type 3 Destroyed cartilage causing pain/dec function
117
How do these Pts present to clinic w/ shoulder arthritis Pts w/ shoulder arthirits and long standing rotator cuff tears may also develop ? issue What will be seen on PE
Diffuse/deep pain worse to posterior shoulder High riding humeral head Equally decreased A/PROM
118
What x-ray findings help support a dx of shoulder arthritis What would be seen if the actual underlying issue was RA? ? is an adverse outcome for these Pts
Flattened humeral head Inferior osteophyte Posterior erosion of glenoid Periarticular erosions Osteopenia Central wear of glenoid Severe loss motor/strength even w/ joint replacement
119
How is shoulder arthritis Tx non-op What procedure is done for mil/mod cases w/ preserved ROM How does Transient Brachial Plexopathy develop
NSAIDs Heat/Ice Stretching exercises Arthroscopy debridement and capsular release - 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)
120
How are brachial plexus injuries further categorized What is the downside of Dx a C8-T1 root avulsion What causes lower trunk (C8-T1) burner/stingers
Prox to dorsal ganglion- pre Distal to ganglion- post No surgical repair Poor recovery prognosis Nerves stretched while arm is abducted
121
How is a preganglionic burner to C8-T1 confirmed on exam What is the corner stone of an accurate Dx of burner/stinger Recurrent episodes of burner Sxs may suggest ?
Horner's Syndrome: Ptosis Myosis Anhidrosis Enophthalmos Neuro Exam Cervical stenosis Inc risk cord injury
122
How are burners Tx non-op 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
R/o spinal cord injury Splint in PROM for weak/paralyzed Protect anesthetic skin PainMan referral Resolution of pain/neuro Sxs Normal neuro exam Full cervical ROM ``` MC- DMT-1 Hypothyroid Dupuytren dz Cervical herniation Parkinson Cerebral hemorrhage/tumor ```
123
How do Pts w/ adhesive capsulitis in shoulder present Where is the most point tenderness elicited on exam What PE finding is pathognemonic for frozen shoulder
Painful freezing phase followed by relieving 6-24mon thaw Deltoid insertion site Contracted coracohumeral ligament
124
What imaging finding helps solidify the Dx of Frozen Shoulder How are frozen shoulder's Tx non-op What type of surgical Tx is an option
Contracted capsule Loss of inferior pouch NSAIDs Moist heat Gentle stretch Arthroscopic capsule release if no relief after 3mon of therapy
125
What is the rehab goal for frozen shoulder What part of the rotator cuff is susceptible to impingement syndrome and how is weakness here tested What is the characteristic presentation
Reduce pain Inc glenohumeral/scapula ROM Supraspinatus tendon- 90 elevated and internal rotation Gradual ant/lat pain worse w/ overhead activity from supraspinatus trauma from coracoacromial arch
126
What PE findings can be characteristic of impingement syndrome What two special tests are usually positive on exam
Gradual ant/lat shoulder pain worse w/ overhead movement Pain at greater tuberosity/subacromial bursa Pain w/ 90-120* abduction Pain w/ lowering Neers, Hawkins
127
X-ray images showing narrowing of space between humeral head and under surface of acromion >7mm suggests ? How are impingements Tx non-op
Long standing rotator cuff tear Exercise x 3-4/day x 6wks Then subacromial injection Then stretching
128
What are the two adverse outcomes of impingement syndrome Tx What are the 3 MC causes for rotator cuff tears What is seen on PE for rotator cuff tears
Rotaotr cuff rupture Long head of bicep rupture Degeneration Chronic impingement Altered tendon blood supply Normal PROM Dec AROM
129
What is the risk if rotator cuff tears are left uncorrected How are rotator cuff tears Tx non-op When are these Pts referred for surgery
High riding humerus Joint destruction Large= joint degeneration CCS Avoidance NSAIDs Strength/stretch rehab 3-6mon non-op failure Acute tears- repair <6wks
130
What is an adverse outcome of rotator cuff surgical Tx What PT population usually have proximal bicep tendon ruptures What are the landmarks that this tendon is found in
Large tears= high failure Debridement may relive pain Older adults w/ chronic shoulder pain d/t rotator cuff Intertubercular groove, intrarticular for proximal 3cm
131
What special test is done for assessing possible proximal bicep tendon ruptures What is an adverse outcome for 10% of these Pts When are proximal bicep tendon ruptures repaired w/ surgery
Ludington- put hand behind head and flex Loss of elbow flexion/forearm supination (screw driver) Young athletes Adults <40y/o as laborers
132
When do Pts need to be referred to Ortho for rotator issues? Pts w/ shoulder instability have recurrent episodes of ? What are the two MC types of instability
Young laborers Older Pts w/ rotator cuff tears and Sxs Subluxation- humeral head slips out of socket Anterior Multi-directional
133
# 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
134
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 Add, internal External= impossible Apprehension- anterior Sulcus- inferior Jerk- posterior
135
? Pt populations are at higher risk for recurrent shoulder instability Define a Hill-Sachs lesion
Younger Pts Multiple episodes Post humeral head compression Fxs hitting anterior glenoid edge
136
How are shoulder dislocations Tx non-op What types of shoudler instability are Tx non-op When do these Pts need to be referred
First anterior= immobilize 3wks Rehab- subscapularis strength Atraumatic/voluntary (AMBRI) instability Failed reduction 2 or > dislocations/3mon w/ rehab Multidirection instability
137
# Define SLAP tear What do PTs present complaining of What special tests are done for suspected SLAP tears
Superior Labrum Anterior to Posterior- injury to superior glenoid labrum and bicep anchor (long head of bicep origin) Painful pop/catch Pain w/ overhead Crank test Resisted supination/external rotation Active compression test Clunk
138
What image is needed for Dx of SLAP tear
MRA= gold standard
139
How are SLAP lesions Tx non-op What is the next step if non-op fails and Sxs persist What is the goal of rehab but MC adverse outcome of SLAP lesions
NSAIDs Rehab towards stabilization, stretch, strength Dx arthroscopy Goal: reduce pain, protect joint MC: shoulder stiffness
140
What causes Thoracic Outlet Syndrome
Compressed brachial plexus/subclavian vessels between superior shoulder girdle and 1st rib
141
What three underlying congenital issues can cause Thoracic Outlet Syndrome These Pts can present w/ Sxs mimicking ? d/t ? ? part of the Pt needs to be palpated to r/o ?
Cervical rib Long C7 processes Anomalous fibromuscular band Brachial plexus compression= Distal/ulnar nerve entrapment Supraclavicular fossa- r/o mass lesion
142
What x-rays are ordered for TOS and why are they ordered What are four adverse outcomes from thoracic outlet syndrome What are two rare but possible outcomes
AP: r/o cervical rib/C7 process PA/Lat: r/o apical lung tumor/infection Weakness HAs Inability to do overhead work Coordination decrease Raynauds Ulcerations
143
? is the MC cause of elbow joint destruction How does this MC cause usually present to clinic How is it Dx
RA Pseudo/gout AP/Lat x-rays
144
How are elbow arthritis' Tx non-op based off of origin What surgical procedure can be helpful When do PTs w/ elbow arthritis need to be referred
Non-rheum inflammatory synovitis/RA: CCS, rehab Post-traumatic/OA: analgesics, stretching Arthroscopic debridement Functionless Locking Pain
145
What muscle originates at the lateral/medial epicondyle of the humerus and inflamed during epicondylitis What makes pain of lateral/medial epicondylitis worse What imaging is used for Dx and severity staging
Lat: Extensor carpi radialis brevis Med: flexor/pronator muscles Lat: Wrist extension and grip Med: Wrist flexion and pronation MRI
146
What two mis-Dxs can occur when evaluating lateral/medial epicondylitis
PIN w/ lateral | Ulnar w/ media
147
What is the most important non-op Tx step for elbow tendonitis What form is more likely to heal w/out surgical Tx When do these Pts become surgical candidates
Stopping aggravating activities Persistent Sxs= CCS injection then debridement Lateral > Medial Recurring pain w/ severe Sxs
148
What are the 4 stages of Tx of humeral epicondylitis What is the MC adverse outcome of Tx How is olecranon bursitis Dx
Reduce pain/inflammation Promote arm strength Return pain free activity Maintenance Surgery fails to completely relieve pain Aspiration= Dx and Thx
149
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 Sxs= NSAIDs, LLD Proven non-septic= compression bandage w/ 8cm diameter foam PCN resistant Staph A Surgical decompression/aspiration Septic bursitis Tx early and Pt not ImmComp
150
Why are chronically inflamed olecranon bursitis' rarely ever InD'd? When do Pts need to be red flagged and referred? What are the two MC nerve entrapment in the upper extremity and what causes the compression
Risk for chronically draining/infected sinus development Septic/recurrent w/ 3 or > aspirations 1st: carpal 2nd: ulnar, cubital tunnel or between humeral/ulnar heads and flexor carpi ulnaris muscle
151
# Define Radial Tunnel Syndrome This syndrome is commonly mis-Dx as ? How is this syndrome differentiated on exam?
Compressed PIN (deep branch of radial) between supinator muscle heads in radial tunnel Lateral epicondylitis PIN= only motor for thumb/finger and ulnar carpi extensor, no numbness/tingling
152
# Define Pronator Syndrome Why is this entrapment condition hard to find or is found late How does ulnar/radial/pronoator nerve compression preset in clinic
Muscular compression of median nerve in proximal forearm Vague, few PE findings, high relation w/ worker's comp Ulnar- medial elbow pain, ring/little finger numbness Radial- pain 4-5cm distal from lateral epicondylitis Pronator- forearm aches w/ proximal radiation
153
What special tests are done for nerve entrapment in the arm What is unique about these nerve entrapment work ups
Tinel Sign- ulnar Elbow flexion test- ASx after 60sec= negative Middle finger- radial PIN= TTP 4cm distal of lateral condyle No lab work EMG/NCV for ulnar entrapment
154
What is the most important step in ulnar nerve compression Tx to prevent ? adverse outcome When is surgical Tx considered What adverse Tx outcome needs to be avoided w/ Pt education
Preventing flexion/pressure Prevents permanent loss of strength/sensation Ulnar: Sxs/weak x 3-4mon w/ non-op Tx Radial: discomfort after 3-6mon of rehab/non-op Pronator: no relief after 3-6mon of rehab/non-op Splints too tight- worsened Sxs
155
What is different about distal bicep tendon ruptures ? imaging is used to Dx by identifying defect of muscle insertion at ? location What is the adverse outcome of distal bicep tendon ruptures if not Tx in timely manner
Uncommon, more weakness than proximal tears MRI: radial tuberosity Lost supination x 50% Lost flexion strength x 15% (initial, but improves)
156
On PE of distal bicep rupture, flexion of elbow against resistance will cause belly of muscle to move in ? direction What nerve can be damaged during surgical correction and why would Naproxen be given post-op These need to be corrected w/in ? time frame
Proximal Radial Decrease heterotopic ossification <2wks of injury
157
? structure is the primary valgus resistor in the arm Tearing of this structure can present as ?
Ulnar collateral ligament Throwing causing a pop w/ medial pain Medial paresthesia (common) Breaking pitches- curve/slider
158
How is a tear to the ulnar collateral ligament Dx w/ imaging What is the MC adverse outcomes of this injury What needs to be avoided during non-op Txs
MRI w/ intra-articular contrast Persistent pain w/ throwing CCS injections
159
When do ulnar collateral ligament tears need to be referred What is the name of the surgical correction procedure Arthritis to the wrist commonly develops as result of ? two things
Competitive throwers >3mon of non-op Txs Tommy John surgery Trauma, RA
160
How does wrist arthritis appear on exam depending on the cause ? random lab test may be needed during an abnormal work up How are these Tx non-op
``` RA: Wrist: radial deviation Finger: ulnar deviation Dec grip w/ pain OA: Swelling Pain Dec ROM ``` Lyme Dz Splint
161
When does wrist arthritis need surgical intervention ? is the MC compression neuropathy of the upper extremity What are common precipitating conditions that can lead to this MC
Dec function Unstable joint Non-op failure Carpal tunnel- median nerve ``` RA tenosynovitis Tumor Pregnancy DM Thyroid ```
162
WHat is the MC Sx reported in Pts w/ Carpal Tunnel ? is the most useful confirmation test How is carpal tunnel syndrome Tx non-op
Numb/tingle in thumb, index, middle finger Electrophysiologic tests Mild: neutral position splint
163
When does Carpal Tunnel need surgical Tx When do these PTs need to be referred De quervain tenosynovitis is swelling/stenosis around sheath of ? tendons
Lost sensory/weak thenar Persistent numbness Atrophy Weakness Non-op failure x 3mon Abductor pollicis longus Extensor pollicis brevis
164
What is the c/c in Pts reporting w/ De quervains? How is this condition Dx on PE How is de quevains Tx non-op
Radial styloid swelling Pain w/ thumb/fist movement Finklestein test 2 wks NSAIDs w/ spica splint Persistent= CCS sheath injection
165
? is an adverse outcome of surgical Tx for carpal tunnel ? 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
Radial sensory nerve injury 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
166
Periarticular arthritic nodules may contain ? cysts How are hand/wrist ganglions Tx When is surgical intervention needed for either
Mucus Wrist: immobilize, aspiration Hand: needle rupture or anesthetic injection Wrist: Sxs, cosmetic Hand: ganglia on flexor sheath causing pain
167
# Define Kienbock Dz and these PTs present to clinic As this Dz progresses, what is the final result
Osteonecrosis of carpal lunate in men 20-40y/o unable to grasp heavy objects End stage arthritis of wrist
168
How does Kienbock Dz appear on x-rays How is Dz staging accomplished w/ imaging How is Kienbock Dz Tx non-op
Early: inc density Later: fragment/collapse MRI Normal/sclerotic- splint, NSAIDs x 3wks
169
Ganglias are the MC benign soft tissue tumors of the hands, what are the 2nd and 3rd MC
2nd: Giant cell tumor 3rd: EIC
170
? are the MC benign and malignant neoplasms of hand bones ? is the MC malignant neoplasm of hand Most hand tumors are painless w/ ? exception
B: enchondromas M: chondrosarcomas SCC Glomus- pressure/cold sensitive
171
Why are malignant melanomas frequently seen in upper arms? When is surgical excision of hand tumors warranted ? type of finger growth needs to be evaluated further
Sun exposure Expanding/Sxs Pigmented subungual lesion
172
? can cause Pts to develop ulnar tunnel syndrome What can happen if this condition goes untreated What are the two MC animal bites and which one is more likely to become infected
``` Wrist entrapment (mass/lesion) Trauma- jack hammer, base of hammer hammering ``` Sensory loss Atrophy Clawed ring/little finger Dog, Cat Cat > Dog
173
What are the MC microbes infected after animal bites Outside of the US, ? is the MC vector for rabies Animal bite w/ purulent drainage suggests wound is at least ? old
Dog/Cat- Pasteurella multocida Dog- AHStrep, Bacteroides, Fusobacterium Dogs In US= bat skunk fox raccoon >10hrs
174
What ABX are used for animal bites How are animal bites of the hand Tx non-op What are the two MC causes of arthritis in the hand/wrist
Early infection: Amox 875mg IV: AmpSulbactam 1.5-3g Q6 Irrigate w/ .5-1L NS Cat bites- no sutures Dorsal hand: 10mL local anesthetic OA Secondary degenerative joint dz
175
What causes pain/swelling associated w/ gout What causes the inflammation process
Lysis of PMN cells from engulfing crystals Monosodium urate crystal collection
176
Diagnosis of tendinitis in these locations means the tendonitis is located where ? ``` Rotator cuff Tennis elbow De Quervain Hamstring Quad Patella Achilles Posterior tibial ```
``` Rotator: supraspinatus insertion Tennis: wrist extensor origin DeQ: abductor pollicis longus/finger flexor sheath/pulley Ham: hamstring origin Quad: quad insertion Jumpers: patella origin Ach: sheath, mid, calcaneal insertion PostTib: midsubstance ```
177
What joints are MC involved in OA/RA of the hand What PE test will cause these OA Pts to have more pain than usual What are the adverse events that could occur to PTs w/ RA of the hand/wrist
OA: DIP PIP, thumb CMC RA: wrist, MCP, tenosynovitis Pain w/ joint palpation Tendon rupture- little, ring, thumb
178
Idiopathic degenerative arthritis of the thumb's CMC MC affects ? Pt populations What causes this idiopathic variety to develop What is the MC Sx and hallmark of arthritis of the thumb CMC joint
Female 40-70y/o Joint configuration/laxicity MC: Pain w/ grip/pinch Hallmark: Tenderness over palmar/radial aspects of joint region
179
What test is performed on PE to Dx thumb CMC arthritis How is thumb CMC arthritis managed non-op Jammed finger is AKA ? and developed by ? action
Grind test Thumb spica splint w/ NSAIDs Splint failure= CCS injection Boutonniere- central extensor ruptures at insertion site on middle phalanx, PIP is flexed unopposed
180
How does a Boutonniere joint appear on PE What PE test is done for Dx confirmation What will be seen on x-rays of Boutonniere deformities
Partially flexed PIP Hyper/extended DIP Joint in flexion, extend PIP Lack of 15-20* PIP extension= rupture PIP flexion= calcification on lateral view of PIP
181
How are Boutonniere's Tx non-op Define Dupuytren Contracture What Pts are more likely to develop this condition
Splint in extension x 6wks (young Pt) or 3wks (old Pt) Thick/contracted palmar fascia Dominant genetics of Northern European men >50y/o
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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) ```
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When does Dupuytren's become surgical candidates What are the two types of finger tip infections What is the MC microbe to cause both types
30* fixed flexion of MCP 10* deformity at PIP Felon- thumb/index tip from puncture Paronychia- tissue around nail; post-manicure/deformity Staph A
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Why do Herpetic Whitlows and Felons need to be carefully differentiated What two occupations are at higher risk for herpetic whitlows What happens if felons are left untreated
HL- clear fluid vesicle around finger tip; don't I&D Felon- I&d for Tx; tender, red Dentists, RTs Distal phalynx osteomyelitis Rupture= septic flexor tenosynovitis
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How are paronychias Tx non-op What are the two types of incisions that include the puncture site for felon Tx What type of closure is used
Warm/moist soak x 10min Q6h w/ PO ABX x 5days Sev infection= nail removal Central volar longitude Dorsal mid-axial Secondary, never suture
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When suturing finger tips back in place, what type of materials are used When is this replantation method an option
Absorbable: 4O/5O chromic or plain gut Thumb: at/prox to IP Finger: prox to middle of middle phalanx or multiple amputations
187
Complete laceration of what two structures will result in immediate loss of flexion at PIP and DIP Where do these structures insert Loss of either of these w/ the other remaining intact will produce ? type of finger movement
Flexor Digit Sublimis Flexor Digit Profundus FDP- distal phalanx after passing between FDS slit FDS- mid phalanx + FDS, - FDP= PIP and MCP flexion - FDS, +FDP= PIP, DIP and MCP flexion
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What type of neuro examination needs to be done to finger trauma When testing fingers after traumatic lacerations, what is tested during flexion ROM How are these injuries initially treated
Two-point discrimination 1st: active 2nd: strength Clean/splint Surgery <7days
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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 Staph/Strep covering IV ABX PO ABX x 7-14days
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What kind of microbe can infect hand wounds from human bites How are these Tx non-op What is the f/u instructions
AHS/Staph A- MC Eikenella corrodens Arthrotomy wash out w/ PCN/1st Gen Cephalosporin F/u 24hrs then, Daily whirpool or dressing change Q12hrs
191
What causes a mallet finger to develop These may present w/out pain if they are older than ? How long are these splinted
Extensor tendon avulsion from distal phalanx 14days Acute: 6-8wks >3mon old: 8wks
192
What do fingernail avulsions in infants need to be assessed for? Permanent deformity is expected if ? structure is damaged How are the remaining injuries Tx
Physeal injury= referral Germinal matrix SubHematoma- decompress Floating nail- remove Suture germinal matrix under nail fold
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Post-nail avulsions need to be wrapped in ? 5 things What structures keep flexor tendons from bowstringing Define Trigger Finger
``` Anti-bacterial ointment Non-adherent gauze Sterile gauze Outer wrap Splint ``` 4 annular 3 cruciform Thick flexor tendon or first annular pulley
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? fingers are MC affected by trigger finger Where do PTs point pain located to ? but the issue lies at the ? How are these Tx non-op
Long and Ring Kids= thumb, other finger involved suspect metabolic d/o Pain at PIP Source at MCP CCS injection x 2 Failure= surgical release
195
When imaging Pediatric elbows, the head of the radius should be pointing in ? direction If peds dislocate their elbow, it's usually in ? direction Why are elbow sprains rare/unlikely in Peds
Towards capitellum Posterior Bones are the weak link
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? 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
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? is the compression and tension side of Peds humerus Osteonecrosis of lateral elbow in Peds is AKA ? LLE includes terms that are different by side of elbow, what are the lateral/medial Dxs
``` Medial= tension Lateral= compression (capitellum osteonecrosis) ``` <10y/o- Panner Dz >10y/o- osteochondritis dissecans Tension: apophysitis of medial epicondyle, UCL strain, olecranaon avulsion Compression: OCD, Panners
198
What two subsequent issues can develop from LLE depending on the Pts age What is a more common sequelae of untreated LLE ? is the MC PE finding of LLE
Epicondyle fragment: 8-12y/o Avulsion: 12-14y/o Delayed/failed olecranon fusion TTP
199
LLE OCD usually occurs in Pts older than ? after ? structure has ossified
>12 y/o after capitellum ossifies
200
What is the MC type of Obstretric Palsy What is the other type of Obstetric Palsy ? PE finding indicated poor recovery prognosis
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 Full bicep function after 3mon Entire plexus involvement Horner Syndrome Nerve avulsions
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? is the MC observed clinical Sx of Obstetric Palsy What is the position of Waiter's tip in words What PE findings are consistent w/ a preganglionic avulsion injury of sympathetic chain
Reduced spontaneous movement- pseudoparalysis Forearm pronated Elbow extended Wrist flexed Shoulder adduct, internal rotated Horners Syndrome Phrenic nerve palsy Nerve involvement- long thoracic, dorsal scapular, suprascapular, thoracodorsal
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What is considered the best non-op Tx for Obstetric Palsy What is the cornerstone of Tx What causes Congenital Muscular Torticollis
Supervised at home exercise program Assessment and monitoring neuro function/recovery 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
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What two Dx are suspected in infants w/ sudden loss of function in part that was mobile at birth How is Congenital Muscle Torticollis differentiated from AARD What does an optic exam need to be conducted for CMT
Sepsis, Abuse AARD- SCM spasm occurs on opposite side of tilt Superior oblique palsy= nystagmus causing torticolis
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How is CMT Tx non-op If CTM has to be Tx w/ surgery, what are the time frames How is AARD initially Tx non-op
Rehab stretching exercise Position beds/table to make baby look away from affected side Problems lasting >12mon= SCM release after 4y/o Soft collar w/ analgesics and Benzos
205
Pediatric reiters is particularly painful if what two structures are involved Pediatric girls are more likely to develop psoriatic arthritis but ? precedes their psoriatic issues ? is the MC bony Fx and location
Achilles Plantar fascia Arthritis before skin Clavicle, middle third
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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
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? type of clavicle Fxs are more likely to result in nonunion ? type of neuro injury usually accompanies humeral shaft Fxs What type of Tx is used for humeral shaft Fxs w/ <2cm of shortening
Displaced lateral or midshaft Segmental Fxs Radial- dec wrist/finger extension w/ lost sensation to dorsal web space U-shaped coaptation x 2wks
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What are the 4 segments that proximal humeral Fxs can be classified as What muscles attach to the different humeral tuberosity What is the MC two-part Fx
Greater/Lesser tuberosity Humeral head Shaft Greater- Supra Infra TM Lesser- Subscap Surgical neck
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What is the most common error that occurs when assessing proximal humeral Fxs How are Fxs w/ <1cm displacement Tx Why are two part Fxs of the greater tuberosity w/ >0.5cm displacement Tx w/ surgery
Shoulder dislocations Sling w/ pendulums after 3wks Restore rotator cuff muscles
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What types of displaced humeral Fxs need to have surgical Tx What types of humeral Fx usually has disrupted blood flow requiring prosthetic replacement What is the MC associated injury to accompany scapular Fxs
Two part humeral neck Displaced 3/4 part Fxs Displaced 4 part Rib Fxs
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How are scapular Fxs Tx non-op What are the operative red flags for these Fxs What are the MC types of elbow dislocations and what structure is always disrupted
Sling w/ motion as tolerated after 1wk Glenoid surface displaced >2mm Acromion Fx w/ impingement Scapular neck Fx w/ >30* deformity Posterolateral; LCL
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What is the terrible triad in adults What is the terrible triad in kids What is the most important part of an elbow dislocation exam
Elbow dislocation, Radial head fx, Coronoid fx Elbow dislocation, Radial head fx, medial epicondyle Fx Neurovascular
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How long after elbow Fx/Reduction should motion be restarted What is an adverse outcome of these types of injuries ? is the MC special test finding during a distal humeral Fx assessment
5-7 days Ulnar nerve entrapment Ulnar nerve dysfunction
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How are distal humerus Fxs Tx non-op Displaced olecranon Fxs will have ? motion inhibited on PE What is a common adverse outcome of olecranon surgical Tx
Sling x 10 days Elbow extension at tricep insertion site Implant irritation requiring implant removal
215
What is the classification methods of radial head Fxs What types of radial head Fxs can have mechanical blocks with them Define Essex-Lopresti Fx
Modified Mason: 1- non/minimal displacement 2- >2mm displacement, angulated neck/mechanical block 3- severely comminuted Types 2 and 3 Radial head Fx w/ injury to forearm
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What is a common adverse outcome of radial head Fxs How are radial Fxs Tx What types are red flags
Loss of last 10* of extension Type 1- move as tolerated Type 2/3- surgical ORIF Type 2 w/ rotation block Type 3 Fx w/ elbow dislocation/instability
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# Define Bennett Fx Define Rolando Fx How are Fxs at the base of thumb Tx non-op and w/ surgery
Oblique thumb base Fx enters CMC joint Less common than Bennett, y-shaped intra-articular Fx Goal: restore axial length, put metacarpal fragment against smaller volar fragment Thumb spica-cast x 4wks Bennett- ORIF
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What are the landmarks to find the hook of hamate that tends to Fx in ? populations What types of x-rays are needed to view the Fx How are these Tx non-op
2cm distal and 2cm radial to pisiform Racquet sports, Golf, Baseball Semi-supinated Carpal tunnel view Wrist immobilization in neutral position
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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
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# 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
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How much angulation is acceptable for wrist Fxs ? is the MC Fx of the hand and when is surgical Tx needed ? is the MC adverse outcomes when Tx Fx of hand
Lateral- <5* of dorsal angulation AP- no less than 15* radial inclination >2mm step off = reduce Boxer Fx- distal > proximal > middle >40* angulation + extensor lag Joint stiffness
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Due to the pulling mechanism of flexor tendons, how to displaced Fxs of metacarpals/phalangeal shafts react ? is the MC Fx carpal bone and in ? PT population What part of the bone is more likely to be broken and how long do these different areas take to heal
Transverse: angulate Spiral: rotate Oblique: shorten Scaphoid, men Middle- 60% Distal: 6-8wks Middle: 8-12wks Prox: 12-24wks
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? type of UE Fx has a high incidence of nonunion and osteonecrosis 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 as a result of a tear to ?
Scaphoid Unstable, complete UCL rupture in thumb MCP PIP Hyperextension Torn volar capsule
224
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
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What type of Peds elbow Fx has a high incidence of neurovascular problems ? is a common neuro injury found w/ Peds elbow Fxs
Supracondylar AIN palsy
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# Define Birth Fx Metaphysical Fx of proximal humerus typically occur in ? age groups while physeal Fxs tend to occur in ? What causes hip impingement to develop and what injury is usually caused by this
Clavicle Fx during birth Meta: 5-12y/o Phys: 13-16y/o Acetabular/femoral bone deformity leading to labral tears
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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 PE test is positive for hip impingement
Groin pain C-sign, worse w/ rotational movement FADDIR- Fixed Adduction Internal Rotation
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# 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
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# Define Pincer Acetabular Impingement What appearance does this have on x-ray and what is the AKA for it What is the most accurate imaging modality for labral and osseous evaluations
Anterior acetabulum more prominent than posterior rim Anterior wall more lateral than posterior: AKA crossover sign MRA
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What is the adverse outcome of hip impingement? ? is Dx and Therapeutic for hip impingements and is the most accurate test to determine ? issues What kind of non-op rehab do hip impingement need?
Etiology of 80% of hip OA Fluoroscopical intra-articular injection Intra-articular etiology for hip pain ROM, strength Long Hx/tendinitis: deep massage, active release
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? do hip impingement PTs need for post-op rehab Post-op hip impingement can have ? neuro issues d/t ? nerve involvement Inflammatory arthritis is commonly seen in ? 3 Dzs and can start out as ? Sxs
CPM device Stationary bike Numb groin/dorsal foot Lateral femoral cutaneous- lateral thigh Hip Sxs MC: RA, Ankylosing Common: End stage Lupus secondary to ON
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Inflammatory arthritis etiology is believed to be from ? and d/t ? pathophys reaction How do PTs w/ inflammatory arthritis of the hip present on PE ? types of gait do they have depending on the length of the Dz
Genetics; response to antigens Dull ache/pain in groin/thigh/butt AM stiffness loosens w/ activity Antalgic- early in Dz Trendelenburg- lost cartilage
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? is the most sensitive PE finding for adults w/ inflammatory hip arthritis and how is inflammation of synnoival fluid tested for When these Pts fail ? type of non-op rehab, what is the surgical Tx for them What are the early/late signs seen on x-rays What is the TxOC
Dec internal rotation Log roll leg ROM/pain free strength failure= total arthroplasty Early: osteopenia/effusion Late: symmetric narrowing/periarticular erosions Arthroplasty
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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 and what can Pts present w/ if condition is uncommon or acute? It Pt is a jogger, what do they describe pain as ?
Exiting pelvis, medial to ASIS Sensory only Cecal tumor Uncommon: Groin ache Acute= pain radiating to SI joint Electric jab w/ hip extension
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What is the MC spot to reproduce hypo/dysesthesia Sxs of lateral femoral cutaneous nerve entrapment Rarely is surgical release needed for Tx unless ? History of OA hip issues can indicate ? secondary issues depending on PTs age
Superior and Lateral knee- MC w/ burning Persistent burning dysethesia Infant/toddler= developmental dysplasia Small child- Legg Calve Perthese Dz Adolescent- SCFE
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What part of the OA Dz process causes Pts to alter gait Name of the two types of gaits Pts can adopt How are young/active Pts w/ this condition Tx w/ surgery
Flexion contracture= increased lumbar extension Antalgic- stride shorter on painful side Abductor lurch- trunk sways over affected side Realignment osteotomy Arthroplasty w/ metal-on-metal Hip fusion: young laborer/vigorous lifestyle
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? Pt population is more likely to have long term complications post-hip arthroplasty ? is an uncommon development for Pts w/ hip OA ? DxHx can indicate a potential cause for Pts osteonecrosis of the hip
Young, active d/t wear and tear Bone loss of femoral head/acetabulum Sickle Cell- affects osteocytes first
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What risk factors can lead to osteonecrosis of the hip? How will these PT present and w/ ? type of gait What is seen on x-ray and what is a beneficial next step if unilateral findings are noted
Steroid Lupus Alcohol Trauma RA Sickle 30-50y/o w/ bilateral Pain, Dec ROM, + straight leg Early: atalgic Late: trendelenburg White crescent sign= subchondral Fx MRI contralateral hip to eval ASx condition
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What is the adverse outcome if Pts prolong Tx of femoral osteonecrosis How is osteonecrosis Tx if femoral collapse has not occurred How are these Tx if collapse has occurred
Femoral head collapse Secondary degeneration Core decompression Vascular/Osteochondral grafts to relieve pressure Core decompression= short term relief Arthroplasty
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What is an adverse outcome of core decompression Tx for osteonecrosis What are the three etiologies of Snapping Hip When does the ITB sublux?
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 Walking/hip rotation Laying w/ affected leg up
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Where do Pts w/ trochanter bursitis induced from ITB snapping hip describe their pain as? Snapping from subluxation of iliopsoas tendon is described and located as ? ? type of snapping is more debilitating and causes Pt to reach for support
Pain in AM/PM Pain w/ laying on affected side Groin pain w/ hip extension from flexed (rising from chair) Intrarticular origin
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How are these snapping movement replicated during a PE? What 3 PE findings suggest the problem lies intra-articular What test is used to evaluate the tightness of the ITB
ITB: rotate hip w/ leg in adduction Ilio: hip extension from flexed position Restricted internal rotation Limp Short limb Lay on unaffected side Flex knee to 90, abduct hip to 40* and extend Hip fails to adduct to midline/+ pain= Pos test
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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
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How is a strained adductor isolated on PE? How is a rectus, iliopsoas or sartorius strains isolated on exam? What are the 5 phases of hip strain rehab
Groin pain w/ passive abduction/resisted strength test RF: Inc pain w/ muscle stretch Ill: deep groin/inner thigh pain Sar: superficial, lateral pain 1: 48-72hrs; RICE, protected weight bear w/ crutches 2: 72hrs-7d; PROM, heat, stimulation 3: 7d+: isometric exercises, inc strength/flexibility
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? are the 4 weakest muscle groups of the hip What are the 3 muscles of the hamstring that are MC injured than anterior muscles How are the etiologies of thigh strain different
Abuductor Rotators Extensor Bicep femoris Semi-membranous/tendinosus Ham: stretched w/ contraction Quad: direct blow
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Origin and insertion of hamstring? ? 3 parts of the quad only span one joint Only one to span two joints is?
Ischial tuberosity Tibia/fibula Vastus medialis/intermedius/lateralis Rectus femoris
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# Define Myositis Ossificans and what is done during rehab to prevent this from developing Transient osteoporosis of the hip is AKA ? and more common in ? populations How long does it take for transient osteoporosis to resolve thus causing Pts to adopt ? gait
Quad contusion causing restricted knee flexion, simulates malignant tumor Active pain free stretching, not passive stretching Marrow Edema Syndrome- middle age men/3rd Trimester 6-12mon w/ antalgic gait
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What are the typical MRI findings for transient osteoporosis of the hip What is an adverse outcome that can occur during this issue How are Pts managed non-op Stretching ? two muscles in particular may help w/ rehab
Femoral neck edema= T1 decreased/T2 increased Femur neck Fx, especially pregnant Pts NSAIDs and crutches until x-rays prove normal density Piriformis Tensor fascia latae
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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
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? 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 ? is an important part of therapy for these PTs
Pain to palpation on lateral greater trochanter- worse w/ hip abduction GMT- tenderness above greater trochanter, worse w/ ab/adduction and rotation Abductor strength
251
What mechanisms usually cause ACL tears and what will Pt report for activity after event ? other 3 structures are possible in descending order Multiple ligamentous injuries need to have ? life threatening issue r/o?
Twist/hyperextension force during non-contact event Pt unable to continue game Meniscal > MCL > L/PCL Popliteal disruption
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? is most sensitive test for ACL tears and why is positioning so important during this test Tibial eminence Fxs are more common in ? Pts Lateral Capsular Sign is AKA ?
Lachman by grasping tibia on medial side- hamstrings relaxed otherwise act as dynamic stabilizers of tibial translation anteriorly Open physes Segond Fx
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Chronic ACL insufficiency leaves ? structure prone to injury and why? ? muscle rehab is used for stability improvement ? ranges of motion need to be avoided due to excessive stress on damaged area Why do Pts report numbness after surgical reconstruction
Posterior horn of medial maniscus; secondary stabilizer to anterior tibial translation Hamstring* curl Isometric quad flex Leg raise 30-10* and varus/valgus stress Damaged infrapatellar branch of saphenous nerve
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? anatomical deviations can make Pts susceptible to ACL damage What is the MC and two possible adverse outcomes of ACL surgery? ? adverse outcome can occur post-op if full ROM was not restored prior to surgery
Foot pronation Large Q-angle Anteverted hip Genu recurvatum/valgum MC: autogenous causes anterior knee/hamstring pain Patellar tendon rupture Graft site Fx Arthrofibrosis w/ loss of motion
255
Isolated patellofemoral OA can exist in ? 3 populations Secondary knee arthropathy usually occurs in Pts w/ ? types of Hx If RA is the cause of the OA, what compartment is affected
MC- Tibiofemoral OA Patellar subluxation/baja Meniscal tears Intra-articular trauma Chronic ligamental insufficiencies Lateral: Valgum d/t ligamentous laxicity
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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
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? Pt population w/ knee OA are candidates for physical therapy which has been to be just as efficacious as ? ? type of management is not recommended for Pts w/ advanced knee OA cases 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 ? occupation can get housemaids knee and d/t what two MC microbes
Poor balance/Hx of falls As effective as NSAIDs for pain relief Arthroscopic Unloading tibial/femoral osteotomy 5-10yrs, Knee replacement Pre-patellar bursitis from excessive kneeling Staph, Strep
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Bursitis are located between ? structures Pes anserinus is the insertion site for ? 3 muscles and commonly develops into bursitis in ? PTs Pes anserinus bursitis is commonly mis-Dx as ? What structure can become compressed by this form of bursitis leading to numbness distal to patella
Bone Ligament Tendon Sartorius Gracillis Semitendin Early OA in medial knee compartment Meniscal pathology Infrapatellar branch of saphenous nerve
259
Septic bursitis presents w/ ? 3 Sxs Non-infectious traumatic bursitis presents w/ ? and w/out ? How are bursitis and septic arthritis of the knee differentiated on x-ray
Pain Erythema Warm + Warm, - pain/erythematous Burs: diffuse pre-patellar swelling SA: suprapatellar pouch swelling
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If septic bursitis is suspected, what is the next best step? How is non-infected bursitis Tx Early onset, mild septic bursitis of the knee can be managed by ? exception
Aspiration to r/o septic arthritis Bursal injection w/ CCS (recalcitrant cases) US/Phoresis NSAIDs Ice LLD Stretches PO ABX
261
What causes and what are the S/Sxs of neurological claudication What are the causes and what are the S/Sxs of vascular claudication What is the initial screening tool for these Pts when suscpecting arterial insufficiency as the etiology
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 ``` Neuro: Lumbar flexion exercise Epidural CCS injectino NSAIDs Decompress ``` Vasc: Initially- foot care/shoes/avoiding hose/pharmacological Surgery (bypass grafts)
262
? type of injury causes MCL/LCL tears MCL injuries can also have ? structure injured depending on the amount of force applied What is commonly and rarely seen suggesting a torn cruciate ligament What injury can occur to the lateral knee at the same time a MCL injury is sustained and how
MCL: Valgus/abudction- football clipping LCL: Varus/adduction ``` Popliteofibular ligament Popliteus tendon Peroneal nerve (extreme) Bicep femoris tendon (extreme) ``` Common: hemarthrosis Uncommon: locking/popping Sxs Lateral femoral condyle presses against lateral tibial plateau= lateral meniscus tears
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Where does the MCL insert on the leg 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
Distal to pes anserinus on tibia Ligaments/posterior capsule are relaxed ACL/PCL injury w/ disrupted posterior capsule Knee dislocation w/ spont reduction; neurovasc w/ ABI
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Laxity measurements of ? much can indicate the grade of sprain How are MCL/LCL sprains managed 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
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How long after MCL/LCL injuries are Pts at higher risk for reoccurence and what is recommended during this time frame ? many compartments are in the lower leg Fx of ? usually leads to compartment syndrome
6mon, wear brace during high risk activities Ant/Lat/Sup, Deep Post Prox tibial Fx involving anterior compartment w/ possible defect in fascia
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What compartments of the lower leg are involved by compartment syndrome it Pt reports numbness in dorsal/plantar regions? Chronic/exertional compartment syndrome may have ? c/c and MC involves ? compartment ? PROM ca also help identify what compartment is involved in acute compartment syndromes
Dorsal foot- ant/lat compartment Plantar aspect- deep posterior compartment First web dorsum paresthesia Weak dorsiflexion MC anterior compartment EHL by moving great toe- anterior Peroneus brevis/longus by foot inversion- lateral Extending great toe- deep posterior Dorsiflex ankle- superficial posterior
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# Define Myositis Ossificans Traumatics and ? is this a sub-category of ? What medical emergency can arise from quad contusions ? 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
MC thigh contusion causing calcified mass via heterotropic ossification Compartment syndrome Heel raises Elastic wrap w/ knee in hyperflexion RICE/ROM
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Origin/Insertion of ITB and what types of movements causes the ITB to change positions Inflammation of ITB is MC seen in ? populations
ASIS to Gerdy Tubercle Knee extension= anterior to lateral femoral condyle Knee flexed >30*= posterior to lateral femoral condyle ``` Distance runner (especially down hill, painful heel strike) Cyclists ```
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What are 3 anatomic RFs placing PTs at risk for developing ITB inflammation ? PE test help confirm this Dx and ? modalities can be used to decrease inflammation When are CCS steroids recommended for ITB inflammation
Rum, genu Internal tibial rotation Pronation of foot Ober test: 30* flexion/flexed knee hop= pop Phoresis/Cryotherapy After stretch, PT, and exercise modification fail
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? population are more likely to have gastrocnemius tears and where Where do Pts report pain location and ? position do they adopt to decrease pain Why do these Pts have a negative Thompson test
>30y/o of medial head at junction push off process Prox and Medial at junction Ankle in plantar flexion- no single leg toe-raise Lateral gastroc and soleus are intact
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? are potential adverse outcomes from medial gastroc tears How long are CAM boots and crutches utilized for What is the goal of gastroc tear rehab
DVT Until ambulation is pain free RICE to control pain/inflammation Movement rehab started after 21days
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? adverse effect can occur from rehab for medial gstroc tears if not done right ? type of meniscus tear is nonfunctional and causes more rapid degeneration and what type of Pt presentation can this occur in ? is the MC PE finding of meniscal tears
Lost dorsiflexion, Calf atrophy Posterior medial tear Obese Pt w/ 'pop' and sharp pain in posterior knee Tenderness on joint lines
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Young Pts w/ meniscal tears that cause large effusions/hemarthrosis indicates tear is located ? 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
<5mm of meniscal attachment sites Degenerative/near central body of meniscus Meniscocapsular junction McMurray= Appley + Thessaly Forced flexion and circumduction
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? image do Pts w/ possible meniscus issues need prior to MRIs especially if they meet ? criteria How are meniscal tears graded How are meniscal tears w/out mechanical Sxs Tx When is arthroscopic debridement warranted
Weight bearing Knee at 45* flexion: sensitive for early OA, recommended in Pts >40y/o ``` 0= no intrameniscal signal 1= focal, no surface communication 2= no surface communication 3= communicates w/ surface ``` RICE, Acetaminophen/Motrin No activities until ASx Young w/ big tears Locked knee Non-surgical Tx failure
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? is the MC site of the femur to develop osteonecrosis What can cause this? ? are early and late radiographic signs that femoral osteonecrosis is occurring
Weight bearing medial condyle ``` MC: female +60y/o Renal transplant Sickle cell Gaucher Dz Steroids ``` Early: Sclerosis, Flat condyle Late: Narrowed spacing, Osteophytes
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Patellar/Quad tendonitis is AKA ? ? is the hallmark Sx of this conditions ? type of atrophy may be seen if condition is left untreated What may be seen on x-rays
Jumper's Knee Anterior knee pain Vastus medialis obliquus Enthesophytes: calcifications of tendinous insertions Heterotopic calcifications of patella poles
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Pt w/ Hx of Osgood-Schlatter Dz and presenting w/ Jumpers Knee may have ? x-ray findings? What are the 3 phases of Tx for Patella/Quad tendonitis but what is the MC adverse outcome of Tx ? Pts are more likely to have quad/patellar tendon ruptures?
Large ossicle from unhealed tibial apophysis 1: NSAID Immobilizer LLD (rest, pain control) 2: Strength Flexibility ROM PRP (pain free motion) 3: Resume activities (resume: heat prior, ice after) Persistent functional impairment Quad: white 40-60y/o men Pat: mid-age AfAm men
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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 ? PE finding is pathgnemonic for leg extensor disruption?
Fall on knee that is partially flexed Endocrinopathy FQN usage Quad/Patella tendinitis Large effusion w/ palpable defect
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What is the hallmark of substantial Quad/Patellar disruptions Why are knee tendon ruptures assessed w/ lateral views w/ 30* of knee flexion? If the Pt is going to retear after surgery, when is it most likely
Inability to perform straight leg raise Inferior patella in line w/ Blumensaat line First 6mon
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? triad presentation suggests Quad/patella tendon rupture and need surgical correction w/in ? days Patellofemoral maltracking usually occurs in ? direction but can be due to laxity of ? Rarely does it go in ? direction but if it does, is due to ?
Palpable defect Unable to extend knee Patella alta/baja <7 days Laterally Medial patellofemoral ligament Medial SurgHx release of lateral retinacular
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What two PE findings can cindicate malalignment is present What two PE findings can contribute to lateral patellar instability ? view on x-ray is used to assess patellofemoral articulation What is the initial Tx for acute patellar subluxation/dislocation
Femoral anteversion Tibial torsion Genu valgum Patella alta Pos J sign Axial: Merchant/Laurin Brace/immobile in extension x 4wks Modified weight bearing Pain meds Ice
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Patellar subluxation/dislocation can occur with mild trauma/rotation in Pts w/ ? anatomic RFs for this to occur Surgical realignment involve moving ? structure ? direction ? is the MC adverse outcome of Tx
``` Patella alta Shallow trochlear groove Flat patella under surface Excessive anterior femoral neck anterior version Externally rotated tibia Ligament laxity ``` Osteotomies of tibial tuberosity medial/anterior Instability/patellofemoral pain
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How do Pts w/ PatelloFemoral Syndrome present How does Symptomatic Malalignment present What needs to be assessed w/ Pt standing
Diffuse anterior knee ache worse after sitting/climbing Retropatellar pain Patellar winking- inc femoral anteversion/weak glutes
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What is the hallmark Tx for PatelloFemoral Syndrome ? kind of taping is used to relieve Sxs during therapy What is the difference in presentation of Patellar Instability and Malalignment
NonSurg therapy without full-arc and open chain quad exercises McConnell- taping that dec lateral pressure Inst: apprehensive to lateral pressure Align: femoral anteversion w/ tibial torsion, valgum deformity
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# Define plica folds and how many are there in the knee Why do these structures become bothersome when inflamed ? plica is most likely to become symptomatic
Synovial fold in knee x 5 Three most distinct: supra: under quad tendon to medial/lateral capsule medial: medial capsule to medial anterior fat pad infra: ligamentum mucosa; anterior covering of ACL Bowstring over femoral condyles Medial
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What is found on PE if medial plica is inflamed How are Sx plica made more pronounced on exam What can be done for Dx and therapeutic
TTP over medial patella Pop at 60* flexion Flex knee to 90, then extend- pop at 60* as plica rolls over medial condyle Local anesthetic and CCS injection
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? is the MC benign synovial cyst of the knee and where is it located ? underlying issues are associated w/ this Dx How do these cause plantar foot numbness
Popliteal/baker cyst- between medial gastroc head and semimembranous muscle Degenerative meniscal tears Systemic inflammatory conditions Tibial nerve neuropathy
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? Pts are more likely to have their Baker's Cyst pop When these pop, what condition is mimicked Origin, insertion and path of PCL
>40 w/ degenerative arthritis/RA DVT Medial intercondylar wall of femur Behind ACL Posterior aspect of tibia
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? four injury mechanisms can suggest issues w/ PCL What is the difference in mechanisms that could result in patella Fx ? is the most sensitive test on PE for this injury
Dashboard injury Fall on flexed knee w/ foot plantar flexed Pure hyperflexion injury Hyperextension after ACL= dislocated knee Fall on flexed knee w/ foot dorsiflexed Post drawer test
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? adverse outcome can occur from PCL tears if not properly assessed Any suspected PCL tear needs ? test done during assessment What causes the pain of shin splints
Damage to tibial/peroneal nerves Instability Meniscal tears ABI Inflamed tibial periosteum
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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 may also be ellicited
Tibialis posterior Pes planus Tenderness along posterior medial crest Pain w/ plantar flexion
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Skipped Quiz 5
46-68
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? is the more common type of hip dislocation How does this MC type appear on PE ? neuro issue is commonly associated w/ these injuries
Posterior Shorter Adducted Flexed Rotated Internally Peroneal division of sciatic nerve
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How do anterior hip dislocations appear What do the different dislocation types look like on x-rays that can tell the direction of dislocation ? types of Fxs are common and ? is the MC complication of hip dislocations
Mild Flexion, Abduct, Rotated Externally Posterior: femoral head smaller Anterior: femoral head larger Posterior wall of acetabulum Osteonecrosis of femoral head
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How are hip dislocations Tx after reduction ? adverse outcome can occur during reductions ? are common injuries seen in Pts w/ femur shaft Fxs and ? neuro checks are needed
Uncomplicated- crutch assisted WBAT x 2-4wks Damaged articular cartilage Acetabulum/Femoral Fxs Faster reduction= dec osteonecrosis risk Ligamentous injury to ipsilateral knee Femoral Peroneal Posterior tibial
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Depending on the location of a pelvic Fx dictates ? images are needed next Define stable pelvic Fx and provide example Combo of what two injuries puts a pelvic Fx Pt at high risk for thromboembolic events
AP- inlet/outlet Acetabular- oblique (intra-articular) Fx on one side (superior and inferios pubic ramus) Sup/Inf ramus and S/I Fx= unstable Pubic symphisis + sacrum/sacral ligament= unstable Pelvic ring + acetabular Fx
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Low energy falls from standing require ? Tx steps Femoral neck Fxs are AKA ? and usually have ? adverse outcomes Intertrochanteric Fxs are AKA ? and have ? common adverse outcome
Protected weight bearing x 6wks Intracapsular- nonunion, osteonecrosis Extracapsular- base of neck to distal lesser trochanter; Implant failure
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? is the biggest RF for proximal femur Fxs Why does this RF increase w/ age ? ethnicity is more likely to have this Fx
Advanced age- risk doubles w/ each decade after 50y/o Dec proprioception Dec protective responses Fall to side, not fwd White
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Pt w/ displaced femoral neck/intertrochanter Fx will look like ? when supine A stress Fx/non-displaced femoral neck Fx will be unable to perform ? test and need to have ? radiograph technique avoided Surgical correction of femur Fxs and initiation of DVT prophylaxis shouldn't exceed ? hrs
Externally rotated w/ abduction Displaced= and shortened Unable to do straight leg raise Avoid Frog-Lateral= MRI <48hrs
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Most Fx of proximal femur are reviewed by ? types of x-rays and what is the next step if films are neg but pain is present ? medical complications are typically seen in PTs w/ proximal femur Fxs How are nondisplaced/valgus Fxs and displaced Fxs Tx
AP pelvis/Cross-table lateral MRI Pneumonia Thromboembolus Ulcer UTIs Non/V: Percutaneous pins x 3 Dis: Arthroplasty
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Femoral neck Fx in Pts younger than 60 are considered ? and all of these Fxs need to be eval'd by ? 3 specialists Femoral neck Fx Tx w/ internal fixation are associated w/ ? two adverse outcomes while the MC complications of surgical Tx of intertrochanteric Fxs Where do tension stress Fxs tend to occur
Medical emergency Ortho Internist Anesthesia IntFix: Osteonecrosis of femoral head, Non-union InterTroch: Arthritis, Failure of fixation w/ nonunion Older Pts- transverse on superior aspect of proximal neck w/ strong tendency to displace
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Who is more likely to develop a stress Fx of the femoral neck Where are tension/compression stress Fxs more likely to develop When will radiographic evidence of this condition be seen and what form is even quicker
Recruits/Runners T: transverse through superior/prox neck in older Pt C: Inferior medial side of femur, less likely to displace in younger Pt 2-4 wks after Sxs start Bone scan detects <48hrs after injury
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Femoral neck stress Fxs can progress into ? deformity How are compression stress Fxs of the femur Tx How are tension stress Fxs of the femur Tx
Varus Non-weight bearing x 6-8wks w/ serial x-rays Internal fixation if Sxs persist Surgery- internal fixation
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What mechanisms causes tibial plateua Fxs What other injuries will be present What two populations does this occur in
Valgus- lateral femoral condyle into lateral tibial plateau Meniscus Collateral ligaments Athletes, Elderly
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What causes a periprosthetic supracondylar Fx to occur after knee replacement Supracondylar Fxs are highly susceptible to ? if left untreated because ? How are these Tx non-op
Anterior femoral cortex is notched during surgery Nonunion- muscular insertion shearing forces Partial weight bearing x 6wks
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? type of lower leg stress Fx has a poor prognosis What is the difference between an anterior and compression stress Fx of the lower leg How long can it take for these to become visible on x-ray
Anterior tibia- risk for complete Fx or more common, prolonged healing time Anterior- tension Fibula- compression 3wks or >
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Pt w/ mild stress Fx pain, is not an athlete or in occupation requiring stress/demand/impact can maintain ? exercise program Severe stress Fxs can only return to normal activity after ? milestone is reached How are severe anterior Fxs Tx w/ surgery and what is an adverse outcome What is a possible and more common adverse outcome of anterior stress Fxs
Below pain threshold w/ x-rays at 3-4wks Pain completely resolved IM pin- anterior knee pain Possible: complete Fx Common: prolonged healing time
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? is a difficult and rare form of stress Fx seen in women Peds w/ femur Fxs older than ? get surgical pins How are Ped femur Fxs Tx depending on type/location of Fx
Dreaded black line= fatigue Fx of anterior cortex in midshaft of tibia >6y/o 6mon-5yr: Spica cast/posterior mold splint Non-displaced neck/Intertrochanter: immobilize Shaft: spica w/ bed rest 6-10y/o: surgical fixation
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? type of femur Fx in kids needs to be evaluated for abuse Younger kids are more likely to have ? two types of tibial Fxs What types are more common in older Peds
<36mon w/ diaphyseal Fx <1y/o/nonambulatory w/ shaft Fx Tibia Diaphyseal Proximal metaphyseal Growth plate Intra-articular
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What are two complex Fxs of distal tibia in kids best seen on CT/oblique x-rays Remodeling is unpredictable in these Pts if deformity is larger than ? ? adverse outcome is common in distal tibial physeal injuries
Triplane, Tillaux >10* Growth arrest
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? are the two MC types of arthritis in the ankle/foot Where are the MC locations in these spots Midfoot OA is commonly seen idiopathically in ? Pts and also after ? injury
OA, Post-traumatic Hallux rigidus Tarsometatarsal Talo-navicular- medial hindfoot Talocalcaneal Older women Tarsometatarsal (Lisfranc) dislocation
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Subtalar arthritis is usually seen after ? injury and causes Pts to experience difficulty w/ ? later in life What is looked for on PE to Dx midfoot arthritis ? special test and imaging is used to identify the specific joint involved
Calcaneous Fx Walking on uneven surfaces Midfoot tenderness w/ dorsal bump Pain w/ pronation/supination Piano key test Weight bearing x-rays
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? is the path of osteophyte growth in MTP arthritis Talonavicular arthritis is best viewed w/ ? type of x-ray ? type of x-ray is needed to evaluate heel varus/vagus deformity
Start lateral, extend superior/medial AP Harris view
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Midfoot arthritis is seen predominantly involving ? area What are the initial Tx steps for Pts w/ arthritis of the foot How is MTP arthritis Tx w/ surgery
Second metatarsal joint Shoe mod/orthotics NSAID Hallux rigidus= rocker bottom ``` Early= cheilectomy Late= arthrodesis ```
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How is midfoot arthritis Tx non-op How are they Tx surgically if Sxs persist
Rigid orthotic/steel shank w. CCS injections Midfoot fusion
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Ankle arthritis is initially Tx w/ ? How are refractory cases Tx surgically Nearly all Pts w/ RA in the foot/ankle will have Sxs located ?
Custom, rigid orthotics CCS Arthrodesis >60y/o= replacement Fore/Midfoot Ankle/hindfoot
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RA induced metatarsalgia commonly occur w/ subluxation or dislocation of ? joints and ? deformities What correlation does severe hallux valgus present w/ ? joint is one of the last ones to be involved by RA
Lesser toe MTP Claw toes Distal migration of fat pad= tarsal head inc in prominence Lesser toe deformities Ankle after talonavicular/subtalar joint
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? drugs are used for foot/ankle RA to decrease the synovitis and Dz progression What are CCS injections good for in these PTs ? type sof orthotic/inserts are used for the different areas involved by RA
Methotrexate a-TNFs Inflammed joints Significant tenosynovitis Metatarsalgia= extra depth shoe w/ molded insole Extensive Dz= molded ankle-foot orthosis Flexible hindfoot- UCBL orthosis
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? is the most reliable surgical Tx for forefoot deformities unless ? joint is involved ? is the only temporary procedure for these PTs and rarerly recommended After hindfoot arthrodesis is performed, Pts still retain ? two motions
MTP/tarsal head fusion; Great toe Tenosynovectomy Dorsi and Plantar flexion
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Young Pts w/ RA induced ankle destruction will also have ? joint involvement If both ankle joints are involved, what is the next step ? but w/ ? adverse outcome ? are the two MC soft-tissue tumors of the foot/ankle and ? are common location for each one of these to develop
Subtalar Hindfoot- tibiotalocalcaneal fusion Worse functional outcome than BTK amputations Ganglia- arising from lateral subtalar/ankle sheath/capsule Plantar fibroma- benign thickening of plantar fascia
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What is a Dupuytren's contracture equivalent in the foot How is this equivalent different How do ganglion cysts and plantar fibromas of the foot appear differently on PE
Fibroma evolves into plantar fibromatosis- benign thickening of plantar fascia Less likely to cause deformity GC- movelable w/ pressure PF- multiple, hard/rubbery on fascial band
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How are ganglia/fibromas of the foot Tx non-op Define Corn A persistent one on the forefoot is AKA ?
Ganglion: 3-4 punctures w/ 18g to promote cyst collapse Fibroma: shoe mod/orthotics Kyperkeratotic lesion usually from deformity Toe= corn, from toe deformity/tight footwear Metatarsal head= callus, usually w/ metatarsalgia Intractable plantar keratosis
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Hard corns are AKA ? and soft ones are AKA ? and develop ? ? type of corns are due to mallet toe or improper shoes How are callus/warts differentiated on PE
Hard: Heloma durum, bony prominence Soft: Heloma molle, web spaced and bony prominence Periungual corns Warts- tender to pinching, not on bony prominence Callus/corn- tender to direct pressure
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? are the initial Txs of callus/corn on the feet How are recurrent ones Tx w/ surgery What are the 4 types of diabetes and ? is the MC in the USA
Paring w/ 15 blade for pressure relief Removing underlying prominence Type 1, 2, Gestational, Secondary Type 2
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? is the primary etiology to a diabetic foot ? type of skin conditions predispose these PTs to foot problems/ulcerations ? is the primary tissue involved in a Charcot foot Pts w/ charcot foot insensitivity measured below ? thresholdare recommended to wear protective foot wear
Peripheral nerve impairment Autonomic dysfunction= dry, scaling, cracking skin Synovial tissue 10g (5.07mm) filament to plantar aspect
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How is charcot foot differentiated from cellulitis foot If diabetic foot presents w/ ulcer and visible bone, ? other Dx is likely to be present and can be mis-Dx by MRI What study is ordered if after MRI there is still confusion about the Dx
Elevate x 1min= charcot foot loses redness Osteomyelitis Tc-99 scan
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? is the first phase of a diabetic ulcer and once an ulcer is ID'd, what is the next step? What test is ordered if the ulcer is non-healing What is the goal and how are Charcot foots Tx
Callus formation Superfiical: Orthotics, contact casting Deep: surgery Vascular studies Goal: PT education/prevention Initial: unweighted, stabilized w/ contact cast (12mon) After swelling reduce: clamshell leg brace (charcot walker)
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Diabetic foot ulcers have the best culture results for causative microbes from ? sample Where do achilles tendon disruption usually occur but what happens if this is mis-dx as ankle sprain When is a Thompson test most accurate for these Pts
Bone biopsy 5-7cm proximal to insertion Weakness and deceased ambulation First 48hrs
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What are the adverse outcomes of Achilles ruptures What do Pts describe their condition as How are tears Tx regardless of severity
Weakened stance phase of gait Walking on soft sand RICE and immobilization w/ crutches x 6 days
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`Achille tendon non-op rehab What is the common adverse outcome for these non-op Txs What two ligamentous structures are commonly injured in ankle sprain
Day 7: exercise Day 14: stretching, should be pain free Re-ruptures are common Lateral ligaments: ATFL CFL Anterior tibifibular syndesmosis- high ankle sprain, Dx w/ squeeze/external rotation test
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If this additional strucutre is injured/involved, what is this injury Dx as ? and tested w/ ? Severe ankle sprain usually have injury to ? joint Un-Tx sprains that result in chronic pain are due to ? stiffness
High ankle sprain: squeeze, external rotation test Sub-talar, MC w/ torn interosseous ligaments Subtalar stiffness
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Chronic ankle instability is MC after ? What is the goal of non-op Tx for ankle sprains What are the 3 phases
Incomplete rehab Prevent chronic pain/instability 1: NSAID, RICE, WBAT 2: when weight bearing w/out inc pain, no plantar flexion 3: proprioception, strength, agility
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? is the most important part of ankle sprain rehab ? is the MC cause of heel pain in adults and how is pain replicated on PE 50% of Pts will develop enthesophyte located ?
Inflammation control w/ RICE x 6 days Plantar fasciitis Passive dorsiflexion of toes (windlass mechanism) Origin of flexor brevis
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How is plantar fasciitits Tx When is surgical release even a consideration What are the goals of early rehab and ? is the important part
Initial: orthotics w/ home stretches, night braces Persistent Sxs: CCS injection 6mon of non-op failure Pain control, inc ROM in ankle Heel cord stretch's
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? non-op Tx may be offered to plantar fasciitis that do not respond to initial non-op Tx methods Posterior heel pain can be caused by ? issues at ? sites
Radial/Focal shock waves Haglund syndrome- retrocalcaneal bursa impingement Achilles tendinosis insertion Retrocalcaneal bursitis Pre-Achilles bursa
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How is posterior heel pain from hump bump different from Haglund Syndrome If calcaneal prominence is noted on PE, where is it seen bigger How is the location of heel pain used to differentiate between DDxs
Bump- posterolateral aspect of heel Lateral side Achilles tendinosis- pain in Achilles, worse w/ squeezing Retrocalcaneal bursitis- pain anterior to Achilles, worse w/ side to side squeeze
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? is one of the main supporting structures of the medial ankle and arch This the MCC of medial ankle pain in ? Pts ? are the RFs
PTT- causes posterior tibialize muscle to be ineffective at supporting medial longitudinal arch >55y/o, overweight woman ``` CCS injections HTN ASx flexible flat foot DM Injury Hx ```
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? are the MC Sxs and what will Pt be UNABLE to do ? PE finding may be seen w/ PT standing Why does this eventually develop into lateral foot pain
Pain/swelling of medial ankle Late Dz: ankle pain No rising on toes "too many toe" from foot abduction (advanced change) /hindfoot valgus Flatfoot abuts fibula, impinges in sinus tarsi
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? happens in long standing PTT dysfunction ? images are ordered Where will changes usually be seen
Dec pain w/ tendon rupture, turns into lateral ankle pain Weight bearing AP/lat Equivocal- MRI Flatfoot Talonaviluar misalignment
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? are adverse outcomes of PTT dysfunction How are these Tx if tenosynovitis w/out flatfoot is present How is PTT dysfunction Tx if flexible flatfoot is present
Painful flat foot induced altered gait Valgus ankle Short leg cast x 4wks, NSAIDs, LLD NO CCS injection UCBL orthotic Ankle brace
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How is PTT dysfunction Tx w/ surgery Define Tarsal Tunnel What are some adverse outcome of this condition
Flexible: tendon transfer w/ realignment osteotomy Rigid: hindfoot arthrodesis Compressed tibial nerve posterior to medial malleolus CRPS, Ulcers
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If Tarsal Tunnel is surgically released, what nerves are freed
Medial/lateral plantar nerves at bifurcation deep to the | Deep Abductor Hallucis fascia
343
MC problem in Pts w/ bunnionettes Hallux Rigidus is AKA ? This is the MC ? of the foot and second MC ?
Pain at 5th MTP joint worse w/ shoe wear Degenerative arthritis of 5th MTP Arthritis manifestation Great toe malady
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Where are hallux rigidus osteophytes found/more pronounced What is the hallmark PE finding of this condition Pts w/ ? presenting c/c have a more severe problem while pain in ? locations is common if Pt has lateral overload
Start at lateral joint but more pronounced at 1st MT dorsum Stiff dorsiflexion that decreases MTP extension Mid-range arc motion pain 2nd/3rd MTP joints
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Toes affected by hallux rigidus usually have normal alignment unless ? How are hallux rigidus Tx non-op What are the two procedures used to Tx this w/ surgery
Prior Dx Hx of hallux rigidus Stiff sole w/ steel shank Morton extension limiting 1st MTP Cheilectomy- dorsal osteophyte Fusion Keller- joint resection in older, less demanding Pts
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# Define Hallux Valgus This Dx is AKA ? and more likely in ? gender What are the principle Sxs
Lateral deviation of great toe at MTP joint Bunion, F>M Pain and swelling worse w/ shoe wear
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? can develop over the medial eminence of the first metatarsal in Hallux Valgus Pts This can cause Pts to develop a callus ? Irritation to ? nerve can cause numbness over medial aspect of great toe
Hypertrophic bursa Medial aspect of great toe Medial plantar sensory nerve
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? is considered a normal valgus angle at the first MTP joint ? is a common foot problem in these Pts How is the severity of these conditions assessed
<15* Second toe over riding laterally deviated great toe Forefoot angle- angle of hallux valgus and intermetatarsal anlge w/ weight bearing x-rays: norm <15*
349
How are bunions Tx ? surgical Tx method is avoided Ingrown toe nails MC affect ? toe
Peds: observation Adults: initially- education, shoe mod ASx= no treatment, even w/ progressive deformity Arthroplasty Great
350
What is the recommended method for trimming toe nails What are the 3 stages of in-grown toe nail's development and Tx per step Why would x-rays be needed and what is an uncommon adverse outcome of this condition
Straight across to keep lateral margin beyond nail fold Stage 1: Induration Tender (soak, trim, hygiene) Stage 2: Purulent Abscess Draina (cephalosporin soak) Stage 3: Granulation inhibits drainage, less pain (excise) R/o subungual exostosis in stages 2-3 Hematogenous seeding of microbes
351
# Define Morton Neuroma Where do Morton Neuromas develop and how do Pts describe these What is the MC presenting Sx
Perineural fibrosis (secondary to nerve irritation) of common digital nerve passing between tarsal heads 3rd web space- walking on marble/sock wrinkle 2nd Rarely 1st, 4th Forefoot pain Dyesthesias Burning plantar pain
352
What PE test is done for suspected Morton Neuromas What sign is positive for this test What type of injection can be therapeutic and Dx
Compression sign Mulder sign- click/grind felt w/ lateral squeeze 1-2mL lidocaine and 1ML CCS prox to tarsal ead
353
How are Morton Neuromas Tx by surgery What do Pts describe their foot pain as if they have metatarsalgia What PE finding suggests overloading of the tarsal head
Release of plantar nerve by dividing transverse metatarsal ligament Walking on pebbles Callus in a line formation
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Whta imaging is needed for metatarsalgia What PE test is usually positive in these PTs if there's an associated MTP instability or plantar plate tear How are these Tx non-op and op
Weight bearing AP/lat Ant drawer- shock test Non: Pad/orthotics, Shave callus Op: callus under tarsal head= plantar condylectomy
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? is a possible adverse outcome of surgical Tx for metatarsalgia Onychomycosis is usually due to ? two microbes How is a Dx made
Floating toe- cock up toe deformity T rubrum T mentagrophytes KO slide prep under microscopy
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What PO meds are used for the Tx of toe nail fungus ? causes plantar warts and when do the reach peak incidence When these lesions occur in clusters they're called ? and usually appear on ? areas
I/F/K-azole Terbinafine HPV during 2nd decade of life Mosaic warts on non-weight bearing area of sole
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? is an indicative PE finding of plantar warts What will be seen if superficial paring is done How are these Tx
Pappillary lines cease of margins and tender to pinching Punctate hemorrhage Fibrillated texture Self resolve 5-6mon Paring w/ keratolytic agents (salycylic acid) w/ occlusive dressing
358
How are plantar warts resistant to initial Tx handled When attempting to Tx w/ curettage, ? structure should NOT be visible upon completion Sesmoid bones of the foot are embedded in ? structures of the foot
1mL injection of anesthetic and epi Cautery/Cryo/Nitrogen SubCu fat- intractable, painful scarring can develop Flexor Hallucis Brevis beneath 1st tarsal head
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? d/os to the foot sesmoids are possible What can cause the onset of pain under the first tarsal head How are the anatomical variants 'bipartite' differentiated on imaging
Inflammation Fx Osteonecrosis Arthritis Forced dorsiflexion of great toe Bipartite- smooth edges Fx- irregular
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? non-Tx step can be done to help relieve the pain of sesmoiditis What are the 3 types of toe deformities What are they MC caused by
Tape toes in plantar flexion Claw: fixed extension to MTP, flexed PIP Hammer: correctable MTP extension, PIP flexion deformity w/out DIP deformity Mallet: flexed DIP deformity w/ normal PIP/MTP Tight fitting shoes Inbalanced intrinsic muscles
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Claw toes are usually secondary to neuro D/o such as ? This deformity is commonly seen in ? population ? toe is MC affected by hammer/mallet toes
Charcot Marie RA DM Second toe, especially if longer than great toe
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? PE finding on toes should raise suspicion for plantar plate ruptures ? can corn development occur when the lesser toes deformities are present Why are these types of corn's not good
Sagittal extension deformity- test w/ shock test PIP dorsum, toe tip Painful and risk of infection
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Radiograph of lesser toe deformities are only needed if ? Claw toe and high arc may need ? additional work up ? is the mainstay of Tx and ? needs to be avoided
Surgical planning Toe ulcers present Neuro Shoe w/ big toe box Heels >2.25"
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# Define Turf Toe What correlation occurs w/ athletes w/ this Dx What are the 3 grades of this injury
Sprain to MTP from hyperextension More missed game time thank ankle sprains Grade 1: stretched capsule; participate w/ mild Sxs Grade 2: partial ligament tear Grade 3: complete tear of MTP ligament complex; compromised walking and playing ability
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What is an adverse outcome of Turf Toe How are these Tx non-op Define Os Trgonum
Hallux rigidus Acquired valgus/varus deformity RICE w/ ROM as tolerated Grade 1-2: rocker bottom w/ protected weight bearing Grade 3: protected weight bearing/immobile x 2wks w/ 6wk rest period Accessory ossicle in posterior talus; Sx in ballet/soccer Pts; Impinged between talus/tibia w/ flexion; rest/LLD or surgery for refractory cases
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# Define Osteochondral Lesion of Talus Define Tarsal Coaltion Define Kohler Dz
Athletic adolescents w/ pain worse w/ activity in ankle region; Tx w/ immobilization/surgery Rigid flatfoot in children during 2nd decade of life; restricted hindfoot motion w/ peroneal spasm from foot inversion, Dx w/ CT Osteonecrosis of navicular bone in boys 4-8y/o; pain at medial arch; short leg walking cast x 8wks
367
# Define Freiberg Infarction Peds w/ Sxs presenting days after an injury may be d/t ? microbe ? is the MC benign and alternate bone tumor of the foot/ankle in kids
Osteonecrosis of head of 2nd metatarsal d/t trauma; Pseudomonas Unicameral/Aneurysmal cyst in calcaneous Osteroid osteoma of tarsal bone
368
? is the MC malignant soft tissue lesion of the foot in peds Accessory navicular variants develop at the insertion site of ? tendon ? causes pain on exam and ? foot deformity may be present
Synovial cell carcinoma Tibialis posterior Inversion against resistance Flexible pes planus
369
What population is more commonly affected by calcaneal apophysitis What do Pts present complaining of When does this bone fusion prevent this Dx from occurring
Active, prepuberty children Posterior heel pain after activity Girls: 9y/o Boys: 11y/o
370
When are x-rays of calcaneal apophysitis needed How are these managed non-op What causes Pes Cavus
Unilateral Sxs Shoe mod w/ 1/4" heel lift/cushion Recalcitrant= cast x 6wks High arches from equinus (plantar flexion)
371
# Define Cavovarus Define Equinocavovarus Progressive unilateral cavus foot is often d/t ? while bilateral is d/t ?
Forefoot equinus in association to hindfoot varus Hindfoot equinus associated w/ hindfoot varus and forefoot equinus Uni: Tethered spinal cord Bi: motor/sensory neuropathy (Charcot Marite Tooth Dz)
372
What x-ray imaging is needed for Pes Cavus What alignment angle is off How are these Tx non-op
Weight bearing AP/Lat Meary angle- increased angle between talus and first metatarsal Mild/flexible deformity: shoe mod/arch support w/ rehab
373
What surgical options are available for Pes Cavus depending on the etiology What surgical procedure is reserved for older PTs w/ rigid deformities Clubfoot is AKA ?
Plantar-fascia release Tibialis posterior/extensor hallicus longus tendon trasnfer Medial cuneiform/first tarsal/calcaneous osteotomy Hind foot fusion (triple arthrodesis) ``` Talipes Equinovarus- CAVE midfoot Cavus forefoot Adduction heel Varus ankle Equinus ```
374
? IDs a true idiopathic clubfoot What causes a positional clubfoot deformity What distinguished a positional clubfoot from other etiologies
Uncorrected w/ passive manipulation Intrauterine molding Flexible deformity Absent calf atrophy/different foot size Spontaneous/rapid resolution
375
Clubfoot may be seen along w/ ? neuromuscular Dzs What congenital Dzs may they be seen in What is different about the prognosis for congenital clubfeet
Myelomeningocele Arthrogryposis Constriction band syndrome Diastrophic dysplasia More rigid/difficult to Tx More likely to return after Tx
376
Clubfeet w/ neuro findings suggests ? spinal tethering d/t ? may be present ? causes the most disability for these Pts ? is a normal PE finding for congenital clubfoot that persists despite Tx
Lipomyelomeningocele Diastematomyelia Socioculture- ostracized Calf atrophy
377
How are clubfoot Tx by surgical correction as the TxOC This TxOC can correct all but ? characteristic of the clubfoot Most Pts will require ? to Tx this uncorrectable characteristic
Ponseti method up to 8y/o- serial long leg casts All except hindfoot equinus after 4-7 casts Percutaneous release of Achilles
378
When does the longitudinal arch of the foot begin and finish developing What is the most common ASx Dx/variant of flatfoot and what is needed for Tx What tends to be the cause of Sx Flatfoot
Start- 4y/o Done- 10y/o Flexible- reassurance Achilles contracture
379
What are the possible etiologies of rigid flatfoot What do Peds w/ flexible flatfoot report w/ c/c of What test is used to test for flexible flatfoot and hindfoot flexibility
Congenital: tarsal coaltion, vertical talus NeuroMusc: cerebral palsy, hypotonia Inflammatory: JIA Quickly fatigue, unable to keep up w/ peers Jack test- great toe extension test Hindfoot- stand on tip toes
380
? Tx step is rarely needed for flexible flatfoot What is the exception What surgical option is preferred if needed
Orthoses Surgery Older child w/ Sxs depsite Achilles stretches/shoe mod Osteotomy to lengthen lateral column of foot
381
# Define Metatarsus Adductus What is the MC cause of this What other deformations are commonly seen w/ the foot deviation
Medial deviation of forefoot in infancy, convex lateral foot Intrauterine positioning CMT Medial tibial torsion Hip dysplasia
382
What is the major reason Pts are referred for tarsus adductus These Pts may be confused to have ? Dx and how is it differentiated What term is given for the great toe positioning seen in these PTs
Parental concern, usually ASx Clubfoot- Neutral hindfoot, normal dorsiflexion Atavistic/Wandering- adduction of great toe
383
How is the severity of metatarsus adductus assessed What are the mild, mod and severe criteria What finding determines the prognosis
Heel bisector line- normal passes through 2-3rd toe Mild: third toe Mod: 3-4th toe Sev: 4-5th toe Flexibility of the deformity
384
What imaging method is used to track the Tx progression of metatarsus adduction What other imaging may be needed depending on the severity of the intrauterine compression causing the foot deformity ? is the MC adverse outcome of this Dx
Serial photocopies US of hips Cosmetics Inability to wear certain shoe types
385
Parents need to be educated to avoid ? with babies that have metatarsus adductus What indicates serial casting may be needed What is the referral red flag for this condition
Lay prone w/ feet turned in Foot doesn't passively over correct on PE Residual adductus at 3-6mon of age Rigid metatarsus adductus in any infant
386
OCD of the talus is best seen w/ ? x-ray view What imaging is better for staging or defining cartilage disruption Tarsal coaltion MC occurs between ? bones
Mortise CT- staging MRI- extent of surface disruption Calcaneous and Navicular/Talus
387
When do tarsal coalition Sxs begin and can be used to ID what bones are joined What kind of pain is reported on presentation These Pts usually have ? foot type
Calcaneonavicular: 9-13y/o Talocalcaneal: 13-16y/o TC: vague, deep CN: laterally Rigid flatfoot- hindfoot valgus, forefoot abduction
388
? imaging is better for Dx of tarsal coalitions How are these Tx based on severity What type is better Tx by surgical resection
CT Observe: ASx- mild Sxs Sev/Sx lasting 4-6wks: short leg walking cast Persistent- resection CN coaltion
389
What procedure is done for tarsal coaltion PTs who are not candidates for resection When do Pts need to be red flagged and referred Define Idiopathic Toe Walking
Arthrodesis Pain after non-surg Txs Toe walking in healthy kids w/ no neuro abnormalities
390
What 3 Hx pieces are needed when assessing toe walking Toe walking is common in children w/ ? underlying issues ? PE finding shows underlying Achilles Tendon contracture
Birth Developmental Family Speech/Language d/os Autism <10* passive dorsiflexion
391
How is toe walking managed/Tx ? Tx is especially helpful in Pts w/ coexisting Achilles tendon contractures What surgical procedure is considered after non-op Tx have failed
Observation Contractures= stretches Autism- PT/OT Serial casting x 2-3 casts over 6wks w/ increased dorsiflexion each cast change Heel cord lengthening w/ 6wks cast immobilization after
392
? type of toe walking is never normal What is the MC cause for this A traumatic disruption to the tarsometatarsal joint is AKA ? after ? mechanism
Unilateral Abnormal limb length Cerebral palsy Spinal tethering LisFranc Fx- tripping athletes
393
How is Lisfranc injury differentiated from sprain on PE When searching for this on x-ray, what is normal alignment Where does the Lisfranc ligament attach
Stabilize hindfoot, rotate/abduct forefoot Painful= Lisfranc Uncomfortable= sprain AP: Medial mid-cuneform lines up w/ 2nd metatarsal Oblique: medial 4th metatarsal lines up w/ medial cuboid Medial cuneiform
394
How are non-displaced Lisfranc Fxs Tx When is surgery warranted What is usually needed prior to surgery
8wks non-weight bearing w/ immobilization then, Rigid arch support x 3mon Fx/Fx-dislocation w/ any displacement= ORIF Immobilization x 3wks
395
What step can be done to help reduce resistant edema in a Lisfranc Fx Define Bimalleolar ankle Fx Trimallerolar Fx means ? Fx is added
Bandage impregnated w/ zinc oxide cream Latera/medial malleolus Fx distal fibula w/ disrupted deltoid ligament Posterior malleolus Fx
396
? structure involvement is a more severe and unstable variant of a posterior malleolus Fx ? other injury may be present w/ trimalleolar Fxs ? PE findings indicate a presumed bimalleolar injury
Extension to tibial plafond Posterior dislocation Fx distal fibular w/ tenderness of medial deltoid ligament
397
# Define Maisonneuve Fx What injuries are present during this type of Fx When assessing the relationship of the tib/fib/talus, ? view is best on x-ray
Unstable external rotation injury Prox fibula, Torn medial deltoid ligament Disrupted tibiofibular ligaments Mortise
398
Minimally displaced ankle Fxs may not be first apparent, what is the next step How are stable distal fibular Fxs Tx How are unstable but nondisplaced Fxs Tx
F/u x-ray in 10-14 days Weight bearing cast/brace x 6wks NWB cast w/ immobilization
399
When are fibula Fxs Tx w/ reduction When is rehab indicated after ankle Fxs What nerves need to be assessed after a calcaneous/talus Fx
Unstable and displaced Elderly PT Full ROM/balance not achieved after 3mon of Fx healing Peroneals Sural Plantar
400
? PE finding suggests plantar compartment syndrome is present after a calcaneal Fx ? type of imaging may be best for these Fxs Fxs to the talus often cause ? other injury
Swelling in area of arch Coronal CT Osteonecrosis
401
# Define Zone 2 Fx of metatarsal This Fx is AKA ? Zone 3 Fxs are usually ? and may result in ?
Proximal diaphysis Classic Jones Stress Fx, non/delayed union
402
Zone 1 metatarsal Zone 2 metatarsal Zone 3 metatarsal
Articular surface of metatarsocuboid joint Articulation of 4th and 5th tarsals 1.5cm distal to zone 2
403
What type of tarsal Fx usually doesn't have non-union How are these Fxs Tx How often is repeat imaging needed
Zone 1 WBAT w/ cast/brace/stiff shoe 1wk and 6wks after
404
? type of tarsal Fxs are difficult to Tx How are they Tx What type are Tx w/ surgery
Zone 2 Cast immobilization w/ non-weight bearing x 8wks Zone 3
405
? is the MC toe Fx'd These are usually Tx by ? Where are the sesmoid bones of the 1st MTP
Little Buddy tape to medial toe of toe Fx Medial and Lateral
406
What surrounds the plantar and dorsal surfaces of the 1st MTP sesmoid bone Which one is more likely to be Fx'd What type of force usually causes a Fx
Plantar: FHB fibers and plantar plate Dorsal: articulates w/ tarsal head Medial > Lateral/fibular MC: direct trauma Hyperdorsiflexion of first MTP
407
Where are accessory sesmoids usually found in the foot ? form of imaging is 100% sensitive for differentiating acute/stress Fxs from bipartite sesmoids ? imaging is used to differentiate Fx from bipartite/osteonecrosis
Under 2nd tarsal head on tibial side Tc-99m MRI
408
How are sesmoid Fxs Tx When do these need to be Tx by surgery Since Tx can take 6-12mon, what is an adverse outcome of Tx
Stiff/rocker bottom shoe x 4wks After clinically healed- felt pad x 6mon Plantar plate rupture Lost dorsiflexion of 1st MTP
409
Why are females more likely to have stress Fxs ? is the MC site for these to develop in the feet ? imaging is more senstive than x-rays and can detect Fxs days of injury
Triad: amenorrhea, osteopenia, d/o eating 2nd tarsal Bone scan, <5 days MRI confirms
410
? foot stress Fxs are more likely to have mal/non-union and require surgical correction How are metatarsal stress Fxs Tx how are calc/fibular stress Fxs Tx
5th metatarsal Jones Fx Navicular stress Fx Stiff sole/brace 2-4wk immobilization in cast
411
Because of high rate of non-union, how are navicular/5th tarsal Fxs best Tx What is a better Tx method especially in athletes What are two predisposing conditions that should be Tx at the same time
Casted w/ crutches to avoid weight bearing Internal fixation Heel varus= 5th tarsal Fx Heel valgus= fibular stress Fx
412
When can Pts return to activity after tarsal stress Fx What needs to be avoided during their healing process
ASx and radiographically proven healed NSAIDs
413
Reflex grades: 0 1 2 3 4 Reflex nerve root for bicep, brachioradialis, tricep, patellar, achilles
Absent Diminished Normal Exaggerated Hyper/Clonus ``` Bicep: C5 Brachio: C6 Tricep: C7 Patellar: L4 Achilles: S1 ```
414
Superficial abdominal reflex nerve root Lower abdominal reflex nerve root Cremaster reflex nerve root Anal reflex nerve root
T7-9 T11-12 T12-L1 S2-4
415
Uni/Bi-lateral pathological reflex means ? What is the MC pathological reflex C5 M/R/S
Bilateral: upper motor lesion Unilateral: lower motor lesion Babinksi Deltoid/Bicep tendon/lateral arm
416
C6 M/R/S C7 M/R/S C8 M/R/S
Wrist extension/brachioradialis/lateral lower arm Wrist flexion/tricep tendon/thenar eminence Finger flexion/none/medial lower arm
417
T1 M/R/S L4 M/R/S L5 M/R/S
Interosseous/none/medial upper arm Anterior tibialis/patellar/medial foot Extensor digit longus/non/dorsal foot
418
S1 M/R/S AC joint injection uses ? landmark for needle entry In most Pts this joint has ? orientation
Peroneus longus/brevis/achilles/lateral foot Neviaser portal- posterior clavicle and anterior scapular spine intersection= posterior of AC joint SuperoLateral to InferoMedial
419
What is the easiest way to inject the subacromial bursa How are Pts positioned for this procedure Where is the needle injected for posterior injection
Posterior Sitting w/ arm hanging and hand in lap to distract acromial space 1cm medial and inferior to posterolateral acromion w/ needle angled 20-30* superiorly
420
What is the injection site for a posterior shoulder joint injection/aspiration When inserting needle, aim for ? structure What is the desired injection site for an ankle injection
2cm medial and inferior to posterior corner of acromion Coacoid tip Medial to anterior tibial tendon: 1cm prox to tip of medial malleolus
421
What is the desired injection site for carpal tunnel injections What is the desired injection site for De Quervains What is an adverse outcome Pts can report and why
1cm proximal to wrist flexion crease in line w/ ring finger metacarpal 45* angle in line w/ both tendons Thumb paresthesia: depolarized sensory branch of radial nerve; reposition 3mm dorsal/volar
422
When conducting digit block on foot, remember sensory nerves run along ? side What medication can be used to reverse Epi when performing digit blocks on the hand Where is the needle injected to perform a volar block and where is lidocaine injected
Plantar side of tarsal Phentolamine Palmar midline of digit near distal palmar crease 1/3 at midline 1/3 at radial digital nerve 1/3 at ulnar digital nerve
423
How are elbow injections/aspirations performed What three landmarks make up the injection triangle What muscle overlies this injection portal
Pt supine w/ elbow flexed to 90* and forearm neutral Lateral epicondyle Radial head Olecranon tip Anconeus muscle
424
Anterior hip injections should only be done by whom w/ fluro What is the Pt positioning needed for this injection Where is the needle injected
IR/Ortho Hip flexed, max abducted, externally rotated Inferior to proximal adductor longus tendon towards femoral head/neck junction
425
What are the land marks for knee injections/aspirations What is the entry site for MCP/PIP injections Where is the ulnar nerve in relation to the olecranon meaning injections are best done on ? side
Laterally 1cm superior and lateral to superolateral aspect of patella Sulcus below carpal head made obvious by flexing finger to 20* Medial face of olecranon; laterally
426
Where is the Pes Anserine bursa located Where are plantar fasciitis injections placed What are the two procedures used for reducing disloacted shoulders
Sartorius, Gracillis, Semitendinosus muscle and MCL 2cm from plantar surface of foot Stimson (gravity assisted) Longitudinal traction
427
What type of arm position is needed when reducing shoulders w/ longitudinal traction What type of adverse palsy can develop d/t Tx Where is the needle injected for Tennis Elbow injections
90* flexion: relaxes bicep muscle Axillary Distal to lateral epicondyle to point of max tenderness
428
During Tennis Elbow injections, the needle usually passes through ? structure Where are Trigger Finger injections placed ? dorsal landmark identifies the radiocarpal joint
Extensor Carpi Radialis brevis Distal palmar crease 1cm distal to Lister tubercle, depression at distal edge of radius

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