Subs 12/20/2016 Flashcards
1
Q
ortelani test
maneuver
purpose
A
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
2
Q
ortelani vs barlow
A
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
3
Q
ddh age presentation dx tx
A
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
4
Q
barlow test
maneuver
purpose
A
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
5
Q
non-traumatic hip pain in teen undergoing growth spurt or obese think…
A
scfe (unless febrile...) slipped capital femoral epiphysis non-traumatic hip pain in teen undergoing growth spurt or fat kid FROGLEG xr surgery
6
Q
insidious onset antalgic gait in 6yo think…
A
Legg-Calve-Perthes disease
xr shows avascular necrosis of the hip
cast
7
Q
scfe age presentation dx tx
A
slipped capital-femoral epiphysis 13yo non-traumatic hip pain in teen undergoing growth spurt or fat kid FROGLEG xr surgery
8
Q
transient synovitis age presentation dx tx
A
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
9
Q
kocher criteria
used for
what are they
A
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
10
Q
septic joint (arthritis) in peds age presentation dx tx
A
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)
11
Q
5 causes of peds hip pain
age pres dx tx
A
- 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
12
Q
tf
“supportive care” includes analgesia
A
t
13
Q
eponym means
A
named after a person
eg osgood schlatters
14
Q
osgood schlatter’s aka
A
tibial tuberosity avulsion
apophysitis of the tibial tuberosity
maybe called osteochondrosis not sure of correctness…
15
Q
adam’s test
A
bend over touch toes
observe shoulder height diffs for scoliosis
16
Q
2 bone tumors to know
pres
dx
tx
A
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
17
Q
mid-shaft diaphyseal onion-skin appearance bone tumor think..
A
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
18
Q
adam’s test
A
bend over touch toes
observe shoulder height diffs for scoliosis
19
Q
when to consider surg for peds fx
A
open (needs clean)
long oblique/comminuted messy ends
growth plate involvement
20
Q
scoliosis vs kyphosis vs lordosis
A
scoli lateral
kyph inc curv like thorax
lumbar lord curve like lumbar
21
Q
distal femoral sunburst appearance bone tumor think
A
osteosarcoma
focal atraumatic bone pain
distal femur (other ends of bones?) SUNBURST appearance xr mri bx (Rb) prob had retinoblastoma as newborn resect
22
Q
when to consider surg for peds fx
A
open (needs clean)
long oblique/comminuted messy ends
growth plate involvement
23
Q
2 bone tumors to know
pres
dx
tx
A
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
24
Q
osteochondroma, anticipate what w regard to
pain
fev
esr
A
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…)
25
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
26
when to consider surg for peds fx
open (needs clean)
long oblique/comminuted messy ends
growth plate involvement
27
scoliosis vs kyphosis vs lordosis
scoli lateral
kyph inc curv like thorax
lumbar lord curve like lumbar
28
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
```
29
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
30
does fev leuk night sweats in bone cancer indicate more ewing sarcoma or osteosarcoma?
ewing sarcoma
31
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...)
32
irregularities and haziness over metaphseal border of proximal tibia in teen athlete think...
osgood schlatter
33
tf
| playing through osgood schlatter pain has bad long term outcomes
f
| can suck it up and play if they want... per meded
34
tf
| cancer is commonly tender
f
| not usually tender (to palpation), but does cause pain
35
systemic dzs that get carpal tunnel more
dm
| hypothyroid
36
```
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
37
phalen sign
press dorsi of hands together into flexion
| pain eg w carpal tunnel
38
carp tun may be presenting sign of this dz
rheumatoid arthritis
43
```
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
44
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...
45
duputyron contracture
| mechanism of injury
```
trick
no mechanism
nodular fibrosis of palmar fascia
assoc w alcoholism and scandanavian male
idiopathic
```
46
```
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)
47
```
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
48
why do we splint carpal tunnel
immobilize to allow tendon swelling in carpal tunnel to resolve
49
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
50
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)
51
if shoulder dislocation affects axillary nerve...
deltoid paresthesias
52
treat shoulder dislocation
relocate, sling
| same for anterior or posterior shoulder disloc
53
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
54
tf
| seizure and lightning strike can cause posterior shoulder dislocation
t
| takes massive trauma to disloc post
55
```
colle's fx
define
common demo
dx
tx
```
dorsally displaced radius/ulna fx
e.g. in old lady w osteoporosis
xr
cast vs operate
56
mechanism of monteggia fx other than fall
upper block
downward blow
(e.g. police baton)
57
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
58
anatomic snuffbox pain think
scaphoid fx
59
anatomic snuffbox pain, xr normal, next step?
cast and re xr for scaphoid fx in a few weeks...
60
boxer's fx
| define
fx of 5th (most common) and/or 4th metacarpal necks from punching
61
tf
| hip pain can present as referred knee pain
t
| so knee pain r/o hip path
62
hip fx mechanism
massive trauma
| or old lady w osteoporosis
63
anatomic change w hip fx
leg shortened
flexed adducted internal rotation if post disloc
flexed abducted external rotation if ant disloc
64
tx femoral head fx
likely to need arthroplasty (joint replacement) as avn likely...
65
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)
66
dx
tx
acl pcl inj
MRI
surg (athetes)
cast (everyone else)
67
mechanism of inj mcl vs lcl
valgus stress mcl inj
varus stress lcl inj
valGus is KnoCK Kneed
varus is wide kneed
68
valgus vs varus
valGus is KnoCK Kneed
| varus is wide kneed
69
dx
tx
mcl lcl inj
MRI
surg (athletes)
hinge cast (everyone else)
70
click on knee extension think
meniscal tear
71
dx
tx
stress fracture of shin
xr
| cast even if xr normal, get f/u xr fx will be present
72
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
73
tx ankle fracture
usually surg as difficult to cast... per meded...
74
pres
tx
achilles tendon rupture
pop while exercising
cast takes months to heal
surg takes weeks to heal
75
```
tx
femoral head fx
intertrochanteric hip fx
fem shaft fx
open fx
```
fem head prosthesis (avn)
intertroch plate
shaft rod
open emergency washout
76
most sensitive physical exam test for acl tear
lachman's
| basically anterior drawer but at 20 deg flexion not 90
77
lachman test
basically anterior drawer but at 20 deg flexion not 90
most sensitive physicalexam test for acl tear
78
why replace femoral head fx
because blood supply is so tenuous that plating will likely lead to avn if not already vascularly compromised
79
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
80
physical exam test for torn meniscus
mcmurray
| rotate while extending knee joint, click on extension
81
physical exam test for mcl tear
valgus stress test
82
physical exam test for lcl tear
varus stress test
83
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
```
84
most common fx in peds
supracondylar humerus fx
| supracondylar area remodeling -- small and weak
85
most common complications of supracondylar fracture
beachial artery inj
median nerve inj
both run along anterior midline of the area
86
which pulses to check after supracondylar fx
brachial a
radial a
(both compromised w brachial a inj)
87
check for complications after supracondylar fx
distal pulses (brachial, radial... possible brachial artery inj)
distal motor and sensory exam (possible median nerve inj)
88
treat supracondylar fx
analgesia
immobilization
ortho consult if displaced
89
prognosis of neurovascular injury after peds supracondylar fx
usually resolves after reduction of displaced fx
| brachial a, median n
90
fracture risk to axillary nerve
Proximal humerus fx
91
fx risk to brachial plexus
clavicle fx
92
incidence of compartment syndrome after supracondylar fx
rare v1%
| usually accompanied by forearm fx
93
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
94
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)
95
tf
| risk of neurovsscular inj w supracondylar fx is HIGH
t
96
when to assess radial and brachial pulses, sensory motor function after supracondylar fx
before AND after reduction
97
mechanism of median nerve and brachial artery injury in supracondylar fx
impingement
98
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
99
most common causes of syringomyelia
arnold chiari malformation
| prior spinal cord injury
100
incidence of syringomyelia after spinal cord injury
3-4%
| 2016 uworld
101
what region involved most commonly in syringomyelia from prior spinal cord inj
cervical
102
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)
103
classic mechanism of spinal cord injury leading to syringomyelia
cervical whiplash in mva
104
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
105
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
106
upper and lower motor neuron deficits w weakness twitching cramping think...
als
107
als sx
upper and lower motor neuron deficits w weakness twitching cramping
108
mechanism
demo
sx
cervical spondylosis
disk degeneration
pts over 40yo
neck pain stiffness
neurologic sx if spinal stenosis develops
109
define spondylosis
general term for pain from spinal degeneration
110
sx of disk herniation
unilateral radiculopathy (pain amd weakness) in distribution of single nerve (compressed nerve route)
111
tf
| nystagmus and scanning speech common in ms
t
112
how many lesions required to dx ms
two separate lesions
113
dx syringomyelia
mri
| enlargement of central canal due to csf retention
114
meniscal tear etiology
young pt rotational force on planted foot
old pt degeneration of meniscal cartilage
115
tf
| meniscus is ligamentous
f
| cartilagenous
116
radionucleotide bone scan used for...
infectious
inflammatory
malignant dz
can detect occult fractures too...
117
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
```
118
tf
| slow onset joint effusion is a presentation of meniscal tear
t
acute pop
locking catching rom dec
slow onset joint effusion
119
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
120
dx meniscal inj
provocative tests (mcmurray, thessaly)
mri
arthroscopy
121
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
122
muscles of the posterior upper leg
```
gluteus medius
gluteus maximus
semimembrinosus
semitendinosus
long head biceps femoris
short head biceps femoris
```
123
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
124
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
125
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
126
visualize anterior tendons of the knee
quadriceps tendon
patellar tendon
lateral and medial retinaculums
127
over 95% of total knee replacements in US are performed for ________
osteoarthritis
128
3 compartments of knee
lateral medial patellofemoral
129
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.
130
osteomyelitis is...
infection of bone and bone marrow
osteo bome
myelo marrow
itis infection
131
etiologies of osteomyelitis respective bugs
| tx
hematogenous
staph a abx
direct traumatic inoculation
polymicrobial surgical debridement
132
pmh in risk of osteomyelitis
dm
| pvd
133
define draining sinus tract in context of osteomyelitis
epithelialized tract that must be resected to resolve infection
134
labs to get for osteomyelitis
cbc crp esr blood cx
135
```
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
136
imaging findings in osteomyelitis
sequestrum (necrotic bone)
involucrum (new bone)
cloaca (drain)
sinus tract (epitheliazed drain to skin or another cavity)
137
most sn and sp imaging test for osteomyelitis
MRI
| CT best for imaging bone, MRI gets soft tissue sinus tract edema etc too
138
most common bugs in osteomyelitis
staph aureus
polymicrobial
pseudomonas
139
visualize the big arteries of the leg
```
femoral
popliteal
genicular arteries
posterior tibial
anterior tibial
(to dorsalis pedis)
peroneal
```
140
how to manage a sinus tract in osteomyelitis
must resect
otherwise will never resolve
141
visualize big veins of the leg
```
great saphenous
posterior tibial
anterior tibial
small saphenous
femoral
external iliac`
```
142
define phlegmon
spreading diffuse inflammatory process with pus... vs walled-off inflammatory mass without bacterial infection...
143
visualize big nerves of anterior leg
```
obturator
inferior gluteal
superior gluteal
femoral
common fibular (aka peroneal, from sciatic)
deep fibular
superficial fibular
```
144
define paprika sign
puctate cortical or cancellous bone bleeding, eg when debriding cortex in OM to find healthy bone that bleeds
145
total knee replacement failure rate due to infection
1%
146
how is chronic osteomyelitis like herpes
it keeps coming back...
| Delahey
147
visualize the big arteries of the leg
```
femoral
popliteal
posterior tibial
anterior tibial
(to dorsalis pedis)
peroneal
```
148
visualize big nerves of the posterior leg
```
superior gluteal
inferior gluteal
sciatic
(tibial, common fibular)
posterior femoral cutaneous
nerve to obturator internus
pudendal
```
149
Most common cause of aseptic knee replacement failure
patellofemoral maltracking
150
tinel sign
tap eg median nerve for carlal tunnel pain paresthesia
