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132 Cards in this Set
- Front
- Back
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cervical osteoarthritis: signs & symptoms
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pain,
restricted motion, radicular symptoms, numbness/tingling (NT) recurrent “kink in neck” or “slept wrong” |
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HNP: general signs & symptoms
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pain,
numbness/tingling weakness limited ROM, radicular symptoms |
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Reason for HNP symptoms
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nerve compression or irritation
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Symptoms that diagnose C4/5 HNP
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C5 nerve root:
- deltoid weakness - not much numbness/tingling - shoulder pain |
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Symptoms that diagnose C5/6 HNP
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C6 nerve root
- biceps weakness - wrist extensor weakness - numbness/tingling along radial aspect |
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Symptoms that diagnose C6/7 HNP
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C7 nerve root
- triceps weakness - finger extensor weakness - numbeness/tingling along dorsal middle finger |
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Symptoms that diagnose C7/T1 HNP
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T1 nerve root
- grip strength week - numbness/tingling along little finger |
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Conservative treatment options for cervical HNP
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rest, cervical collar, traction
PT NSAIDs or steroids epidural injections |
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Surgical treatment options for cervical HNP
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discectomy +/- fusion
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Stenosis: definition
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narrowing of canal or foramen
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Stenosis: causes
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arthritis,
HNP, dislocation/subluxation, infection |
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3 types cervical fracture
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flexion (most common)
extension compression |
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6 types of cervical orthopedic pathology
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osteoarthritis
HNP stenosis fracture radiculopathy brachial plexopathy |
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Shoulder joints involved in OA
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gleno-humeral joint
acromial-clavicular joint (AC) |
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Impingement in shoulder: definition
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anything that narrows subacromial space (< 7mm on MRI)
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Causes of subacromial impingement
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- subacromial spur, clavicular spur
- coraco-acromial ligament thickening or calcification - hypertrophy of the rotator cuff - loose body - fracture (greater tuberosity) - Os acromiale (ossicles on anterior portion of acromion) - 2° instability |
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Shoulder joint impingement: signs & symptoms
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rotator cuff irritation, tear;
pain, weakness |
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Shoulder joint impingement: conservative treatment
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- rest,
- NSAIDs, - subacromial injection - PT (strengthen lower parts rotator cuff to keep humoral head down in joint) |
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Shoulder joint impingement: surgical treatment
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subacromial decompression:
- arthroscopic or open +/- rotator cuff repair - correct instability |
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2 types of shoulder tears
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traumatic or degenerative
biceps |
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Traumatic/degnerative shoulder tears: locations
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rotator cuff
labrum |
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Biceps tears: types
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traumatic
SLAP tear (superior labrum, anterior to posterior) tenosynovitis biceps instability |
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Shoulder fractures: locations
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humerus,
clavicle, glenoid/scapula |
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Types of shoulder orthopedic pathologies
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Osteoarthritis
Impingement Tears Fracture Calcific tendonitis Thoracic outlet syndrome Reflex sympathetic dystrophy |
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Elbow instability: types
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- ulnar/humeral
- radial head - often in young children - Monteggia fracture --- fx of ulna displaces radial head --- in older children |
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Elbow fractures: locations
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radial head
olecranon distal humerus (supracondylar) ulna |
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2 syndromes 2* impingement of Median nerve
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Anterior Interosseus nerve
Carpal Tunnel Syndrome |
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anterior interosseus nerve
- what - where |
largest branch of median nerve
passes btw 2 heads of pronator teres |
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Impingement of anterior interosseus nerve
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impairment of
- flexor pollicis longus, - flexor digitorum profundus, - pronator quadratus abnormal pinch |
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Most common neuropathy in upper extremity
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carpal tunnel syndrome
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Where is Posterior Interosseus Nerve
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Arcade of Frohse
btw 2 heads of supinator |
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Symptoms of posterior interosseus nerve impingement
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motor involvement only; no sensory
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Ulnar Tunnel Syndrome
- basic presentation - location of nerve |
cubital tunnel – funny bone area
btw flexor carpi ulnaris muscle heads increased stretch with elbow flexion mimics tenous elbow but with NT in small & ring fingers |
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snapping ulnar nerve
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ulnar nerve subluxation
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Hand/wrist ganglion
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anywhere associated with joint
tendon usu. involved synovial fluid – can be aspirated, but will recur usu. cosmetic |
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Hand/wrist ganglion: locations
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wrist most common (90%)
hand tendon related (filled with synovial fluid) |
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Gangion treatments (rate of occurrence)
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aspiration - 50% recurrence
surfical excision – 5-10% recurrence |
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Trigger finger
- definition - signs & symptoms - treatment |
tenosynovitis: inflammation of synovium that surrounds tendon
s/s: pain, swelling, pain moving finger or sticking Tx: cortisone - surgery to release eyelit - recurrent surgeries weaken muscle |
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Why is healing of scaphoid fractures slow?
F/U recommendations |
blood supply distal to proximal
F/U 3-4 weeks s/p initial (-) Xray |
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2 causes of wrist instability
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- SLAC wrist (Scapho-lunate advanced collapse)
- chronic untreated scaphoid fracture or scapholunate dissociation --- dissociation causes “gap-toothed sign” --- can be corrected with fusion or bone grafting |
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3 types of lumbar orthopedic pathology
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arthritis
stenosis fracture |
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lumbar fracture: treatment options
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brace
balloon w/ cement to allow fx site to elevate |
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gross sign on hip fracture
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unilateral leg shortening
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orthopedic pathology characteristic of hip joint over other locations
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avascular necrosis
2* temporary or permament loss of blood supply to femoral head |
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Knee instability: types
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ACL (most common)
MCL PCL multiligament (usu. trauma related) |
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Meniscus injury
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Meniscal tear
- degenerative - buckethandle - horizontal cleavage - radial Discoid meniscus |
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Causes of patellar instability
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may be multifactoria
hip anteversion tight lateral retinaculum lax medial retinaculum OR lax patellofemoral ligament traumatic patella alta hypoplastic trochlea connective tissue disorder (Ehlers Danlos, Marfans, etc) |
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elevated Q angle indicates...?
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mechanical etiology of patellar instability
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Osteoarthritis in the knee: locations
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unicompartmental
patellofemoral multicompartmental |
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Articular cartilage damage in the knee: causes
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osteochondral defect (OCD) – area bare of cartilage, exposed bone
chondromalacia fracture bone bruise |
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Bakers cyst usually indicates what?
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pathology on back of knee joint, e.g.: meniscal tear
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Pigmented Villonodulal Synovitis
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thickened hypertrophy of synovium
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Tendon ruptures of knee:
- which ones? - treatment |
patellar tendon, quad tendon
Tx: immediate surgery |
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LisFranc's injury
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dislocation of LisFranc’s joint (btw 1st & 2nd metatarsal joint)
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Plantar fasciitis
- etiology - signs & symptoms - treatment |
usu. 2° inadequate arch support
pain can flair in morning b/c of toe flexion during sleep Tx: orthotics, esp. splint during sleep |
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Osteomyelitis
- etiology - signs & symptoms - treatment |
most commonly S. aureus
Tx: percutaneous drainage or surgical I&D I.V. ABS x6 weeks |
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Diaphysis
- type of bone - function |
Diaphysis - cortical - stability
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Metaphysis
- type of bone - function |
Metaphysis - cancellous - cushioning
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Cortical bone structure
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comprised of osteons (Haversian systems)
osteons communicate w/ medullary cavity by Volkmann’s canals Haversian system - osteon w/ central haversian canal - central canal contains cells, vessels, nerves - Volksmann’s canal connects osteons |
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Cancellous bone structure
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trabecular or spongy bone
bony struts (trabeculae) oriented in direction of greatest stress |
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3 mechanisms of bone formation
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cutting cones
intramembranous (periosteal) bone formation endochondral bone formation |
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Cutting cones
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primarily a mechanism to remodel bone
osteoclasts at the front of the cutting cone remove bone trailing osteoblasts lay down new bone |
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intramembranous (periosteal) bone formation
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long bone grows in width
osteoblasts differentiate directly from preosteoblasts & lay down seams of osteoid does NOT involve cartilage anlage (precursor) |
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endochondral bone formation
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long bone grows in length
osteoblasts line cartilage precursor chondrocytes hypertrophy, degerate & calcify (area of decreased O2) vascular invasion of cartilage occurs, followed by ossification (increased O2 tension) |
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bone healing: 2 prerequisites
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blood supply
mechanical stability |
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blood supply in long bones: 3 sources
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nutrient artery (intramedullary)
periosteal metaphyseal |
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nutrient artery (intramedullary)
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normally major blood supply for diaphyseal cortex (80-85%)
enters long bone via nutrient foramen forms medullary arteries up and down bone |
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periosteal vessels
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arise from capillary-rich periosteum
normally supply outer 15-20% of cortex can supply much greater proportion cortex if medullary blood supply injured |
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metaphyseal vessels
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arise from periarticular vessels
penetrate the thin cortex in metaphyseal region anastamose with medullary blood supply in adults (in children, physis interrupts) |
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Normal bone blood supply pattern
Fractured bone blood supply pattern |
endosteal/medullary: internal --> external
periosteal/external: external --> internal |
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Mechanical stability in bone healing
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early stability promotes revascularization
after 1st mo., loading & interfragmentary motion promotes greater callus formation mechanical load & small displacements @fx site stimulate healing inadequate stabilization may result in excessive deformation at fx site 2° interruption of tissue differentiation into bone (soft callus) over-stabilization reduces periosteal bone formation (hard callus) |
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3 stages of bone healing
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inflammation
repair remodeling |
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Repair step of bone healing
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periosteal callus forms along periphery of fx site
– intramembranous ossification initiated by preosteoblasts intramedullary callus forms in center of fx site – endochondral ossification at site of fx hematoma callus formation mineralization |
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Remodelling step of bone healing
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woven bone gradually converted to lamellar bone
medullary cavity reconstituted bone restructured in response to stress & strain (Wolff’s Law) |
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Direct bone healing
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occurs when no motion at fx site (i.e.: rigid internal fixation)
NOT involve formation of fx callus steps: (1) cutting cone formed, crosses fx site (2) osteobasts deposit lamellar bone behind osteoclasts – form 2° osteon (3) gradually, fx healed by formation of numerous 2° osteons slow process – months to years (av. 18 months) |
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direct bone healing: contact healing
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direct contact btw fx ends
allows healing to begin w/ lamellar bone immediately |
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direct bone healing: gap healing
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gaps > 200-500 μm primarily filled w/ woven bone
- subsequently remodeled into lamellar bone - larger gaps healed by indirect bone healing |
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Indirect (secondary) bone healing
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occurs when fx not rigidly fixed (more naturally occuring)
bridging periosteal (soft) callus+ medullary (hard) callus re-est structural continuity callus subsequently undergoes endochondral ossification process fairly rapid: 6 – 12 weeks |
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Transforming Growth Factor (TGF)
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superfamily of growth factors
promotes prolif, diff’n mesenchymal precursors for osteoblasts, osteoclasts, chondrocytes - stimulates endochondral and intramembranous bone formation - induces synthesis of cartilage-specific proteoglycans & type II collagen - type II collagen occurs w/ 2° components of healing - stimulates collagen synthesis by osteoblasts |
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Bone Morphogenic Proteins (BMP)
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Osteoinductive proteins initially isolated from demineralized bone matrix
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BMP that induces cell differentiation
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BMP-3 (osteogenin) – v. potent inducer of mesenchymal tissue diff’n into bone
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BMPs that promote endochondral ossification
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BMP-2 and BMP-7 induce in segmental defects
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BMPs that regulate extracellular matrix production
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BMP-1 cleaves C-terminus of procollagens I, II, III
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Fibroblast Growth Factors (FGF)
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acidic form (FGF-1) & basic form (FGF-2)
increase proliferation of chondrocytes and osteoblasts enhance callus formation FGF-2 stimulates angiogenesis |
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Platelet-Derived Growth Factor (PDGF)
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dimer of products of 2 genes, PDGF-A & PDGF-B
stimulates bone cell growth increase type I collagen synthesis by increasing number of osteoblasts PDGF-BB stimulates bone resorption by increasing number of osteoclasts |
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Insulin-like Growth Factor
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stimulates bone collagen and matrix synthesis
stimulates replication of osteoblasts inhibits bone collagen degradation |
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Interleukins important in bone healing
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IL-1 stimulates bone resorption
IL-1 & IL-6 synthesized w/ decreased estrogen |
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Cytokines important in bone RESORPTION
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IL-1
TNF-α TNF-β |
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Cytokines needed for bone resorption & formation
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TGF-β
PDGF |
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Cytokines important in bone FORMATION
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IGF-1
IGF-2 FGF |
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Prostaglandin E: role in bone healing
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stimulate osteoblastic bone formation;
inhibit activity of isolated osteoclasts |
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Leukotrienes: role in bone healing
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stimulate bone formation;
enhance capacity isolated osteoclasts form Howship lacunae |
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Hormones that influence bone healing
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Estrogen
- stimulates fx healing thru receptor mediated mechanism - modulates release of specific inhibitor IL-1 Thryroid hormones - Thyroxine & triiodothryonine stimulate osteoclastic bone resorption Glucocorticoids - inhibit Ca2+ absorption from the gut - causes increased PTH --> increased osteoclastic bone resorption |
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Local anatomic factors that influence healing
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Soft tissue injury
Interruption of local bloody supply Interposition of soft tissue at fx site bone death cause by radiation, thermal or chemical burns, or infection |
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Systemic factors that cause problems with bone healing
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Malnutrition
- causes reduced activity and proliferation of osteochondral cells - decreased callus formation Smoking - cigarette smoke inhibits osteoblasts - nicotine causes vasoconstriction diminishing blood flow at fx site Diabetes Mellitus - associated with collagen defects including: --- decreased collagen content --- defective cross linking --- alterations in collagen sub-type ratios |
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Role of EM field in bone healing
Wolff's Law |
in vitro bone deformation --> piezoelectric currents & streaming potentials
Wolff’s Law – bone responds to mechanical stress -- needs (-) charge for bone healing Exogenous EM fields may stimulate mech. loading & stimulate bone repair clinical efficacy v. controversial |
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Types of clinical EM devices for bone healing
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microamperes
direct electrical current capacitively coupled electric fields pulsed EM fields (PEMF) |
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Fragility fractures
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caused by fall of standing height or less
osteoporosis – most common cause 33-50% of women will get in life time 15-33% of men likelihood increases with ag |
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Vitamin D3 deficiency
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deficiency common with age
lack of sunlight deficiency osteomalacia very common in nursing homes may interfere with fx healing |
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Vitamin D3 dosages
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Young: 400 IU/day
Older: 600-800 IU/day maintenance if deficient: 50,000 IU/week |
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Lab test to diagnose vitamin D deficiency
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1,25 OH Vit D level
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Prevalence of metabolic and vitamin D deficiencies in bone healing problems
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84% all people with problems healing have metabolic or endocrine abnormalities
64% - vit. D deficiency |
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Anatomy unique to skeletally immature bones
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order: epiphysis, physis, metaphysis, diaphysis
physis – growth plate periosteum – thicker, osteogenic, attaches firmly at periphery of physes bone – more pourus, ductile |
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Periosteum in children
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osteogenic
more readily elevated from diaphysis and metaphysis than in adults often intact on concave (compression) side of the injury - may be helpful as a hinge for reduction - promote rapid healing periosteal new bone contributes to remodeling |
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Physeal anatomy: gross
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secondary centers of ossification
primary ossification center – diaphyseal secondary ossification centers – epiphyseal occur at different stages of development girls earlier than boys |
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Physeal anatomy: histologic zones
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reserve zone – matrix production
proliferative zone = cellular proliferation, longitudinal growth hypertrophic zone - subdivided into maturation, degeneration, provisional calcification - location of most pediatric fractures |
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Physeal anatomy: vasculature
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medullary arteries do not anastamose – interrupted by physis
about-face of arteries provides area of turbulence in which bacteria can get stuck |
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Examination of injured child
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assess location of deformity or tenderness
carefully assess and document specifically: distal neurologic and circulatory function radiographic evaulation – xrays |
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xray evaluation of child bony injury
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at least 2 orthogonal views (front/back or 2 sides)
include joint above and below fracture understand normal ossification patterns – comparison radiographs rarely needed |
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Fractures common only in immature skeletons
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physeal injuries – “weak link”
buckle or torus fracture (crushed end) plastic deformation greenstick fracture |
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buckle or torus fracture (crushed end)
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compression failure
stable usu. at metaphyseal/diaphyseal junction |
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plastic deformation
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microscopic failure in bending
permanent deformity can result forearm, fibula common |
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greenstick fracture
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bending mechanism
failure on tension side incomplete fracture – plastic deformation on compression side may need to complete fracture to realign |
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Salter-Harris Classification for pediatric fractures
Type I - Type II - Type III - Type IV - Type V - |
Type I – through physis
Type II – through physis & metaphysis - **most common Type III – through physis & epiphysis Type IV – through metaphysis, physis, epiphysis Type V – crush injury to entire physis |
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Type I & II Salter Harris fractures: treatment
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closed redution, immobilization
exceptions: proximal femur, distal femur |
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Type III & IV Salter Harris fractures: treatment
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intraarticular and physeal step-off
needs anatomic reduction may need ORIF |
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Physeal fractures
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traditionally believed to occur primarily through zone of hypertrophy
some fractures may traverse more than one zone growth disturbance/arrest potentially related to site of fx w/in physeal zones, disruption vascularity |
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Fracture tx in children – general principles
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children heal faster
need less immobilization time stiffness of adjacent joints less likely restore lenth, alignment, rotation when possible keep residual angulation as small as poss., using closed tx methods |
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closed treatment of peds fractures: general principles
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molded casts, cast changes, cast wedging, etc.
achieve adequate anesthesia/analgesia/relaxation local or regional anesthesia, conscious sedation or general anesthesia exceptions to closed methods: Salter III, IV; multitrauma |
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closed treatment of peds fractures: methods
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gentle reduction of physeal injuries – traction 1st, adequate relaxation
use well molded casts/splints use immobilizatio method on day of injury that will last entire course of tx consider likelihood of postreduction swelling repeat xrays q 7d - doc. mntn of acceptable position until early bone healing |
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reduction principles in pediatric fractures
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in gen, do not remanipulate physeal fx after 5-7 days (risk further damage)
metaphyseal/diaphyseal fx can be remanip’d w/ analgesia < 3wks s/p injury |
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immobilization time in pediatric fractures
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physeal injuries heal in half time of nonphyseal injuries
healing time dependent on fx, location, displacement stiffness from immobilization rare – ergo, err toward more time in cast |
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Open treatment of pediatric fractures
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respect and protect growth cartilage
adequate visualization (resect periosteum, metaphyseal bone if needed) keep fixation in metaphysis/epiphysis if possible when much growth φ remains use smooth K-wires if need to cross physis * displaced intra-articular fx will not remodel – anatomic reduction mandatory |
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Complications of fractures in children
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malunion
limb length discrepancy physeal arrest nonunion (rare) crossunion osteonecrosis |
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Remodeling of children’s fractures
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occurs by physeal and periosteal growth changes
greater in younger children greater if near a rapidly growing physis |
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remodelling in children's fractures not as reliable in which cases?
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midshaft angulation
older children large angulation (>20-30°) rotational deformity will not remodel **intraarticular deformity will not remodel |
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remodeling in child fractures more likely if...?
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2 years or more growth remaining
fx near end of bone angulation in plane of movement of adjacent joint |
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primary sequella of growth arrest 2* to limb fracture in children
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limb length deficiency
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partial cessation of longitudinal growth: 2 outcomes
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angular deformity if peripheral
progressive shortening if central |
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physes susceptible to growth arrest
- why? - where? |
large cross sectional area
large growth potential complex geometric anatomy distal femur, distal tibial, proximal tibial, distal radius |
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growth arrest/growth slowdown lines
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aka: transverse lines of Park, Harris lines
occur after fractures or stress (e.g.: chemotherapy) ~ lifelines in tree trunk result from temporary slowsown of normal longitudinal browth thickened osseous plate in metaphysis radiodense on xray appear 6-12 weeks after fx should be parallel to physis – indicates no growth disruption |
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angling of growth slowdown lines suggests what?
follow up: |
if angled or point to physis, suspect physeal bar
imaging physeal bar scanogram/orthoroentgenogram tomograms/CT scans MRI map bar to determine location, extent |
