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615 Cards in this Set

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Indications for splinting
Fractures
Sprains
Joint infections
Tenosynovitis
Acute arthritis/gout
Lacerations over joint
Puncture wounds and animal bites
Pain control
Long Arm Posterior Splint
- Elbow and forearm injuries
- Distal humerus fx
- Both bones forearm fx
- Unstable proximal radius/ulna fx

Doesnt completely eliminate supination/pronation - either add anterior splint or use double sugar-tong if complex or unstable distal forearm fx
Double sugar tong
Elbow and forearm fx -prox/mid/distal radius and ulnar fx

Better for most distal forearm and elbow fx - limits supination/pronation and flexion/extension
Cockup splint
- Soft tissue hand/wrist injuries - sprain, carpal tunnel night splints
- Most wrist fx, 2nd-5th metacarpals
- Some add dorsal splint for increased stability
- Not used for distal radius or ulnar fx - can still supinate or pronate
Forearm sugar tong
- Distal radius or ulnar fx
- Prevents supination/pronation and immobilizes elbow
Radial and Ulnar gutter
Fractures, phalangeal and metacarpal and soft tissue injuries of the little and ring fingers
Thumb spica
Scaphoid fx - seen or suspected (check snuffbox tenderness)
- Lunate fx
- All thumb fx
- De Quervain tenosynovitis
Finger splints
Sprains - dynamic splinting

Dorsal/volar splints - phalangeal fractures, gutters better for proximal fractures
Jones compression dressing
- Short term immobilization of soft tissue and ligamentous injuries to knee or calf
- Pain relief
- Allow slight flexion and extension, can add posterior knee splint to further immobilize knee
Posterior ankle splint
- Distal tibia/fibula fx
- Reduced dislocations
- Severe sprains
- Tarsal/metatarsal fx

Use coaptation splint to posterior splint - eliminates inversion/eversion especially useful for unstable fractures and sprains
Stirrup splint
Similar to posterior splint, less inversion/eversion and plantar flexion, great for ankle sprains
Complications for casting
BURNS - thermal injury as plaster dries, increased number of layers, extra fast drying, poor padding - increase risk

ISCHEMIA

PRESSURE SORES

INFECTION
Why do you do ophtalmologic examination when suspect child abuse
Shaken baby syndrome or retinal hemorrhages
Skeletal survey includes :
Skull - frontal and lateral
Spine - frontal and lateral
Chest
Extremities
Additional views as needed
Multiple rib fractures healing on xray is pathognomonic for _
CHILD ABUSE - ESPECIALLY POSTERIOR PART
Bruises - abuse vs accidental
ABUSE - on padded areas, pattern injuries, many lesions

ACCIDENTAL - on poorly padded areas, non-specific patterns, few lesions
Differential diagnosis for bruises
CHILD ABUSE
Bleeding disorders
Mongolian spots
Henlich-Shonlein purpura
Cupping, coining
Which lesion is virtually pathognomonic for child abuse
Metaphyseal fracture - results from tearing and shearing forces
Most vulnerable part of bone in infant
Distal metaphysis (no chondrocytes - makes it weaker then physis, fewer organized cells and less calcification makes it weaker then proximal metaphysis or any other part of the bone)
what is central to radiologic diagnosis of abuse
RIB FRACTURES - posterior rib fractures are highly suggestive of abuse
Which parts of ribs are most commonly fractured in abuse
Head and neck - only in abuse and MVA
High specifity injuries suggesting abuse
- Classic metaphyseal lesions
- Rib fractures - head+ neck, posterior
- Scapular fractures
- Spinous process fractures
- Sternal fractures
Compartment syndrome definition
Elevation of interstitial pressure in closed fascial compartment that results in microvascular compromise
Tissue threshold to ischemia - muscle _ , nerve _
Muscle 4 hours
Nerve 8 hours
Causes of compartment syndrome
Fractures of long bones
CRUSH INJURIES
Burns
Pneumatic tourniquette
High injury trauma/blunt trauma
Ischemia/reperfusion
Penetrating injuries (snake spider bites)
Chronic overuse
Which compartment is most commonly involved in compartment syndrome in lower extremity
Anterior compartment (stronger fascia, lower compliance, less subcutaneous fat for shock absorption)
6 P's of compartment syndrome
Pain (out of proportion)
Paresthesias
Pulselessness
Passive movement pain
Pallor
Paralysis
You should consider diagnosis of compartment if pressure within compartment is equal to or exceeds _
30 mm Hg
Treatment of compartment syndrome
Fasciotomy
Debridement of necrotic muscle
Jelonet dressing
IV heparin
Most common symptoms of PE
Dyspnea
Pleuritic chest pain
Cough
Hemoptysis
Signs of PE
Tachypnea
Rales
Tachycardia
4th heart sound
Accentuated pulmonic compound of 2nd heart sound
Circulatory collapse
In PE EKG will often show
Sinus tachycardia
T wave and ST segment changes - S1Q3T3
What does chest x ray show in patient with PE
Non specific changes (12% normal)

- Hamptons hump - wedge shaped formation in lower part of the lung from occlusion of the vessel

Westmark sign - changes distal to occlusion of pulmonary artery

Also atelectasis, small pleural effusion, infiltrate, elevated hemidiaphragm
Which tests are don to diagnose PE
- PULMONARY ANGIOGRAPHY - gold standard
- CT
- Ventilation-perfusion scanning
- D dimer
In diagnosis of PE 2 algorithms are used -
- Clinical suspicion + ventilation-perfusion scanning
- Clinical suspicion + CT scan/D-dimer
Wells criteria assess
Likelihood of patient having PE
What has become a modality of choice for diagnosis PE
CT SCAN (pulmonary angiography is a gold standard but it is less available and more invasive)
Mortality rate for patients with PE
30% w/out treatment

2-8% with prompt intervention
65-90% of PE arise from _
DVT in lower extremities
Virchow triad
Vascular intimal injury
Hypercoagulability
Venous stasis
Risk factors for PE
SURGERY
- Immobilization
- Stroke
- Smoking
- History of DVT
- Malignancy
- Chronic heart diseases
- Fractures
- Oral contraceptives
What should be INR in patients on Coumadin
2-3
SYmptoms for flexor tenosynovitis
- Pain with passive stretching
- FUsiform swelling (sausage fingers)
- Erythema
- Intact sensation
Normal extension of the hip is _
20-30 degrees
Normal flexion of the hip is
135 degrees
Normal abduction of the hip is _
45-50 degrees
Normal adduction of the hip is _
20-30 degrees
What is a weight bearing portion of the hip ( would decrease in OA)
Superior portion of acetabulum
Causes of hip pain
Hip fracture
Hip dislocations
OA
Osteonecrosis
Iliotibial band tendonitis
Intraarticular pathology
Trochanteric bursitis
Pediatric causes - unique to children - growth plate problems, infections
Inguinal hernia
Intraarticular pathology
Labral tears
Ossified loose bodies
Synovitis (pigmented villonodular)
Septic arthritis - pediatric patients and post joint replacement
How would typical patient with septic arthritis present
- Pain in anterior aspect of the hip
- Pseudoparalysis - patients are not paralyzed but it is very painful so they are trying to limit use of the extremity
- Fever
- Possible trauma history - if patient is bacteremic even small trauma can cause septic arthritis
- Patient is usually 4 years old with no underlying illnesses
What is a common positioning of the hip in patients with septic arthritis and why
Hip is in: external rotation, abduction and mild flexion - in this position capsule holds most fluid - most comfortable position
Which blood tests should you do in patient with septic arthritis
CBC
CRP
ESR

CRP and ESR are both acute phase reactants, CRP is more acut and ESR is more chronic - both used to evaluate progress in patients with septic arthritis
Blood cultures in patients with septic arthritis are always positive - T/F
FALSE - 40-50% are positive
If you see x ray changes in patients with septic arthritis what does it mean
Long standing infection
Is ultrasound useful as diagnostic tool in patients with septic arthritis
It looks for echogenecity - very sensitive for effusion but not infection, effusion can be normal (synovial fluid) or can be infectious (pus)
What procedure is used to determine organism in septic arthritis
Large bore needle aspiration - if you think joint is infected but nothing is coming out, inject sterile saline solution to give volume and suck it back out and bacteria will follow the fluid, dont inject anything bactericidal - will kill causative organism before determination
Describe WBC levels in patients with septic arthritis
Over 50000 and 90% PMN
Glucose levels in synovial fluid of patients with septic arthritis are _
40 mg/dL less then serum levels (also do blood glucose levels to compare)
How do you confirm diagnosis in patients with septic arthritis
Gram stain - can confirm diagnosis in 50% of cases

Cultures - positive in 50-80% of patients
How do you treat septic arthritis of the hip
Early diagnosis is very important. Also get cultures of synovial fluid as soon as possible to determine appropriate antibiotic, and do hip arthrotomy to drain surgically.
In high risk low birth weight neonates causative organisms of septic arthritis of the hip are _
S. aureus followed by group B strep
In kids 3 months- 3 years old causative organisms of septic arthritis of the hip _
H.influenza type B, followed by Staph and Strep, declined drastically with H. flu vaccine
In kids older then 3 years old causative organisms for septic arthritis of the hip are_
S aureus (50%) , strep (25%)
What are the possible causes of Legg-Perthes-Calve disease
- Clotting factors/blood viscosity
- Endocrine abnormalities (thyroid disorders, higher T3/T4 levels)
Usual age of presentation for LCP disease/sex
4-10 years old boys (often small for age)
WHat is common presentation of child with LCP disease
Limping (antalgic gait)- can present for weeks or months, usually no pain but if it does exist its mild and affects knee
What motions are limited in child with LCP disease
Internal rotation and abduction, internal rotation is best tested in extension
Which test is positive for LCP disease
Trendelenburg test - test for gluteus medius strength, opposite side drops
Pain is referred from hip to suprapatellar region - what nerve is involved
Femoral
Pain is referred from hip to medial thigh - what nerve is involved
Obturator
Pain is referred from hip to buttock - what nerve is involved
Sciatic nerve
What is a recommended treatment and goals for management of LCP disease
- Relief of weight bearing
- Bedrest, traction, spica, slings, frames
- Present goals- maintenance of hip motion and containment of involved femoral head from bases for treatment, inital goals are to restore mobility and to reduce pain
- Operative and non-operative containment - if femoral head is not covered completely by acetabulum can do pelvic osteotomy and manipulate to get full coverage
What is prognosis for patients with LCP disease
Majority of patients will do well in 5th decade, 50% of untreated patients will develop arthritis by age of 55
How do patients with OA of the hip usually present
Groin, buttock, and or thigh and knee pain
Conservative measures for treatment of OA of hip
Activities modification
NSAIDS
Weight control
Tylenol
Injections
Assistive devices
2 types of hip fractures
Intracapsular
Extracapsular
Hip fracture patients typically present with what deformity
Limb is shortened and externally rotated
Hip fractures cause pain where
Usually groin pain , can also have thigh or knee pain - may not be weight bearing, both passive and active motion cause pain
Which imaging tests do you order when you suspect hip fracture
AP pelvis
AP hip
Shoot through lateral of hip
MRI
Bone scan
4 types of intracapsular hip fractures
Capital
Subcapital
Transcervical
Basicervical
2 types of extracapsular fractures
Intertrochanteric
Subtrochanteric
Anterior hip dislocations occur as result of _
Abduction and external rotation forces
If hip is flexed at the time of injury anterior hip dislocation is _
Anterior and inferior
If hip is extended at the time of injury anterior hip dislocation is _
Anterior pubic
Posterior dislocations of the hip occur when _
Longitudinal force is applied in line with femur and acting on adducted hip
Which posterior dislocation is worse when hip is more abducted or adducted
When hip abducted - worse dislocation, more adducted - cleaner dislocation
How do posterior dislocations present
Will be flexed at the hip, adducted and internally rotated
How do anterior dislocations present
Externally rotated with various degrees of flexion and abduction
How do you treat hip dislocations
- Emergent reduction
- Closed reduction is attempted first unless there is associated hip or femoral neck fracture (ipsilateral)
- Complete paralysis should be obtained prior to attempt reduction
Which tests do you order when child presents with limping
ESR
CBC
Metabolic profile
Which anatomical cause of cervical region can result in limping
Cervical instability C1-C2
Joint diseases of hip that can cause limping
- Septic arthritis (toddler-adult)
- Dislocated hip
- Developmental dysplasia of hip
- LCP disease (AVN of femoral head)
- Slipped capital femoral epiphysis
- Benign tumors - fibrous dysplasia, unicameral bone cyst
- Stress fracture of the hip
- Snapping hip - iliotibial band
Joint diseases of knee that cause limping
- Osteochondritis dissecans - AVN of femoral condyle
- Tumor - benign or malignant
What can cause leg length discrepancy
- Growth arrest (infection, fracture, burn, JRA)
- Fracture (physeal fracture)
- Septic joint
- Knee trauma - fracture, ligamentous injury
- RA
- Discoid meniscus (congenital abnormality of lateral meniscus - prone to tearing)
- Osgood Schlatter
- Patellar instability (can shear off femoral condyle)
- Pathologic fractures
- Brodies abscess (infection)
Which fractures of the knee are more common in little children vs older children
Little children - avulsion fracture, older children - ACL tear
What is Kohler disease
AVN of navicular bone
What is Sever disease
Apophysitis of tendo-achilles insertion
Which problems in feet can cause limping
- Clubfoot
- Tarsal coalition
- Tight shoes
- Foreign body
Neurologic causes of limping
Cerebral palsy (diplegia, hemiplegia)
Spinal cord pathology
Tumors
In acute hematogenous osteomyeilitis infection begins where
Metaphyseal venous sinusoids
Describe cellulitic phase of acute hematogenous osteomyelitis
Infection begins in metaphysis and as it spreads metaphyseal vessels thrombose and prohibit inflow of WBC which must slowly migrate there from medullary cavity
- Pus has not been produced yet
- At this age antibiotics alone can be sufficient
Subperiosteal stage of acute hematogenous osteomyelitis
Once pus forms, to lessen interosteal pressure it will exit through porous metaphyseal cortex - this elevates periosteum and forms subperiosteal abscess
How do you diagnose acute hematogenous osteomyelitis
- Half of patients have history of recent or concurrent infection
- May refuse to move limb
- Tenderness over involved bone
- Decreased range of motion over adjacent joints
- Swelling, erythema and warmth over bone later
In acute hematogenous osteomyelitis ESR and CRP are _ EXCEPT in _

WBC are _
ELEVATED (90%)

EXCEPT sickle cell anemia patients, kids on steroid medications, and neonates

ELEVATED
Organisms causing acute osteomyelitis in neonates
S aureus
Group B strep
Gram negative coliforms
Organisms causing acute osteomyelitis in infants and children
S aureus
Organisms causing acute osteomyelitis in patients with sickle cell anemia
Salmonella
Organisms causing acute osteomyelitis in adolescents
S. aureus, gonorrhea
In acute osteomyelitis blood cultures are ALWAYS positive - T/F
FALSE - in 40-50%
Are there any x ray changes in acute osteomyelitis
Little change except soft tissue swelling for 7-10 days
How is definitive diagnosis of acute osteomyelitis made
By bone and subperiosteal aspiration
Antibiotics for treatment of acute hematogenous osteomyelitis in neonates
Oxacillin with cefotaxime or gentamicin
Antibiotics for treatment of acute hematogenous osteomyelitis in infants and children
Oxacillin or Cefazolin

Clindamycin or vancomycin if allergic to penicillin or cephalosporins
In neonates why does infection spread fast to joint

Why not in older kids?
Metaphyseal vessels communicate with epiphyseal in cartilaginous precursor of ossific nucleus permitting a route to spread to joints

As child matures epiphysis develops separate blood supply and there is no longer communication with metaphyseal vessels
Which areas are intraarticular in neonates and why is this important
Metaphysis of hip, proximal humerus, proximal radius and distal lateral tibia are intraarticular - provide tracks under the capsule into joint
How does infection affect growth plate in neonates
Thrombosis of vessels can cause ischemia of growth plate and infection can cause subsequent lysis of growth plate - complete ischemia and lysis of physis before ossification can lead to necrosis and reabsorption of femoral neck and head
Why do neonates get infections by microorganisms typically not seen in older children
Immune system is immature making inflammatory response compromised
Why is detection of osteomyelitis in neonates is often delayed
Minimal symptoms - malaise, failure to gain weight, no fever, ESR and WBC can be normal
Long term complications of osteomyelitis in neonates
Osteonecrosis of epiphyses, joint dislocation and premature physeal arrest
SUBACUTE HEMATOGENOUS OSTEOMYELITIS

Pain _

Fever _

Loss of function _

Prior antibiotic therapy _

Elevated WBC count _

Blood cultures _

+ bone cultures _

initial radiographs _

Site _
Pain MILD

Fever FEW PATIENTS

Loss of function MINIMAL

Prior antibiotic therapy OFTEN (30-40%)

Elevated WBC count FEW

Elevated ESR MAJORITY

Blood cultures FEW POSITIVE

+ Bone cultures POSITIVE IN 60%

Initial radiographs FREQUENTLY ABNORMAL

Site ANY LOCATION (CAN CROSS PHYSIS)
Assesment of open fractures in children should include _
ABC's
Patient disease
Size of wound
Degree of contamination
Crush (myoglobinuria)
Bone loss
Vascular and nerve injury
Degree of periosteal slipping
If wound is contaminated with soil or barnyard , which organisms should you suspect
Tetanus

Clostridium (gas gangrene)
If wound is contaminated in fresh water ponds which organisms should you suspect
Pseudomonas aeruginosa

Aeromonas hydrophilia
Which pathogenic contaminates of the wound are hospital acquired
MRSA

Pseudomonas aeruginosa
Which pathogenic contaminates of wound can be received from patient to patient
HIV

Hepatitis
If patients presents with open wound (fracture) and is not immunized up to date which immunizations should be given
Tetanus for clean or minor wounds and tetanus + immunoglobulin for under immunized
What is a treatment plan for open fractures in pediatric patients
Assess and document
Splint fracture
Give antibiotics
Debridement within 5-6 hours if at all possible
Do not close initially
Repeat debridement as needed
What is the most important prognostic factor in kids with septic arthritis for outcome and prevention of growth anomalies
Duration of symptoms prior to treatment - requires urgent treatment, delay can cause destruction of articular cartilage
Signs and symptoms of septic arthritis in kids
Fever (38-40 C)
Pain
Effusion and joint warmth
Loss of motion
Tenderness
In infants - limited spontaneous motion and assymmetric posture of extremity
In septic arthritis in kids WBC are _
Elevated in 30-60% of patients with left shift in 60% of those with elevated count
Which blood test in kids with septic arthritis is more sensitive then others
ESR - higher in patients with septic arthritis then in patients with osteomyelitis
What is differential diagnosis of septic arthritis in kids
JRA
Hemarthrosis
Cellulitis
Osteomyelitis
Henoch-Shonlein purpura
Rheumatic fever
Slipped capital femoral epiphysis
Lyme disease
Sickle cell crisis
Transient synovitis (hip)
Crystalline arthropathies (rare in children)
LCP disease
What would x rays show in septic arthritis
Soft tissue swelling, adjacent bone destruction, joint narrowing (late)
When assessing for septic arthritis of hip in kid what other things should you consider
Appendicitis
Psoas abscess
Pelvic osteomyelitis
Aspiration of effusion in septic arthritis will show fluid that is _
Cloudy
Most joint with early treatment in septic arthritis respond well to _
Aspiration and antibiotics
In septic arthritis of the hip there is risk of _ so its best treated with _
AVN
Surgical drainage
When should surgery be considered in kids with septic arthritis
If aspiration fails once or twice
When should antibiotic therapy be started in septic arthritis patients
After you have all cultures - including joint aspirations
Infants and young children also need LP to look for meningitis
In neonates antibiotics used for treatment of septic arthritis are _
Oxacillin + cefotaxime or gentamicin
In child younger then 4 years old antibiotics used for treatment of septic arthritis are _
Oxacillin + cefotaxime or cefuroxime
In child over 4 years old antibiotic used for treatment of septic arthritis is _
OXACILLIN
In immunocompromised kids antibiotics used for treatment of septic arthritis are -
Oxacillin + ceftriaxone
Initial treatments of nail puncture wounds are _
Tetanys prophylaxis
Excision of devascularized skin flaps
Irrigation of puncture tract
Should antibiotic coverage for gram positive organisms be given in kids with nail puncture wounds
Only if there is evidence of cellulitis or soft tissue infection
Possible complications of nail puncture wounds
Cellulitis
Osteochondritis
Osteomyelitis
Soft tissue abscess
Pyarthrosis

(Psedomonas osteomyelitis-osteochondritis 0.6-1.8 %)
Which organism is found in 93% of all nail pucture wounds osteomyelitis
Pseudomonas aeruginosa
Pseudomonas species have propensity for which part of the foot
Cartilaginous structures
What is a treatment for pseudomonas osteochondritis
Surgery to careful exploration for foreign bodies, debridement of dead tissue and extensive lavage
7 day treatment of parenteral antibiotics
What are the main steps in treating any infection
- Identify organism
- Arrest tissue destructions (antibiotics or surgery if antibiotics cannot reach site)
- Use surgery to prevent long term complications (AVN) or chronic joint changes
Adolescent idiopathic scoliosis definition
Structural lateral curvature of the spine occuring at or near onset of puberty for which no cause could be determined
Factors well known to predict curve progression
Lesser maturity and larger curve magnitude
Which curves tend to progress more
Over 50 degrees with more rotation
Which patients with scoliosis are at increased risk of cor pulmonale
High angle thoracic curves of more then 100 degrees
In patients with scoliosis (nonsmokers) significant FVC limitations start to occur _
after 100-120 degrees curve
Which x ray view is taken in patients with scoliosis
Standing x ray of spine - requires special grid for entire spine on one grid
If patient has structural leg length discrepancy put block under short limb until iliac crests are at level
What are you looking for on xrays in patients with scoliosis
Interpedicular widening
Congenital abnormallities
Rib pencilling
Skeletal maturity
Typical idiopathic curves in scoliosis
Left lumbar and right thoracic
Juvenile idiopathic scoliosis presents with high incidence of _
Neuroaxis abnormalities
Which imaging test needs to be ordered in patients with juvenile idiopathic scoliosis
MRI - over 10 degrees deviation indicates progression
Diastemotomyelia
Boney or fibrous defect that splits spinal cord, as child grows and spine elongates traction occurs on the cord - can cause neuromuscular scoliosis
Diplomyelia
Split cord - can cause neuromuscular scoliosis
Tethered cord
Traction on end of cord - thickened filum terminale, lipoma
Myelomeningocele
Neural tube defect - can cause neuromuscular scoliosis
Hydrosyrinx
Expansion of spinal cord with CSF, scoliosis improves and sometimes resolves when hydrosyrinx is treated
Lower motor neuron diseases that can cause neuromuscular scoliosis
Polio
SMA
Dysautonomia
Myopathic causes of neuromuscular scoliosis
Muscular dystrophies
Arthrogryposis
Patient with congenital scoliosis should also be evaluated for _
Heart problems
GU - need renal evaluation
Spinal cord
Klippel feil syndrome
Congenital scoliosis treatment
- Bracing - only for compensatory curves
- Hemiepiphyseodesis (under 7 years old)
- Fusion - fuse early
Which infection is responsible for torticollis
Retropharyngeal abscess - erodes alar ligaments that connect C1 and C2 and you get cervical instability - need fusion
Congenital muscular torticollis
Head side bent and rotated - contracted SCM, packaging defect
What else do you need to check in kids with congenital muscular torticollis
HIPS
What is Klippel Feil syndrome
Congenital cervical spine fusions
Possible etiology of Klippel Feil syndrome
Homox gene
Problems associated with Klippel Feil
Sprengel's
Deafness
GU anomalies - get renal ultrasound
Synkinesis (mirror movements)
Pulmonary problems
Congenital heart disease
Spinal cord
Other congenital problems (syringomyelia, neuroschisis, etc)
Sprengel deformity
Check shoulder height - retract shoulders
Scapula starts forming along cervical vertebrae, migrates distally with the limb, fibrous tether, shortening of the muscle
Which orthopedic problems are common in patients with Down Syndrome
Ligamentous laxity
C1-C2 instability
Occipital cervical instability
Which diseases are associated with cervical kyphosis
Diastrophic dysplasia
Larson syndrome - multiple joint dislocations, foot deformities, etx
Spondylolysis and spondylolisthesis in kids
Defect of posterior elements with fracture or slippage, not always painful
Treatments for spondylolysis and spondylolisthesis in kids
Activity limitations
Bracing if recent
Surgery if recalcitrant symptoms
Scheuermann disease (definition, common site, x ray findings)
Inflammation of growth plates of vertebral bodies
- increased thoracic kyphosis
In thoracolumbar kyphosis + pain, in lumbar no deformity + pain
X rays- Cobb angle >45 degrees, wedging of 5 consecutive vertebrae
Discitis
Inflammatory lesion of interverebral disc, narrowing disk space, self limiting inflammation, disc space infections (S. aureus)
Differential diagnosis for back pain in children
Trauma - compression fx, physeal fx
Vertebral infection - S.aureus, TB
Muscle spasm
Psoas abscess
Tumor
Diagnosis of DDH includes _
Typical neonatal hip dislocation
Hip instability
Late presentation hip dislocation
Teratologic hip dislocation
Acetabular dysplasia
Which DDH is hardest to identify
Bilateral
DDH is more prevalent in _
girls
Etiology of DDH
Remains uncertain
Possible causes:
Position in utero - very important
Hereditary
Postnatal positioning
Intrinsic dysplasia vs ligamentous laxity
Periods at risk for DDH
Impossible before 12th week of gestation
Muscles are formed by 18 weeks
Last 4 weeks from positioning
Early postnatal period
What is most common position in utero that causes DDH
Single breech + genu recurvatum (butt first + hyperextended knees)
What are risk factors for packaging defects
Women
Large babies
First pregnancy
Effect of post natal positioning on DDH
Increased with swaddling
More frequent during winter and spring
Hip can dislocate with forced positioning
Which tests should be included in newborn exam to test for DDH
Ortolani
Barlow
What is necessary requirement for correct performance of Barlow and Ortolani tests
Baby need to be completely relaxed (this includes crying)
How do you diagnose DDH in older child
- Limited abduction
- Galeazzi sign - looks at femoral lengths
- Leg length discrepancy
- Asymmetric skin folds
- Increased lumbar lordosis - muscles of hip are contracted and pulling which increases lordosis in order to stay straight
X ray findings in patients with DDH
Acetabular dysplasia
Shallow acetabulum
Absent ossific nucleus
Femoral head displaced laterally
Pavlik harness is treatment for _
Hip instability
Treatment of DDH in older children
- Reduce hip
- Avoid AVN by excessive pressure
- Casting and surgery depend on age
Do children with DDH need regular follow up
X rays until child is walking - then once a year, recheck in adolescence for late subluxation
Which pediatric hip condition is an orthopedic emergency
Slipped Capital Femoral Epiphysis
What is common age group for SCFE
12-15 year old
Patient with SCFE commonly presents with _ pain
KNEE
Risk factors for SCFE
Overweight
Endocrinopathies - especially hypothyroidism
Delayed skeletal maturation
Triad of symptoms for SCFE
Knee pain
Limping
External rotation of the extremity
Untreated SCFE leads to _
Progressive slippage and early arthritis - onset of OA directly depends on degree of slippage
Which treatment is reliable in patients with SCFE
Early treatment with screw fixation (EARLY DIAGNOSIS IMPORTANT !!!!!!!)
If the slip in SCFE becomes unstable what complication is likely
AVN
In patients with _ due to ligamentous laxity and collagen problems slipped capital femoral epiphysis can persist even after treatment
DOWN SYNDROME
Age group for children with LCP disease
3-9
In LCP disease pain is at _
hip
When LCP disease is bilateral you need to consider _
Hypothyroidism or skeletal dysplasia
LCP disease =
AVN of femoral head
Which processes occur in bone in LCP disease
Collapse and fragmentation
Children with LCP disease aged 6-9 statistically benefit from _
Surgery to redirect femoral head into acetabulum
Best outcome of treatment in LCP disease occurs in children
Younger then 6 at time of onset
Which treatments are used to preserve motion and reduce symptoms in LCP disease
Bracing, casting, traction and bed rest
What are consequences of leg length discrepancy
Increased energy expenditure of gait
Functional scoliosis (insignificant)
Pelvic obliquity causing increased center-edge angle of hip of long leg
Neurologically intact children with leg length discrepancy will compensate by _
toe walking
Which conditions should you beware of when diagnosing leg length discrepancy
Wilms tumor
Hemihypertrophy (look at size of hands and face)
Name things that can cause functional leg length discrepancy
Flexion contractures of hip or knee
Abduction or adduction contractures of hip
Pelvic torsion
Treatment of leg length discrepancy of 0-2 cm
No treatment necessary
Treatment of leg length discrepancy of 2-6 cm
Shoe lift, epiphysiodesis, shortening or leg lengthening
Treatment of leg length discrepancy of 6-20 cm
Lengthening (possible combined with other procedures)
Treatment of leg length discrepancy of over 20 cm
Prosthetic lifting
Which imaging test is used to assess leg length discrepancy
Scanogram - x ray with ruler to measure lenght of long bones
When adolescent patient presents with knee pain what are the things you should be concerned about
HIP PATHOLOGY - especially slipped capital femoral epiphysis
Physeal fractures
Tumors - night pain is very concerning
Patellofemoral syndrome is also called _
patellar chondromalacia
Patellofemoral syndrome is most common in _
Adolescent girls
In patellofemoral syndrome pain is localized to _
anterior knee
In patellofemoral syndrome patient experiences locking and feeling of knee giving way - T/F
FALSE - no locking and giving way
In patients with patellofemoral syndrome pain gets worse with _
Stairs, walking hills and weather changes
Which test is positive in patellofemoral syndrome
Patellar grinding test
In patellofemoral syndrome you need to strengthen _ and stretch _ (muscles)
Strengthen quads
Stretch hamstrings
Which exercises are best in patients with patellofemoral syndrome
Exercises with knee in nearly full extension - shallow squats, terminal extension weights, bike riding with seat fairly high
What are recommendations for patients with patellofemoral syndrome
Avoid deep knee bends and stairs
Decrease force across patella
NSAIDS for symptoms
Osgood Schlatters disease is a childhood equivalent of _
Patellar tendonitis
Describe Osgood Schlatters disease
In growing adolescents proximal tibial apophysis is weak and susceptible to overuse injuries - microfractures with elevation of tubercle and bursitis
Treatments for Osgood Schlatters
-Decrease activity during periods of severe pain
- Severe pain improves with rest
- Ice knees after vigorous activity
- Hamstring stretching
- NSAIDS periodically
Patients with Osgood Schlatters have slight predisposition toward
Tibial tubercle fractures
Why can small avulsions occur in Osgood Schlatters
Quadriceps pulls on tibial apophysis
Osgood Schlatters is most common in _
11-14 year old boys
Triad of symptoms for diagnosis of patellar subluxation
Hurts anteriorly
Gives way
Positive apprehension test
Osteochondritis dessicans is AVN of _
Medial femoral condyle
Osteochondritis dessicans can lead to _
Osteochondral fractures
Chondral flaps
Chondral separation
Loose joint bodies
Common cause for meniscal surgery in children
Discoid lateral meniscus
With discoid lateral meniscus patients experiences
Snapping in lateral aspect of knee and occassional blocking of extension
Children are more likely to have _ then ligamentous injuries
Physeal injuries
When patient presents with bowed legs always keep in mind _
Dwarfism and metabolic disorders
Tibia vara is also called _
Treatment -
Diagnosis -
Blounts disease
Treatment - surgery and bracing
Diagnosis - x rays
Difference between tibia vara and physiological genu varum
Genu varum is normal, tibia vara only gets worse and leads to early DJD
Patient present with pain out of proportion to injury and pain on passive stretch, it is a surgical emergency - what is the diagnosis
COMPARTMENT SYNDROME
If child isnt walking independently by 24 months what do you need to do
Refer for evaluation of significant developmental delay to orthopedic surgeon or neurologist
Child should be able to do reciprocal crawling by what age?
6-9 months
If primitive reflexes persist in child what can it indicate
Cerebral palsy
Hand grasp reflex tests _
Extuinguishes by_
Tone of upper extremity flexors
2-4 months
Plantar grasp reflex - describe
Extuinguishes by _
If persists indicate _
Tonic flexion and adduction of toes when stroked on bottom of foot
Extuinguishes by end of 1st year
If persists - developmental delay, birth injury
In Moro reflex baby _ when startled
Extends all 4 extremities
Persistence of Moro reflex after 6 months indicates _
Cerebral palsy
Moro reflex is decreased or absent in _
Floppy baby syndrome
Asymetry of Moro reflex indicates _
Peripheral nerve injury or cerebral palsy
Stepping reflex in baby should disappear by _
1-2 months
Placing reaction (baby lift foot and steps when brought to edge) persists until _ and its absence indicates _
12 months
Brain damage
In crossed extension reflex pressure is applied to _ and opposite leg _ and toes _
Inguinal area

Flexes, adducts, extends

Fan
Crossed extension reflex should disappear by _ and if it persists it indicates _
1 month

partial spinal lesion
In asymmetric tonic neck reflex, baby is lying on the side and head is rotated to the side , arm and leg on chin side should _ , and on occiput side should _
Extend

Flex
Asymmetric tonic neck reflex should persist until _ and if it persists after that indicates _
4-6 months

Cerebral palsy - contributes to neuromuscular scoliosis in those kids
Which reflex appears at 6 months and persists throughout life and its absence indicates brain damage
Parachute reaction - when held at stomach extends arms as if to break fall (diminished response indicates hypertonicity in upper extremities)
In plain films in kids _ and _ is not visible
Non ossified bone and cartilage
Characteristics of toddlers gait
- Wide base
- Little arm swing
- Short stride length
- Higher center of gravity
- Little ground clearance
- Mild foot drop
Center of gravity in gait of adult is _
Anterior to S2
Requirements of gait
Stability in stance
Clearance in swing phase
Appropriate swing phase repositioning
Adequate step length
Conservation of energy
Toeing out during walking can indicate _
External hip rotation
External tibial torsion
Calcaneovalgus
Vertical talus
Pes planus
Toeing in during walking can indicate
- Internal femoral torsion
- Internal tibia toria
- Metatarsus adductus
- Equinovarus deformities
Multiple epiphyseal dysplasia presents with progressive _ deformity, DJD, pain and altered mechanical axis
VALGUS
Differential diagnosis for valgus
- Post traumatic/post infection partial growth arrest
- Salter II fracture of proximal tibia
- fibular hemimela
- Genu recurvatum
- Physiological genu valgum in adolescents
Achondroplasia causes varus/valgus deformity
VARUS
Differential diagnosis for varus
- Blounts disease
- Skeletal dysplasia
- Fibrocartilaginous dysplasia
- Fibrous cortical tether of distal femur
- Rickets
- Post traumatic/post infection partial growth arrest
- Combination of external femoral rotation and internal tibial torsion
- Tibial bowing
In positive Trendelenburg test which muscle is weak
Gluteus medius
What happens to knee when patient has weak quadriceps femoris
It locks
During walking patient is unable to push off with toes which results in calcaneus gait and tibia shifts posteriorly over talus in last portion of stance phase - which muscle is weak in this patient
Gastrocnemius - soleus
Patient has steppage gait to clear foot through swing phase, patients externally rotates foot and lifts foot higher - which muscles are weak
Dorsiflexors of the foot
Patients weightbearing is shortened during stance on affected side to relieve or lessen pain - this gait is called _
Antalgic
Most common form of polydactyly
Small nubbin on lateral border of foot (postaxial), may have a nail
What treatment is indicated in polydactyly
Surgical to ensure comfortable foot wear
Syndactyly is caused by _
Failure of programmed cell death
Syndactyly usually occurs _ where
Between 3d and 4th toes - skin only, partial webbing
Surgical intervention is medically necessary in syndactyly
no, cosmetic - shoe fit generally not a problem
4 types of syndactyly
Complete - webbing entire length of digit
Incomplete - webbing partial length of digit
Simple - soft tissue union
Complex - boney union
In metatarus varus (adductus) medial border of the foot curves _
Inward
With any packaging defect you should also check _
hips
Etiology of clubfoot deformity
Idiopathic
Packaging defect
Arthrogryposis
Myelodisplasia
Hereditary
With clubfoot deformity you also check _ and _
Hips for dysplasia or instability
Spine for sacral cleft, dimples and hairy patches
Signs of clubfoot
- Adductus of forefoot
- Varus of hindfoot
- Posterior and medial creases
- Supination of mid and forefoot
- Empty heel pad
Vertical talus is also known as _
Rockerbottom foot - rigid foot, cannot plantarflex, can palpate head of talus on plantar foot
Cleft foot is caused by _
Central failure of formation
Goal of treatment of cleft foot is _
Comfortable shoe wear
Flat foot is called
Pes planus
Which arch is flattened in pes planus - what else is abnormal
Longitudinal
Hindfoot valgus
Subluxation of talonavicular joint
Which type of pes planus is painful and should be refered to orthopedic surgeon
Rigid
3 types of tarsal coalitions
Syndostosis - bone coalition
Synchondrosis - cartilage coalition
Syndesmosis - fibrous coalition
Increased height of longitudinal arch is called _
Cavus/cavovarus
X rays are high/low energy
HIGH - only gamma rays are higher
X rays are measured in _
Roentgens
Radiopacity is dependent on 3 factors - what are they
Atomic number
Physical density
Thickness
With any packaging defect you should also check _
hips
Etiology of clubfoot deformity
Idiopathic
Packaging defect
Arthrogryposis
Myelodisplasia
Hereditary
With clubfoot deformity you also check _ and _
Hips for dysplasia or instability
Spine for sacral cleft, dimples and hairy patches
Signs of clubfoot
- Adductus of forefoot
- Varus of hindfoot
- Posterior and medial creases
- Supination of mid and forefoot
- Empty heel pad
Vertical talus is also known as _
Rockerbottom foot - rigid foot, cannot plantarflex, can palpate head of talus on plantar foot
Cleft foot is caused by _
Central failure of formation
Goal of treatment of cleft foot is _
Comfortable shoe wear
Flat foot is called
Pes planus
Which arch is flattened in pes planus - what else is abnormal
Longitudinal
Hindfoot valgus
Subluxation of talonavicular joint
Which type of pes planus is painful and should be refered to orthopedic surgeon
Rigid
3 types of tarsal coalitions
Syndostosis - bone coalition
Synchondrosis - cartilage coalition
Syndesmosis - fibrous coalition
Increased height of longitudinal arch is called _
Cavus/cavovarus
X rays are high/low energy
HIGH - only gamma rays are higher
X rays are measured in _
Roentgens
Radiopacity is dependent on 3 factors - what are they
Atomic number
Physical density
Thickness
Higher atomic number more/less radiopaque?
More radiopaque
Air less dense so it appears _
Black - radioluscent
Fluid and soft tissue is more dense so it appears _
Grey/radiopaque
Thicker substance is more/less radiopque
More radiopaque
When two tissues/objects overlap, how do they appear on film
Additive - appear more white
Which tissues have same radiopacity
Soft tissue and fluid
Fat is more lucent then _ but more opaque then _
Bone/soft tissue

Gas
Most radioluscent material visible on film
GAS
Most opaque shadow seen on radiographs
Metal
In x ray machine there is electrode pair - cathode and anode, cathode is _ , anode is _
Cathode - heated element
Anode - tungsten plate or beam
How x ray works - free electrons from _ collide with _ - knocking an electron out of _ . A _ fills gap releasing energy as x ray photon.
Heated cathode
Tungsten atom
Lower orbit
Higher orbit electron
95% of electron energy is deposited as _ , 5 % generates _
Heat on anode

x rays
1 gray equals _
100 rads
How do you protect from radiation
Reduce time of exposure
Increase distance from radiation source
Provide radiation shielding
Where should you view radiographs
Darkened quiet room with at least two viewing boxes and good illuminator
You always need two orthogonal projections when viewing x rays - T/F
TRUE
Radiographic views are named according to _
Direction primary beam enters and leaves tissues and body part being examined
Digital radiography uses _
photostimulable phosphor plate and image reader-writer
Computed tomography is _ rotated around patient
Fanned x ray beam
Compute tomography uses _ to display as image
Mathematical measurements of transmissions at various angles
How does ultrasound work
Sound waves are sent through patient and returning echo is recorded as image
Resolution of images in ultrasound depends on _
Wavelength and frequency of waves
Low frequency ultrasound has _ wavelength, _ resolution, _ depth of penetration
Longer

Less

Greater
High frequency ultrasound has _ wavelength, _ image detail and superior for _
shorter

greater

orthopedic views of ligaments and tendons
What is the origin of signal used in generation of MRI images
Proton (hydrogen nucleus)
What is the feature exploited in detecting NMR signal in MRI
Magnetic moment (spin) of H nucleus when placed in strong external magnetic field
In MRI response of excited proton is measured when _
Second (RF) signal is applied to small slice of scan
T1 MRI image measures energy released as _
Proton exposed to RF signal realigns to magnetic orientation
T2 MRI image measures energy transmitted by _
Wobbling effect of protons that have been exposed to RF signal (they are out of phase and release energy as they become in phase)
Every tissue has same T1 and T2 property on MRI - T/F
FALSE - every tissue has unique T1 and T2 property (can have same T1 but different T2, or same T2 but different T1)
Normal and strained muscle have same appearance on _ , but different on _ (T1, T2)
Same T1

Different T2
Fat and muscle have same appearance on _, but different on _ (T1, T2)
Same T2

Different T1
When radioisotope localizes in skeleton, _ is measured and recorded
Gamma radiation
First isotope used clinically for bone scannin
Strontium 85
Which isotope has shorter half life then Strontium 85 but poor soft tissue clearance
Strontium 87
Which isotope has short half life (excreted in urine after 4 hours) and binds to _ in bone
Technetium - binds to Ca in bone
Which isotope used to tag WBC's
Indium
Which isotope impregnates into Ca hydroxyapatite crystals uptake in neutrophils and bacteria
Gallium 67
Which isotope doesnt require in vivo use
IgG labeled
Factors affecting uptake of isotopes
Bone turn over rate
Blood flow to area
Trauma
Time isotope is in system
Example of metabolic imaging is _
PET scan
PET scan is best to use for detection of _
Soft tissue neoplasms or osseous metastases
What is the name of tracer used in PET scans
2-deoxy-2-fluoro-D-glucose
What does PET scan measure
Glucose utilization by tissue
PET scans can be combined with _ for precise imaging
CT scans
DEXA scan stands for _
Dual energy x ray absorption
DEXA scan measures absorption of _ and compares to _
2 beams of radiation into hip and spine

standard
DEXA scan calculates _ and uses them to identify if patient has _
T scores

Osteopenia or osteoporosis
If you need cross sectional capability which imaging modality would you choose
CT scan
For early detection of fracture or infection and degree of involvement, imaging modality that you would choose would be _
Bone scan
For identification of bone contusions, articular cartilages, relationships of neurovascular structures to other anatomy which imaging modality would you choose
MRI
For identification of fluid filled tissue and vascular supply imaging modality of choice is _
Ultrasound
What is the best therapy of ankle sprain
PT with emphasis on proprioceptive training
How do you diagnose Achilles tendon rupture
Local tenderness/swelling
Palpable defect
MRI/ultrasound
Inability to plantar flex foot
Thompson test detects _
Achilles tendon rupture
Describe Thompson test
When you squeeze calf - foot will normally plantar flex - in Achilles tendon rupture that doesnt happen
With medial gastrocnemius/plantaris muscle tear pain is more _
proximal, mid to upper medial calf
Will Thompson test be negative in plantaris muscle tear as well
NO - positive - squeeze calf and foot plantar flexes
Which orthopedic condition of foot is most underdiagnosed and unrecognized
Posterior tibial tendon insufficiency = "acquired flatfoot"
"Too many toes" sign is sign of _
Posterior tibial tendon insufficiency
Patient presents with pain in medial malleolus, unable to stand on toes Diagnosis?
Posterior tibial tendon insufficiency
Patient complains of morning pain in foot (1st few steps extremely painful) - what should you immediately consider
Plantar fasciitis
What is main treatment of plantar fasciitis
Participation to tolerance
Jones fracture is a fracture of _
Base of 5th metatarsal - at metaphyseal-diaphyseal junction
Acute Jones fracture shows _ on x ray
sharp margins
Non unions are very common with Jones fracture - T/F
TRUE
Patient presents with compression, pain between fingers - what should you immediately be considering
Mortons neuroma
What is key distinction of claw toes
Marked hyperextension of MTP joints
Knee swelling within 4-6 hours of injury indicates _
Hemarthrosis
Fat globules in the blood on aspiration indicate _
Fracture
If aspirate has cloudy appearance you should think about _
Infection
String sign means _
Viscosity of aspirate - indicates infections
Patient presents with knee effusion with joint pain, warmth, erythema and swelling, what should be you first suspicion
Infection
What is the location for aspiration of the knee
Superior lateral pole of patella
Patient presents with pain, snapping, swelling, stiffness, decreased ROM, feeling of instability and locking of the knee- diagnosis
Torn meniscus
Patient presents with acute meniscal tear - what is the probable mechanism of injury
Twisting injury with foot planted
Which symptom is not present in chronic meniscal tear
Knee locking
You examine patient with torn meniscus - what would you find
Pain at joint line
Positive McMurrays test
Popping or catching of knee
Knee locking
Swelling and stiffness
Differential diagnosis for meniscal tear
Ligamentous injury
Loose bodies
Osteochondritis dissecans
How would you treat torn meniscus
Arthrotomy
PT
Meds
Patient presents with post traumatic pain and swelling, knee feels unstable and there is immediate effusion - what does this patient have?
ACL rupture
Over 70% of patients presenting with immediate effusion have _
ACL rupture
Patient presents with ACL tear - what is possible mechanism of injury
Hyperextension or deceleration injury
Patient presents with chronic knee instability after old injury - what should you be thinking
ACL with posterior medial meniscal horn tear
Which test is most sensitive for ACL tear
LACHMANS
You suspect patient has ACL rupture what test would you do ?
Anterior drawer test
Pivot shift test
Lachmanns test
Differential diagnosis for ACL tear
PCL, MCL, meniscal injury or combination
Which procedure usually fail in treatment of ACL rupture
Primary repair
Which surgical procedures are used in treatment of ACL tear
Grafts (auto/allografts)
Radiofrequency heat
Simple debridement
Patient presents with PCL tear - what is probable mechanisms of injury
High energy trauma - dashboard, posterior force on anterior tibia
Patient presents with palpable deformity of the knee and the knee is flexed - what is possible diagnosis
Patellar dislocation
Over 90% of patellar dislocations occur _
Laterally
You evaluate patient for patellar dislocation - which test is positive?
Apprehension
Patient has patellar dislocation what is your treatment plan
Reduction
Immobilization
Braces
Arthroscopic procedure
Open procedures (realignment)
Patient presents with pain around knee cap,no history of injury, crepitance and increased pain when going up the stairs - what is most likely diagnosis
Patellofemoral syndrome (chondromalacia)
You examine patient with patellofemoral syndrome - which tests would you perform
Patellofemoral grind test
Clarks test - compression of patella with contraction of quads
Lateral J sign - lateral movement of patella in extension above trochlear groove
Differential diagnosis of patellofemoral syndrome
Patellar malalignment
Osteoarthritis
Osteochondritis dissecans
Plica syndrome
Patient presents with patellofemoral syndrome - what are surgical options of treatment
Chondroplasty
Lateral release
Open realignment
Patellectomy
Patient presents with painful and swollen prepatellar bursa and increased temperature - diagnosis?
Prepatellar bursitis
Patient presents with collateral ligament tear - what do you find on exam
Pain
Instability
Effusion
Locking
You evaluate patient for collateral ligament damage and see calcifications on x rays due to old MCL tear - what is your diagnosis
Pellegrini-Stieda disease
What is differential diagnosis for collateral ligament rupture
ACL rupture
Meniscal injury
Tibial plateau fracture
Patient presents with pain and swelling, popping and locking of the knee - further tests find necrosis of subchondral bone - diagnosis
Osteochondritis dissecans
Which x ray do you order in evaluating patient with osteochondritis dissecans and what would you commonly see
Tunnel view - lesion on lateral aspect of medial femoral condyle
Differential diagnosis for osteochondritis dissecans
ACL rupture
Meniscal injury
Most common cause of loose bodies in the knee
Osteochondritis dissecans
The conservative treatment of osteochondritis dissecans would include
long leg casting
What are the surgical treatments of osteochondritis dissecans
In situ pinning
Debridement
OATES
Drilling/microfracture
Removal of free fragment
Autologous cartilage transfer
What is the best surgical procedure for treatment of osteochondritis dissecans
OATES - take pieces of HA and implant
Patient presents with knee pain and states that it only hurts with weight bearing and doesnt with rest, he also has deformity, decreased ROM, swelling and crepitance/catching of the knee - most likely diagnosis is _
OA of the knee
Most common location of OA of knee is _
Medial femoral condyle
You order weight bearing x ray on patient with OA of knee - what would you see
Density changes on xray - sclerotic bone due to OA, medial femoral condyle space is collapsed, lateral widened
Differential dx for OA of knee
Torn meniscus
Hip pathology
Chondromalacia
Conservative treatment of OA of knee would include
PT
Meds
Injections
Assistive devices
Surgical options for treatment of OA of knee
High tibial osteotomy
Unicompartmental knee replacement
Total knee replacement
Sport with highest percent of reportable and high severity injuries
Female gymnastics
Most common site of injuries in sports in both men and women
Knee and ankle
Patient is taking a banned drug which was banned because it causes liver damage, it significantly increases androgenic plasma serum levels, however patient reports increased psychological and physical well being, you advise patient that drug increases risk of uterine and prostate cancer and also can cause hirsutism, gynecomastia, liver disease and virilization
What is the name of the drug patient is taking
DHEA
DEHYDROEPIANDROSTERONE
Patient is taking a banned drug, his endogenous testosterone is increased (300 mg/day) - what is the name of drug he is taking
Androstendione
Patient is taking banned drug, he reports increase in muscle mass and delay in fatigue - name of drug and mechanism of action
CREATINE - increases formation of ATP
Patient is taking a nutritional supplement that is banned in sports - he reports increased muscle mass and increased rate of recovery after strenuous exercise -what is the name of supplement and what is is a metabolite of
Beta-hydroxy or beta-methylbutyrate - metabolite of leucine
Human growth hormone is restricted in sports because it _
Increases type II fast acting muscle fibers and decreases fat
Which drugs are restricted in sports
Diuretics
beta blockers
Human growth hormone
Why is EPO banned in sports
Increases RBC mass (natural hormone produced by kidney)
Men have higher RBC counts - T?F
T
Women have significantly higher rates of injury of _
Knee (ACL, collateral ligament, meniscus)
Stress fractures are more common in men/women?
Women - poor nutrition,menstrual irregularities
Your female patient is young athlete, she refuses to maintain normal weight, has intense fear of weight gain, disturbed body image and 3 consecutive months of amenorrhea - diagnosis
Anorexia nervosa
Patient has anorexia nervosa - what would you find on exam
Amenorrhea
Fat and muscle loss
Dry hair and skin
Lanugo
Cold discolored extremities
Decreased body temp
Dizziness
Bradycardia
Young female athlete presents with complain of recurrent binge eating, over eating and sense of loss of control, she has recurrent compensatory vomitting and abuses laxatives, she also engages in fasting and over exercise and has negative self image - diagnosis?
Bulimia nervosa
Female athlete triad
Amenorrhea

Eating disorder

Osteoporosis
Pregnant patient asks you if she can continue exercising with pregnancy You give following advice
maternal heart rate should not exceed _ , strenuous activities should not exceed _ minutes, she should avoid _ maneuver and _ exercise after 4th month, she needs to increase _ and maternal core temp should not exceed _
140 beats per min

15 min

valsalva

supine

caloric intake

38 degrees C
In young athletes under 12 which shoulder injuries are more common
Fractures (dislocations are rare)
Little league shoulder is stress reaction to _
Proximal humeral epiphysis (widening and microfracture)
Microinstability in pediatric shoulder leads to _
Labral tears
Little league elbow includes _
Medial epicondylar apophysitis
Lateral joint compression
OCD of capitulum
Ulnohumeral chondromalacia
Madelungs deformity is _
Shortened and deformed distal radius
Pediatric wrist injuries in sports are common among
Weight lifters and gymnasts
47% of all low back pain in young athlete is due to _
Spondylolysis
Spondylolysis occurs due to excessive repetitive _
hyperextension
Young athlete presents with snapping pain in hip with external rotation - what are the possible causes of his condition
Tight iliopsoas, bursitis, inflammation
Young athlete presents with painful snapping at greater trochanter - diagnosis
Snapping iliotibial band
Young athlete presents with posterior heel pain - differential diagnosis?
Severs apophysitis
Achilles tendonitis
Plantar fasciitis
AVN of navicular bone is called _
Kohlers disease
AVN of 2nd metatarsal head is called _
Friebergs disease
Patient presents with acute onset of muscle soreness which occured during unaccustomed exercise, its accompanied by weakness and easy fatiguebility - diagnosis and probable location
Muscle strain - muscle tendon junctions
Treatment of muscle strains
RICE + NSAIDS
Patient complains of pain in lower leg that is brought by exercise and relieved with rest - what is diagnosis, why occurs and possible complication
Chronic exertional compartment syndrome - fascia does not accomodate increased swelling and blood flow, can progress to typical compartment syndrome (watch for 6 P)
In tendon overuse injuries type _ collagen is replaced by type _
Type I by type II
Physical therapy modalities that both use cortisone cream and bring into tissue by electrical stim or sound waves
Iontophoresis
Phonophoresis
Patient presents with loss of consciousness after trauma on field, he also experiences retrograde amnesia, tinnitis, blurred vision. He has headache and has trouble concentrating. He complains of nausea, vomitting, disturbed balance, excessive sleep and depression- diagnosis
CONCUSSION
In concussion _ is disrupted which causes stretching of _ . This results in opening of _ channels. Extracellular increase of _ leads to release of _ amino acids which leads to influx of _ to cell which causes neuron injury and death - cerebral blood flow _
Neuronal cell membrane
Axons
Potassium
Potassium
Excitatory
Ca
Decreases
Football player presents 2 days post concussion with headache, slower reflexes, impaired memory and concentration, depression and excessive sleep - diagnosis
Post concussion syndrome
Post concussion syndrome is caused by _
Continued NT dysfunctions
Patient is an athlete who has sustained initial head injury, returned to play while still symptomatic and sustained second head injury.Second head injury resulted in loss of cerebral autoregulation, cerebral vascular congestion, increased intracranial pressure and brain herniation - diagnosis
Second impact syndrome
Patient presents after trauma - he didnt lose conscioussnes and had post traumatic amnesia for less then 30 minutes - he has concussion grade _
When can he return to play
I
Can return if asymptomatic for one week (if completely asymptomatic can return same day)
Patient sustained trauma, lost consciousness for less then 5 minutes and had post traumatic amnesia for more then 30 minutes, he has concussion grade _
When can he return to play
II
Can return to play when asymptomatic for one week
Patient has sustained trauma during play, he was unconscious for more then 5 minutes and had post traumatic amnesia for more then 24 hours. He has concussion grade _
When can he return to play
III
He may not return to play for at least one month - can return then if asymptomatic for one week
Mildest form of heat injury
Heat cramps
Patient presents with painful muscle cramps and spasms that occured after intense exercise in high heat, he has mild fever (less then 102) - diagnosis and how would you manage it
Heat cramps - move to cold place and rest, fan patient, give cool sports drinks and stretch cramped muscles
Patient presents with muscle cramps, nausea and vomitting and high fever (over 102), you diagnose patient with heat exhaustion - what is management?
This occured due to loss of electrolytes and water due to excessive sweating - move to cool place and rest, remove excessive clothing, give cool sports drinks, if no improvement give IV fluids
After being several hours in heat patient presents with high fever over 104, warm dry skin, he is confused, lethargic - diagnosis, is condition serious and how do you treat it
LIFE THREATENING - HEAT STROKE - patient can progress to stupor, seizures, coma and death, bodys heat regulation system is overwhelmed - need to move to cool place, call 911, remove excessive clothing, fan, drench skin with cool water, place ice bags in armpits and groin, give cool fluids if alert or IV fluids if not, and monitor urine output
Landmarks for hip PE
Greater trochanter
ASIS
Iliotibial band
Ischial tuberosity
Gluteal muscle mass
Hip adductors
Ober test evaluates _
Contraction of iliotibial band and fascia lata
Thomas test test for _
flexion contractures
How do you measure true leg length
Measure from ASIS to medial malleoli, then while supine flex knees and place feet together, judge knee discrepancies for tibial vs femoral length discrepancies
Flexion of knee
120 degrees
Extension of knee
180 degrees
External rotation of knee
507 degrees
Landmarks for evaluation of knee
Patella
Tibial tubercle
Patellar tendon
Adduction tubercle
Fibular head
Popliteal space
Popliteal artery
Suprapatellar pouch
Medial and lateral femoral condyles
VMO
Apprehension sign checks to see if patella is prone to _
Lateral subluxation or dislocation
Drawer test evaluates _
ACL and PCL
How is Lachman test different from anterior drawer
Leg flexed approximately 20 degrees
Clark maneuver tests for _
Patellar grind
Apley compression test - patient is _ (prone/supine) with one leg _ to _ degrees - perform downward compression and _ - elicits pain
Prone
Flexed to 90 degrees
Internal/external rotation
Mcmurray test includes _
Valgus stress and external rotation - take from flexion to extension
Varus and valgus stress tests are done at _ degrees of flexion and check for _
30 degrees

MCL, LCL
Ankle plantar fkexion _ degrees
dorsal flexion _ degrees
50

20
Which pulses do you measure on foot
Dorsalis pedis
Posterior tibial
To perform Ober test you place patient in _ position, _ knee, let knee drop - if knee stays abducted it demonstrates tight _
Lateral position
Abduct knee
Iliotibial band or fascia lata
In Thomas test you place patient _ , _ hip to 90 degrees and try to _ opposite extremity
Supine
Flex
Extend
Internal/External rotation of knee
10 degrees
Q angle
Line from ASIS to center of patella, then second line from patella to tibial tubercle
Anterior drawer test of the ankle assesses
stability of anterior talofibular ligament
How do you test for pes planovalgus
Look from behind for "too many toes", also look at arch height, compare both sides
Finkelstein tests for what disease
deQuervains disease - active and passive ulnar deviation of wrist
Thumb grind test tests for _
OA at base of thumb
When testing for Froment sign you ask patient to _
hold paper between thumb and index finger
Adsons test should show what_
Radial pulse and tingling with shoulder abduction
Spurling test
Head tilted and rotated then downward pressure - facet and nerve root impinges
Biceps reflex level
C5
Brachioradialis reflex level
C6
Triceps reflex level
C7
Biceps innervation level
C5-C6
Triceps innervation level
C7
Wrist flexion innervation evel
C7
Wrist extension innervation level
C6
Shoulder abduction (deltoid)innervation level
C5
Patellar tendon reflex level
L4
Achilles tendon reflex level
S1
Which root has no reflex
L5
Toe extension innervation level (extensor digitorum longus)
L5
Foot eversion (fibular tendons) innervation level
S1
Anterior tibialis muscle innervation level
L4
Sensory level for medial side of leg
L4
Sensory level for lateral leg to dorsum of foot
L5
Sensory level of lateral foot
S1
When you ask patient to toe walk what root are you testing
S1
When you ask patient to heel walk what root are you testing
L4-L5
Lasegues straight lef lifting test suggests _
Nerve root irritation (pain shoots down leg)
Contralateral Lasegues tests _
hip
Straight leg drop test tests _
pull of iliopsoas (hip pain)
Patrick test differentiates hip disorders from _
SI pain
Gaenslens sign is indicative of _
How is it done
SI pain - done by droping leg off table
Mennel sign is done in what position
PRONE (extended leg)
Patient presents with loss of sensation on medial leg, EMG showed fibrillation of sharp waves in tibialis anterior, myelogram shows bulge in spinal cord adjacent to disc L3-L4
What is the root involved?
Reflex?
Root L4
Reflex Patellar
Muscle - tibialis anterior
Patient presents with loss of sensation in lateral leg and dorsum of foot, EMG shows fibrillation of sharp waves in extensor hallucis longus,myelogram shows bulge in spinal cord adjacent to disk L4-L5
Root ?
Muscles?
Reflex?
Root L5
Muscle - extensor hallucis longus (also extensor digitorum longus and brevis, medial hamstring, gluteus medius)
No reflex (tibialis posterior)
Patient presents with loss of sensation in lateral foot, EMG shows fibrillation of sharp waves in peroneus longus and brevis, myelogram shows bulge in spinal cord adjacent to disc L5-S1
Root?
Reflex?
Other muscles involved
Root S1
Reflex Achilles tendon
Other muscles - flexor hallucus longus, gastrocnemius, lateral hamstringm gluteus maximus
Most common level of herniation
L5-S1
Drop arm sign tests for _
how is it done
Patient unable to hold arm abduction 90 degrees against gravity - tests for rotator cuff injury or tear
Lift off test tests for _ how is it done
Tests for rotator cuff tear - put patients dorsum of hand on back - unable to lift off against resistance
In Apley scratch test you ask patient to _
Indicates _
touch contralateral superior medial corner of scapula
Indicates rotator cuff pathology particularly superspinatus
In Neer impingement sign examiner _
stands behind patient and immobilizes scapula then jerks arm into forward and upward position
Yergasons test evaluates function of _
How is it done
long head of biceps
Arm beside trunk and flexed 90 degrees at elbow, patient supinates against resistance
Anterior apprehension sign is done _ while posterior apprehension sign is done _
Anterior - seated
Posterior - supine
Anterior and posterior drawer tests of shoulder test for _
Instability
Thompsons test of elbow indicates _
How is it done
Lateral epicondylitis
Dorsiflex wrist with elbow and wrist on extension
In Golfers elbow sign you ask patient to _
Extend flexed elbow against resistance
Reverse Cozen test tests for _
How is it done
Medial epicondylitis
With arm supinated patient flexes and extends elbow against resistance
Hip joint type
Synovial ball and socket
Hip joint involves articulation between _ and _
Head of femur and acetabulum of os coxa
Hip socket is deepened by _ ligament and _
Transverse acetabular ligament (spans opend end of acetabulum) and acetabular labrum (fbrocartilaginous rim attached to bony rim of acetabulum and transverse acetabular ligament)
Capsule of hip joint has 2 attachments _
superior and inferior
Superior - brim of acetabulum near labrum and transverse acetabular ligament
Inferior - anteriorly to intertrochanteric line and junction of neck of femur with trochanters, posteriorly posseses free (unattached) border that covers approximatley 2/3 of proximal femoral neck
Hip capsule is constructed of two laminae of fibers _
Superficial lamina - longitudinally oriented fibers which limit movement of limb in specific direction
Deep lamina - "zona orbicularis" - provides "screw home" effec between head of femur and acetabulum - greatly enhances hip joint stability
Hip ligament that assumes position of inverted Y, attaches superiorly to AIIS and inferiorly to intertrochanteric line - name of ligament and which way is it tightest in?
ILIOFEMORAL LIGAMENT - tightest in extension
Ligament that forms medial inferior portion of hip capsule, attaches medially to brim of pubic portion of acetabulum and obturator crest of superior pubic ramus and laterally to neck of femur near lesser trochanter - name of ligament - it becomes tight in _ and limits _
PUBOFEMORAL LIGAMENT - becomes tight in extension and limits abduction
A gap between _ and _ ligaments anteriorly and inferiorly, covered by _ and its bursa - (iliopectineal bursa)
Iliofemoral and pubofemoral
Psoas major
This ligament is attached posteriorly to ischial portion of acetabulum, laterally to neck of femur medial to root of greater trochanter, fibers are spiral and form posterior free margin of capsule
This ligament becomes tight in _
Ischiofemoral ligament
Becomes tight in extension
Ligamentum teres capitis femoris is _ ligament
This ligament limits _
Intracapsular
Adduction
Blood supply to hip joint
Lateral and medial femoral circumflex arteries
Superior and inferior gluteal arteries
Obturator artery provides branch to head of femur via ligamentum teres capitis femoris
Which rotation of hip is greater - lateral or medial
Lateral
Knee joint type
Synovial, modified hinge joint (modified because it does allow some rotation)
Knee joint is joint between _ and _
Femoral and tibial condyles and femur with patella
How is knee joint supported
Muscular attachments
Capsular ligaments that cross joint
Intracapsular ligaments
Strong collateral ligaments
Knee capsule is thickest _ where it reinforced with ligaments
Posteriorly
Knee capsule is buttressed laterally by _ and anteriorly by _
Laterally - iliotibial tract
Anteriorly - expansions of fascia lata
Lateral and medial patellar retinacula is expansion of _ muscles
Vastus lateralis and medialis
Oblique popliteal ligament is the expansion of _ muscle
semimebranosus tendon
Arcuate popliteal ligament is an expansion of _ muscle
attachment of biceps femoris to fibular head
2 extracapsular ligaments of knee are _
Ligamentum patellae + collateral ligaments (medial and lateral)
Ligamentum patellae is an extension of _
quadriceps tendon across patella to tibial tuberosity
This knee ligament is broad and thin but tough, it passes from medial femoral epicondyle to upper medial portion of tibia below condyle and attaches to medial meniscus
Medial (tibial) collateral ligament
This knee ligament is "pencil like" cord from lateral femoral epicondyle to head of fibula, it is not attached to lateral meniscus because tendon of popliteus muscle passes between it and capsule of the knee
Lateral (fibular) collateral ligament
Name two intracapsular ligaments of the knee
ACL, PCL
Shape of lateral meniscus is _ , medial _
Lateral - lunar, medial - semi-lunar
_ ligaments attach lateral margins of menisci to margins of tibial plateau
Coronary
Menisci are attached to one another anteriorly via _
Transverse geniculate ligament
Function of menisci
Help cushion joint and stabilize articulation by deepening the articular surfaces
ACL prevents _ when foot is _
Posterior displacement of femur
Firmly fixed
PCL prevents _ when foot is _
Forward displacement of femur
Firmly fixed
Proximal tibiofibular joint is what kind ?
Synovial plane glidng joint
Distal tibiofibular joint is what kind of joint
Fibrous (tibiofibular syndesmosis)
In proximal tibiofibular joint capsule is strengthened by _
anterior and posterior ligaments of head of fibula
In distal tibiofibular joint which ligaments maintain integrity of joint
Interosseous ligament - thickened inferior portin of interosseous membrane
Anterior, posterior and transverse tibiofibular ligaments
Which ligament helps to form "tenon" of talocrural joint (ankle) by extending below the inferior margin of distal talofibular joint
Transverse talofibular ligament
Talocrural joint (ankle) type
Synovial hinge joint
Which motions are possible at ankle joint
Flexion and extension (dorsiflexion and plantar flexion)
Medial ligament of ankle consists of __
Deltoid ligament - anterior tibiotalar, tibionavicular, tibicalcaneal, posterior tibiotalar
Lateral ligament of ankle consists of _
Anterior talofibular
Calcaneofibular
Posterior talofibular
Motions allowed at subtalar joint
Inversion and eversion of posterior portion of foot
Forms highest portion of medial longitudinal arch
Talocalcaneonavicular joint
Talocalcaneonavicular joint is supported by strong _
Plantar calcaneonavicular ligament (spring ligament)
Forms highest portion of lateral longitudinal arch
Calcaneocuboid joint
Calcaneocuboid joint is supported by _
long and short plantar ligaments
This joint identifies line of division between forefoot and hindfoot which allows foot to function securely on uneven (slanting and irregular) surfaces, allowing forefoot to move on hindfoot in plantar flexion and dorsiflexion, inversion and adduction and eversion and abduction
MIDTARSAL JOINT
Tarsometatarsal and intermetatarsal joints are what type
Plane synovial
Metatarsophalangeal and interphalangeal joints are what types of joints
synovial hinge
Which joints increase joint capsule stability in metatarsophalangeal and interphalangeal joints
Plantar and collateral ligaments
3 arches of feet
lateral, medial and transverse
Which foot arch composes a flat rigid component which provides a stable base for upright posture
Lateral arch
Which foot arch composes a higher more resilient curvature that lateral longitudinal arch
Medial arch
Which foot arch includes bases of all metatarsals
Transverse arch
Which ligaments support lateral longitudinal arch
Long and short plantar ligaments
Which ligament supports medial longitudinal arch
Plantar calcaneonavicular ligament
What ties together proximal and distal ends of longitudinal arches
Plantar aponeurosis
Which two muscles provide tendinous attachments to inferior surface of most of tarsal and metatarsal bones thereby forming tendinous sling for support of both longitudinal arches
TIbialis posterior and fibularis longus
Which two muscles provide tendinous attachments to superior portion of longitudinal arches much like cables of suspension bridge
Tibialis anterior and peroneus brevis
When considering support of arches of foot _ support is more important during static balance while _ is greater during active movement
Ligamentous support
Muscular support
Which muscle provides means of feeling or "grasping" surfaces as we stand/walk/run
Flexor digitorum longus
Which muscle provides impetus for each step we take
Flexor hallucis longus
Muscles that extend thigh and flexes leg
Hamstrings
Muscle that extends leg
Quadriceps femoris
Specific muscle that holds patella in place
Vastus medialis
Chief invertors of foot
tibialis anterior and posterior
Chief evertors of foot
Fibularis longus and brevs
Major injury triad with lateral impact to knee
ACL
MCL
Medial meniscus