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126 Cards in this Set
- Front
- Back
Iliopsoas: Origin, Insertion, Action, Innervation
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Origin: L1-L5 (psoas maj), Iliac crest (iliacus)
Insertion: Lesser trochanter Action: Hip flexion Innervation: Ventral rami L1, L2, L3 (femoral nerve) |
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Quads (***Rectus Femoris, Vastus lateralis, vastus intermedius, vastus medialis: Origin, Insertion, Action, Innervation
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Origin: ***AIIS (rectus), Linea aspera (lateralus and medialis), femur (intermedius)
Insertion: Tibial tuberosity Action: Knee Extension, ***hip flexion (rectus only) Innervation: Femoral (L2, L3, L4) |
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***Sartorius: Origin, Insertion, Action, Innervation
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Origin: ASIS
Insertion: pes anserine Action: Hip flexion, hip ext. rotation, knee flexion Innervation: Femoral nerve (L2, L3, L4) |
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Hamstrings (semimembranosus, semitendinosus, biceps femoris): Origin, Insertion, Action, Innervation
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Origin: Ischial tuberosity
Insertion: pes anserine (tendinosus), medial tibial condyle (membranosus), head of fibula (femoris) Action: Hip extension, knee flexion Innervation: Sciatic nerve, L5, S1, S2 |
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Gluteus maximus: origin, insertion, action, innervation
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Origin: sacrum and ilieum
Insertion: Gluteal line, IT band Action: Hip extensor (in hip flexion), hip abduction (upper fibers), hip adduction (lower fibers) Innervation: Inferior gluteal n. (L5-S2) |
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Gluteal medius/minimus: origin, insertion, action, innervation
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Origin: ilium
Insertion: greater trochanter Action: hip abduction Innervation: superior gluteal (L4-S1) |
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Gracilis: origin, insertion, action, innervation
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Origin: pubis
Insertion: pes anserine Action: hip adductor Innervation: obturator nerve (L2-L4) |
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Adductor longus/brevis/magnus: origin, insertion, action, innervation
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Origin: pubis (longus/brevis), ischium (magnus)
Insertion: linea aspera Action: hip adduction Innervation: obturator nerve (L2-L4) |
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Pectineus: origin, insertion, action, innervation
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Origin: pubis
Insertion: linea aspera Action: hip adduction/flexion/int rotation Innervation: femoral n., 20% obturator |
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Tensor Fasciae Lata: origin, insertion, action, innervation
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Origin: iliac crest
Insertion: IT band --> Gerdy's tuberacle, lateral aspect of proximal tibia Action: hip abduction/flexion/int rotation Innervation: superior gluteal |
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Piriformis, superior gemellus, inferior gemellus, obturator internus, obturator externus, quadratus femoris: origin, insertion, action, innervation
Hint: The trick is just remembering the origins |
Origin: sacrum (piriformis), ischium (sup/inf gemellus, quad. femoris), obturator foramen (obturator int/ext)
Insertion: greater trochanter Action: hip ext. rotation Innervation: For all EXCEPT obturator ext. - Ventral rami (L5-S2); post. branch of obturator n. (obturator ext.) |
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Name the hip flexors
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iliopsoas, rectus femoris, sartorius
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Name the hip extensors
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hamstrings (semitendinosus, semimembranosus, biceps femoris), gluteus maximus
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Name the hip adductors
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gracilis, adductor longus, adductor brevis, adductor magnus, pectineus
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Name the hip abductors
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gluteus max/med/min, tensor fasciae lata
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Trendelenburg's Sign is caused by weakness of the ________.
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Hip abductors (Dr. Matt Seeley, BYU, and Dr. Rike Mitchell, BYU, taught me that it was mostly due to the gluteus medius)
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What is unique about the origin of the obturator externus?
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Originates on the anterior aspect of the pelvis (obturator foramen on the pubic/ischium bone)
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What is the primary hip INTERNAL rotator?
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TRICK QUESTION! Some say there is no "primary" muscle. It's a secondary function of several muscles.
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Main artery supplying blood to the neck/head of the femur
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medial circumflex femoral artery
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What makes up the border of the femoral triangle? What is contained within the triangle?
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Borders: inguinal ligament, sartorius muscle, adductor longus muscle
Contents: (NAVL) femoral nerve, femoral artery, femoral vein, femoral lymphatics |
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Non-operative Tx of muscle tears
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Physical Therapy
NSAIDs Injections |
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Operative Tx of muscle tears
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Debridement
Repair |
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Describe and Tx: Greater trochanteric pain syndrome
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- bursa around the greater trochanter becomes inflammed and irritated/tender by mechanical stress
- injections, PT, bursectomy |
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Describe and Tx: External Snapping Hip
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- Audible popping sound on lateral hip
- thickened/tight IT band (or anterior gluteus max. fibers) moving over the greater trochanter (GT) - Slips over GT anteriorly when flexed, posteriorly when extended - possible (+) Ober's test - Activity modification, IT stretching, injections, surgical release |
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Describe and Tx: Internal snapping hip
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- due to iliopsoas coursing over bony prominances: pelvic brim, femoral head, lesser trochanter
- NSAIDs, physcial therapy, surgical release |
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Describe and Tx: meralgia paresthetica
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- pain, numbness, tingling over anterolateral thigh
- tender over inguinal ligament by ASIS - symptoms with hip extension - correct underlying disorder, NSAIDs (non-operative Tx successful in 25-91% of patients). . . surgery as a solution isn't that great (recurrent Sx, sensory loss) |
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Who gets meralgia paresthetica
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- thin, young, athletic
- obese, pregnant, any other increases in intra-abdominal pressure - construction workers - tight pants, belts |
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piriformis syndrome
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- sciatic nerve passing under piriformis m. gets compressed
- low back, butt post. thigh pain, worse with sitting, squatting, stairs - cyclist, runners - NSAIDs, PT, injections, surgical release of piriformis (rare) |
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hamstring avulsion/tear
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- result of quick +/- acceleration (like in water skiing)
- Pt. will feel a "pop" - ecchymosis, ischial tuberosity tenderness - non-operative Tx, return to sports in 4-6 weeks |
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slipped capital femoral epiphysis
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- epiphysis slips upon the metaphysis of the femur
- seen in obese kids due to excess shear forces from extra weight, 10-17 y/o - STABLE classification: can walk with or w/o crutches - UNSTABLE classification: can't even limp or bear any weight (worse prognosis), usually severe and suddent onset of pain |
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three histologic zones of epiphysis (bone)
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- Reserve: little Ca
- Proliferative: high O2, glycogen (aerobic metabolism) - Hypertrophic: cell death, release Ca |
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Legg-Calve-Perthes Disease
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- skeletally immature patients
- necrosis of femur head (idiopathic...patients just suddenly lose blood supply to femur head/neck.) - conservative Tx works well (for >50% of patients) . . . keep the hip "contained" - if age >8 y/o, poor prognosis |
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Infantile hip dysplasia (developmental dysplasia of the hip, DDH)
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- displacement of femur head and acetabulum, causing abnormal hip development
- Seen in: left hip, females (5:1), breech delivery, first born, (+) family Hx, caucasion and Navajo - recognize/screen early (Barlow's, Ortolani's, and "Galeazzi's sign" screening exams) - "containment" of hip joints during treatment (casting, open/closed reduction, brace, etc...) |
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adult hip dysplasia
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- Shallow acetabulum --> reduced contact area --> overload of anterosuperior joint surface --> cartilage breakdown
- surgery only if symptomatic |
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Femoroacetabular impingement
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- ball and socket don't fit appropriately
- CAM type: aspherical femoral head, the head/neck bumps into acetabulum causing pain - PINCER type: aspherical acetabulum, extra bone on rim of acetabulum bumps into femur head/neck causing pain - non surgical Tx: activity modification, NSAIDs, ice, PT (stretching may worsen Sx) - surgical Tx: grind down the extra bone |
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Between CAM and PINCER impingement, what is more common
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Trick Question - it's "mixed." There will usually be a little of both seen in the presenting patient.
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Avulsion fracture
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pretty much anywhere there is an origin or insertion, your muscle can rip off a piece of its origin/insertion
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Stress fracture: types and common sites
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- fatigue fractures: normal bone, abnormal stresses
- insufficiency fractures: abnormal bone, normal stresses - common sites of fractures: femoral neck, sacrum, pubic rami, acetabulum, femoral head |
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Classic descriptions of stress fractures
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- Female Triad: eating disorder, amennorhea, osteoporosis
- Military recruits |
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Stress fractures risk factors (hey that rhymes)
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- smoking
- sudden increase in activity level - steroid use |
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Stress fractures: tension-sided vs. compression-sided
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- tension-sided = superior neck
- compression-sided = inferior neck |
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Stress fractures Tx
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- restriction on weight bearing
- surgical pinning (tension injuries, >50% neck width) |
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Orthopaedics practice characteristics (kind of patients they work on, etiologies, illness severities, working location)
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all of the above - they work on everyone, everything, and everywhere.
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Major advances in orthopedic surgery in the last 50 years
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- total joint technology
- microsurgery - arthroscopy - internal fixation of fractures - limb salvage - bone/soft tissue lengthening apparatus |
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Ligaments consist mostly of _____
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type 1 collagen (80%-90%)
Note: 10-20% type III collagen |
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Function of the ACL
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prevent anterior sliding of the tibia upon the femur
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Function of the PCL
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prevent posterior sliding of the tivia upon the femur
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Taking a hit to the medial side of the knee and bending it laterally (abnormally) is which type of stress? (valgus/varus)
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varus stress
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primary ligamentous restraint to varus stress (hint: it's probably the MCL or the LCL, think about it)
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LCL
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are the menisci in your knees vascularized?
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Yes, but only in the periphery, thus, injuries on the outside heal better.
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Vascularization of the leg - start with abdominal aorta, and name the main branches going down the leg.
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abdominal aorta, common iliac, external iliac, femoral (deep femoral branches off higher up), popliteal (femoral changes name in popliteal fossa), and finally posterior/anterior tibial
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The purpose of the patella
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It's all about physics! It increases the mechanical advantage of extensor muscles (via transmitting forces greater distances and increasing functional lever arm of the quad).
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The etiology of patellofemoral pain syndrome
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The patella is abnormally tracking/sliding across the femur (patellar tracking theory).
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***General causes of patellar tracking problems and patellofemoral pain syndrome
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1 - overload (most common)
2 - malalignment 3 - trauma |
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Term used for a patella that's too high/low
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patella alta/baja (respectively high/low)
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The muscles (and their innervation) of the pes anserine
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HINT: SGT. FOT ("Sargent fought") = sartorius/femoral, gracilis/obturator, semiTendinosus/tibial
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Name the knee extensors and their vascular supply
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muscles: rectus femoris, vastus lateralis/medialis/intermedius
vascular supply: femoral a. (everything but medialis = LCFA; medialis = profundia femoris) |
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Name the knee flexors
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sartorius, semimembranosus, semitendinosus, biceps femoris, popliteus, gastrocnemius, plantaris
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The muscle innervated by the common peroneal nerve
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SHORT head of the biceps femoris
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T or F: The ACL is composed of 2 bundles.
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True - the "anterior-medial" (small) and the "posterior-lateral" (large)
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Which ligament is more important in regards to knee stability: The ACL or PCL
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ACL
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T or F: The PCL is smaller than the ACL
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False - it's twice as large
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Hyline cartilage consists mostly which type of collagen
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Type II
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The menisci in your knee consist mostly of which type of collagen
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Type 1 (98%)
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The "category" (for lack of a better word) of cartilage the discs your menisci made of
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fibrocartilage
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Palletofemoral pain syndrome: Describe
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- insidious onset, anterior knee pain
- not localized to a single point (as meniscus pain would) -- Circle or U-Sign (patient will say "it hurts around here" as they trace the shape w/ finger) - Stiff - No locking (occasion "pop," "grind," or "catch") - No swelling - Normal physical exam |
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***T or F: The actual source of the pain in patellofemoral pain is the articular cartilage
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False; however, we don't really know what it is. (Bone, skin, muscle, nerve, retinaculum?)
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Risks of overload contributing to patellofemoral pain syndrome
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- BMI > 25
- training volume - prior exercise history - competition training |
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Describe the two main categories of malalignment (which contributes to patellofemoral pain syndrome)
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- Patella displacement (the train is pulled off of the track): Patella pulled off track by unequal forces of muscle (VM, VL) and non-muscle (misshapen trochlea, IT band, retinaculum issue, Q-angle) structures.
- Internal femoral rotation (the tracks are pulled our from underneath the train): femurs int. rotated - toes may even be pointing forward. Weak ext. rotators and abductors? |
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When to get imaging for patellofemoral pain syndrome
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- Age >50 y/o
- Acute injury - It's not getting better |
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***T or F: the most common (and successful) type of treatment for patellofemoral pain is non-operative
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true - typically see a 68-87% improvement.
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***non-operative Tx for patellofemoral pain usually includes
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- reduce pain (rest, ice, and maybe NSAIDs). There are arguments against efficacy of NSAIDs.
***- correcting the underlying biomechanical problem, typically with PT. (e.g. strengthening, stretching, taping, bracing, etc) |
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Poor prognostic factors of patellofemoral pain
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- crepitation (audible joint noises during joint use)
- bilateral symptoms - old age |
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Who I should seriously consider referring my patient to if they have patellofemoral pain
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physical therapist
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***most common cause of anterior knee pain
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patellofemoral pain syndrome
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T or F: Numbness of the sole of the foot is an indication for amputation
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FALSE (from trauma lecture, and its associated lecture)
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T or F: A variable to take into consideration of a possible amputee should be how well that person could cope with an amputation.
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True. "...a patient’s degree of ‘‘self-efficacy’’ (ie, how well they believe that they can handle change and maximize their future potential) may be the single greatest determining factor studied [which may predict patient outcomes]."
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From reading for trauma lecture: What did the LEAP study give us
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Offers a "wide variety of preinjury, injury, treatment, and outcome variables to examine lower extremity injuries [and] . . . give enhanced insight into the factors that drive measurable outcomes."
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From reading for trauma lecture: What is a "MESS" score and what does it take into account?
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- Mangled Extremity Severity Score = a score greater-than or equal-to 7 is an indication for amputation.
- Score takes into account skeletal/soft tissue injury, limb ischemia, shock, and patient age. |
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Orthopaedics-Specific History:
Pre-injury Variables |
•Pre-injury ambulatory status
•Pre-injury musculoskeletal complaints •Livelihood, demands of job, hobbies •Handedness (spine or UE injury) •Tetanus status •Smoking, diabetes |
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Orthopaedics-Specific History:
Injury Variables |
•Exact time of injury
•Mechanism of injury (indicator of “energy transfer”) •Syncope, head impact, Loss of consciousness •Environment in which injured (especially open fx) •Other traumatic complaints •Subjective motor / sensory deficits |
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Orthopaedic Exam
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•Skin (open/closed wounds, eccymosis, edema)
•Skeletal stability •Joint Motion •Nerve – Motor AND Sensory •Blood Supply (like capillary refill) |
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open vs closed fracture
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- open: bone sticking out of skin
- closed: bones within skin |
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displaced vs non-displaced fracture
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- non-displaced: this could be like a hairline fracture, where the bones are still set in place where they should be.
- displaced: the opposite |
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simple vs segmental vs comminuted fractures
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simple: a single break
segmental: two breaks in a bone, with a "loose" piece in the middle comminuted: bone is splintered or crushed |
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What is ATLS and how did it get started (why)?
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- ATLS = adv. trauma life support
- Started by a Dr. whose family was in an accident and got split up to different centers. He noticed the centers with more trauma experience had better outcomes. He wanted to make a program (ATLS) to provide better trauma care and outcomes. |
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Three ways ATLS decreased morbidity ("The ATLS concept")
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1 - early intervention (speed saves)
2 - team approach (simultaneous work) 3 - dedicated systems (repetition breeds excellence) |
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Differential Dx for shock in trauma
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- hypovolemia
- neurogenic - cardiogenic |
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6 places INTO which you may bleed
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1 - head/neck
2 - chest 3 - abdomen 4 - pelvis 5 - extremities 6 - environment |
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The 4 places into which you may bleed OUT (dead)
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1 - chest
2 - abdomen 3 - pelvis 4 - environment |
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The orthopedic's role in ATLS
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better long-term outcomes (i.e. 6 months from now, what will be this patient's chief complaint?)
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It's better to be upright than prone/supine, so what are the disadvantages of lying supine and immobile?
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- pulmonary health
- venous thrombus (pulm. embolus) - soft tissue breakdown (bed sores) - muscle atrophy (longer rehab) - loss of ultimate potential R.O.M. |
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Orthopaedic Emergencies
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•Unstable pelvic ring fracture
•Open fracture (infection - debridement is critical, antibiotic prophylaxis) •Dysvascular limb / Mangled extremity •Septic joint •Knee / Hip dislocation •Compartment syndrome •Spinal injury / Cauda equina |
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nerve at risk of getting injured with a hip dislocation?
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sciatic
Note: there is also a risk of avascular necrosis to the femoral head - this demands prompt reduction and post-reduction CT |
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***Compartment Syndrome: Describe
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• Hx of crush, ischemia, entrapment, high energy fracture
• Injury leads to local release of cytokines and inflammatory mediators • Local pressure rises to exceed tissue perfusion pressure (usually from swelling in a non-distensible anatomical location) • Most common in the leg, can happen in any closed body compartment |
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***Compartment Syndrome: The 5 P's
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• Pain out of proportion
• Pain on passive strech • Parasthesias • Pallor • Puselessness Note: The last three are especially bad signs |
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Composition of ligaments
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- fibroblasts = 20% (notice sparse cellularity)
- extracellular matrix = 80% |
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***Name the tests to do to test the following ligaments: ACL, PCL, MCL, LCL
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ACL = Lachmann's Test
PCL = posterior drawer MCL = Valgas stress to knee joint @ 30 degrees LCL = Varus stress to knee joint @ 30 degrees NOTE: Test varus/valgus stress at full ext. too. If that is abnormal, there's a cruciate injury too. |
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T or F: Gross instability of the knee joint could indicate surgical intervention.
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True
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Meniscal injury: Location of tearing in the majority of acute vs chronic cases
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Acute: Lateral > Medial
Chronic: Medial > Lateral Hint: Remember "chronic conditions eat at you from the INSIDE out (medial > lateral)" |
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Acute ACL Treatment – Isolated injury
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- Crutches for comfort
- No real need for immobilizer - ICE - NSAIDS - Begin weight bearing when comfortable - Begin Range of Motion |
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Describe PCL Injury grading system
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Grade 1 - anterior to tibia
Grade 2 - flush with tibia Grade 3 - posterior to tibia Note: By definition, it's impossible to have a gr. 3 PCL injury in isolation |
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In isolated PCL injury and rehab, what group of muscles should you avoid working early on?
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the hamstrings
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Shape: Medial Meniscus vs Lateral Meniscus
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Medial: crescent
Lateral: circular |
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Capsule attachment (loose/firm): Medial meniscus vs Lateral meniscus
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Medial: firm
Lateral: loose |
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Functions of the meniscus
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- shock absorption (axial load to horiz. stress, only half stiff as articular cartilage)
- bridging anatomical gap (joining flat and curved surfaces) - "passive stability" (helps the ACL) - lube/nutrition (shifts synovial fluid during motion) |
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menisci tear patterns
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- bucket handle (look for double PCL on MRI from the "handle" flipping up)
- oblique ("flap" or "parrot beak") - radial transverse (tearing straight away from center) - horizontal (tear runs inside - "longways" - along the meniscus) - complex degenerative |
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The menisci is mostly made of
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Type 1 collagen (75%) and water (75% of the extra cellular matrix)...then there's some elastin in there and other stuff too.
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Menisci injury: onset, mechanism, pain presentation, mechanical Sx,
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Onset: swelling over days (as opposed to bleeding into a joint), acute = young, chronic = old
Mechanism: twist, hyperflex Pain: constant/intermittant, side of knee or posterior Mech. Sx: popping, locking, catching |
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Menisci injury, PE findings: inpsection, palpation, ROM, strength, sensation, reflexes
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inspection: effusion, poss. quad atrophy
palpation: effusion, joint line tenderness ROM: reduced, painful upon flex/ext Strength/Sense/Reflex: Normal |
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Special tests for meniscus
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- joint line tenderness (palpate joint for tenderness)
- McMurray's test (+ if click(s) present) - Apley grind test (reversed McMurray's, patient prone, flex knee, grind menisci, distracting joint alleviates pain) - Bounce home test (hold heel and knee slightly bend, let go of knee. Pain?) |
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Grading for menisci tears on MRI
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0 = normal
1 = irregular increase in signal 2 = linear increase in signal 3 = abnormal signal increase extends to meniscal surface |
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Menisci injury: Non-operative Tx options - what are they and who are they for?
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- Activity modification
- Rahab - NSAIDs/Corticosteroid injection - less-active patients and/or minor Sx and/or significant arthritis |
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Menisci injury: surgical Tx options
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- remove small pieces if tear is inside
- repair and allow to heal tears on outside |
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partial/total menisectomy leads to...
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early arthritis
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Exercise vs Physical Activity
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Exercise: planned, structured, goal-oriented
Physical Activity: LIFE, housework, work-work, lifestyle |
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Ingredients for success in physical activity counseling
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Tools: screen patients for "sedentarism"
Systems: treat physical activity data for a patient as one of their vital signs Education: providers and patients Culture Change: providers and patients |
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Screening Tool: Physical Activity Vital Sign (PAVS)
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Two questions:
1 - how many days in the past week have you participated in physical activity where heart/breathing were faster/harder than normal? 2 - How many days in a typical week you participate in activity like this? |
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5 levels in the process of patient-centered education and counseling
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1.Cognitive (knowledge, awareness)
2.Attitudinal (beliefs, intentions) 3.Instrumental skills 4.Behavioral (coping actions) 5.Social (social support) |
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The Stages of Change
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• Precontemplation
–No exercise, and not even thinking about it • Contemplation –No exercise, but thinking about it now and then • Preparation –Irregular participation in exercise • Action –Regular exercise for < 6 months • Maintenance –Regular exercise for >6 months |
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The 5 A's of counseling in change
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Ask - address their agenda for change
Advise - provide personalized info ***Assess - identify the patient's barriers Assist - strategy to overcome barriers Arrange - arrange follow-up times |
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Common barriers to exercise
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- Environmental (not close to gym, not safe, etc)
- Social (support) - Attitude - Physical - Caregivier (because I'm too busy being one) |
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T or F: Resistance training is important to include in an exercise program - just like cardio exercises
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True
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T or F: Time spent sitting is independently associated with total mortality, regardless of physical activity level
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True - 30 minutes of running cannot undo 6-8 hours of sitting
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Max HR vs Exercising HR
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Max HR = 220 - age
Exer HR = (MaxHR)(X) Note: X represents number between .55 and .90 (.55>x>.90) |
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Structures involved in the "terrible/unhappy triad" (aka "blown knee")
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1 - ACL
2 - Medial meniscus 3 - MCL |