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Ortho PANRE 3

Orthopedics

QuestionAnswer
Tib/fib: which one is weight bearing? Tibia
Knee Hx: MOI ( twist, blow to knee, trauma); Pain; Instability, pops, clicks, grinding; swelling; pain hip/ ankle/ foot; prior
Knee: DDx: Ant. Knee Pain Patellofemoral dysfxn; Patellar tendinitis; Plica/ Fat Pad irritation
Knee: DDx: Swelling (immediate): ACL, fx, dislocation, meniscus
Knee: DDx: Swelling (Intermittent) Meniscus, gout, chondral lesions
Patella Tests Med/Lat glide; Apprehension (instability); Inhib test (PFS); Q angle; J Tracking; Poplit Angle (Hamstring tightness); Modified Thomas Test (Quad/ hip flexor tightness)
Q angle angle formed by line: ASIS to ctr of patella & line fr ctr of patella thru tibial tubercle; <20 degrees = nl
Medial knee tests MCL or Valgus; McMurray
McMurray test: sensitivity = Only 65%
McMurray test: medial (ME) = Ext rotation w/ flexion & valgus
McMurray test: lateral Internal rotation w/ flexion & varus
McMurray test: true positive = A click (not pain)
Lateral knee tests Ober; Nobles compression; PLC; reverse pivot; posterolateral drawer; dial
IT Band tests Obers; Nobles compression test
Obers Inability for Up Leg to go down to table (= tight lateral structures)
Nobles compression test Pain over lat. Fem condyle at 20 deg knee flexion
PLC tests Posterior drawer & Recurvatum (with PCL); dial test at 30 degrees flexion; reverse pivot shift; Quad active test
ACL Tests Lachman; ant drawer (unreliable); Pivot shift (difficult)
ACL Tests: gold standard = Lachman
Knee Films AP, Lateral; Merchant; Tunnel view (look for OCD)
Knee Films: Merchant Patella (Instability; DJD; Chondral lesions)
Knee DJD: Fairbanks Changes Flattened Tib. plateau; cec. joint space; Osteophytes; Subchondral cysts
MRI in ortho: for: ACL ( >95%); Menisc (>85%); chondral lesion (cannot quantify size); MCL,LCL,PLC,PCL; Bone Contusions/ Edema; tumors; fx?
Quad active test: When quad mx is activated, pulls tibia forward; when it relaxes, tibia sags
Recurvatum test: Pulling up on toe to about 15 degrees of hyperextension, then just falling back (as if not attached properly at knee)
Lachman test: At 20 degrees flexion; stabilize femur, pull up on tibia
Ant drawer test: knee is flexed to 90, then pull on tibia
Thomas test: If hip flexors are tight, when pull one leg up, other leg also pulls up somewhat
Most common knee ligament tear MCL
MCL: Tx: conservative; NSAIDs; Ice; Rest; Bracing; PT; RTP?; Surgical: Rare
OCD = Osteochondritis Dissecans
OCD & Chondral Defects: Hx: Intermittent swelling after exercise, locking, catching, vague pain
OCD & Chondral Defects: Tx: NWB, progress slowly over 6 weeks or more
Plica Syndrome: Hx: snapping, esp with squats (can also be MMT)
ITB Syndrome AKA Runners Knee
LCL Tear: Varus test Grade I-II: conservative; 1-2 wks(I), 4-6 wks (II)
LCL Tear: Varus test Grade III: consider surgical repair/ reconstruction; assess for concomitant injuries (PLC)
Patellar Dislocation: Hx: visual sublux/ dislocation, twisting motion; previous occurrence? Brace? N/V status
Patellar Dislocation: Tx: extension brace 1-2 wks; quad strengthening; RTP w/ buttress brace
ACL Tx Extension Post-op brace locked at 0 deg or knee immobilizer for very short term (until referred); mostly for protection; ACE for swelling; NSAIDs; PT (Prehab); Refer; consider brace
ACL: recovery time if reconstructed: 9-12 mos
Theater sign seated, kneecap pushes into articular cartilage (spongy, water is displaced); sit up, kneecap pushes into waterless sponge space: pain.
PFS: Tx: PT for: VMO (vastus medialis obliqus) (co-contract with adductors); hip abductors/ ext rotators
Hemarthrosis usually due to injury (most common ACL), rapid effusion (2-4 hrs)
most common cause of knee pain in pts <45 yo = PFPS; esp women
young pt w/ant knee pain worse w/repetitious flexion & without clear alternative cause: PFPS
Local TTP, pain on motion and at rest; occasional loss of active movement; swelling, erythema, warmth: bursitis (inflammation of synovial membrane over bony prominences)
Most common knee injuries medial: anserine bursitis; MCL (most common lig); medial meniscus (most vulnerable)
Diffuse anterior knee pain w/ swelling & inflammatory change = inflammatory arthritis (RA, gout, pseudogout) or septic arthritis
meniscus tear dx made by: MRI or diagnostic arthroscopy
Lachman test assesses: anterior-to-posterior laxity
McMurray test: rotate foot outward to test medial meniscus; inward to test lateral; + is painful click
Knee pain DDx OA, effusion, pop cyst, bursitis, ACL/coll lig, meniscus tear, PFPS, ITB, stress fx injury to ACL/PCL, meniscus, PF syndrome, bursitis, OSD, ITB, baker cyst, OA, RA
tests for suspected (knee & hip) OA ESR, RF, synovial fluid analysis, imaging
Noncontact knee injury; pop; pivoting stress ACL (Lachman / ant drawer test)
8 – 10yo male with limp, knee pain Legg-Calve-Perthes Disease
12 – 15yo overweight male knee pain, limp, hip pain (knee XR normal) SCFE
Adolescent male with knee pain, tenderness over tibial tuberosity Osgood-Schlatter disease
Retropatellar knee pain esp. in females Patellofemoral pain syndrome – increased Q angle, strengthen quadriceps
Degenerative area at proximal end of patellar tendon patellar tendonopathy (must distinguish from osgood schlatter)
Sudden pop with plantarflexion (& Pain with active plantarflexion but strength intact) = Medial gastrocnemius tear (RICE, no surgery)
bucket handle tear meniscus tear (McMurray may reduce); tx arthroscopic repair or debridement (conservative tx not helpful)
Immediate swelling: Big 4: ACL Tear; Patella Dislocation; Fx; Meniscus tear (not always); Within first few hrs: Hemarthrosis
Patella Tests Med/Lat glide; Apprehension (instability); Inhib test (PFS); Q angle; J Tracking; Poplit Angle (Hamstring tightness); Modified Thomas Test (Quad/ hip flexor tightness)
Q angle angle formed by line: ASIS to ctr of patella & line fr ctr of patella thru tibial tubercle; <20 degrees = nl
Medial knee tests MCL or Valgus; McMurray
Nobles compression test Pain over lat. Fem condyle at 20 deg knee flexion
ACL Tests Lachman; ant drawer (unreliable); Pivot shift (difficult)
ACL Tests: gold std = Lachman
Quad active test: When quad mx is activated, pulls tibia forward; when it relaxes, tibia sags
Lachman test: At 20 degrees flexion; stabilize femur, pull up on tibia
Ant drawer test: knee is flexed to 90, then pull on tibia
Thomas test: If hip flexors are tight, when pull one leg up, other leg also pulls up somewhat
Most common lig. Tear = MCL
Medial Meniscus Tear: Hx Twisting injury (Acute); Degenerative; Swelling +/- ; Locking/ catching
ACL Tx Extension Post-op brace locked at 0 deg or knee immobilizer for very short term (until referred); mostly for protection; ACE for swelling; NSAIDs; PT (Prehab); Refer; consider brace
ACL: recovery time if reconstructed: 9-12 mos
Theater sign seated, kneecap pushes into articular cartilage (spongy, water is displaced); sit up, kneecap pushes into waterless sponge space: pain
Dx given to pt who present w/traumatic knee effusion, until proven otherwise ACL tear
possible graft choices in an ACL repair bone-patellar tendon-bone, hamstring autograft, cadaver allograft
Gait Analysis: Width of the gait: Normal =2-4 in heel to heel; Wide based gaits = instability
Gait Analysis: Pelvic shift: in gluteus mx weakness: lateral shift is accentuated to the side involved
Gait Analysis: Length of step: Ave length is 15 in. With age/ fatigue/ pathology: step is shortened
Steppage gait = Weak ankle dorsiflexors results in increase knee & hip flexion
Flat foot gait = Gastrocnemius/ Soleus weakness (S1-S2 radiculopathy)
Back Knee gait = Quadriceps weakness forces pt to push on thigh w/ hand to try to lock knee in stance phase
Trendelenberg (abduction lurch) gait = Gluteus medius weakness (L5); pt lurches toward weak side to place COG over hip
Extensor lurch = Gluteus max weakness (S1); pt thrusts thorax posteriorly to maintain hip extension
Foot Drop = Weakness of tibialis anterior (L4)
Pelvic Films: Pelvic ring fx is commonly: disrupted in 2 places
Hip Films: Order: AP pelvis w/ both hip joints; Lateral of affected hip
Hip fx: prevalence 90% in > 65 y.o. pt
Femoral Neck fx: Garden type I Incomplete fx w/ valgus impaction; ORIF
Femoral Neck fx: Garden type II Complete fx w/o displacement; ORIF
Femoral Neck fx: Garden type III Complete fx / partial displacement; Prosthetic replacement
Femoral Neck fx: Garden type IV Complete fx w/ total displacement; Prosthetic replacement
Femoral Stress fx: Sx Groin pain with running, progressing to ADL pain
Femoral Stress fx: Dx: Xray may be negative; Bone scan pos in 2-8 days
Femoral Stress fx: most common area = Femoral neck
Hip Dislocation: prevalence 90% are posterior
Hip Dislocation: PE: hip flexed, adducted & internally rotated
Hip Dislocation: Allis Maneuver Anesthesia; Assistant stabilizes pelvis w/ pressure on iliac sp; Gently flex hip to 90; apply progressive traction to extremity; apply adduction/ internal rotation
Avulsion fx of Hip: ASIS: locus = origin of Sartorius
Hip Pointer injury: MOI Direct blow to iliac crest
Legg-Calve-Perthes Dz: MOI Avascular necrosis of the femoral head
Legg-Calve-Perthes Dz: prevalence Child 2-11 y.o.
Legg-Calve-Perthes Dz: Xray = Mottled femoral head
Legg-Calve-Perthes Dz: Rx: Containment of femoral head with bracing / casting
Legg-Calve-Perthes Dz: Outcome: self limiting, revascularization occurs in some
Slipped Capital Femoral Epiphysis: prevalence Obese, pre-pubescent boys > girls; 40% are bilateral; most are idiopathic
Slipped Capital Femoral Epiphysis: Sx Limp & hip, thigh, or knee pain; loss of IR, flexion, & abduction
Slipped Capital Femoral Epiphysis: Rx: surgical fixation & non wt bearing
Snapping Hip Syndrome: MOI 1: ITB snaps over Gr trochanter; 2: Iliopsoas tendon snaps over ASIS
Transient Hip Synovitis: must R/O: septic hip; Legg-Calve-Perthes
Transient Hip Synovitis: Etiology Inflam immune response to URI; inc synovial fluid in hip joint causing pain
Transient Hip Synovitis: Xray: Capsular swelling
Transient Hip Synovitis: Lab: WBC & ESR normal; Joint fluid aspiration is normal
Meralgia Paresthetica = Lateral femoral cutaneous n. entrapment; Exits pelvis near ASIS
Meralgia Paresthetica: Sx: Pain & burning over lateral thigh
DDH = developmental dysplasia of the hip
Positive Faber test suggests: hip disease, iliopsoas spasm, or sacroiliac disease
Hip dx tests: wt bearing xray; bone scan if suspect fx/necrosis; MRI TOC for fx not seen in xray, and necrosis/ infxn/tumor; u/s for kids effusion
osteonecrosis Groin pain (less often thigh / buttock pain) = femoral head dz. Wt-bearing & pain w/motion, possibly rest/night pain; RF: steroids; dx: MRI sens > xray/scan
severe anterolateral hip tenderness, severe pain w/wt bearing, intolerance to passive hip rotation; xray normal (dx w/MRI) = occult hip fx (nondisplaced fx of femoral neck)
Hip pain DDx hip dysplasia; nerve entrapment; ankyl spondylosis; RA; lumbar disk pathology
Idiopathic AVN of femoral head; painless limp = L-C-P dz (3-12 yo, M>F); tx abduction bracing
Hip Dislocation: prevalence 90% are posterior
Hip Dislocation: PE: hip flexed, adducted & internally rotated
Hip Dislocation: Allis Maneuver Anesthesia; Assistant stabilizes pelvis w/ pressure on iliac sp; Gently flex hip to 90; apply progressive traction to extremity; apply adduction/ internal rotation
Trochanteric Bursitis: Sx Pain over Gr trochanter when moving hip into full flexion; Extreme point tenderness; Pain at night lying on affected side; poss crepitus over trochanter
Trochanteric Bursitis: Rx: Hip stretches, meds, injection
Hip Pain: Other Causes DDH (Peds); Tumor; Osteosarcoma; Ewing; Metastatic dz; Multi myeloma
Displacement of proximal femoral epiphysis due to disruption of growth plate = SCFE
Created by: Abarnard