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Ortho > Shoulder and Knee > Flashcards

Shoulder and Knee Flashcards

1
Q

Gamekeeper’s/skiers thumb is injury to what liagment

A

ulnar collateral ligament (UCL sprain or tear)

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2
Q

Where are the bursas in the knee?

A
  1. suprapatellar bursa
  2. subcutaneous prepaterllar bursa– on top of patella
  3. subcutaneous infrapallar bursa
  4. deep infrapatellar bursa
  5. subsartorial (pes anserinus) bursa
  6. Semimembranosus bursa– behind the knee
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3
Q

Describe the blood distribution of the meniscus

A
  • Blood supply comes from the outside (red zone)
  • Inside part is (white zone)–> tear has a little chance of healing due to little blood supply

*Get MRI to tell location of the tear or a scope

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4
Q

When performing a PE of the knee/lower leg always evaluate:

A
  1. Gait evaluation
  2. Passive and active range of motion (ROM)
  3. Any obvious deformity or muscular atrophy (Vastus Medialis Oblique VMO), swelling or effusion.
  4. Tenderness over joint line, patellar, etc.
  5. Patellar tracking (lateral) and instability
  6. ligament instability testing
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5
Q

What PE tests evaluates the collateral ligaments of the knees

A

Valgus: push knee in and rotate leg outward= tests MCL

Varus: push knee out and rotate leg inward= tests LCL

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6
Q

What PE tests evaluates the cruciate ligaments of the knees

A

Lachman’s** (30 degree of flexion created by knee under the thigh)
Pivot shift
Anterior/posterior drawers

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7
Q

What PE tests evaluates the menisci of the knees

A 
McMurrays 
Apley test (same as mcmurry but pt is prone not supine)
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8
Q

What is a normal Q angle

A

15-20 degrees

  • valgus angulation btwn the pull direction of the quads and patella tendon
  • *if increased= patella is lateralized w/ respect to center groove
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9
Q

how do you test patella laxity/instability

A
  1. patellar apprehension test

* increase Q angle creates instability

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10
Q

tx of increase Q angle/ anterior-knee pain syndrome

A

VMO (Vastus Medialis Oblique) strengthening

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11
Q

what type of x-rays do you need to ask for with OA evaluation

A

weight bearing

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12
Q

describe the x-ray views for knees

A
  1. AP
  2. Lateral
  3. Merchant view: shows if patella is tilted, if increase Q angle then you will have a tilted patella, J tracking
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13
Q

what is the common MOI for ACL tears

A

-trauma with a twisting or hyperextension force with foot planted

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14
Q

What is O’Donoghue’s or unhappy triad?

A

injury to

  1. meniscus
  2. MCL tear (or LCL but less likely)
  3. ACL tear

*50% of pts with ACL tears, also have meniscus injury

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15
Q

Presentation of ACL tear

A
  1. Acute injuries are usually associated with a rapid effusion (hemarthosis in the first 24 hrs),
  2. unable to weight bearing and
  3. feeling of a mechanical “giving away.”
  4. Most patients will NOT be able to ski down the hill, or walk.
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16
Q

Radiology findings suggestive of ACL tear

A
  1. Segund fx– LCL avulsion fx (involves the lateral aspect of the tibial plateau)
  2. Kissing bone edemas
  3. ACL avulsion tx
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17
Q

3 types of grafts used for ACL tear reconstruction

A
  1. Bone-tendon graft
  2. Hamstring tendons (semitendinosus and gracilis)** most common
  3. Allograft
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18
Q

What is a buckle-handle tear?

A

inner rim of the meniscus pulls away from the residual meniscal body, resulting in a longitudinal tear pattern that resembles the shape of a bucket
-meniscus flips on itself and causes mechanical locking**

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19
Q

What is Chondromalacia Patellae

A

aka patellar-femoral pain syndrome

  • inflammation of the underside of the patella and softening of the cartilage
  • often caused by increased Q angle which causes the patella to track laterally
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20
Q

tx of Grade IV Chondromalacia Patellae

A

Tx: can do a lateral release of patella tendon or osteotomy/unicompartment arthroplasty (MAJOR SURGERY)

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21
Q

Risk factors for tendon ruptures

A
  1. long term steroid use
  2. quinolone antibiotics (“-floxacin” meds)
  3. alcohol abuse

*Ask about these with all tendon ruptures

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22
Q

Patella alta can appear with what type of tendon rupture?

Patella baja can appear with what type of tendon rupture?

A

alta- patellar tendon rupture

baja- quadriceps tendon ruptures

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23
Q

Insall-Salvati method for determining patella alta/baja

A

normal: 1
Alta: over 1.2
Baja: less than 0.8

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24
Q

complications of a tibia fx

A
  1. genu varus deformity
  2. non-union

**Always check for compartment syndrome

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25
Q

tx for patellar fx

A

open reduction and internal fixation (ORIF)

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26
Q

what is a Bipartite patella

A 
ongenital condition (present at birth) that occurs when the patella (kneecap) is made of two bones instead of a single bone
*usually a benign and incidental finding
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27
Q

tx of a knee dislocation

A
  1. true ortho and vascular surgery emergency involving multi-ligamen and neuro-vascular injury (popliteal artery/nerve)
  2. STAT angiogram and reduction
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28
Q

When someone has a chronic foot drop they need to be put in an

A

AFO (ankle foot orthotic)

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29
Q

One pound wt. lost equals __ lbs of less joint stress in people with knee OA

A

4lbs

**Arthritis is the most common cause of disability in the United States

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30
Q

When is a unilateral compartment knee replacement done

A

younger pts with patellar compartment and opposite lateral/medial compartment free of arthritis

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31
Q

What is an osteochondral defect (OCD)?

A
  • focal area of damage that involves both the cartilage and a piece of underlying bone (results in hole in the bone from cartilage collapse)
  • These can occur from an acute traumatic injury to the knee or an underlying disorder of the bone

*Painful!

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32
Q

tx of osteochondral defect (OCD

A

shave the hole or put a bone plug in (OATS procedure)

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33
Q

How do you reduce a patellar dislocation

A

Reduction: extend knee and push on it (give propofol for pain)

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34
Q

What is a popliteal cyst (Baker’s cysts) associated w/

A

degenerative meniscal tear and systemic inflammory conditions such as RA

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35
Q

What is a baker’s cyst

A

benign swelling of the semimembranosus/popliteal bursa with synovial fluid

*causes a bulge and a feeling of tightness behind your knee. The pain can get worse when you fully flex or extend your knee or when you’re active.

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36
Q

Most frequently dislocated joint in adults

A

shoulder

*most mobile joint

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37
Q

what do you worry about with shoulder dislocations and reductions

A

axillary nerve (neurovascular supply)

38
Q

What DDX can cause referred shoulder pain

A
  1. MI
  2. pneumothorax
  3. cervical spine problems
  4. Diaphgragmatic irritation
  5. thoracic outlet syndrome
39
Q

PE of Shoulders

A
  1. look at front and back for deformity/atropy
  2. AROM and PROM
  3. apprehension/relocation tests for multidirectional instablilty
  4. Special tests
40
Q

what is sulcus sign associate with

A

inferior shoulder instability

41
Q

what special tests are associated w/ anterior labrum tears

A

O’Brians test

42
Q

what special tests are associated w/ rotator cuff injuries

A
  1. Neer’s impingement sign: pain and/or tenderness w/ forward flexion
  2. Hawkins: pain and/or tenderness with abduction and internal rotation in the scapular plane
  3. Drop arm test
43
Q

what special tests are associated w/ AC joint pain

A

cross arm test

44
Q

Scapular winging is due to

A

long thoracic nerve palsy

45
Q

What xray views are included in a trauma series for the shoulder

A

AP
scapular Y
axillary view

46
Q

What xray views are included for instabiliity views for the shoulder

A

AP
West point axillary
Stryker notch

47
Q

What xray views are included in impingement studies for the shoulder

A
  1. supraspinatus outlet

2. 30 degree caudad AP

48
Q

What is the money xray view shot for shoulder dislocations?

A

Axillary lateral view

*need image for shoulder out and in

49
Q

What is the most common type of shoulder dislocation and what is the MOI

A

Anterior dislocation are the most common with an external rotation and abduction motion as the mechanism of injury (throwing motion).

50
Q

Secondary causes of shoulder dislocations

A
  1. seizures
  2. electrical shock
  3. sport-related trauma
  4. MVA
51
Q

What are 2 ways to perform a closed shoulder reduction?

A
  1. Traction/counter-traction technique: Longitudinal traction, with gradual abduction and external rotation until a clunk is heard and felt. (WORKS BETTER)
  2. Gravity-Assisted Reduction (Stimson technique) with longitudinal traction with 5-15 lbs.– good for chronic or recurrent dislocations
  • Always check Neuro-Vascular function before and after reduction!!!!
  • Use profolol
  • *the sooner you can reduce it the better
52
Q

How do you test neurovascular fxn in a shoulder dislocation

A
  1. assess feeling on deltoid and on radial side of arm (sensory)
  2. ask to fire the deltoid muscle (motor)
  3. check distal radial pulse
53
Q

What is a Bankart lesion associated with?

A

-Is an injury of the glenoid and/or LABRUM due to anterior or posterior shoulder dislocation and it is usually an indication for surgery

54
Q

After a shoulder dislocation, you should think about what 2 possible injuries?

A
  1. Bankart- labrum injury

2. Hill Sach’s fx- humerus injury

55
Q

What is a Hill Sach’s fx associated with?

A
  • cortical depression in the head of the Humerus bone.
  • It results from forceful impaction of the humeral head against the Anterior-inferior glenoid rim when the shoulder is dislocated anteriorly
56
Q

What muscles comprise the rotator cuff

A
  1. supraspinatus
  2. infraspinatus
  3. teres minor
  4. subscapularis

*the supraspinatus as the most commonly injured (closest to acromion)

57
Q

Sx of rotator cuff injuries

A
  1. impingement,
  2. tear,
  3. proximal head of biceps tendon rupture or secondary to instability.
  4. Could be from degenerative changes or from an acute trauma
  5. location of pain: anterior, lateral or superior, with lateral pain over the Deltoid as the most common location.
  6. Pain worse with motion at, or above shoulder level.
  7. tenderness over sub-acromial space, greater tuberosity of AC joing
58
Q

T/F Degeneration of the rotator cuff is a part of the NORMAL aging process

A

True

59
Q

First-time anterior shoulder dislocation in patients 40 years old or older, also have a 40-60% incidence of rotator cuff tears (RCT). You should get what imaging?

A

GET AN MRI–> often have dislocation + rotator cuff tear

60
Q

Rotator cuff injuires impingment diagnostic ad therapeutic test

A
  1. Injection of 10cc of local anesthesia (commonly a combination of short and long acting anesthesia and a corticosteroid) in the subacromial space (not shoulder JOINT)
    - may also inject AC joint but not as easy (tight joint)

*Document percentage of pain before and after injection, with pain relief of at least 50% as diagnostic for rotator cuff injury

61
Q

non-surgical managment of a rotator cuff injury

A
  1. NSAIDS, ice, rest
  2. Cortisone injection
  3. activity modification
  4. PT for at least 3 months (US, phonophoresis, motion and RC strengthening)
62
Q

surgical managment of a rotator cuff injury

A
  1. Subacromial decompression (arthroscopic or open) with bursectomy.
  2. Distal clavicle resection (Munford Procedure)
  3. Rotator cuff repair
63
Q

The most common cause of an AC joint separation is

A

falling on the shoulder

64
Q

Symptoms of an AC joint separation

A
  1. range from mild tenderness felt over the joint after a ligament sprain to
  2. the intense pain of a complete separation.
  3. Grade II and III separations can cause a considerable amount of swelling
  4. In grade III separations, you may feel a popping sensation due to shifting of the loose joint and usually cause a noticeable deformity on the shoulder.
65
Q

PE and physical of AC joint separation

A
  1. Deformity at the AC joint

2. Xrays, weight vs non-weight baring with increased coraco-clavicular distance

66
Q

What are the different grades of AC joint separations?

A

Grade 1- injury to capsule
Grade 2- elevation of clavicle- no ligaments torn
Grade 3- corico-clavicular ligament is torn

67
Q

Treatment of AC joint separations

A
  1. Ice, rest, NSAIDs ( if no contraindications)
  2. 2 - 4 weeks in sling (symptomatic Rx )
  3. Grade III controversial for surgery vs. conservative Rx, with late sequelae of AC joint DJD as a common complication of surgical fixation.
68
Q

fractures of the shoulder

A
  1. Proximal Humerus (5%)
  2. Mid-shaft Humerus
  3. Scapula
  4. Clavicle (5% of all fx seen in ED)
69
Q

Proximal humerus fractures usually occur in what patients and from what MOI

A
  • older pts who have osteopenic/osteoporotic and fragile bone
  • ground-level fall
70
Q

Treatment of proximal humerus fractures

A
  1. Most commonly treated non-operative with a sling and early range-of-motion (ROM) exercises.
  2. Gentle ROM exercises may begin after 7-10 days, if the fracture is stable.
  3. When fracture displacement occurs, operative intervention is recommended.

*The majority of fractures (about 85%) are non-displaced.

71
Q

In the Neer classification of proximal humerus fractures, the proximal humerus is made up of four parts:

A
  1. humeral head (articular surface)
  2. greater tubercle
  3. lesser tubercle
  4. diaphysis (shaft)

*Part 4 is the worst – head loses vascular supply so need emergent surgery

72
Q

types of humerus greater tuberosity avulsion fractures

A
  1. avulsion
  2. depression
  3. split

*If not displaced, we don’t tend to fix it

73
Q

Most mid-shaft humerus fractures are a result of

A

a direct blow such as a MVA

74
Q

Treatment of mid-shaft humerus fractures

A
  1. Most are treated non-operatively with close to 100% fracture union rate.
  2. Extremely important to assess neuro-vascular function with the RADIAL nerve as the structure at highest risk for injury.
  3. Radial nerve test: Cannot dorsiflex wrist? Cannot push against a hitch hiking thumb against resistance, can you feel arm
75
Q

What type of brace is used for a mid-shaft humerus fracture

A

Sarmiento brace

*2 weeks in this brace and the bone fragments won’t move anymore

76
Q

Treatment of non-displaced scapula fractures

A

usually treated conservatively

77
Q

What is considered a “floating shoulder”

A

Any scapula fracture through the body, and/or extending into the glenoid fossa, or a comminuted fracture that is associated with a clavicle fracture

*considered and orthopedic emergency

**If scapular fracture goes along with a clavicle fracture is a RED FLAG!! (worry about a floating shoulder)

78
Q

tx of a floating shoulder

A

This is an extremely unstable fracture and requires emergent arteriogram and CT scan

*first repair the artery and then repair the clavicle and scapula

79
Q

Because conservative treatment of a floating shoulder may result in ___ of the shoulder girdle, a floating shoulder usually requires operative stabilization

A

displacement (medialization)

80
Q

Associated injuries seen with a floating shoulder in up to 80-90% of patients:

A
  1. Pulmonary injuries (pneumothorax and pulmonary contusion).
  2. Shoulder dislocations (anterior or posterior).
  3. Brachial plexus injuries and Axillary Artery injury
81
Q

clavicle fractures are commonly seen in what patients

A

neonates and children
*generally heal well

*In adults, the force required to fracture the clavicle is greater and healing occurs at a slower rate

82
Q

Clavicle fractures in adults have a higher risk of complications such as

A

malunion and non-union

83
Q

pitfalls of clavicle fx

A
  1. visible lump

2. pain w/ carrying a back-pack

84
Q

Tx of a clavicle fx

A
  1. sling or figure 8 strap for 3-4 weeks in children and 4-6 weeks in adults
    * Figure 8 not frequently used that much bc it doesn’t do that much–> stabilizing with sling does the same thing
85
Q

What is the most common type of biceps tendon rupture and what it its tx

A

rupture of the proximal long head of the biceps and it is usually non-surgical, other than for cosmetic reasons.

86
Q

distal bicep tendon ruptures are associated with ___ and tx is ___

A

weakness in supination

treatment is surgical repair depending on co-morbidity factors.

87
Q

What is the popeye deformity associated with

A

proximal biceps tendon rupture

88
Q

Shoulder OA is a gradual, progressive, mechanical, and biochemical breakdown of the ___ and ___ including ___

A

articular cartilage and other joint tissues, including bone and joint capsule

89
Q

Risk factors for shoudler osteroarthritis

A
  1. age
  2. genetics
  3. sex
  4. weight
  5. joint infection
  6. hx of shoulder dislocation
  7. previous shoulder injury
  8. certain occupations: heavy construction or overhead sports
90
Q

Shoulder Xray showing shoulder replacement surgery needs to be done due to OA

A
  1. AP
  2. humerus head becomes flat
  3. big tear drop osteophyte or bone spur
91
Q

A “tear drop osteophyte” is associated with

A

severe OA needing shoulder replacement surgery

92
Q

Types of shoulder arthroplasties

A
  1. total shoulder
  2. hemi
  3. reverese total shoulder- LAST RESORT, does not tolerate a lot of stress

Ortho (6 decks)

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