Subs 12/20/2016 Flashcards
ortelani test
maneuver
purpose
in infant eg w ddh
hold a knee in either hand
one at a time
aBduct and anteriorly pressure the hip joint
CLUNK (not a click) if hip was dislocated now relocated
to test if hip dislocated
ortelani vs barlow
ortelani push ante
in infant eg w ddh
hold a knee in either hand
one at a time
aBduct and Anteriorly pressure the hip joint
CLUNK (not a click) if hip was dislocated now relocated
vs
barlow push below
-opposite of ortelani
aDduct and Posteriorly to see if can dislocate
ddh age presentation dx tx
developmental dysplasia of the hip
newborn
clunky hip (ortelani, barlow)
if not better 4 wks wait/watch get US to dx
tx w harness to allow acetabulum to grow around femoral head
barlow test
maneuver
purpose
in infant eg w ddh
hold a knee in either hand
one at a time
aDduct and posteriorly pressure the hip joint
CLUNK (not a click) if hip located now dislocated
to see if if hip can be dislocated easily
non-traumatic hip pain in teen undergoing growth spurt or obese think…
scfe (unless febrile...) slipped capital femoral epiphysis non-traumatic hip pain in teen undergoing growth spurt or fat kid FROGLEG xr surgery
insidious onset antalgic gait in 6yo think…
Legg-Calve-Perthes disease
xr shows avascular necrosis of the hip
cast
scfe age presentation dx tx
slipped capital-femoral epiphysis 13yo non-traumatic hip pain in teen undergoing growth spurt or fat kid FROGLEG xr surgery
transient synovitis age presentation dx tx
any age
non-weight bearing hip pain post viral illness
clinical dx (r/o septic arthritis w kocher criteria (non-wb fev leuk esr)
supportive care (analgesics) unless think septic joint w more kocher crit then consider tapping arthrocentesis
kocher criteria
used for
what are they
for septic arthritis (vs transent synovitis) in peds with accutely irritable hip with both of these on the ddx
- non weight bearing
- fever (^38.5C 101.3F)
- Leukocytosis (^12,000cells/mm3)
- ESR ^40mm/hr
pts on either extreme of score (0/4, 4/4) readily ruled out or in for septic arthritis, but intermediate range needs further workup
septic joint (arthritis) in peds age presentation dx tx
any age Kocher criteria /4 -non-weightbearing fever leukocytosis ESR ele ^50,000 wbc's on arthrocentisis drain and abx
(38.5C 101.3F
12 wbc
40 ESR)
5 causes of peds hip pain
age pres dx tx
- ddh newborn clunky hip us if not better in 4 wks harness
- legg-calve-perthes 6yo insid antalgic gait xr cast
- scfe 13yo growth spurt or obese atrauma frog leg xr sx
- septic joint any age kocher crit fev leuk esr nonwb tap ^50,000wbc drain abx
- transient synovitis post viral nonwb hip pain use kocher crit supportive care
tf
“supportive care” includes analgesia
t
eponym means
named after a person
eg osgood schlatters
osgood schlatter’s aka
tibial tuberosity avulsion
apophysitis of the tibial tuberosity
maybe called osteochondrosis not sure of correctness…
adam’s test
bend over touch toes
observe shoulder height diffs for scoliosis
2 bone tumors to know
pres
dx
tx
both pres focal atraumatic bone pain
ewing sarcoma
mid-shaft diaphyseal ONION-SKIN appearance xr mri bx t11,22 (33 = pat ewing’s number) resect
osteosarcoma distal femur (other ends of bones?Y) SUNBURST appearance xr mri bx (Rb) prob had retinoblastoma as newborn resect
mid-shaft diaphyseal onion-skin appearance bone tumor think..
ewing sarcoma
focal atraumatic bone pain
MID-SHAFT diaphyseal ONION-SKIN or moth-eaten or sunburst but LOCATION matters more appearance xr mri bx t11,22 (33 = pat ewing’s number) resect
adam’s test
bend over touch toes
observe shoulder height diffs for scoliosis
when to consider surg for peds fx
open (needs clean)
long oblique/comminuted messy ends
growth plate involvement
scoliosis vs kyphosis vs lordosis
scoli lateral
kyph inc curv like thorax
lumbar lord curve like lumbar
distal femoral sunburst appearance bone tumor think
osteosarcoma
focal atraumatic bone pain
distal femur (other ends of bones?) SUNBURST appearance xr mri bx (Rb) prob had retinoblastoma as newborn resect
when to consider surg for peds fx
open (needs clean)
long oblique/comminuted messy ends
growth plate involvement
2 bone tumors to know
pres
dx
tx
both pres focal atraumatic bone pain
ewing sarcoma
mid-shaft diaphyseal ONION-SKIN appearance xr mri bx t11,22 (33 = pat ewing’s number) resect
osteosarcoma distal femur (other ends of bones?) SUNBURST appearance xr mri bx (Rb) prob had retinoblastoma as newborn resect
osteochondroma, anticipate what w regard to
pain
fev
esr
no pain
no fever
normal esr
normally asymptomatic or with palpable mass, benign grown in childhood growth plates (may look like osteosarcoma by positon at ends of bones… but no focal atraumatic bone pain not sunburst no alk phos from bone destruction…)
distal femoral sunburst appearance bone tumor think
osteosarcoma
focal atraumatic bone pain
distal femur (other ends of bones?) SUNBURST appearance xr mri bx (Rb) prob had retinoblastoma as newborn resect
when to consider surg for peds fx
open (needs clean)
long oblique/comminuted messy ends
growth plate involvement
scoliosis vs kyphosis vs lordosis
scoli lateral
kyph inc curv like thorax
lumbar lord curve like lumbar
most common bone cancer in peds
osteosarcoma distal femur (other ends of bones?Y) SUNBURST appearance xr mri bx (Rb) prob had retinoblastoma as newborn resect
tf
alc phos elevated in osteosarcoma
t
bone destruction
distal femur (other ends of bones?Y) SUNBURST appearance xr mri bx (Rb) prob had retinoblastoma as newborn resect
does fev leuk night sweats in bone cancer indicate more ewing sarcoma or osteosarcoma?
ewing sarcoma
osteochondroma, anticipate what w regard to
pain
fev
esr
no pain
no fever
normal esr
normally asymptomatic or with palpable mass, benign grown in childhood growth plates (may look like osteosarcoma by positon at ends of bones… but not sunburst no alk phos from bone destruction…)
irregularities and haziness over metaphseal border of proximal tibia in teen athlete think…
osgood schlatter
tf
playing through osgood schlatter pain has bad long term outcomes
f
can suck it up and play if they want… per meded
tf
cancer is commonly tender
f
not usually tender (to palpation), but does cause pain
systemic dzs that get carpal tunnel more
dm
hypothyroid
carpal tunnel path pres dx tx assoc dz to f/u
inflammation/compression of median nerve
pain paresthesias paralysis 1st 3 digits
phalen tinel thenar atrophy
eeg if surg dec conduction
splint out of flexion analg intraarc corricosteroids
f/u rheumatoid arthritis… carp tun may be presenting sign
phalen sign
press dorsi of hands together into flexion
pain eg w carpal tunnel
carp tun may be presenting sign of this dz
rheumatoid arthritis
jersey finger vs mallet finger vs trigger finger
flexor tendon tear eg grabbing jersey ripped away
extensor tendon tear eg dip hyperflexed when stubbed trying to catch ball
extensor stenosing tenosinovitis may hear a POP when passively extended
tx splint nsaids intraartic steroids… surg
dequervain’s tenosynovitis
pres
dx
tx
mom carrying baby vs guy lifting weights
fist thumb twist pain on ulnar dev
splint nsaids intraartic corticosteroids… no surg… don’t cut inflammatory process… but… do cut to relieve carpal tunnel, do cut trigger finger…
duputyron contracture
mechanism of injury
trick no mechanism nodular fibrosis of palmar fascia assoc w alcoholism and scandanavian male idiopathic
duputyren's contracture path pres dx tx
fibrosis of palmar fascia causes flexion contracture of fingers
assoc w alcoholism and scandanavian men
clinical dx
surg release fascia
(nsaids do nothing as fascial not inflammatory dz)
felon path pres dx tx
abscess in pulp of finger usually assoc w penetrating trauma
pain (compartment pressure) fev leuk
clinical dx
i and d… so small that need for abx rare
why do we splint carpal tunnel
immobilize to allow tendon swelling in carpal tunnel to resolve
treat carpal tunnel syndrome
splint as often as tolerable if that does not help: xr to ro other path eeg to ro path more proximal than carpal tunnel surg cut carpal tunnel relieve pressure
splint xr eeg cut
general principles for fracture treatment
two xr perpendicular to each other
closed, approximated - consider casting
open, angular, comminuted - consider orif (and emergency washout if open)
if shoulder dislocation affects axillary nerve…
deltoid paresthesias
treat shoulder dislocation
relocate, sling
same for anterior or posterior shoulder disloc
mechanism of injury ant vs post shoulder dislocation
any trauma can cause ant dislocation, easier to do
massive trauma to get post disloc, eg seizure, lightning strike
tf
seizure and lightning strike can cause posterior shoulder dislocation
t
takes massive trauma to disloc post
colle's fx define common demo dx tx
dorsally displaced radius/ulna fx
e.g. in old lady w osteoporosis
xr
cast vs operate
mechanism of monteggia fx other than fall
upper block
downward blow
(e.g. police baton)
Galeazzi fx
define
mech
radial shaft fx w DRUJ inj
-ulnar styloid fx
-widening of DRUJ on AP view
-dorsal or volar displacement on lateral view
-radial shortening (≥5mm)
trauma to dorso lat (rad) aspect vs foosh in pronation
anatomic snuffbox pain think
scaphoid fx
anatomic snuffbox pain, xr normal, next step?
cast and re xr for scaphoid fx in a few weeks…
boxer’s fx
define
fx of 5th (most common) and/or 4th metacarpal necks from punching
tf
hip pain can present as referred knee pain
t
so knee pain r/o hip path
hip fx mechanism
massive trauma
or old lady w osteoporosis
anatomic change w hip fx
leg shortened
flexed adducted internal rotation if post disloc
flexed abducted external rotation if ant disloc
tx femoral head fx
likely to need arthroplasty (joint replacement) as avn likely…
mechanism of injury acl vs pcl
and drawer sign acl vs pcl
posterior trauma acl inj, ant drawer sign
anterior trauma pcl inj, post drawer sign
(ligaments named for distal insertion)
dx
tx
acl pcl inj
MRI
surg (athetes)
cast (everyone else)
mechanism of inj mcl vs lcl
valgus stress mcl inj
varus stress lcl inj
valGus is KnoCK Kneed
varus is wide kneed
valgus vs varus
valGus is KnoCK Kneed
varus is wide kneed
dx
tx
mcl lcl inj
MRI
surg (athletes)
hinge cast (everyone else)
click on knee extension think
meniscal tear
dx
tx
stress fracture of shin
xr
cast even if xr normal, get f/u xr fx will be present
tf
tib fib typically break together
tishfish
if tib breaks, fib likely to break as much weaker cannot support weight
fib can break solo w lateral trauma eg
tx ankle fracture
usually surg as difficult to cast… per meded…
pres
tx
achilles tendon rupture
pop while exercising
cast takes months to heal
surg takes weeks to heal
tx femoral head fx intertrochanteric hip fx fem shaft fx open fx
fem head prosthesis (avn)
intertroch plate
shaft rod
open emergency washout
most sensitive physical exam test for acl tear
lachman’s
basically anterior drawer but at 20 deg flexion not 90
lachman test
basically anterior drawer but at 20 deg flexion not 90
most sensitive physicalexam test for acl tear
why replace femoral head fx
because blood supply is so tenuous that plating will likely lead to avn if not already vascularly compromised
tf
pain in anatomic snuff box is pathognomonic for scaphoid fx, even if xr neg
t
so thumb spica cast
f/u xr 3 wks
physical exam test for torn meniscus
mcmurray
rotate while extending knee joint, click on extension
physical exam test for mcl tear
valgus stress test
physical exam test for lcl tear
varus stress test
humeral supracondylar fx
mechanism
4 compx
foosh brachial artery inj (runs ant midline) median nerve inj (runs ant midline) cubitus varus deformity compartment syndrome/volkmann's ischemic contracture
most common fx in peds
supracondylar humerus fx
supracondylar area remodeling – small and weak
most common complications of supracondylar fracture
beachial artery inj
median nerve inj
both run along anterior midline of the area
which pulses to check after supracondylar fx
brachial a
radial a
(both compromised w brachial a inj)
check for complications after supracondylar fx
distal pulses (brachial, radial… possible brachial artery inj)
distal motor and sensory exam (possible median nerve inj)
treat supracondylar fx
analgesia
immobilization
ortho consult if displaced
prognosis of neurovascular injury after peds supracondylar fx
usually resolves after reduction of displaced fx
brachial a, median n
fracture risk to axillary nerve
Proximal humerus fx
fx risk to brachial plexus
clavicle fx
incidence of compartment syndrome after supracondylar fx
rare v1%
usually accompanied by forearm fx
volkmann contracture
aka
volkmann ischemic contracture
compartment syndrome of ue not timely treated can lead to ischemia and contracture - elbow flex, wrist pron flex, mp ext
tf
supracondylar fx is a risk for limb length discrepancy
f
distal humeral physes comtribute little to length, but can get cubitus varus deformity
(prox humerus, forearm fx can cause length discrepancy)
tf
risk of neurovsscular inj w supracondylar fx is HIGH
t
when to assess radial and brachial pulses, sensory motor function after supracondylar fx
before AND after reduction
mechanism of median nerve and brachial artery injury in supracondylar fx
impingement
define syringomyelia
sx
blocked csf flow in central canal causes fluid buildup and compression of neural tissue, most often medial crossing fibers of spinothalamic pain temp and corticospinal ue motor
so ue motor weakness
pain temp loss
most common causes of syringomyelia
arnold chiari malformation
prior spinal cord injury
incidence of syringomyelia after spinal cord injury
3-4%
2016 uworld
what region involved most commonly in syringomyelia from prior spinal cord inj
cervical
time to onset and progression of syringomyelia sx after spinal cord inj
mos to years
gradual progression
(3-4% incidence after spinal cord injury, usually cervical)
classic mechanism of spinal cord injury leading to syringomyelia
cervical whiplash in mva
tf
dorsal column function compromised in syringomyelia
f
light touch vibration proprioceotion intact
medial structures compromised - spinothalamic crossing pain temp and crossing medial corticospinal motor in ue or cape-like distribution
physical exam findings in syringomyelia
typically cervical
medial structures compromised - spinothalamic crossing pain temp and crossing medial corticospinal motor in ue or cape-like distribution
dorsal columns light touch vibration proprioceotion intact
upper and lower motor neuron deficits w weakness twitching cramping think…
als
als sx
upper and lower motor neuron deficits w weakness twitching cramping
mechanism
demo
sx
cervical spondylosis
disk degeneration
pts over 40yo
neck pain stiffness
neurologic sx if spinal stenosis develops
define spondylosis
general term for pain from spinal degeneration
sx of disk herniation
unilateral radiculopathy (pain amd weakness) in distribution of single nerve (compressed nerve route)
tf
nystagmus and scanning speech common in ms
t
how many lesions required to dx ms
two separate lesions
dx syringomyelia
mri
enlargement of central canal due to csf retention
meniscal tear etiology
young pt rotational force on planted foot
old pt degeneration of meniscal cartilage
tf
meniscus is ligamentous
f
cartilagenous
radionucleotide bone scan used for…
infectious
inflammatory
malignant dz
can detect occult fractures too…
muscles of the anterior upper leg
psoas iliacus tensor fasciae latae (iliotibial band) vastus lateralis vastus intermedius rectus femoris vastus medialis sartorious gracilis adductor longus adductor brevis adductor magnus pectineus
tf
slow onset joint effusion is a presentation of meniscal tear
t
acute pop
locking catching rom dec
slow onset joint effusion
thessaly test
basically standing mcmurray
-pt stands on one foot knee flexed 5 deg, twist to both sides, pos if reproduces sx (catching clicking locking)
-repeat at 20 deg flexion
don’t forget to start w healthy side
dx meniscal inj
provocative tests (mcmurray, thessaly)
mri
arthroscopy
manage meniscal inj
minor sx, older pt - rest nsaids persistent sx (3-4 wks), impaired function - surg for sx relief and prevent further damage
intraarticular glucoccorticoid inj if due to oa in older
muscles of the posterior upper leg
gluteus medius gluteus maximus semimembrinosus semitendinosus long head biceps femoris short head biceps femoris
advantages
disadvantages
of medial parapatellar approach to TKA
standard/familiar
good exposure
risk of medial capsular repair failure
lateral patellar subluxation
risk to medial blood supply
advantages
disadvantages
of lateral parapatellar approach to TKA
useful for fixed valgus
prevents lateral patellar subluxation
technically demanding
medial eversion of patella is more difficult
may require tibial tubercule osteotomy
advantages
disadvantages
of midvastus approach to TKA
mid (medial) vastus
does not disrupt quad tendon so much
patellar tracking
less extensile
exposure difficult in obese pts
visualize anterior tendons of the knee
quadriceps tendon
patellar tendon
lateral and medial retinaculums
over 95% of total knee replacements in US are performed for ________
osteoarthritis
3 compartments of knee
lateral medial patellofemoral
Nonoperative therapies for the patient with knee osteoarthritis include
activity modification, weight loss (for those who are obese), use of a cane, analgesics, and/or nonsteroidal antiinflammatory agents.
osteomyelitis is…
infection of bone and bone marrow
osteo bome
myelo marrow
itis infection
etiologies of osteomyelitis respective bugs
tx
hematogenous
staph a abx
direct traumatic inoculation
polymicrobial surgical debridement
pmh in risk of osteomyelitis
dm
pvd
define draining sinus tract in context of osteomyelitis
epithelialized tract that must be resected to resolve infection
labs to get for osteomyelitis
cbc crp esr blood cx
define bone sequestrum involucrum cloaca sinus tract
piece of dead/necrotic bone from osteomyelitis (or rarely osteod osteoma) infection causing inflammatory exudate, increased intramedullary pressure, vascular thrombusis, lack of blood, necrosis, difficulty delivering hematogenous abx
new bone forming
(latin for sewer or drain) opening in involucrum for drainage of purulent and necrotic material
epitheliazed tract extending from cloaca to skin surface or another cavity
imaging findings in osteomyelitis
sequestrum (necrotic bone)
involucrum (new bone)
cloaca (drain)
sinus tract (epitheliazed drain to skin or another cavity)
most sn and sp imaging test for osteomyelitis
MRI
CT best for imaging bone, MRI gets soft tissue sinus tract edema etc too
most common bugs in osteomyelitis
staph aureus
polymicrobial
pseudomonas
visualize the big arteries of the leg
femoral popliteal genicular arteries posterior tibial anterior tibial (to dorsalis pedis) peroneal
how to manage a sinus tract in osteomyelitis
must resect
otherwise will never resolve
visualize big veins of the leg
great saphenous posterior tibial anterior tibial small saphenous femoral external iliac`
define phlegmon
spreading diffuse inflammatory process with pus… vs walled-off inflammatory mass without bacterial infection…
visualize big nerves of anterior leg
obturator inferior gluteal superior gluteal femoral common fibular (aka peroneal, from sciatic) deep fibular superficial fibular
define paprika sign
puctate cortical or cancellous bone bleeding, eg when debriding cortex in OM to find healthy bone that bleeds
total knee replacement failure rate due to infection
1%
how is chronic osteomyelitis like herpes
it keeps coming back…
Delahey
visualize the big arteries of the leg
femoral popliteal posterior tibial anterior tibial (to dorsalis pedis) peroneal
visualize big nerves of the posterior leg
superior gluteal inferior gluteal sciatic (tibial, common fibular) posterior femoral cutaneous nerve to obturator internus pudendal
Most common cause of aseptic knee replacement failure
patellofemoral maltracking
tinel sign
tap eg median nerve for carlal tunnel pain paresthesia
