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Ortho PANRE 3
Orthopedics
| Question | Answer |
|---|---|
| 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
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