Othropedics
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| Toddler Fx of Tibia | child stops walking, tender tibial diaphysis, normal x-ray; cast anyway and check in few wks for callus
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| Child abuse signs | TRANSVERSE fractures can only happen from direct blow; spiral fractures may be suspicious
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| Salter-Harris Grading of Epiphyseal Plate Injuries | I-V: "SALTR" - sliced physis, above epiphysis (met), lower than physis (epi); through entire epiphysis (epi, phy, met); raised d/t compression
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| Limping Child | suspect tumor of infx if child has pain, night pain, or refuses to use joint/limb; sheck spine, leg length, DDH (dev dysplasia of hip); paplate growth plates and ROM; use MRI/CT
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| Pediatric Elbow Ossification Centers | "CRITOE" 1, 3, 5, 7, 9, 11 (Capitellum, Radial head, "internal" medial epicondyle, Trochlea, Olecranon, "External" lateral epicondyle)
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| Polydactyly: Simple vs. Complex | duplication d/t failure of differentiation: skin only vs. skin and bone fusion...not a medical emergency
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| Pediatric Foot deformities that resolve w/o surgery | metatarsus adductus, positional calcaneovalgus
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| Congenital vertical talus (rocker bottom) foot | usually associated with other genetic or neuromuscular disorders
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| Pediatric foot problems d/t casing or bad shoes | skew foot, overriding 5th toe
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| Club Foot (Talipes Equinovarus) | CAVE: Cavus (forefoot), Adduction (forefoot), Varus (subtalar), Equinus (hindfoot)
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| Olecranon bursitis | non-tender mass from falling on elbow; drain and inject lidocane
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| Radial head dislocation | "nursemaid's elbow;" common preventable injury in 1-3yo children d/t sudden yank on arm; Tx: SUPINATION and FLEXION
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| Radial Head Fractures | 1. Non-displaced: positive fat pad, can flex/extend; 2. Displaced: >2mm may need internal fixation of mechanical obstruction limiting ROM
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| Elbow Dislocation | Very common with falls; #1 in kids falling with outstretched arms; Tx: pop it back into place, splint, NSAIDs
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| DIP dislocations | RARE
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| PIP dislocations | 1. DORSAL most common d/t hyperextension; Tx: flex wrist and buddy tape; 2. Volar-keep wrist in neutral with PIP in extension
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| Meniscus | Knee occasionally locks; McMurry Test - rotation of tibia on femur in supine; Apley grind - prone
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| Lateral Collateral Ligament | contols varus motion of knee; isolated injury is RARE; repair if ACL or PCL are injured and knee has ROTATORY instability
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| Medial Collateral Ligament | controls valgus motion/ER of knee; Injury d/t Direct Blow to lateral aspect; Tx: NONSURGICAL
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| PCL | Injury d/t dashboard injuries; Tests: Posterior Drawer, Quad Active, Posterior Sag (best sign); Tx: conservative b/c surgery isn't that good
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| ACL | Most common in women; Tests: Lachman's (30*), anterior drawer, pivot shift (in OR), MRI; Tx: based on ACTIVITY LEVEL and INSTABILITY...surgery only for people who want to twist knee b/c 80% do well conservatively; autograft (patellar tendon)/allograft
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| Patellar femoral syndrome | most common knee injury (pain walking down stairs), unknown cause, dysfunction d/t Q-angle; Tx: VMO, hyaluronic acid injections
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| Patellar tendon rupture | failed extensor mechanism (inferior pole dimple); surgery needed to reattach patella and debride degenerative ends
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| Patellar tendonitis | "jumper's knee;" volleyball/soccer; anteior knee pain w/crepitis and 4 stages: 1. pain after activity; 2. pain at start of activity; 3. pain at rest and w/activity; 4. complete rupture; Tx: PT or reattachment; Osgood-Schlatter's disease in adolescents
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| Quad Rupture | failed extensor mechanism; MORE COMMON than patellar tendon rupture (superior pole dimple); pain/swell knee/thigh; Tx: Conservative and surgery if chronic
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| Knee Bursitis | 1. Prepatellar; 2. Intrapatellar; 3. Pes anserine (goose foot) - sartorius/gracilis/semitendinosis; pain on medial side of knee common w/OA and runners; Tx: aspirate, manage conservatively
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| Tibio-Fibular Somatic Dysfunction | Posterior proximal fibular head causes paresthesias d/t common fibular n.; ER of tibia and dorsiflexion of ankle; posterior lateral malleolus and anterior prox fibular head; Tx: OMT
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| Iliotibial Band Syndrome | friction and irritation; Dx: Obers Test; Tx: RICE, run on flat track
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| 5th Metatarsal Fx | ballet dancers; WBAT in hard shoe unless Jones fx (metaphyseal/diaphyseal jxn) --> ORIF b/c of avascular region
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| Plantar Fasciitis | overuse of flexor tendons on plantar surface (fat female, runners, flat feet); pain in AM w/first steps; Tx: conservative NSAIDs and stretching, night splint, steroid injection
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| Achilles Tendonitis | Thompson test (squeeze calf); MRI; pain after exercise, hill climbing
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| Ankle fracture x-rays | mortise view, lateral view, AP view; cast 6wks NWB if non-displaced; Displaced needs ORIF
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| Ankle Sprain: Grade I | stretched ATFL, Negative anterior drawer/talar tilt; Tx: RICE
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| Ankle Sprain: Grade II | Complete sprain of ATFL/Partial of CFL; some instability; Mild anterior drawer, Negative talar tilt; Tx: RICE and splint
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| Angle Sprain: Grade III | Complete tears of ATFL and CFL; unstable, Postive anterior drawer and talar tilt; Tx: short leg cast 3-4wks, or surgery for chronic sprained ankle
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| High, syndesmodic ankle sprain | pain on squeeze test, dorsiflexion and external rotation; Tx: conservative
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| Avascular Necrosis of Hip | d/t dislocation or fx; Tx: Preservation of hip (decompression and grafting) OR Late stage prosthetic replacement of hip
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| Hip Dislocations | EMERGENCY!! most are posterior dislocations d/t car accidents; thigh is flexed and internally rotated; Reduce w/in 6hrs to avoid vascular injury; x-ray prior and CT after (check for acetabulum fx)
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| Femoral Neck Fx | 1. Subcapital Non-displaced: small surgery w/cannulated screws; 2. Subcapital Diplaced: big surgery; hemiarthroplasty
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| Intertrochanteric femur fx | pain at groin; stable or unstable; surgical fixation w/screws and WBAT as soon as possible; excellent blood supply - heals well
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| Hip fx in general | pain on ROM, asym length and ER of foot when supine; Groin pain (fx, dislocation, OA, infection) or Lat Hip Pain (gr troch bursitis); Tests: Trendelenburg gait (abductor weakness), Oberg test(inflamed/tight ITB); CT or MRI-occult fx; SURGERY d/t blood sup
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| Rotator Cuff Tear | supraspinatus is most often affected (infraspinatus, subscapularis, teres minor); Lidocaine test - pain doesn't resolve; drop arm test; Hx of working overhead or fall; weak abduction/ER; surgery based on activity or >50% torn
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| Rotator cuff DDx | bursitis, calcific tendonitis, subacromial impingement
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| Subacromial impingement syndrome | one of the most common causes of pain in adult shoulder d/t pressure on RC from acomrium when arm is lifted; radiates to deltoid tuberosity/bicep tendon; night pain; Lidocaine test relieves symptoms; Tx: rest, PT, NSAIDs, activity modification
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| Acute back pain workup | get an MRI if myelopathy is progressive; DXM CCsteroid relieves inflam/arthritis/some cancer
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| Spinal cancers | secondary to metastasis of breast and prostate cancer (thyroid, lung, kidney); 1. bone scan (most sensitive), 2. x-ray (look for compression fx), 3. CT/MRI, 4. biopsy
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| Chronic Regional Pain Syndrome | pain out of proportion ot injury; vasospastic (Raynaud's) or related to nerve injury
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| Dupuytren's Disease | associated w/EtOH and genetics; CT disorder causes contracture/nodule of flexor tendon in hand distal to palmar crease; surgery only for fxn not for pain reduction
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| Compression neuropathy: Carpal Tunnel | entrapment/compartment syndrome causes neuro/vascular disease distal to compression; Dx: parasthesia/ischemia; Tinnel's/Phalen's Tests; Tx: splint/OMT
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| Pronator Tunnel Syndrome | proximal median n. compression; resists pronation of forearm; provocation at pronator teres
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| Ulnar tunnel syndrome | at wrist; d/t ganglion cyst, muscle, ulnar a. aneurysm, or hamate hook fx
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| Cubital (funny bone) tunnel syndrome | ulnar n. operative in situ decompression/anterior transposition at elbow
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| Radial tunnel syndrome | pain at lateral elbow, work related, NOT lateral epicondylitis, painful resisted supination
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| Referred back pain | peptic ulcer disease, cholecystitis, pancreatitis, retrocecal appendicitis, AAA (worst back pain in life), pelvic inflammatory disease, prostatitis, endometriosis
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| Neural claudication | comfortable hunched over (sitting/bending/leaning); Tx: PT, aerobic activity and NSAIDs
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| Vascular claudication | comfortable standing, NOT walking (unless downhill) or sitting; hairless extremities, calf pain
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| Night back pain | indication of tumor or infection w/fever, malaise and massive weight loss
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| Spondylolysis | arthritis of spine
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| Spondylolisthesis | forward slippage of vertebral body on the one below or on sacrum; Tx: fusion or disc replacement
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| Spine evaluation | pain (location, axial-myofascial strain, degen disc, instability; radicular-lumbar sciatica); sensory loss (dermatomal? generalized?); weakness (isolated? generalized?)
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| Lesegues sign | straight leg raise w/dorsiflexion of foot causes pain in buttock from sciatica
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| Straight leg raise | + sign for sciatica if pain radiates down past knee; Contralateral leg raise pain is 95% pathognomonic for herniated disc!!
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| Cauda equina syndrome | bowel/bladder incontinence; saddle anesthesia; bilateral LE weakness; usu d/t large disc herniation
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| Compression fx of lumbar spine | non-traumatic wedge-shaped; Tx: bracing, pain management, PT; surgery for instability; x-ray/CT/MRI
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| Metastatic disease of T spine | MOST COMMON region for spinal metastasis; can cause fx, kyphosis, etc...bone scan to look for other mets
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| Compression fx of thoracic spine | vertebral body compressed in stellate pattern d/t significant force in young/osteoporosis in old; Dx: x-ray, dexa scan for osteoporosis; Tx: depends on spinal stability in T/L spine (3 columns: anterior (wedge-stable), middle, posterior); pain/brace/OP
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| Spinal stenosis | can occur in 3 places: central canal/subarticular lateral recess/foraminal nerve root exit; flexion can relieve pain; pseudo neuroclaudication w/pain on standing erect; Tx: PT/NSAIDs, steroids, decompression laminectomy/fusion
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| Herniated nucleus pulposus | check for cauda equina syndrome (anal sphincter tone w/ trauma); Dx: MRI
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| Thoracic outlet syndrome | cold limbs, parasthesia, transient pain, pallor; Tests: 1 Adsons - dec pulse w/ inhalation/cervical rotation; 2. Wrights test - lift arm over head and pulse dec; 3.Costoclavicular maneuver - hyperextend/hyperpronate arm to dec pulse; Tx: PT, sling/stretch
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| Ssheuermann's kyphosis | goose-neck deformity; anterior wedging of 3 consecutive vertebrae w/apex at T6-8 or T10-12; compensatory hyper-lumbar lordosis
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| Scoliosis | idiopathic, congenital, degenerative (osteoporosis), neuro-muscular (never brace); common curves: R-thoracic, L-lumbar, double curve; severe disese causese lung vol restriction (cor pulmonale - Rventricle hypertrophy/pneumonia)
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| Treatment of scoliosis | 52degrees - critical angle=surgery; Skeletally mature: observe/brace (20-50)/surgery (40-50); Skeletally mature: surgery for pain, >60degrees or cosmetics
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| Milwaukee brace | scoliosis apex above T7
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| TLSO - Boston brace | scoliosis apex below T7
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| Most common cause of back pain | 1. Muscle spasm, 2. muscle strain, 3. arthritis, ...zebra: herpes zoster
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| Spinal nerves exit below their corresponding vertebral body | herniated discs will NOT irritate the nerve roots at their level, rather the nerve roots from the segment above
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| T-spine has most tumor metastasis | b/c of internal and external venous plexuses...lots of drainage from costal veins
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| Ligaments of spinal column | suprasinous, interspinous, ligamentum flavum, (spinal cord), post longitudinal, anterior longitudinal
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| Most spinal cord injuries are: | crushing injuries that displace material into neural foramen and impinge on nerves or spinal cord; lacerations/transections are very rare
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| Whiplash Associated Disorder (WAD) | commonly d/t acceleration/deceleration injuries; pain develops slowly over several hrs/days; nerve root irritation causes muscle spasm (occasionally torticollis); occiptial headaches; later back pain; MRI may be useful
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| C1-C2 instability | Rheumatoid arthritis, Down syndrome, ankylosing spondylitis (brittle/stiff)
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| Most common Atlas (C1) fracture | Jefferson fracture d/t axial loading; shallow diving; downward force pushes occipital condyles into lateral masses of atlas
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| Most common Axis (C2) fracture | Type II Odontoid fracture; fx at base of odontoid; unstable
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| Physical exam findings for fx of atlas or axis | death, head supported by hands, cannot nod/rotate head, severe occipital headache; MUST BE IMMOBILIZED to avoid death
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| C-spine x-rays: | AP and lateral; Open mouth view - odontoid process of C2; Swimmer's view - C7 on fat people;
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| Soft cervical collars | soft tissue injury
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| Hard cervical collars | isolated fx; SP, TP, lamina; OR vertebral body injuries: extension teardrop or compression fx
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| Immediat stabilization and Halo fixation | Burst fx or compression fx
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| Surgical repair for cervical injuries | 3 Conditions: 1. neurological deficit, 2. Spinal instability, 3. intractable pain; traumatic disc disruption; burst fx; flexion teardrop fx;
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| epiphysis | ends of bone that ossify separately and ankylose later
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| physis | growth plate
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| metaphysis | secondary ossification ctr
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| diaphysis | shaft of long bone
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| x-rays | good for bone; fx, maturity, pathology
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| MRI | softer tissues; tendons, ligaments, cartilage
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| CT | bones and organs
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| bone scan | osteoblastic activity; fx, inflammation, tumor; very sensitive, not specific
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| critical dislocations | compromise blood supply; must be corrected w/in 6hrs
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| Recellularization | packing an injury site w/ bone graft, growth factors, bioactive reagents to encourage cell attachment and function
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| Directionof fractures | transverse, oblique, spiral, longitudinal
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| Type of fractures | avulsion, greenstick, displaced (name displacement and angulation)
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