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126 Cards in this Set

  • Front
  • Back
Iliopsoas: Origin, Insertion, Action, Innervation
Origin: L1-L5 (psoas maj), Iliac crest (iliacus)
Insertion: Lesser trochanter
Action: Hip flexion
Innervation: Ventral rami L1, L2, L3 (femoral nerve)
Quads (***Rectus Femoris, Vastus lateralis, vastus intermedius, vastus medialis: Origin, Insertion, Action, Innervation
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)
***Sartorius: Origin, Insertion, Action, Innervation
Origin: ASIS
Insertion: pes anserine
Action: Hip flexion, hip ext. rotation, knee flexion
Innervation: Femoral nerve (L2, L3, L4)
Hamstrings (semimembranosus, semitendinosus, biceps femoris): Origin, Insertion, Action, Innervation
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
Gluteus maximus: origin, insertion, action, innervation
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)
Gluteal medius/minimus: origin, insertion, action, innervation
Origin: ilium
Insertion: greater trochanter
Action: hip abduction
Innervation: superior gluteal (L4-S1)
Gracilis: origin, insertion, action, innervation
Origin: pubis
Insertion: pes anserine
Action: hip adductor
Innervation: obturator nerve (L2-L4)
Adductor longus/brevis/magnus: origin, insertion, action, innervation
Origin: pubis (longus/brevis), ischium (magnus)
Insertion: linea aspera
Action: hip adduction
Innervation: obturator nerve (L2-L4)
Pectineus: origin, insertion, action, innervation
Origin: pubis
Insertion: linea aspera
Action: hip adduction/flexion/int rotation
Innervation: femoral n., 20% obturator
Tensor Fasciae Lata: origin, insertion, action, innervation
Origin: iliac crest
Insertion: IT band --> Gerdy's tuberacle, lateral aspect of proximal tibia
Action: hip abduction/flexion/int rotation
Innervation: superior gluteal
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.)
Name the hip flexors
iliopsoas, rectus femoris, sartorius
Name the hip extensors
hamstrings (semitendinosus, semimembranosus, biceps femoris), gluteus maximus
Name the hip adductors
gracilis, adductor longus, adductor brevis, adductor magnus, pectineus
Name the hip abductors
gluteus max/med/min, tensor fasciae lata
Trendelenburg's Sign is caused by weakness of the ________.
Hip abductors (Dr. Matt Seeley, BYU, and Dr. Rike Mitchell, BYU, taught me that it was mostly due to the gluteus medius)
What is unique about the origin of the obturator externus?
Originates on the anterior aspect of the pelvis (obturator foramen on the pubic/ischium bone)
What is the primary hip INTERNAL rotator?
TRICK QUESTION! Some say there is no "primary" muscle. It's a secondary function of several muscles.
Main artery supplying blood to the neck/head of the femur
medial circumflex femoral artery
What makes up the border of the femoral triangle? What is contained within the triangle?
Borders: inguinal ligament, sartorius muscle, adductor longus muscle
Contents: (NAVL) femoral nerve, femoral artery, femoral vein, femoral lymphatics
Non-operative Tx of muscle tears
Physical Therapy
NSAIDs
Injections
Operative Tx of muscle tears
Debridement
Repair
Describe and Tx: Greater trochanteric pain syndrome
- bursa around the greater trochanter becomes inflammed and irritated/tender by mechanical stress
- injections, PT, bursectomy
Describe and Tx: External Snapping Hip
- 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
Describe and Tx: Internal snapping hip
- due to iliopsoas coursing over bony prominances: pelvic brim, femoral head, lesser trochanter
- NSAIDs, physcial therapy, surgical release
Describe and Tx: meralgia paresthetica
- 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)
Who gets meralgia paresthetica
- thin, young, athletic
- obese, pregnant, any other increases in intra-abdominal pressure
- construction workers
- tight pants, belts
piriformis syndrome
- 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)
hamstring avulsion/tear
- 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
slipped capital femoral epiphysis
- 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
three histologic zones of epiphysis (bone)
- Reserve: little Ca
- Proliferative: high O2, glycogen (aerobic metabolism)
- Hypertrophic: cell death, release Ca
Legg-Calve-Perthes Disease
- 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
Infantile hip dysplasia (developmental dysplasia of the hip, DDH)
- 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...)
adult hip dysplasia
- Shallow acetabulum --> reduced contact area --> overload of anterosuperior joint surface --> cartilage breakdown
- surgery only if symptomatic
Femoroacetabular impingement
- 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
Between CAM and PINCER impingement, what is more common
Trick Question - it's "mixed." There will usually be a little of both seen in the presenting patient.
Avulsion fracture
pretty much anywhere there is an origin or insertion, your muscle can rip off a piece of its origin/insertion
Stress fracture: types and common sites
- fatigue fractures: normal bone, abnormal stresses
- insufficiency fractures: abnormal bone, normal stresses
- common sites of fractures: femoral neck, sacrum, pubic rami, acetabulum, femoral head
Classic descriptions of stress fractures
- Female Triad: eating disorder, amennorhea, osteoporosis
- Military recruits
Stress fractures risk factors (hey that rhymes)
- smoking
- sudden increase in activity level
- steroid use
Stress fractures: tension-sided vs. compression-sided
- tension-sided = superior neck
- compression-sided = inferior neck
Stress fractures Tx
- restriction on weight bearing
- surgical pinning (tension injuries, >50% neck width)
Orthopaedics practice characteristics (kind of patients they work on, etiologies, illness severities, working location)
all of the above - they work on everyone, everything, and everywhere.
Major advances in orthopedic surgery in the last 50 years
- total joint technology
- microsurgery
- arthroscopy
- internal fixation of fractures
- limb salvage
- bone/soft tissue lengthening apparatus
Ligaments consist mostly of _____
type 1 collagen (80%-90%)

Note: 10-20% type III collagen
Function of the ACL
prevent anterior sliding of the tibia upon the femur
Function of the PCL
prevent posterior sliding of the tivia upon the femur
Taking a hit to the medial side of the knee and bending it laterally (abnormally) is which type of stress? (valgus/varus)
varus stress
primary ligamentous restraint to varus stress (hint: it's probably the MCL or the LCL, think about it)
LCL
are the menisci in your knees vascularized?
Yes, but only in the periphery, thus, injuries on the outside heal better.
Vascularization of the leg - start with abdominal aorta, and name the main branches going down the leg.
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
The purpose of the patella
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).
The etiology of patellofemoral pain syndrome
The patella is abnormally tracking/sliding across the femur (patellar tracking theory).
***General causes of patellar tracking problems and patellofemoral pain syndrome
1 - overload (most common)
2 - malalignment
3 - trauma
Term used for a patella that's too high/low
patella alta/baja (respectively high/low)
The muscles (and their innervation) of the pes anserine
HINT: SGT. FOT ("Sargent fought") = sartorius/femoral, gracilis/obturator, semiTendinosus/tibial
Name the knee extensors and their vascular supply
muscles: rectus femoris, vastus lateralis/medialis/intermedius
vascular supply: femoral a. (everything but medialis = LCFA; medialis = profundia femoris)
Name the knee flexors
sartorius, semimembranosus, semitendinosus, biceps femoris, popliteus, gastrocnemius, plantaris
The muscle innervated by the common peroneal nerve
SHORT head of the biceps femoris
T or F: The ACL is composed of 2 bundles.
True - the "anterior-medial" (small) and the "posterior-lateral" (large)
Which ligament is more important in regards to knee stability: The ACL or PCL
ACL
T or F: The PCL is smaller than the ACL
False - it's twice as large
Hyline cartilage consists mostly which type of collagen
Type II
The menisci in your knee consist mostly of which type of collagen
Type 1 (98%)
The "category" (for lack of a better word) of cartilage the discs your menisci made of
fibrocartilage
Palletofemoral pain syndrome: Describe
- 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
***T or F: The actual source of the pain in patellofemoral pain is the articular cartilage
False; however, we don't really know what it is. (Bone, skin, muscle, nerve, retinaculum?)
Risks of overload contributing to patellofemoral pain syndrome
- BMI > 25
- training volume
- prior exercise history
- competition training
Describe the two main categories of malalignment (which contributes to patellofemoral pain syndrome)
- 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?
When to get imaging for patellofemoral pain syndrome
- Age >50 y/o
- Acute injury
- It's not getting better
***T or F: the most common (and successful) type of treatment for patellofemoral pain is non-operative
true - typically see a 68-87% improvement.
***non-operative Tx for patellofemoral pain usually includes
- 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)
Poor prognostic factors of patellofemoral pain
- crepitation (audible joint noises during joint use)
- bilateral symptoms
- old age
Who I should seriously consider referring my patient to if they have patellofemoral pain
physical therapist
***most common cause of anterior knee pain
patellofemoral pain syndrome
T or F: Numbness of the sole of the foot is an indication for amputation
FALSE (from trauma lecture, and its associated lecture)
T or F: A variable to take into consideration of a possible amputee should be how well that person could cope with an amputation.
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]."
From reading for trauma lecture: What did the LEAP study give us
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."
From reading for trauma lecture: What is a "MESS" score and what does it take into account?
- 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.
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
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
Orthopaedic Exam
•Skin (open/closed wounds, eccymosis, edema)
•Skeletal stability
•Joint Motion
•Nerve
– Motor AND Sensory
•Blood Supply (like capillary refill)
open vs closed fracture
- open: bone sticking out of skin
- closed: bones within skin
displaced vs non-displaced fracture
- non-displaced: this could be like a hairline fracture, where the bones are still set in place where they should be.
- displaced: the opposite
simple vs segmental vs comminuted fractures
simple: a single break
segmental: two breaks in a bone, with a "loose" piece in the middle
comminuted: bone is splintered or crushed
What is ATLS and how did it get started (why)?
- 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.
Three ways ATLS decreased morbidity ("The ATLS concept")
1 - early intervention (speed saves)
2 - team approach (simultaneous work)
3 - dedicated systems (repetition breeds excellence)
Differential Dx for shock in trauma
- hypovolemia
- neurogenic
- cardiogenic
6 places INTO which you may bleed
1 - head/neck
2 - chest
3 - abdomen
4 - pelvis
5 - extremities
6 - environment
The 4 places into which you may bleed OUT (dead)
1 - chest
2 - abdomen
3 - pelvis
4 - environment
The orthopedic's role in ATLS
better long-term outcomes (i.e. 6 months from now, what will be this patient's chief complaint?)
It's better to be upright than prone/supine, so what are the disadvantages of lying supine and immobile?
- pulmonary health
- venous thrombus (pulm. embolus)
- soft tissue breakdown (bed sores)
- muscle atrophy (longer rehab)
- loss of ultimate potential R.O.M.
Orthopaedic Emergencies
•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
nerve at risk of getting injured with a hip dislocation?
sciatic

Note: there is also a risk of avascular necrosis to the femoral head - this demands prompt reduction and post-reduction CT
***Compartment Syndrome: Describe
• 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
***Compartment Syndrome: The 5 P's
• Pain out of proportion
• Pain on passive strech
• Parasthesias
• Pallor
• Puselessness

Note: The last three are especially bad signs
Composition of ligaments
- fibroblasts = 20% (notice sparse cellularity)
- extracellular matrix = 80%
***Name the tests to do to test the following ligaments: ACL, PCL, MCL, LCL
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.
T or F: Gross instability of the knee joint could indicate surgical intervention.
True
Meniscal injury: Location of tearing in the majority of acute vs chronic cases
Acute: Lateral > Medial
Chronic: Medial > Lateral

Hint: Remember "chronic conditions eat at you from the INSIDE out (medial > lateral)"
Acute ACL Treatment – Isolated injury
- Crutches for comfort
- No real need for immobilizer
- ICE
- NSAIDS
- Begin weight bearing when comfortable
- Begin Range of Motion
Describe PCL Injury grading system
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
In isolated PCL injury and rehab, what group of muscles should you avoid working early on?
the hamstrings
Shape: Medial Meniscus vs Lateral Meniscus
Medial: crescent
Lateral: circular
Capsule attachment (loose/firm): Medial meniscus vs Lateral meniscus
Medial: firm
Lateral: loose
Functions of the meniscus
- 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)
menisci tear patterns
- 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
The menisci is mostly made of
Type 1 collagen (75%) and water (75% of the extra cellular matrix)...then there's some elastin in there and other stuff too.
Menisci injury: onset, mechanism, pain presentation, mechanical Sx,
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
Menisci injury, PE findings: inpsection, palpation, ROM, strength, sensation, reflexes
inspection: effusion, poss. quad atrophy
palpation: effusion, joint line tenderness
ROM: reduced, painful upon flex/ext
Strength/Sense/Reflex: Normal
Special tests for meniscus
- 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?)
Grading for menisci tears on MRI
0 = normal
1 = irregular increase in signal
2 = linear increase in signal
3 = abnormal signal increase extends to meniscal surface
Menisci injury: Non-operative Tx options - what are they and who are they for?
- Activity modification
- Rahab
- NSAIDs/Corticosteroid injection
- less-active patients and/or minor Sx and/or significant arthritis
Menisci injury: surgical Tx options
- remove small pieces if tear is inside
- repair and allow to heal tears on outside
partial/total menisectomy leads to...
early arthritis
Exercise vs Physical Activity
Exercise: planned, structured, goal-oriented
Physical Activity: LIFE, housework, work-work, lifestyle
Ingredients for success in physical activity counseling
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
Screening Tool: Physical Activity Vital Sign (PAVS)
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?
5 levels in the process of patient-centered education and counseling
1.Cognitive (knowledge, awareness)
2.Attitudinal (beliefs, intentions)
3.Instrumental skills
4.Behavioral (coping actions)
5.Social (social support)
The Stages of Change
• 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
The 5 A's of counseling in change
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
Common barriers to exercise
- Environmental (not close to gym, not safe, etc)
- Social (support)
- Attitude
- Physical
- Caregivier (because I'm too busy being one)
T or F: Resistance training is important to include in an exercise program - just like cardio exercises
True
T or F: Time spent sitting is independently associated with total mortality, regardless of physical activity level
True - 30 minutes of running cannot undo 6-8 hours of sitting
Max HR vs Exercising HR
Max HR = 220 - age
Exer HR = (MaxHR)(X)

Note: X represents number between .55 and .90 (.55>x>.90)
Structures involved in the "terrible/unhappy triad" (aka "blown knee")
1 - ACL
2 - Medial meniscus
3 - MCL