Orthopedics
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Dorsal Wrist Compartment I | APL & EPB
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Dorsal Wrist Compartment II | ECRL, ECRB
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Dorsal Wrist Compartment III | EPL
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Dorsal Wrist Compartment IV | extensor digitorum comunis (four tendons) & extensor indicis (EDC, EI)
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Dorsal Wrist Compartment V | extensor digiti minimi (EDM)
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Dorsal Wrist Compartment VI | extensor carpi ulnaris (ECU)
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Median nerve: Motor | Wrist flexors, thumb opposition
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Median nerve: Sensory | Volar thumb, radial 2 ½ digits
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Ulna nerve: Motor | Intrinsics, Adductor Pollicis
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Ulna nerve: Sensory | Ulnar 1 ½ digits volar & dorsal
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Radial nerve: Motor | Wrist extensors, APL, EPB
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Radial nerve: Sensory | Dorsal thumb & radial half of hand
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Wrist Hx: includes: | Handedness; Occupation; trauma; location of pain; numbness, paresthesias
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Wrist Exam: Inspect for: | swelling, scars, masses
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Wrist Exam: Specific tests | Tinel, Phalen; Finkelstein; Foveal; Watson
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Watson Test for S-L dissociation: | Stabilize volar scaphoid w/ thumb & bring wrist from ulnar to radial deviation; there will be a clunk or pain
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Wrist ROM: radial deviation: | 20 degrees
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Wrist ROM: ulnar deviation: | 55 degrees
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Wrist ROM: flexion : | 90 degrees
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Wrist ROM: extension: | 70 degrees
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Wrist Radiographs | AP, Lateral, Oblique
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Wrist Radiographs: clenched fist: | Scapholunate dissociation
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Wrist Radiographs: Scaphoid | Ulnar deviation
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Wrist Radiographs: Carpal Tunnel | Hamate, pisiform injuries
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Wrist Radiographs: Comparison views | Growth plate injuries
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Wrist Radiographs: Lateral View: | Check 2-20 degree palmar tilt of articular surface of radius; dorsal aspect of distal radius is smooth; capitate sits in lunate
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Wrist Radiographs: PA View: | Check radius lies distal to ulna; radial border of Scaphoid is intact; No more than 2mm of intercarpal joint space; no abnormalities of radius or ulna cortex;
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Wrist Radiographs (PA): Impact fx may only show: | increased density at radial metaphysis
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Wrist Radiographs: beak, bulge or density at fused epiphyseal line is: | not a fracture; IS a physeal scar
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Gilula Arcs: articular surfaces of carpal bones s/b: | parallel, joint spaces similar width & parallel cortical margins
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Gilula Arcs: any break in the lines or overlapping of normally parallel joint spaces suggestive of: | joint injury
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De Quervain Tenosynovitis: Hx: | Radial wrist pain
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De Quervain Tenosynovitis: Anatomy: | 1st Dorsal compartment; APL & EPB tendon moves over radial styloid
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De Quervain Tenosynovitis: Dx: | Pos Finkelstein
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De Quervain Tenosynovitis: Tx: | Ice, thumb spica, rest, ionto
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De Quervain Tenosynovitis: Injection: | Marcaine/ Kenalog In 1st dorsal compartment; directed toward radial styloid
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De Quervain Tenosynovitis: last intervention: | Surgical release
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CTS: Hx: | Pain, numbness, paresthesia in median n. distn
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CTS: Anatomy: | 10 structures pass through carpal tunnel (9 tendons, 1 (median) n.)
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CTS: PE: | Positive Tinel’s and Phalen’s
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CTS: Consider: | EMG, Neurometrics
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CTS: Tx: | Splinting, ergonomics
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CTS: Injection: | 1ml Marcaine/40mg Kenalog; ulnar to palmaris longus at proximal wrist crease at 30 degrees
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CTS: Surgical release | cut transverse carpal ligament
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Tinel Sign | Percuss over median n. carpal tunnel; tingling or pain in median n. distn = Pos
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Phalen Test | Acute flexion of wrists for 60-90 sec => numbness & tingling over median n. distn
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Ganglion Cysts: Sx: | Painful or painless
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Ganglion Cysts: Distribution: | 65% Dorsal (SL joint), 25% radio-volar, 10% other flexor tendon sheaths (retinacular), occult
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Ganglion Cysts: Aspiration: | 18 g needle & 10 cc syringe; instill 40 mg Kenalog; compressive bandage; surg excision for recurrence
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Ganglion Cysts: recurrence | 10 % recurrence after excision
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Scapholunate Dissociation = | Traumatic SL ligament tear; >2mm space at SL joint
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Scapholunate Dissociation: S/S | Wrist pain & instability; Letterman sign; Watson Test
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Scapholunate Dissociation: dorsal rotary subluxation leads to: | dorsal intercalated segment instability (DISI) & SL advanced collapse (SLAC)
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SL dissociation: Rx: | SL ligament repair, PRC, Arthrodesis
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TFCC Tear = | Triangular Fibrocartilage Complex
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TFCC fn: | Stabilizes distal radioulnar joint
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TFCC Tear: MOA = | Acute or repetitive overuse
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TFCC Tear: PE: | TTP over TFCC; (+) Foveal sign
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TFCC Tear: dx tests | X-Ray (Look for ulnar variance); MRI / Arthrogram
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TFCC Tear: Rx: | Splint, NSAIDs, PT; injection; arthroscopic repair
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Ulna Impaction Syndrome S/S: | Ulnar wrist pain, swelling & weakness
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Ulna Impaction Syndrome MOA: | Ulna head impinges carpi
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Ulna Impaction Syndrome: X-ray shows: | cystic or sclerotic changes of the lunate &/ or triquetral
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Ulna Impaction Syndrome: leads to: | lunotriquetral ligament attrition
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Ulna Impaction Syndrome: Rx: | Ulna shortening
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Kienbock Dz = | Lunatomalacia
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Kienbock Dz: MOA | Repetitive microtrauma => lunate collapse secondary to vasc insuff & avascular necrosis
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Kienbock Dz: S/S | Radiating wrist pain & swelling over lunate; pain on middle finger dorsiflexion
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Kienbock Dz: Rx: | Surgical unloading, fusion, vascular implantation
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Monteggia fx = | Ulna shaft fx; Proximal radius dislocation
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Monteggia fx: tx | ORIF vs long arm cast for 6 weeks
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Galeazzi fx = | Radial fracture; distal Ulna dislocation
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Galeazzi fx: tx | ORIF vs long arm cast 6 weeks
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MUGR = | monteggia = ulna; Galeazzi = radial
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Greenstick fx = | Incomplete fx
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Greenstick fx: MOA | thick periosteum in children prevents displacement; dorsal cortex intact
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Greenstick fx: tx | Reduction (if needed) & short arm cast for 3-4 weeks
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Night Stick fx = | Isolated Ulna fracture
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Night Stick fx: tx = | Cast or splint for 4 wks; then functional splint for several wks
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Both Bone Forearm Fx: MOA | Fall or direct hit
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Both Bone Forearm Fx: Displacement or angulation > 10 degrees: | needs ORIF
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Both Bone Forearm Fx: Non displaced, non-angulated fx: | may be put in long arm cast 6 wks
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Colles Fx: MOA | FOOSH injury; dorsal angulation of distal fragment
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Colles Fx : if < 15 degrees angulation: | acceptable; short arm cast for 4-6 wks
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Colles Fx : if > 15 degrees or sig displaced: | reduction, CRPP, ORIF
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Smith Fx: MOA | Fall on back of hand; Hyperflexion injury; volar angulation of distal fragment
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Smith Fx: minor angulation = | acceptable; short arm cast 4-6 wk
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Smith Fx: significant angulation = | Reduction, CRPP, ORIF
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Barton Fx = | Intra-articular fracture; displaced radial articular fragment
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Barton Fx: tx | ORIF
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Chauffeur Fx: MOA | Oblique fx through the base of the radial styloid
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Chauffeur Fx: Tx | Long arm cast for 1 mo. followed by short arm cast for 2 wks
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Torus Fracture = | Buckle fracture with intact periosteum
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Torus Fracture: Common in: | children
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Torus Fracture: Tx | 3-4 weeks immobilization in a short arm cast; young kids need long arm cast (lest they take cast off)
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Scaphoid Fx: MOA | FOOSH injuries
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80% of scaphoid fx occur at: | waist
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Scaphoid Fx: 1/3 will develop: | osteonecrosis
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Scaphoid Fx: Healing time: Distal | 6 weeks
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Scaphoid Fx: Healing time: Waist | 3 months
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Scaphoid Fx: Healing time: Proximal | 4 months
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Scaphoid Fx: Healing time: RX: | Percutaneous screw fixation; ORIF w/ bone graft
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Scaphoid Fx: Imaging: | AP, Lat, oblique, scaphoid views; MRI; Bone scan 72 hrs post injury
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Scaphoid Fx: If initial imaging neg: | Immobilize in thumb spica or cast; repeat radiographs in 10-14 days
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Both Bone Forearm Fx: Displacement or angulation > 10 degrees: tx | needs ORIF
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90% of distal radial fractures are: | Colles Fx; FOOSH injury; dorsal angulation of distal fragment
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Most common carpal fx = | Scaphoid Fx (2/2 FOOSH)
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Ganglion Cysts: Hx: | Swelling at wrist (usually dorsal); Leak of joint fluid
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