PM&R qbank review Flashcards
What subtype of cerebral palsy is most associated with a risk of epilepsy ?
Spastic Quadriplegia
-Epilepsy affects 25-45% of pts w/ CP.
- pts w/ spastic quadriplegia are likeliest to develop seizures, with an estimated incidence between 50-94%
- Spastic Hemiplegia ~30%
-CP pts w/ spastic diplegia, ataxic CP, and dyskinetic CP are less likely to develop seizures
Describe what an F wave is
F wave is a pure motor, late response which occurs after the CMAP. It is a variable response and not a true reflex since it does not travel through a synapse along its nerve pathway when stimulated.
Produced using supramaximal stimulation -> initiates antidromic motor response to the anterior horn cells in the spinal cord -> which then produces an orthodromic motor response in the recording electrode
Describe an H-reflex
-EDx analogue of a monosynaptic reflex
-Initiated with submaximal stimulus at long duration
-Preferentially activates IA afferent nerve fibers –> orthodromic sensory response to the spinal cord –> orthodromic motor response back to recording electrode
Describe an A (Axon) Wave
When performing a CMAP study, a response can be evoked by submaximal stimulation and abolished with supramaximal level.
THe stimulus can travel antidromically along the motor nerve and becomes diverted along a neural branch formed by collateral sprouting due to previous denervation and reinnervation.
Typically occurs between CMAP and F-wave. This waveform represents collateral sprouting following nerve injury.
Which type of injury pattern would most likely result in traumatic SCI paraplegia?
Acts of Violence
-Almost all recreational sports related SCI result in tetraplegia
- 52% of fall-related SCIs result in tetraplegia usually in the elderly
Patient with newly diagnosed HIV presents with neuropathic pain in glove/stocking distribution. What infectious agent is the most likely cause of his neuropathy?
CMV –Directly infects peripheral nerves.
Classic presentation of CMV neuropathy is a mononeuropathy multiplex pattern (painful, stepwise, multifocal sensorimotor deficits). May be rapidly progressive –> with nerve injury due primarily to axonal degeneration, although segmental demyelination may be present as well.
How would you expect a patient with suspected CMV neuropathy to present clinically and on EDx?
CMV –Directly infects peripheral nerves.
Classic presentation of CMV neuropathy is a mononeuropathy multiplex pattern (painful, stepwise, multifocal sensorimotor deficits). May be rapidly progressive –> with nerve injury due primarily to axonal degeneration, although segmental demyelination may be present as well.
What type of motor potentials would you expect to find when needling the paralytic side of a patient with Bell’s Palsy?
Myokymic Potentials
What is the classic presentation of the Miller-Fisher Variant of Guillain-Barre Syndrome?
Miller-Fisher Syndrome accounts for appx 5% of cases. Characterized by the triad of:
1. Ophthalmoplegia
2. Areflexia
3. Ataxia
- Fixed, dilated pupils may be present
-25% pts develop LE weakness
-Axonal sensory neuropathy is often detected.
-Unlike classic BGS, motor and demyelinating components are minimal.
-Associated with GQ1a and GQ1b autoantibodies related to C. jejuni infection
Pure hemisensory stroke most likely results from infarct of what structure?
Thalamus (Ventral posterolateral nucleus of the thalamus)
What class of drugs should be avoided in patients with Parkinson Dementia?
Dopamine antagonists (Droperidol, metoclopramide, phenothiazines)
What is the typical clinical and EDX presentation of a patient with suspected HNPP ?
Pathology?
Pts typically present in 2nd-3rd decade of life. PResent with sudden, painless mononeuropathies at compression sites. Weakness typically resolves in days to months.
NCS show prolonged distal motor latencies, focal slowing at compression sites, and reduction of SNAP amplitudes.
Biopsy demonstrates tomacula (focal myelin thickening) , segmental demyelination, and axonal loss.
Most commonly due to AD PMP22 deletion (PMPS pressure 22 y/o’s)
The ___ nerve supplies cutaneous innervation to the supraorbital region
The ___ nerve supplies cutaneous innervation to the superolateral portion of the orbit
The ___ nerve supplies cutaneous innervation to the temporal region
The ___ nerve supplies cutaneous innervation to the chin region
- Supraorbital nerve
- Supratrochlear nerve
- Zygomaticotemporal nerve
- Mental nerve
What sound would you here on needle EMG in a patient with suspected Myokymia?
Myokymic Discharges = Marching Soldiers
50 presents for EDX of LLE for suspected L5 radiculopathy and low back pain. You note a waveform that starts with an initial positive deflection followed by a quick uprising while testing a muscle. You notice the waveform in another quadrant during needling of the same muscle. You notice the waveform again in two separate muscles that fire regularly.
How would you interpret this EMG waveform?
Positive sharp wave/fibrillation potential.
Always has an initial positive deflection, regular rhythm, and sounds like rain on a tin roof. They are generated by a single denervated muscle fiber (NOT A DENERVATED MOTOR UNIT)
What is Paget-Schroetter Syndrome?
It is an upper extremity DVT, particularly an axillary-subclavian VT that is associated with strenuous and repetitive activity of the upper extremities, and particularly involves the dominant arm.
Risk factors include anatomical abnormalities at the thoracic outlet and repetitive trauma to the endothelium of the subclavian vein
What is the mechanism of action of clonidine
Alpha-2 agonist that can be used in treatment of sympathetic and neuropathic pain
What is the classic presentation of a patient with suspected Legg-Calve Perthes Disease?
LCP is avascular necrosis of the femoral head in children ages 2-12
- Most commonly age 4-8
- Boys > Girls
- Painless limp
Treatment
Limiting weight bearing, bracing, and surgery
What are the two main subscores when using the Modified Barthel Index?
Self-care and mobility. Use FIM scores for paraplegics as the MBI will not be sensitive in detecting small changes of functional ability in those with paraplegia as they can perform many of them independently.
Skinny female cross country athlete complains of foot pain. Pain has been persistent for one month and has progressed in intensity and frequency. She is not able to bear weight on her foot.
Diagnosis?
What is the most accurate imaging modality to confirm the diagnosis?
This patient has a stress fracture likely 2/2 Female Triad Syndrome.
MRI is the best imaging modality to detect a stress fracture due to its high sensitivity, lack of radiation, and high differentiating power.
De Quervain’s tenosynovitis involves what extensor compartment?
Entrapment of the EPB and/or APL tendons at the styloid process of the radius. w/in the 1st extensor compartment of the wrist.
What are the Ottawa knee rules
If one of the following is present, XR is indicated:
- Age > 55
- Isolated tenderness of the patella
- Tenderness of the fibular head
- Inability to flex knee 90 degrees
- Inability to take ≥4 weight-bearing steps
Patient completely severs the median nerve, but still has 3/5 strength in APB. What is the explanation for this?
The APB is innervated by the ulnar nerve
–> Richie-Cannieu anastomosis.
RCA is an anomalous ulnar to median communication in the palm between the deep branch of the ulnar nerve and the recurrent branch of the median nerve.
3 RCA types:
1. All Ulnar hand
2. Motor innervation dominantly by ulnar nerve
3. Some median innervates muscles innervated by ulnar nerve
In a flexion fracture of the humerus or hyperflexion fractures of the humerus, which nerve is most likely to be compromised?
Flexion type of pediatric supracondylar humeral fractures are rare. Ulnar nerve is at high risk for injury
What biomarker has the highest specificity for SLE?
Anti-double stranded DNA
Anti-Ro and Anti-La are primarily associated with?
Sjogren Syndrome
Anti-histone bodies are associated with?
Drug-induced lupus
Physical Exam findings of the hands suggestive of RA? (Most to least suggestive)
- Atrophy of interosseous muscles of hands
- Symmetric inflammation of small joints of hands most commonly involving the MCP and PIP joints
- Ulnar deviation of digits
- Swan neck deformity
Risk factors for developmental dysplasia of the hip
Commonly associated with what other MSK issue?
- Female Gender
- Family history
- breech positioning
- Oligohydramnios
There is correlation between DDH and congenital muscular torticollis (Especially in boys)
What structure is at risk for secondary injury following a lunate dislocation injury?
A dislocated lunate typically compresses the recurrent branch of the median nerve –> altered sensation over the palmar aspects of the lateral digits and weakness in thumb opposition.
Ottawa Ankle Rules
Plain XR of the ankle indicated for pts who have pain in the malleolar zone and:
1. Have bone tenderness at the posterior edge or tip of the lateral or medial malleolus
- Are unable to bear weight both immediately after the injury and for 4 steps in the ER or office
**Of note, if the patient can transfer weight twice to each foot ( 4 steps), they are considered able to bear weight even if they have a limp
When is a foot XR series indicated in a patient who presents with acute foot pain?
Plain XRs of the foot are only indicated for patients who have pain in the midfoot zone and:
- Have bone tenderness at the base of the 5th metatarsal or the navicular bone
OR
2. Are unable to bear weight both immediately after the injury, anc cannot walk for than 4 steps in the ED/Office.
Young athlete suffers from an aortic dissection. He is tall and lanky. On exam, has pectus carinatum (pigeon chest), and hindfoot valgus.
- Diagnosis and gene involved?
- Pts dad asks if the pts siblings need to be screened. What is the best advice?
- Marfan Syndrome, associated with abnormalities of the aortic root.
- Autosomal dominant inheritance pattern due to a mutation of the gene for the Fibrillin-1-protein (FBN1 gene) - Current guidelines recommend that 1st degree relatives of the patient should undergo counseling and genetic testing if there is a known gene mutation associated with aortic aneurysms and/or dissection
If the patient’s relative is found to have the mutation they should undergo aortic imaging
What is Baxter’s Neuritis?
Entrapment of the 1st branch of the lateral plantar nerve between the abductor hallicus and quadratus plantae muscle.
Clinical presentation: Typically complain of foot pain at the end of the day or after prolonged activity. Can have paresthesias laterally across the heel.
Motor weakness of the abductor digiti minimi muscle might be noted.
**Pathognomonic sign is pain on palpation of the nerve between abductor hallucis and quadratus plantae muscles along the medial border of the foot.
EMG is unreliable as well as diagnostic block
Describe Salter-Harris Classification
“SALT ED”
S-Straight through; Fx straight thru physis
A-Above; Fx of physis and extends into metaphysis
L-Lower; Fx of physis and extends thru epiphysis
T-Through; Think vertical fx involving metaphysis, physis, epiphysis
ED-Erasure of physis; Crush injury of physis
In patients with detrusor-sphicter dyssnergia (DSD), urethral pressure measuremens with typically show an acute urethral pressure rise of ______ within 30 seconds of detrusor contraction
In pts with DSD, urodynamic studies will show an acute urethral pressure rise of > 20 cm H20 within 30 seconds of detrusor contraction
Describe the five different phenotypic presentations of Osteogenesis imperfecta (OI)
Stature
Dentinogenesis
Sclerae
Bone fragility
Bone Healing
Time of first Facture
Type I - Mildest form, fxs heal normally ; normal growth; ligamentous laxity is observed
Type II- Most severe; usually lethal in perinatal period. Baby has triangular faces with micrognathia, small chest cage. Death 2/2 pulmonary insufficiency and CHF. Death w/in days-weeks of birth
Type III- Mod severe form; fxs in utero; multiple fx in first 1-2 years of life. Impaired bone healing, very similar to type 3; opalescent sheen on teeth; dark blue sclera; dwarfed
Type IV- Least common; Majority have dentinogenesis imperfecta with normal sclera
Type V- Autosomal dominant; significant for callus formation during fracture healing. Normal teeth and sclera. Calcification of interosseous membrane between ulna and radius -> limited supination/pronation of forearm
What neurologic finding is found in ~50% of patients of osteogenesis imperfecta Type I ?
~50% of pts with OI Type I develop progressive hearing loss with both sensorineural and conductive components that begin in the late teens or twenties
What is the most common cause of atraumatic hip pain in children? What is the typical clinical presentation?
Transient Synovitis; Most commonly occurs in boys age 3-8. Typically experience symptoms for 1-3 days and present with an antalgic gait and an abducted and externally rotated hip at rest. Pain is exacerbated with internal rotation of the hip
**Pain with internal rotation is less severe in cases of septic arthritis
SCFE is characterized by ____.
Demographics?
Presentation?
SCFE is characterized by posterior displacement of the femoral head through the physeal plate. Most commonly occurs in little fat adolescent boys (12-14 y/o) and is bilateral in 20-40% of cases. Pts with SCFE present with hip, groin, thigh, or knee pain that is worse with physical activity and demonstrate altered gait.
How does Legg-Calve-Perthes disease usually present?
LCP disease is avascular necrosis of the femoral head. Classically presents with gradually worsening hip pain that may NOT be relieved with rest.
When is each foot orthosis indicated?
Deep Heel Cup
Semi-rigid plate
Wide plate
Reverse Morton’s
Deep heel cup, semi-rigid plate, wide plate -> medial column overload
Reverse Morton’s extension –> Lateral column overload
What is a Monteggia Fracture?
Fracture of the proximal 1/3 of the ulna with associated dislocation of the radial head
Tx = closed reduction and casting in supination or ORIF or intramedullary nailing
Are supracondylar fractures of the humerus considered to be intra or extra articular fractures?
Supracondylar fractures of the humerus are extra articular fractures of the distal humerus.
Type I supracondylar fractures that are nondisplaced can be immobilized with a posterior splint and sling or collar and cuff sling
What is a Galeazzi Fracture
Fracture of the distal 1/3 of the radial shaft with associated radioulnar joint injury.
Treatment= ORIF of the radius with stabilization of the distal radioulnar joint
What is patellar chondromalacia?
How is it diagnosed?
Treatment?
Softening of the patellar cartilage that results from long-standing patellofemoral pain syndrome.
Diagnosed arthroscopically
In Osgood-Schlatter disease, where is the pain localized?
What type of activity increases risk?
Most often seen in preteen and adolescent males who perform repetitive jumping exercises.
Pain is localized over the tibial tubercle
What is the best method for determining the level of amputation in pts planned to undergo BKA/AKA?
Transcutaneous oxygen pressure (TcPO2) is used to find the level of amputation with enough blood perfusion to increase chance of successful wound healing and decrease risk of re-amputation.
A median TcPO2 of 28 mmHg is likely to provide sufficient perfusion for successful wound healing.
In a patient with C4AIS-A injury, the likelihood of regaining antigravity strength can, in part, be predicted by?
Initial strength of the muscle one level below the neurologic level of injury as well as the rate of recovering antigravity strength.
In pts with no motor strength at the first caudal level, recovery may continue for up to two years after injury
In a patient with C4AIS-A injury with no motor strength at the first caudal level, recovery may continue for up to ___ years after injury
Two years post injury
Patients with complete cervical SCI lesions usually recover ___levels of function
Patients with complete cervical SCI usually recover one root level of function
Sea shell murmur –>
Fat sputtering on frying pan –>
Rain on a tin roof –>
Motor boat engine –>
Dull Thud –>
Seashell murmur –> MEPPs
Fat sputtering on a frying pan –> EPPs
Motorboat/Machine Gun –> CRDs
Dull regular thud –> Positive sharp wave
Identify common sites of radial nerve injury associated with UE fractures.
Most frequent site of radial nerve compression?
- Spiral groove of the humerus
- Juncture of the middle and distal 1/3 of the arm
- Radial Tunnel
- Compression b/w brachioradialis and ECRL
Most frequent site of radial nerve compression is in the proximal forearm in the area of the supinator and involves the PIN branch.
In fractures of the humerus, at the junction of the middle and proximal 1/3 as well as distally on the radial aspect of the wrist
What is the most sensitive imaging modality for early detection of heterotopic ossification?
Triple phase bone scan
Which vertebral level exhibit pseudosubluxation in almost half of all pediatric patients?
Pseudosubluxation of C2 on C3 is a common variant seen in almost 50% of pediatric patients younger than 8 y/o.
Main cause is increased ligamentous laxity and more horizontally positioned facet joints
Pseudosubluxation is present when the spinolaminar line connecting the anterior portions of the spinous process of C1 and C3 is within 2 mm of the C2 spinous process. If > 2mm, indicates true subluxation.
Most cervical spine fractures in children occur at what level?
C1-C3 region
The most sensitive clinical exam maneuver to diagnose transient synovitis?
Treatment plan?
Log Roll
Bed rest for 7-10 days, NSAIDs. Advise all pts with transient synovitis to have repeat XR within 6 months to exclude Legg-Calve-Perthes disease
What is the most specific screening tool for diagnosing malnutrition?
Most sensitive?
Malnutrition Screening Tool (MST)
Most sensitive = MST and Mini Nutritional Assessment (MNA)
How can you differentiate between infantile spinal muscular atrophy and infantile botulism based on physical exam alone?
Infantile SMA symptoms do not include bulbar manifestations (facial and pharyngeal weakness, ptosis, dilated pupils)
Synovial fluid findings in osteoarthritis usually suggest a non-inflammatory process if the WBC count is _________
< 2000/mm3
Inflammatory conditions like RA, lupus, or gout usually present with opaque synovial fluid, high proteins, WBC between 2000 - 50,000, and PMNs > 50%
What happens to each of the following cardiac parameters as people age:
-Max HR
-Cardiac Output
-LVEF
- Maximal end diastolic Volume
- HR decreases 2/2 drop out of cardiac pacemaker cells
- Cardiac output is lower in elderly
- Ejection Fraction Decreases
- End diastolic volume increases
What is the optimal postoperative dressing for a trans-tibial amputee?
Rigid removable dressing;
Provides compression to control edema and reduce limb volume. Provides protection and can be removed for inspection. It has been shown to reduce the length of hospital stay and increase the likelihood of patient ambulating at discharge
What happens to the following parameters during exercise?
Inotropy
Chronotropy
Cardiac output
stroke volume
Preload
Systemic Vascular Resistance
Inotropy (contractility) - Increases
Chronotropy (HR) - Increases
Cardiac Output- Increases
Stroke Volume - Increases
Preload- Increases
Systemic Vascular Resistance- Decreases
Identify the following for each of the following muscles:
1. Compartment
2. Innervation
3. Action
Fibularis longus
Fibularis Brevis
Fibularis Tertius
Fibularis longus and brevis are located in the lateral compartment of the leg. Both are innervated by the superficial fibular nerve. Both are involved in foot eversion and plantar flexion.
Fibularis tertius is located in the anterior compartment of the leg. It originates from the distal part of the anterior fibula and inserts onto the dorsum of the shaft of the 5th metatarsal bone. It is involved in foot eversion and dorsiflexion. Innervated by the deep fibular nerve.
What is the treatment of choice for children < 6 mo with developmental hip dysplasia?
Infants up to age 6 months are usually treated with a Pavlik Harness. Prevents hip extension and limits adduction; permits hip flexion and abduction
What is the treatment of choice for children > 6 mo with developmental hip dysplasia?
The treatment of choice for children > 6 mo with DDH is Closed or Open reduction in the OR under anesthesia with a hip spica cast
What is the purpose of a pavlik harness?
Prevents hip adduction and extension in children with developmental hip dysplasia
What clinical manifestations are most consistent with neurogenic shock in the setting of an acute SCI?
Fatal consequence of SCI that manifests as hypotension, bradyarrhythmia, and temperature dysregulation with resultant hyperthermia.
Associated with cervical and high thoracic SCI.
Bradycardia 2/2 interruption of autonomic pathways in the spinal cord resulting in decreased vascular resistance.
Tachycardia is absent because of loss of sympathetic tone.
Focal neurologic deficit is not necessary for the diagnosis of neurogenic shock**
Neurodegenerative diseases pathologically characterized by a-synuclein-positive intracellular inclusions are associated with this sleep-wake cycle disorder?
REM-sleep behavior disorder
What it is the treatment of choice for a patient with post traumatic elbow stiffness with normal radiographs?
Functional ROM of the elbow is from 30-130 degrees flexion-extension and from 50 deg supination to 50 deg prnation.
1st line tx = PT with PROM exercises
If PT fails and pt has elbow flexion contracture > 30 degrees or elbow flexion < 130 degrees, static, progressive casting/splinting is indicated
Chiari II malformation typically involves displacement of ______________ thru the foramen magnum.
Medulla, cerebellar tonsils, and cerebellar vermis
Anti-smith antibodies are associated with _____.
Anti-dsDNA antibodies are associated with _____.
ANti-centromere antibodies are associated with _____.
Anti-Smith –> Lupus
Anti-dsDNA –> Lupus
Anti-Centromere –> CREST Syndrome
What is the most common location of a pressure ulcer in a patient with spinal cord injury within 2 years?
Sacrum
Explain the “Sign of Benediction”
Median nerve injury
Loss of innervation to lateral 2 lumbricals of the hand and the lateral half of FDP. –> Flexion weakness at PIP joints of 4-5, but MCP flexion at 4-5 remains intact 2/2 lumbricals 4,5.
The EDC is left unopposed –> the MCP joints of digits 2-3 remain extended while attempting to make a fist.
A very important distinction when differentiating Intersection Syndrome from De Quervain’s is the fact that a patient with Intersection syndrome would display ___________
Pain in the 2nd dorsal compartment several centimeters proximal to the radial styloid, while a patient with De Quervain’s occurs directly over the radial head.
Risk factors associated with increased prevalence of frailty?
Older age,
Low education level,
current smoker,
non-white,
not married,
current depression,
current use of antidepressants, intellectual ability,
current use of postmenopausal hormone therapy
Which type of head injury has the highest risk of developing post traumatic seizures?
Penetrating head trauma
Weakly positive birefringence, rhomboid shaped crystals is associated with? Tx?
Pseudogout . Preferred initial management is with joint aspiration followed by intra articular steroid injection
