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119 Cards in this Set
- Front
- Back
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Triad for ACL tear
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ACL
MCL medial meniscus |
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ACL tear presentation
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noncontrast pivoting injury
a "pop" felt by the patient acute knee swelling (hemarthrosis) -females are 8x > males |
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exams for ACL tear
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lachman's test (most sensitive for acute injury)
Pivot shift test (sensitive test under anesthesia) |
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Treatment for ACL tear
-non operative and operative |
non operative:
-PT, quad rehab, bracing (you need ACL for football, soccer basketball) Operative: (esp in pt < 30) -in younger, if untreated --> future DJD -arthroscopically assisted ACL reconstruction -Patellar tendon or hanging graft (reconstruct ACL) -may use allograft (risk ok dz transmission) |
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Achilles tendonitis
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cumulative impact loading & repetitive microtrauma to tendon
-common in runners -post ankle pain reproducible w/palpation & stretching of tendon -soft tissue swelling or crepitus |
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Tx for achilles tendonitis
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NSAIDs
heel lift PT for strengthening, stretching exercises, modalities immobilization in cast, splint, brace (7-10 days for severe sympto cases) |
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do you inject tendon sheath for treatment of achilles tendonitis?
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NO,
-it will lead to rupture |
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Achilles tendon rupture etiology
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continuum of chronic tendinitis
result of acute traumatic injury |
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How do pt present with achilles tendon rupture?
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history of sudden snap in post ankle region w/acute onset of pain & swelling
(common in basketball & racket sport players) -history of sensation being shot or kicked in back of leg |
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what test do you perform and what do you find in PE with achilles tendon rupture?
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Thompson's test: no plantar flexion w/calf squeeze is positive test
PE finds palpable defect of the Achilles tendon |
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bunion etiology
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hereditary
secondary to pes planus (flatfoot) long first metatarsal MC females tight toe box shoes |
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What is a bunion?
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hallus valgus
deformity at first MTP joint w/lateral deviation great toe & large medial prominence at 1st metatarsal head |
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diag for bunion?
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inc hallus valgus angle (nl = 15 deg)
inc inter-metatarsal angle (nl < or = 9 deg) |
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non op and op tx for bunions
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non op: shoe modification to relieve pressure over medial prominence
Op: many types of operative corrections depending on severity of deformity |
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where is MC place for ingrown toenail?
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great toe, due to poor nail care or pincer nail
(wearing tight box shoes causes nail to have enlarged arch |
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tx for ingrown toenails
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warm soaks
elevation of nail edge remove part of nail (may reoccur as it grows out) |
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what is RSD?
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reflex sympathetic dystrophy of complex regional pain syndrome
(CRPS) |
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complex regional pain syndrome
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spectrum of conditions that have common dysfunction & pain that is out of proportion
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What are the 2 types of CRPS?
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type 1: RSD syndrome
-pain that extends beyond area supplied by periphearl nerve & out or proportion to inciting event Type 2: causalgia -similar to type 1 in all aspects but follows nerve injury |
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what fracture is MC injury that precipitates RSD
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distal radius fracture
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Who is most at risk for RSD?
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pts 30-50 yrs
women 3x more likely smokers |
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3 stages of RSD
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stage 1: acute
stage 2: dystrophic stage 3: atrophic |
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Stage 1
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acute
-3 months -severe pain out of proportion to injury -burning,throbbing or cutting pain Autonomic nervous system dysfunction -hypersensitivity to light touch -swelling in affected extremity -inc sweating, chang of skin color (red to cyanotic) -temp changes -inc hair & nail growth |
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stage 2
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dystrophic: after 6-12 weeks
-loss of skin lines (pale & waxy) -joint stiffness, brittle nails -muscle spasms, persistent pain xrays & bone scans will show changes |
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stage 3
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atrophic
-loss of muscle & skin -permanent joint contractures -loss of motions -persistent pain becomes severe |
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diag test for RSD?
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plain films: spotty areas of osteopenia or demineralization in bones (Sudek's atrophy)
3 phase bone sans: esp 3rd stage --> inc uptake in extremity & correlate with RSD |
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Adverse outcomes of RSD
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chronic, debilitating pain
joint contractures, stiffness skin & muscle atrophy develop loss function in affected extremity disability is equivalent amputation psych problems (depression, anxiety, potential to commit suicide) |
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Treatment for RSD
-non med tx |
early recognition & prompt tx, high index of suspicion
(if left untreated, pts can have sig disability) early motion & use is KEY to recovery educate pts is next MOST imp aspect of treatment -referral to OT |
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pain management tx for RSD
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neurontin, elavil, narcotics
oral steroids & NSAIDS do not alter course of dz (nor recommended) |
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compartment syndrome
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ant & lat compartments most affected
consistent systems w/running & time to onset R/O stress fracture with bone scan may require fasciotomy |
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the 5 P's of compartment syndrome
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pain (earliest & most reliable indicator)
pallor paralysis paresthesia pulselessness |
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definition of compartment syndrome
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intracampartmental tissue pressure elevates
venous pressure elevates & obstructs venous outflow --causes escalating cycle of cont inc in intracampartmental tissue pressure & results in dec in arterial flow END result: necrosis of muscle & nerve tissues (can occurin 4-8 hours) |
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chronic compartment syndrome
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in long distant runners, new military recruits
others involved in major change in activity level (in these, SS less acute & tend to improve w/rest following exercise) -also termed exercise induced compartment syndrome (not an emergency) |
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which compartments are MC affected muscular compartments in acute compartment syndrome?
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anterior compartment of leg
volar aspect of forearm |
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which compartments are MC involved in exercise induced compartment syndrome
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anterior & lateral leg compartments
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Characteristic early SS of acute compartment syndrome
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pain that is disproportionate to injury
sensory hypoesthesia distal to involved compartment |
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Diag test for compartment syndrome
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diastolic pressure minus intracompartmental pressure is < or = 30 mmHg
use stryker monitor: 14 gauge needle & sterile saline that moves to document pressure |
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Tx for compartment syndrome
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surgical fasciotomy (essential - immediately)
wound left open, w/delayed closure or skin grafting performed after swelling subsides |
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Pump bump other name
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Haglund's deformity
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what is pump bump?
imaging? treatment? non op and op |
similar to retrocalcaneal bursitis
xrays reveal prominence of posterior superior tuberosity of calcaneus Tx: non-op: heel lift, heel modification of shoes op: resection of prominence of post superior tuberosity of calcaneus |
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Quadriceps tendon rupture
(when to tx) |
MC 40 yrs
palpable defect in quad tendons inability of pt to actively extend knee or perform SLR (straight leg raise) operative tx within a week |
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patellar tendon rupture
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MC in 40 + patients
palpable defect in patellar tendon instability of pt to actively extend knee or SLR Primary operative tx within a week |
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patellar tendinitis
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AKA "jumper's knee"
-common in athletes in jumping sports (volleyball/basketball) -pain at inferior pole of patella & patellar tendon -pain worse w/extension Tx: NSAIDS, PT -stretching (quads, hamstrings) -strengthening -ultrasound -orthoses (Chopat) |
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types of patellar tendonitis
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osgood schlatter: traction (bump under the knee)
Larsen-Johansson: overuse (inflammation under patella) |
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Quadriceps tendonitis
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localized pain
supportive tx similar to patellar tendonitis -NSAIDs, PT |
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Prepatellar bursitis
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AKA housemaid's knee
-hx of prolonged kneeling (on prepatellar bursa) or direct trauma -pain to palpation over swollen prepatellar bursa Supportive tx: RICE, NSAIDs |
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Pes Anserinus
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painful swelling at insertion of sartorius, gracilis, semitendinosus muscles
(at anteromedial aspect of prox tibia--5 cm below anteromedial joint line) |
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treatment for Pes anserinus
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PT (tight hamstrings/quads) -stretching!
NSAIDS activity restriction Judicious use of steroid injections can also help |
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Synovial plica
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thickened band of synovial tissue
medial patellar plica (synovial shelf) (plica can abrade medial femoral condyle) |
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Treatment for synovial plica
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NSAIDS, PT
-knee injection relieves about 50-70% may need operative resection diagnosis is overused consider PFS (patellar femoral syndrome) |
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What are the patellaofemoral disorders? (5)
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lateral patellar compression syndrome
patellar instability chondromalacia abnormalities of patellar height patellofemoral arthritis |
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lateral patellar compression syndrome
-what is it? |
tight lateral retinaculum w/lateral tilting of patella
imbalance of Quads & hamstrings |
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Tx for lateral patellar compression syndrome
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non-op:
-activity modification -NSAIDS -PT w/lots of stretching -strengthining of vastus medialis obliquus (VMO) muscles OP: lateral retinacular release (50/50 success rate) |
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Patellar instability etiology & diag
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etiology: abnl alignment of lower extremity, excess Q angle
-patella alta (knee cap rides high) -vastus medialis musculature -systemic ligamentous laxity Diag: -exessive lateral mobility of patella -apprehension (to examiner's attempt to push patella laterally) -may have had actual dislocation -radiographs & CT: eval patellar tracking |
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Tx for patellar instability
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for acute dislocation: treat w/progressive ROM in brace like MCL injuries
-cast for 6 weeks Rehab: mainstay of treatment -closed-chain quadriceps rehab Proximal &/or distal operative realignment for cases that fail to improve w/rehab |
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Chondromalacia
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"softening" or degeneration of articular cartilage on undersurface of patella
-pathologic diagnosis (seen on MRI too) -tx options limited -Treat like PFS (patellar femoral syndrome) |
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abnormalities of patellar height
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patella alta: high riding patella
-(may be assoc w/patellar instability) Patella baja: low riding patella -may be assoc w/arthrofibrosis (stiff knee) |
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patellofemoral arthritis
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DJD (degenerative joint disease)
-injuries & malalignment contribute -crepitus & pain common Tx: supportive, VMO strengthening & stretching -treat like knee DJD -late -- anteromedial tibial tubercle transfer |
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calcaneal fractures
-causes? -where else do you need to check for other potential fractures? |
causes: axial load (falling and land on the heel)
need to check at least up to the L spine) |
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xrays that are important for calcaneal fxs
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bohler's angle: MC
crucial angle of Gissane (nl: 25-40 deg) |
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what is MC mechanism of injury for ankle sprains?
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ankle inversion (85%)
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ankle sprain grades
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1: mild: micro tear, mild pain, delayed edema (recover 1-2 wks)
2: moderate: partial tear, immediate disabling pain & swelling -lateral ecchymosis (recover in 4-8 wks) Grade 3: severe: show fx blister -complete tear, immediate instability & swelling large area of ecchymosis (recover 6-12 wks or even longer) |
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What direction do lateral ligaments get injured from?
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anterior to posterior
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what is MC ankle ligament injured?
what ligament is next? |
ATFL
-anterior talofibular ligament CFL (calcaneofibular ligament) is next PTFL (posterior talofibular ligament) is last and uncommon |
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ankle sprain presentation
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localized tenderness over lateral ankle
deltoid ligament injuries present w/medial tenderness |
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Tests for ankle sprains
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ATFL injury: anterior draw test positive (nl < 6 deg, > 6 = abnl)
ATFL & CFL: inversion stress test positive -assess for syndesmotic injury (squeeze test & abduction external rotation stress test) -r/o ankle fracture or proximal fracture (Maisonneuve's fx) |
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indications for xraying acute ankle injury to r/o fx
(4) |
tenderness to palp at posterior tip of lateral malleolus
tenderness to palp at posterior tip of medical malleolus inability to bear wt at time of injury or time of PE Eck's rule: better to get diag right rather than miss something |
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Treatment for ankle injuries
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RICE: rest, ice, compression, elevation
NSAIDs cast immobilization reserved for pts w/severe pain -bracing for grade 1 & 2 (air cast, arizona brace) |
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tx after acute phase tx or ankle injuries
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PT helpful
ROM exercises strengthening exercises Proprioceptive training (write ABC's w/foot) |
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Tx for chronic ankle sprains
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muscle strengthening exercises
operative reconstruction: get stress films, MRI's DDX: talus fx, RSD, tendonitis, tendon subluxation, ankle instability |
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Rheumatic Arthritis
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systemic disorder w/chronic erosive synovitis
crippling dz, 3x MC women (25-45 yrs) synovium thickens --> inflamed & hypertrophic |
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features of RA
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gradual onset weakness, fatigue, anorexia
followed by joint involvement: stiffness (most in morning), swelling, heat, redness symmetric joint involvement (hands & feat) dec life expect: 3-7 yrs |
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What are the charateristic deformities assoc w/RA?
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subluxations
dislocations joint contractures tendinitis bursitis rheumatoid nodules Organ involved: pulm fibrosis, pericarditis, vasculitis |
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Lab & tx for RA
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Rheumatoid factor + in 75%
Tx: early recognition & dz modifying agents -exercise, moist heat, rest, pt education MEds: anti-inflam- ASPIRIN drug of choice -gold, METHOTREXATE |
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American College of Rheumatology criteria for RA
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1-4 must be present for 6+ weeks
-morning stiffness > 1 hr -3 or more joints w/swelling -arthritis of hand joints w/swelling -symmetric arthritis -Rheumatoid nodules -xray changes typical of RA - RF + |
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Juvenile Rheumatoid arthritis (still's disease) features
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systemic (20%): spiking fevers, rash, splenomegaly, lymphadenopathy, pericarditis, myocarditis
Pauciarticula (40%): larger joints, GIRLS, iridocyclitis (high % vision loss) Polyarticular: 40%, resembles adult dz (sm joints & cervical spine involvement; closure of growth plates early) |
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SLE
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joint pain & swelling in 90%
common in women in 4-5th decade |
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Osteoarthritis
-what it is -clinical features |
MC type of non-inflam arthritis
-primary: idiopathic -- wear & tear -secondary: trauma, metabolic, rheumatoid, gouty Features: PAIN (MC initial ss) -pain w/activity, relief w/rest |
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xray & tx for osteoarthritis
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xray: joint space narrowing, spur formation, sclerosis, subchondral cyst formation
Tx: pain relief & prevent progression KEY -rest, wt loss, stretching, ROM, low impact activities, anti-inflam, steroid injections, viscosupplementation -surgical tx: arthroplasty or fusion |
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What specialty tests do you do for ACL laxity
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lachman's test
anterior drawer pivot shift test |
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PCL laxity specialty tests
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posterior draw test
quad active drawer test posterior sag sign |
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MCL/LCL laxity specialty test
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valgus stress test
varus stress test -need to make sure that knee is flexed 30 degrees (takes tension of PCL & allows direct exam of collateral ligaments) |
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posteriolateral corner injury specialty test
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excessive external rotation
posterolateral draw test reversed pivot shift test external rotation (varus) recurvatum test external rotation test |
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Meniscal injury specialty test
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joint line tenderness
McMurray's test Apley's compression/distraction test Squat test/duck walk (Childress test) Bounce home test |
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patellofemoral pathology tests
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patellar tilt (passive)
patellar grind patellar glide patellar apprehension: pain w/passive lateral displace of patella assoc w/patella instability Q-angle: ASIS to patella to tibial tuberosity (nl < 15 deg; greater in women -avg 17 deg)) J-sign: lateral deviation of patella (as knee moves into terminal extension) |
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What is patellar tilt?
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pt lying supine & quads relaxed
exam lifts lateral edge of patella away from lateral femoral condyle Normal angle: 15 deg (males may have angles < 5 deg than females) |
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plantar fascitis
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pulling of plantar fascia assoc w/microtrauma to plantar fascia insertion
-cavus or planus foot --> inc SS -nerve intrapment of medial calcaneal nerve can occur SS: acute tenderness at medial tubercle of calcaneus & over course of plantar fascia |
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What is important to R/o with plantar fasciitis?
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r/o seronegative spondyloarthropathies (HLA B27)
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Treatment for plantar fasciitis
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Non - op:
-NSAIDs, stretching, night splints -orthoses -corticosteroid injections -conservative tx for 9-12 mos before considering operative intervention |
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Kohler's Bone disease
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osteonecrosis of navicular
-painful limp about 5 yrs -local tenderness -flattening & sclerosis of bone |
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Tx for Kohler's bone disease
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7-8 wk casted (Wt bear ok)
-recovery seen in 2-3 yrs |
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MOrton's Neuroma
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degeneration & prolliferation of planter digital nerve producing painful mass near matatarsal heads
-shooting pain radiating distsaslly to affected digits -MC painful when wearing shoes w/narrow toe box -palpation between metatarsal heads elicits painful SS |
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where is MC site for Morton's Neuroma?
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between 3rd & 4th metatarsals
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Tx for Morton's neuroma?
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accommadative padding in shoes or wide toe box
-cortisone injections -surgical excision for cases refractory to conservative tx |
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Metatarsalgia
-what it is and tx |
pain beneath metatarsal heads
-high heels, tight heel cords, callus TX: metatarsal pads, rest, change in shoes, metatarsal bar, NSAIDs -surgical excision & shortening of MT head, gastroc lengthening |
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what is Freiberg's dz
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collapse of subchondral area of metatarsal head caused by avascular necrosis
-pain & limitation of motion -pain worsens w/inc activity & relieved by rest -MC affects 2nd metatarsal head |
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tx for Freiberg's dz
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Non-op: alleviating discomfort by dec stress at involved joint
-short leg walking cast -postop shoe Op: later stages of disease |
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Hallux Rigidus
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degenerative arthritis of first MTP joint causing stiffness
-may arise 2nd to repetitive trauma or metabolic dz or after surgery -pain & restricted motion of first MTP joint -palpable bone spur on dorsal aspect of 1st metatarsal head Xrays show MTP joint narrowing & osteophytes (bone spurs) |
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Tx for Hallux Rigidus
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non op: NSAIDs, orthoses, shoes
Op: excision of bone spur + portion of joint surface |
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Hallux Varus (monkey toe)
-cause -presentation -diag -treatment |
cause: congenital or iatrogenic
present: discomfort in shoes, pain along medial side of great toe diag: adducted position of great toe Tx: non-op: valgus strapping & splinting, stretching Op: operative correction of deformity |
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Hammer toe
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poorly fitted shoes lead to progressive "buckling" of toes
-contracture of FDL (flexor digitorum ligament?) tendon -may result from muscle imbalance (neuromuscular ds) |
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how does hammer toe present?
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plantar flexion of PIP joint w/dorsiflexion of MTP joint
-longer digits typically are affected more often -pain & discomfort in shoes |
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diag & tx for Hammer toe
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diag: xrays reveal dorsiflexion of prox phalanx w/plantar flexion of middle &/or distal phalanges
Tx: taping, if it fails, operative |
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Claw toe
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may be assoc w/neuromuscular, arthritic ds
-simultaneous contracture of long extensors & long flexors of toe -affects multiple toes & typically present as bilateral condition -plantar flexion of DIP & PIP joint w/dorsiflexion of MTF joint Tx: operative |
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how do you differentiate claw toe from hammer toe?
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by hyperextension of MTP joint
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Mallet toe
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poor fitting shoes cause toe to plantarflex at DIP joint (tightness of FDL tendon)
-plantar flexion of DIP joint (MC 2nd toe) -pain when tip of toe strikes ground |
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treatment for mallet toe
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non op: padding to prevent tip of toe from striking ground
Op: release FDL tendon |
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overlapping 5th toe
-etiology -presentation -tx |
etiology: usu congenital shoes on toe
present: pain resulting from pressure from shoes on toe Tx: operative correction varies according to severity of deformity (may include amputation) |
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GOUT (primary)
etiology |
abnl purine metabolism
sodium urate crystals hyperuricemia men in 3/4 decade of life incidence inc w/age rare in W unless postmenopausal obesity, lead exposure, ETOH, diuretics (risk for development) |
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clinical features of primary gouty arthritis
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usu sudden onset, lower extremity
-involve MP joint (BIG TOE), precipitate by exercise, diet, physical/emotional stress -may look like cellulitis, tender to palp |
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diag and labs for primary gouty arthritis
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xrays: normal early; late findings have erosions
labs w/inc ESR & hyperuricemia -aspiration is diagnostic |
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treatment for primary gouty arthritis
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terminate or prevent attacks
acute attacks -modification diet, wt loss, no more than 2 ETOH drinks per day, HTN (no diuretics) Prophylactic agents: allopurinol, probenecid |
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Pseudogout (chondrocalcinosis)
-definition -clinical features |
deposits of calcium pyrophosphate dehydrate crystals (CPPD)
SS: similar to gout but 60-70 yrs -knee MC affected -may see calcifications of soft tissues |
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Diag & tx for Pseudogout
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CPPD crystals from synovial fluids, xrays
Tx: steroid injection, anti-inflammatories |
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what are the 2 types of knee dislocations?
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patella & tibiofemoral
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How do you remove articular fragments resulting from patellar dislocation?
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best removed arthroscopically
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Knee dislocation
-what eval must be done? |
= true orthopaedic emergency
-require evaluation of the artery |
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multiple ligament injury
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likely assoc w/knee dislocation
-need arteriogram to asses vascular status (MANDITORY) |
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Tx for multiple ligament injury
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-reduction, arteriogram
-delayed reconstruction of torn ligaments 5-7 days after injury -primary repair of bony avulsions -reconstruction of intrasubstance ligament injuries |
