Ortho: Phase 2 Flashcards
Difference between amputation and disarticulation
What 3 disease processes account are the cause for 2/3 of amputations?
Define Ray Resection
Amp- through bone
Disart- through joint
Majority: DM, Infection, PVDz
Remaining: Trauma Tumors Congenital
Toe and all/part of metatarsal
Mid-foot amputations are performed through what level?
What are two common adverse outcomes of hindfoot amputations
Define Syme Disarticulation
Trans/Tarso-metatarsal
Dec function
Poor prosthetic management
Foot disarticulated at ankle, heel pad covers site
Below the knee amputation is AKA ?
Above the knee amputation is AKA ?
? is the initial step for prosthetic pain/pressure issues?
Transtibial amputation
Transfemoral amputation
Socket modification
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?
Bone spurs
Pressure/bruise
Heterotopic bone
Symptomatic neuromas
Socket mod, non-bulky dressings
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
Impaired elderly mobility
Genetics Obesity Age Trauma
Pain Stiff Deformity
Ankle Wrist Elbow
Joint pain
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
Mild pleocytosis
Elevated protein
Normal viscosity
Joint crepitus- softening of articular cartilage
DIP- Heberden
PIP- Bouchard
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
First CMC joint
Articulation of Calcaneus Talus Navicular
Hallux valgus/rigidus
Subtalar joint
PIP swelling
Pain w/ pressure
Swelling
Dec ROM
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
Varus- bow legged
Baker cyst between gastroc/semimembranosus
Toe out, externally rotated, dec internal rotation
Abudctor lurch: Tilts to affected side
What will be seen on x-rays of OA
Non-pharm Tx of OA
Pharm Tx of OA
Lost joint space
Osterophytes
Sclerosis
Subchondral cysts
Avoidance Weight Education
NSAIDs, then Acetaminophen
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
Viscosupplementation
Isometric exercises
Lost function
Pain at night/unresponsive to non-surg Tx
What 4 joints are effectively corrected with arthrodesis
Define RA
What are common Sxs of RA and what joints are more commonly involved symmetrically
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
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
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
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
Periarticular osteopenia
Bony erosions
C1-2
IgM against Fc portion of IgG
Anti-CCP Abs
? 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?
Inc ESR/CRP; Dec serum albumin
Platelets
Osteoporosis
Dec immune function from DMARDs
Psoriatic Ankylosing IBS Reactive/Reiters
- RF and ANA (antinuclear antibodies)
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
GI Ocular Derm
Enthesitis- inflammed insertion site
Sacroiliitis, Kyphosis
Peripheral joint involvement (ankle hip shoulder)
What part of the body does Ankylosing Spondylitis affect?
What other conditions are associated with this Dx?
What is the Tx plan?
Sacroiliac joint, rarely involved peripheral joints
Iritis Aoritis Carditis Enthesitis Uveitis
NSAIDs, Exercise
What parts of the body are affected by arthritis associated w/ IBS
What other conditions can be present w/ this Dx
What is the Tx
Asymmetric/oligoarticular involvement of SI, ankle, knee
Crohns Enthesitis Uveitis
NSAIDs
What parts of the body are involved w/ Psoriatic arthritis
What other conditions can also exist
What is the Tx
Erosion of wrist ankle SI hands
Dactylitis Iritis Nails Enthesitis Skin lesions
NSAIDs Methotrexate Biologics
What parts of the body are involved in Reiter Syndrome
What other conditions can co-exist with this Dx
What is the Tx?
Asymmetric oligoarticular of SI, ankle, knee
Urethritis Dactylitis Iritis Enthesitis
Infection Tx, NSAIDs
What microbe pathogens can cause Retiers?
What are the 5 patterns of psoriatic arthritis
Chlamydia Shigella Salmonella Yersinia Clostridium Campylobacter
Asymmetric oligoarthritis Symmetric polyarthritis Sacroiliitis Arthritic mutilans DIP
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
DIP involvement w/out rheumatoid nodules
Terminal phalange reabsorption
Proliferative bone reaction
Bamboo: Enthesitis of anulus fibrosus
Poker: ALL ossification, Facet autofusion
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
Usually HLA-B27 pos
Inc ESR/CRP
Negative RF and ANA Abs
PE/Hx
Indomethacin
What drugs are used for Sxs of AnkSpond not controlled by NSAIDs
What drug may be used for chronic reactive arthritis?
What is best for the Tx of Psoriatic Arthritis
TNF-a: Etanercept, Infliximab, Adalimumab
Sulfasalazine
Non/DMARDs
Photo therapy for skin lesions
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 ?
Kyphosis
Pain at rest/night
Eye/Skin/Pulm manifestations
Intercompartmental > perfusion= ischemia
35mmHg= Dx
Trauma
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
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
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
? 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)
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
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
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
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
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
? 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
? 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
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)
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
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
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
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
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
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
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
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
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
? is the most important non-op Tx for Lyme Dz
Lyme Dz risk remains low if tick is removed w/in ? time frame
How are these PTs Tx w/ ABX
Skin/Clothing checked for ticks
<36hrs
Doxy 100mg BID x 28days
Amox 500mg TID x 28 days
<8y/o: Amox 20mgg/kg
What are the 3 types of osteoporosis
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
? 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
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
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
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
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
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
? 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
? 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
How are ASx spinal neoplasms found during the search for mets Tx non-op
How are painful metastasis Tx
When is surgery indicated
Chemo/Rad/Hormones
Radiation if no deformity/neural compression
Pain w/ neurodeficit- decompression and stabilization w/ post-op radiation
What is a common adverse outcome after surgical decompression of spinal neoplasms?
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
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
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
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
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
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
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
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
? 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
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
? 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
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
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
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
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
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
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
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*
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
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
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
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
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
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
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)
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
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
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
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
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
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
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
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
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
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
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
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
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
Define TUBS
Define AMBRI
What type of forces cause a ant/posterior dislocation
Traumatic Unidirectional instability w/ Bankhart lesion best Tx w/ Surgery
Atraumatic, Multidiretional Bilateral signs of laxity, REhab as preferred Tx, and Inferior capsule shift
Post: Adduct w/ internal
Ant: Abduct, external
What is a common but poor prognostic presentation in Pts w/ multidirectional instability
Pts w/ posterior dislocation present holding arm in ? position w/ ? movement impossible
What are 3 special tests performed for shoulder instability to isolate the direction of instability
Voluntary dislocation
Add, internal
External= impossible
Apprehension- anterior
Sulcus- inferior
Jerk- posterior
? 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
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
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
What image is needed for Dx of SLAP tear
MRA= gold standard
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
What causes Thoracic Outlet Syndrome
Compressed brachial plexus/subclavian vessels between superior shoulder girdle and 1st rib
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
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
? 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
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
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
What two mis-Dxs can occur when evaluating lateral/medial epicondylitis
PIN w/ lateral
Ulnar w/ media
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
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
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
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
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
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
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
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
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)
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
? 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
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
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
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
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
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
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
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
? 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
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
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
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
Ganglias are the MC benign soft tissue tumors of the hands, what are the 2nd and 3rd MC
2nd: Giant cell tumor
3rd: EIC
? 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
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
? 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
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
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
What causes pain/swelling associated w/ gout
What causes the inflammation process
Lysis of PMN cells from engulfing crystals
Monosodium urate crystal collection
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
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
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
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
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
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
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)
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
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
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
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
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
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
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
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
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
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
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
? 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
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
? 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
? 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
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
LLE OCD usually occurs in Pts older than ? after ? structure has ossified
> 12 y/o after capitellum ossifies
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
? 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
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
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
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
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
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
? 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
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
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
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
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
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
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
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
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
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
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
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
MC type of distal radius Fx seen in adults
? is the name of the Fx that is opposite of the MC
Define Barton Fx
Colles- Fx tilts dorsal w/ Fx of ulnar styloid
Smith- Fx fragment tilts volar
Intra-articular carpus Fx w/ subluxation of carpus and displaced radius fragment
Define Chauffeurs Fx
What is an adverse outcome from wrist Fxs
How are these Tx non-op
Oblique radial styloid Fx
Compartment syndrome
Sugar tong x 3 wks
Short arm cast x 3wks
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
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
? 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
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
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
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
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
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
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
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
? 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
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
? 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
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
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
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
? 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
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
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
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
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
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
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
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
? 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
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
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
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
What non-leg sourced issues can lead to trochanteric bursitis?
Where can this pain radiate to?
How do Pts describe pain
Lumbar spine dz
Leg, butt, or knee, NOT to foot
Worse when rising, improves, worse <30min
Unable to lie on affected side
? is the essential finding on PE for Dx trochanteric bursitis and what movement makes pain worse
How is this Dx different from gluteus medius tendonitis and what movement makes pain worse
? 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
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
? 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
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
? 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
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
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
? 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
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
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
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
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)
? 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
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
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
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
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
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
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
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
? 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
? 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
? 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
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
? 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
? 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
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
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
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
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
? 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
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
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
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
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
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
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
? 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
? 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
? 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
? 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
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
Skipped Quiz 5
46-68
? 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
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
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
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
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
? 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
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
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
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
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
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
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
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
? 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 >
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
? 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
? 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
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
? 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
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
? 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
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
How is midfoot arthritis Tx non-op
How are they Tx surgically if Sxs persist
Rigid orthotic/steel shank w. CCS injections
Midfoot fusion
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
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
? 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
? 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
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
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
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
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
? 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
? 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
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
? 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)
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
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
`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
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
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
? 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
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
? 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
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
? 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
? 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
? 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
? 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
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
If Tarsal Tunnel is surgically released, what nerves are freed
Medial/lateral plantar nerves at bifurcation deep to the
Deep Abductor Hallucis fascia
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
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
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
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
? 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
? 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*
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
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
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
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
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
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
? 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
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
? 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
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
? 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
? 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
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
? 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
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”
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
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
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
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
? 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
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
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)
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)
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
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
? 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
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
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
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
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
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
? 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
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
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
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
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
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
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
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
? 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
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
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
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
? 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
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
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
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
? 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
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
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
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
? 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
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
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
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
? 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
? 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
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
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
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
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
? 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
