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
