MSK Ultimate
exam findings for cubital tunnel syndrome
**another condition where we pay attention to weakness as it may become permanent** can see intrinsic atrophy positive tinels at the elbow reproducing dysesthesias and or pain along the peripheral ulnar nerve distribution 2 point discrimination > 5 mm diminished intrinsic muscle strength
Secondary prevention happens after illness or serious risk factors have already been diagnosed. Examples?
-Routine screening: mammograms, colonoscopy
Assessing strength of muscles: Movement and full PROM, unable against gravity
2
Bone densitometry using DXA with t score below _________ is osteoporosis
2.5
Assessing strength of muscles: Full AROM, but not against resistance
3
Grade ____ AC separation: complete rupture of AC and CC ligaments :/
3
hemoglobin X ______- = Hct
3
curves with Cobb angles under _____ tend not to progress curves with Cobb angles of __ to ___ degrees at skeletal maturity progress of 1 degree per year
30; 50-75 (can be a problem later in adulthood)
Pelvis view to see hip joints nicely
AP pelvis
two thoracic views
AP, Lateral
if you suspect spinal stenosis, get these xrays:
AP, Lateral, Flexion, Extension views
Three lumbar views
AP, Lateral, Oblique (Can pick up the pars fracture)
ankle views
AP, Medial oblique (Mortise joint), Lateral
Foot Views
AP, Medial oblique, lateral
hip views (take individually)
AP, frog leg
what x-rays to get SCFE diagnosis
AP, frog-leg views of hip acute pain-crossed tibia
Knee views
AP, lateral (febella), tunnel (find osteochondritis dissecans), sunrise
elbow films
AP, medial oblique, lateral(must be 90 degrees), jones
Thumb Views
AP, oblique, lateral
Minimal radiography for a fx
AP/Lat, including joints above and below where indicated
standard cervical series
APOM (AP open mouth) APLC (AP lower cervical) LCN (Lateral cervical neutral)
APAP aka
Acetaminophen
Barely an NSAID-antipyretic and analgesic, but lacks anti-inflammatory activity. common cause of accidental overdose, avoid in severe liver disease
Acetaminophen (APAP)
AC ligament connects:
Acromion and Clavicle
Tx and monitoring of PAN
Aggresive tx of HTN treat underlying cause if needed (antivirals?) treat complications corticosteroids cytotoxic therapy ESR and CRP may be helpful to monitor during tx, monitor for infection if they are on corticosteroids, monitor for delayed appearance of neoplasms after tx
Tx for prepatellar bursitis (septic)
Aggressive: sterile aspiration, gram stains, cultures, sensitivities Gram stain + -> surgical bursectomy if skin is broken treat it as septic
Risk factors for osteoarthritis
Aging Gender-F Obesity Genetics Joint injury Anatomic factors (less cartilage) Occupation (those that use same joints continuously, for example athletes)
What med can you use to keep uric acid level low in gout?
Allopurinol
first line urate lowering therapy for gout, generally well tolerated. Must screen ppl of Chinese, Thai, and Korean descent for HLA B*5801 genetic variant-SJS warning. Must maintain hydration.
Allopurinol
Serum urate-lowering therapy should be initiated to prevent recurrences in persons with a history of gout and any one of the following: at least two flares per year (one per year in persons with chronic kidney disease stage 2 or greater), tophi, or a history of nephrolithiasis. Name of drug?
Allopurinol, continue 3-6 months after flare. Indefinite if 1 or more tophi present.
C-reactive protein (CRP)
An acute phase reactive protein, rise above normal limits earlier than ESR but returns to normal earlier than ESR (peaks early, faster return to normal)
What does a fat pad sign indicate?
An occult elbow fx
Sacral view
Angulated lumbrosacral spot view (take it if you think someone might have ankylosing spondylitis, stress fracture of sacrum)
poorly aligned ankle fx may lead to _________ down the line
Arthritis
Which nerve roots leave below the pedicle?
C-8, T- 1-12, L- 1-5
Tx for Osgood Schlatter
Conservative RICE, NSAIDs, cho pat straps 3-4 weeks off of sports
features of congenital scoliosis
Curve is typically a short c-shaped curve Other skeletal anomalies common(hemivertibrae, block vertibrae, bridging bars, fusion of ribs, etc--this may happen during bone segmentation) Often involved with congenital anomalies with GU system (kidneys form at same time as bones)
Salivary gland calculi (stone in salivary gland)-when they eat something, the gland swells up. If you suspect that, tell them to do what?
Eat something sour (dill pickle, lemon)-sometimes they salivate so much it will pop loose and be a treatment
If someone has lupus and gets tested for syphilis through a VDRL, what might happen? What test could you follow up with to make sure that syphilis is actually negative?
False positive RPR or T. pallidum test
Over 90% of cases of SLE occur in men. T or F
False, 90% of SLE occurs in women. It frequently starts during childbearing years.
The MIC number is important in determining what abx to use. T or F.
False, as long as it is susceptible that is good enough. Other factors when choosing which abx are more important
Usually, we want to always operate on a broken clavicle as they hardly heal on their own. T or F
False, clavicles should heal on their own if possible (unless its a distal clavicle fx)
In systemic JIA, the arthritis is usually the first presenting sx. T or F
False, it is hard to diagnose because arthritis may not present right away
PAN generally affects women more than men. T or F
False, mostly affects men
x-ray is non-ionizing radiation, meaning that it does not cause any harm to us. t or f
False, x-ray uses ionizing radiation, it is dangerous to us as there are high frequency photons that create free radicals in our body.
Recurrent attacks of inflammatory arthritis diet: alcohol, high fructose soft drinks, MC in MTP joint of great toe Crystals negative birefrigence tx?
Gout Tx: prednisone colchicine prophylatic: allopurinol
Hallmark of gout- joint aspirate says what? Uric acid will be _______ because the crystals are _____________.(this test is better for monitoring tx, not diagnosis) WBC will be close to normal
Gout: Needle-shaped negatively birefringent crystals Elevated; monosodium urate
Flip to see grading of AC separation
Grade 1-3 most common, what you will be tested on. use x-ray to determine grade (1 is usually tender with no deformity, 3 there is more separation noted)
Staphylococcus, streptococcus, and enterococcus are all
Gram + aerobes
Lincosamides(Clindamycin) what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
Gram +, anaerobes Bacteriostatic, inhibitors of protein synthesis Caution hepatic impairment Use when pt has PCN allergy PO, IV Widely into body tissues and fluids including bone, abscesses, CSF penetration is poor Cumulative dose dependent C. diff box warning, hepatotoxicity
Haemophilus influenzae, neisseria, moraxella, vibrio, and pseudomonas are all
Gram - aerobes
An incomplete fracture with angular deformity, seen in children. bending of bone
Greenstick
Pediatric population fractures
Greenstick (one side of bone only-bending) Buckle (force fx that doesnt break bone completely, makes a little bump in it)
WHO: Average number of years that a person can expect to live in "full health" by taking into account years lived less than full health
Health adjusted life expectancy
History questions for ddx of gout
History of trauma? History of obesity? Flares in past? What is your diet like? Alcohol, tobacco use?
H&P for a fx
History: Mechanism of injury and timing PE: Whole extremity, joints above AND below -Observe: swelling, eccyhmosis, deformity, skin integrity (lacerations, abrasions) -Palpate: tenderness, crepitus, and compartment tightness -Function: surrounding joints ROM Neurologic and Vascular status
Colles fx examination
History: usally FOOSH tenderness and swelling, deformity and impaired wrist ROM Check skin for breaks Check median nerve function (Palmar parethesias)
Provide support, flexibility, and resilience. most abundant cartilage. 60-70% water may become calcified-only cartilage with this capacity intercostals, wall of trachea and bronchii articular cartilage of bone epiphyseal plate fetal axial skeleton
Hyaline cartilage
Findings for a proximal humerus fx
I: dramatic eccyhmosis of entire upper arm/chest wall P: focal proximal upper arm pain and tenderness S: cant assess NV: Sensory motor: musculocutaneous, radial, median, ulnar M: ok to perform gentle motion of the elbow, wrist, and fingers--crepitance of shoulder w/ this exam
exam findings for a supracondylar humerus fx
I: significant swelling and guarding P: diffuse tenderness most exquisite at supracondylar regions Neuro: Check radial, median, ulnar sensorimotor
exam findings for midshaft humerus fx
I: upper arm swelling P: be gentle, tenderness is diffuse NV: Radial-> can you bring the wrist up, extend the fingers (if not, surgery immediate) Sensation over dorsal forearm and hand and wrist extensor / Extensor Pollicis Longus strength.
What to do with this type of inversion injury: Distal 5th metatarsal (dancer's) fracture
Immobilize in posterior mold splint, non-weight bearing, refer to ortho
A fracture that occurs when one bone hits or "impacts" an adjacent bone
Impaction
Types of ankle fx. What should we focus on?
Malleolar, bimalleolar (lateral and medial), trimalleolar (posterior, lateral, medial) Often will disrupt tib-fib ligament and disrupt mortise joint-would need to be restored perfectly->weightbearing. (exception: distal fibular fx)
Flexion deformity of toe DIP joint, bad fitting shoes (crammed into shoe), callus formation likely. tx?
Mallet toe, surgery
Tx for skier's/gamekeeper's thumb
Minor-Thumb spika RICE, PT, etc Major-Surgical repair
neuropathy of interdigital nerve, usually proximal to bifurcation usually supplying 2nd nd 3rd toes nonspecific inflammation of nerve and proliferative CT most common in middle aged women-high heels may be culprit
Morton's neuroma
Cardinal rules of what views to get for imaging
Must have two views at 90 degrees to eachother
Syndrome causes muscle paralysis Inability of NMJ to transmit enough signals from the nerve junction, ACh cannot attach to receptors at motor end plate. Antibodies attack ACh
Myasthenia gravis
is hormone therapy a recommened tx for osteoporosis
No (increased risk for breast cancer)
Tx for fibromyalgia
No cure Focus on symptomatic relief Start with lose dose Avoid narcotics and steroids Non-pharm: exercise, therapy, massage, sleep hygiene Med can be added for certain things like depression, sleep disturbances, pain (be careful)--small dose Tricyclics (amitryptiline) may be a good option especially if they have sleep disturbances
Malignancies associated with Sjogren's syndrome:
Non-hodgkins lymphoma Thyroid cancer
DMARDs are broken up into two categories
Nonbiologic (methotrexate, hydroxychloroquine, sulfasalazine) Biological (anakinra, canakinuman, tocilixumab) Choice depends on severity of dz, preference of route, side effects, pregnancy (NO methotrexate)
Antipyretic (decrease fever), analgesic (decrease pain), antinflammatory drugs that are hydrophobic weak acids. They inhibit COX-1 and/or COX-2 enzymes, are well absorbed orally, and are excreted via the kidney.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
T score greater or equal to -1
Normal
Lab findings for OA
Normal Neg RF, Anti-CCP negative ESR and CRP: normal Leukocytosis absent
ESR results: normal and not normal
Normal is less than 20 mm per hour Always worry if its over 100 (or greater than 50 for non-rheum conditions)
Thin cartilage-bone rubbing together
Osteoarthritis
toe walking management
PT, casting, night splints, surgery
Cat bite-organism
Pasteurella multocida
Connective tissue sheath of skeletal muscle: fibrous CT surrounding fascicles (groups of muscle fibers)
Perimysium
Outer fibrous layer of bone, inner osteogenic layer. Osteoblasts, osteoclasts, osteogenic (stem), nerve fibers, blood vessels, secured to underlying bone by sharpeys fibers
Periosteum
Tendons that are evertors and pass posterior to lateral malleolus
Peroneals
Diagnositic criterea for OA
Persistant usage related joint pain Age greater than 45 Morning stiffness less than 30 min
lab findings for sjogrens syndrome
Positive SS-A (Ro) antibody Positive SS-B (La) antibody anti-ds DNA antibody Positive ANA Positive RF
Abx used for prevention of infection
Prophylactic
sx of polymyositis
Proximal limb weakness (hip, thigh, shoulder) gait slow and waddling Dysphagia Weakness of extensor neck muscles Respiratory impairment Cardiac involvement (30%): EKG changes, CHF- the heart is a muscle!
what type of scaphoid fx has poor healing, high non-union rate, therefore needs surgery?
Proximal pole
Pseudogout will look like what on the joint aspirate test? What are the crystals composed of?
Pseudogout: Rhomboid shaped positively birefringement crystals Calcium pyrophosphate
Puncture wounds of feet that cause nonhematogenous OM are often caused by ______. For this may reason you may need multiple antibiotics
Pseudomonas
Tx for OA (non-pharm)
Pt education Weight loss exercise, PT/OT walking aids, knee braces rest for only short periods/acute
Extensor mechanism of knee includes
Quadriceps tendon, patella, patellar tendon
Injury to ulnar collateral ligament of thumb "I fell on my hand and now I cant have a cup of coffee (weak pinch or poor grasp)" swelling or bruising over the thenar eminence instability of metacarpal joint of thumb
Skier's thumb/Gamekeeper's thumb
monobactams (aztrenoman) abx type, what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
beta-lactam Mostly gram -, resistant to narrow spectrum b-lactamases and metallo-b-lactamase Bactericidal, disrupt cell wall synthesis Not a lot of cross reactivity-if they have pcn allergy you are probably safe. CI: Cross reactivity with ceftazidime, check allergies IM, IV only Time dependent Hepatotoxicity
Carbapenems abx type, what type of bacteria, MOA, bactericidal or bacteriostatic, time or concentration dependent
beta-lactam reserved for serious infections, IV only bactericidal, disrupt cell wall synthesis time-dependent CNS toxicity (seizure) Derm reactions
common source of bacterial resistance breaks open b-lactam ring and deactivates drug
beta-lactamases
Penicillin allergy do not prescribe:
beta-lactate abx penicillins
muscles of the flexor compartment of the arm
biceps brachii, coracobrachialis, brachialis
how to describe the ddx for PAN
broad
if you have this disease you are predisposed to disc herniation
degenerative disc disease
Tx for fx
depends alignment and immobilization Urgent: displaced, open, angulated, nerve or vascular injury, impending compartment syndrome, risky fractures-immediate referral Stable, non-displaced: cast or splint and follow up referral
tendinitis on radial side of wrist- pick up baby
dequervain's tenosynovitis
sx of disc herniation?
dermatomal pain, numbness, weakness.
Parts of Scotty Dog
dog ear-SP neck-pars interarticularis eye-pedicle nose-transverse process front leg- inferior articular process back-lamina
movement superiorly
dorsiflexion
clavicle fx: usually arm turned inward and downward. Open fractures result from severe tenting and piercing of overlying skin-> what to do
emergent!
vertebra that are most tipped into the curve apex
end vertebra (E)
Delicate membrane on internal surface of bone, also contains clasts and blasts
endosteum
Escheria coli, klebsiella pneumoniae, salmonella, serratia, shigella are all
enterics
what is bursa
extension of synovial joint outside joint cavity-it can secrete fluid, can get inflamed causing bursitis
Boutenniere Deformity: what doth and what is it related to
extension or hyperextension at DIP, flexion at PIP; RA
common hand deformities in OA
heberden nodes-DIP joints bouchard nodes- PIP joints hold up index finger (DIP is head, PIP is body)
scoliosis can be.. (causes)
idiopathic, neuromuscular, congenital, syndromic
internal tibial torsion, as measured by the thigh-foot angle, is a cause of ___ in toddlers.
in-toeing
bony rotational problem of femur, tibia, or foot-common. usually normal and will resolve by itself.
in-toeing, out-toeing
''Radicular'' means
nerve
Other skeletal muscle relaxants: Diazepam-benzo, Tizanidine, Baclofen, Carisoprodol (Avoid)
ok
typical question on a test: appropriate tx for scaphoid waist fx?
thumb spica cast
5th metatarsal (jones) fracture: transverse fx of base of 5th greater than 15 mm distal to proximal end (diaphyseal) less common, more severe
(pic on right is a pseudo-jones: styloid avulsion fx --more benign)
reducing GI risk of NSAIDs for patients
*Risk is dose and duration dependent Take with food Consider celecoxib Avoid indomethacin, diclofenac, ketorolac Use phrophylaxis with hx of ulcer (PPI, PGE analog)
Target serum uric acid levels during therapy are 5-6 mg/dl. xanthine oxidase inhibitors for gout: second line treatment:
-Allopurinol, Febuxostat -Probenicid
topical NSAIDs: example and use
-Diclofenac: Voltaren gel, Pennsaid solution, Flector patch -Effective for osteoarthritis, acute injury, no evidence for neuropathic pain. -low incidence of adverse effects
Methods of primary prevention to promote health (can be population or individual basis)
-Safe means of transportation -Sanitation -Eating healthy, good exercise,
criteria for screening:
-Significant effect on quality or length of life -Prevalence sufficiently high to justify costs -Acceptable methods of tx available -Asymptomatic period during which detection and tx significantly reduce morbidity and mortality -Sufficient sensitivity -Sufficient specificity -Acceptable to patients
opioids for chronic pain should only be used when:
-alternative therapies have not provided sufficient pain relief -Pain is adversely affecting function/quality of life -Potential benefits outweigh potential harm -Can only be continued when there is well-documented benefit after a trial of opioid therapy
how to diagnose impingement syndrome
-an arc of pain- from 90-120 degrees of abduction or forward flexion -Hawkins maneuver (arm at 90 degrees of forward flexion and have it rest on one of your arms--you can put the hand under their arm and on opp shoulder. Then do passive internal rotation) -impingement test/neer test (you stand behind them, stabilize the scapula with one hand and the other brings their arm up in passive forward flexion) -maintained rotator cuff strength (if arm down at side and elbow flexed at 90 degrees, they can still resist when you push on palm) full ROM
types of forefoot fx
-complete midshaft metatarsal fx, usually crush mechanism->RICE -phalanges
drug-drug interactions of NSAIDs
-increased serum concentrations of: Phenytoin, warfarin -Methotrexate: can decrease renal clearance, usually ok w/doses used for rheumatoid arthritis
growth plate aka
-physis
Assessing strength of muscles: No movement
0
CRP results-standard
0-8 mg/L
Assessing strength through movement/ROM: what are the 5 levels you can ascribe to the patient's injury?
0: No movement 1: Trace movement 2: Movement and full PROM, but unable against gravity 3: Full AROM, but not against resistance 4: Full ROM against gravity & resistance, but weak 5: Full ROM against gravity, full resistance
Assessing strength of muscles: Trace movement
1
Grade ____ AC separation: ligament is stretched, it is tender but no deformity.
1
two types of proximal femur fractures, describe complications
1. Femoral neck aka intracapsular hip fractures (high risk for avascular necrosis and nonunion)-need surgery 2. Intertrochanteric region fx (extracapsular hip fx), require more robust fixation, risk for implant failure
Manifestations of systemic JIA (4)
1. Fever (>101.3, high spiking fever that returns to normal, happens on a daily basis). *Lack of response to abx. 2. Rash Macular, salmon-pink. Axilla, around waist MC-tight clothing or heat makes it worse. Worse when febrile. Koebner phenomenon. 3. Arthiritis any joints, MC wrists, knees, ankles, hips 4. Systemic manifestations hepatospenomegaly lymphadenopathy pericarditis **uveitis is rare
diagnostic criteria for RA
1. Inflammatory arthritis of 3+ joints 2. Symptoms lasting at least 6 weeks 3. Elevated CRP or ESR ANA also positive in 1/3 of patients 4. + RF (may be 0 in 20% of pts) or anti-CCP
Clinical presentation of reactive arthritis
1. arthritis most common below the waist-knees/ankles 2. enthesitis inflammation of tendon heel pain/achilles 3. dactylitis sausage fingers 4. back pain 5. conjunctivitis 6. urethritis
Warnings for allopurinol
1. hypersensitivity reactions including SJS/TEN 2. check HLAB*5801 in patients of Chinese, Thai, Korean descent 3. hepatotoxicity 4. avoid with mercaptopurine/azathiprine
Scoliosis: Lateral curvature of the spine greater than ____ degrees
10 (anything less is a convexity)
If someone has a normal result on a DEXA scan, how long can you wait before you check it again
10-15 years
Female hemoglobin levels
12-15.5 g/dL
Male hemoglobin levels
13.5-17.5 g/dL
classification of ankle sprain: ligament stretching, local tenderness, minimal swelling
1st degree
Gout is characterized by painful joint inflammation, most commonly in the ____________, resulting from precipitation of monosodium urate crystals in a joint space.
1st metatarsalphalangeal (MTP) joint
Grade ____ AC separation: partial rupture of AC ligament
2
how many ATPs are needed for a cross bridge cycle?
2 (1 to attach, 1 to detach)
Peak incidence of oligoarticular JIA
2-3 years old, more common in females
New guideline for Vancomycin dosing: for known or suspected severe S. aureus infection, use 24 hours area under the curve to minimum inhibitory concentration ratio--abbreviated as:
24AUC:MIC Patient data is collected-trough and peak
when do we have peak bone mass?
25-35
classification of ankle sprain: severe stretching, partial tear abnormal stress tests
2nd degree
Ankle sprain with complete tear of ligament, cant bear weight
3rd degree (may need surgery)
Assessing strength of muscles: full ROM against resistance and gravity, but weak
4
polyarticular occurs with greater than _ joints. it is idiopathic or autoimmune
4
OM tx - chronic
4 weeks-24 months of IV/po abx can be managed as outpatient if not systemically ill good wound care, take pressure off wound manage comorbid conditions, especially DM
Fracture of the proximal femur needs ortho referral and surgery in ___ hrs due to high risk of thromboembolic events.
48
Assessing strength of muscles: full ROM against gravity, full resistance
5
oligioarticular involves less than ___ joints. can be idiopathic or autoimmune
5
Cervical: how many bones, how many nerves
7, 8 (C8 leaves below the pedicle)
What percent of motion happens at C1 and C2
90
overlap between actin and mysosin appears darker, this is known as the _______
A band
During muscle contraction which band does not change size
A band (I band and H zone shorten)
what is a medical home?
A place where you can go where multiple providers of different specialties can work together. This might be helpful for SLE crisis, systemic sclerosis for example
What is the Thompson test?
A positive test results when squeezing of the calf muscle plantarflexes the foot. This is normal. IF there is an achilles tendon rupture, nothing will happen.
Sprain: typical mechanism: fall onto lateral shoulder (football) ligamentous injury Affected joint is TTP pain, guarding, often deformity
AC Separation (check axillary nerve-sensation on deltoid)
Loss of articular cartilage resulting in: Pain at the AC joint with overhead or push pull movements (bench press) Tenderness at the AC most common Prominence at the AC joint Pain on crossed arm adduction (crossover test) Common in older age weight lifters
AC joint arthritis
A tear of the anterior cruciate ligament
ACL tear
lab findings for polyarticular JIA (no single diagnostic test
ANA (MC pos in younger children) ESR: mild elevations mild anemia RF pos if you older than 10 (10-20%)
lab findings for oligoarticular (no single diagnostic test
ANA and ESR might be pos/elevated CBC normal RF normal
Testing for systemic sclerosis
ANA- elevated in over 90% of patients but this is not specific test more specific testing-refer to rheum Test for complications
Most common age, gender, and presentation for structural scoliosis (idiopathic)
Adolescent (12-16) Females affected 4:1 Right thoracic convexity
Locations of red marrow, adults/infants
Adults: Trabecular cavities of heads of femur and humerus Diploë of flat bones Infants: Medullary cavities and all spaces in spongy bone (eventually replaced by triglycerides)
Mental checklist for opioids: ABCD PQRS
Alcohol Benzos Clearance and metabolism of drug Delirium, dementia and fall risk Psychiatric comorbidities Query the Prescription Monitoring Program Respiratory insufficiency and apnea Safe driving, work, storage, and disposal
Lordosis, kyphosis, scoliosis, deformity, spondylolisthesis, fracture alignment are related to what word of the TABCs of radiologic interpretation?
Alignment
Warning of tramadol
Also inhibits reuptake of 5-HT and norepi, caution with other serotenergic drugs. lowers seizure threshold.
Synergist of triceps brachii
Anconeus
Decreased hemoglobin aka
Anemia
Fx: Bones are not straight
Angulated fracture (2nd pic it has been reduced and casted)
tests for lupus
Anti nuclear antibody (ANA)-may be present in many diseases
really important test for RA-very specific
Anti-CCP antibody, 98% specific for RA
clinical presentation of oligoarticular JIA
Arthritis Usually asymmetrical MC in LARGE joints (knees, ankles, wrists, elbows) rarely in hips limping w/o pain walks funny in morning but then improves joint tender and swollen, NO erythema
clinical presentation of RA
Arthritis (morning stiffness, greater than 1 hour, symmetric joint swelling- MCP, PIP, IP (thumb), MTRP, elbows shoulders knees DIP usually spared insidious onset Extra-articular involvement (see image)
___________ joint pain has loss of active and passive ROM (range of motion), or "locking"
Articular
Not used for MSK pain- doesn't have a great analgesic or antinflammatory effect. mostly used in CV disease for prevention of clots
Aspirin (ASA)
Modifiable risk factors of osteoporosis
BMI Smoking Alcohol Calcium/vitamin D Vision-impaired may lead to fall Overall health Medications
ganglion cyst of the knee-joint fluid. what is it called and what is the tx
Baker's cyst tx the intra-articular pathology-meniscal tear, OA or cause of hemarthrosis (ACL, intra-articular fx, patellar dislocation)
One bone pieces overlaps another piece
Bayonetted fracture
Cephalosporins abx type, what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
Beta-lactam 5 different generations/spectrum different in each (as time goes on, better cell penetration, more focus on gram negative) No CI Bactericidal, disrupt cell wall synthesis PO, IM, IV Widely distributed, 3-5th generation has best CSF penetration Time dependent Renally eliminated Rash, diarrhea
Penicillins what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
Beta-lactam Mostly gram + (susceptible staph, strep) Bactericidal, disrupt cell wall synthesis Allergies are common Avoid intrathecal injection, sciatic nerve injection PO-preferred Widely distributed in around the body, low CSF penetration Time dependent Renally eliminated Rash, diarrhea
Better prognosis vs worse for SLE
Better: isoloated skin and MSK involvement, earlier diagnosis, milder disease, disease-specific tx and good medical care Worse: Renal and CNS disease, mortality currently result of medication side effect or CV events.
fusion of two or more vertebrae due to failure of segmentation of somites small vertebral bodies appear to be fused, anterior concavity important to recognize this is a congenital anomaly
Block vertebrae (note the vertebral bodies are slightly smaller, appear to be fused at the anterior aspect, creating an anterior concavity across all 3 segments)
what to monitor with chronic NSAIDs use
Blood pressure, CBC, BUN, Creatinine, AST
1 cause of genu varum. bilateral, worsens with walking. obesity. mechanical overload of tibia tx is bracing or surgery
Blount's disease
Cortex, medullary cavity, trabecular pattern, overall density are things you would look for related to what TABCs of radiological interpretation?
Bone
fewer X-rays pass through the _______, which leads to less exposure of the image. These show up light grey on x-ray.
Bone
Work up for OM-Labs
Bone aspiration (pus) and/or bone bx with gram stain and culture (culturing sinus tract or open wounds is not accurate) In acute WBC, ESR, CRP could be elevated, these are more helpful for tx monitoring
Microstructure of bone: Consists of ground substance in which numerous collagen fibers are embedded, proportions vary with age, location, and metabolic status
Bone matrix
The anterior compartment of the arm contains what muscles and whats the innervation
Brachialis, biceps brachii; musculocutaneous nerve
Tetracyclines (doxycyline) what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
Broad-spectrum, including intracellular pathogens Bacteriostatic, inhibits protein synthesis Only doxycycline can be used in peds-tooth discoloration PO-empty stomach, large glass of water, IV widely into body tissues and fluid, poor CSF penetration is poor Cumulative dose-dependent Photosensitivity, hepatotoxicity
subacute OM, localized cystic OM; pus and necrosis encapsulated in granulation tissue usally 2/2 staph aureus often these ppl need abx, bx to make sure this isnt a malignancy
Brodie abscess
compression injury of long bones, usually distal radius. what is it and MOI?
Buckle fracture, FOOSH tx: splint or short arm cast 3-4 weeks
Goals of tx for osteoporosis
Build up bone density, fall prevention, prevent secondary cause of bone loss, reduce morbidity and mortality
Flattened, fibrous sacs with synovial membrane that contain synovial fluid
Bursae
congenital spine defect: sagittal cleft in a vertebral body, etiology is unknown, most common in the thoracolumbar junction
Butterfly segment (clearly the other bodies adapted to this, there is upward curvature of the body below. thats how you tell its not trauma)
Crest syndrome (limited scleroderma)
C - calcinosis of the fingers R - Raynaud's E - Esophageal dysmotility S - Sclerodactyly T - Telangiectasia
What tests are positive for femoral acetabular impingement?
C-sign, Anterior impingement, posterior impingement
Which nerve roots leave above the pedicle?
C1-C7
What dermatomes of the upper extremity are good to know? what do they innervate?
C5 (deltoid), C6 (biceps, wrist extensors), c7 (triceps and wrist flexors), c8 (claw-lumbricals)
someone has numbness of thumb, what dermatome is probably affected
C6
Tx for pes planus (tarsal coalition)
CAM boot 4-6 weeks PT- help with tight heel cords cast if nothing else works: surgery
Standard lab tests for SLE
CBC (is hematologic ok?), Serum creatinine and urinalysis with microscopy (kidneys) ESR and CRP (inflammation markers-often elevated) Complement levels (the additional tests the rheum specialists would do) Looking for other organ involvement-> LFTs Creatine kinase assay Spot protein/spot creatinine ratio
Monitoring-Parenteral abx tx
CBC weekly BMP weekly Serum inflammatory markers at beginning/end of parenteral therapy
Septic arthritis, what to order?
CBC, joint aspiration with culture (high WBC, low glucose, high protein), ESR, CRP, Procalcitonin (bacterial blood cultures) blood cultures, X-Ray (soft tissue swelling/effusion)
Which one tests muscle damage? Creatinine or Creatine kinase?
CK
someone is started on statins and they have a lot of muscle issues what could you check to make sure the muscle isnt being damaged?
CK
what lab do you order to get LFTs
CMP
NSAIDs CV effects
COX-1: vasoconstriction, platelet aggregation, thrombosis COX-2: vasodilation Bottom line: Upsets balance Increase risk of CV events (MI, stroke, death) even in healthy pts (rare). risks increases over time
Celecoxib is a selective NSAID, only inhibits ______.
COX-2 (less GI affects, CV risk controversial)
complex bony injuries; bone, muscle, fat tissues images
CT
computer x-ray. cross sectional, takes an image all the way around them, good for looking at fine bony detail, thorax, liver, urinary tract, GI tract, head trauma
CT (computer tomography)
Bones that are difficult to visualize with xray, you can do a
CT scan
Most commonly fractured ankle bone mechanism: compression usually involved with other injuries-check everywhere especially spine.
Calcaneus
Flip to see a CT of pseudogout
Calcified tophy in knee joint to medial and lateral collateral ligaments and intracondyle notch, erosion at medial plataeu
When blood calcium is too high, what hormone will tell the osteoblasts to deposit Ca in bone
Calcitonin
High risk osteoporocis are recommended to have pharm intervention, including:
Calcium (limit 500-600 mg per dose) and vitamin D (essential for calcium absorption- 15 min of sun at least 2x a week) Biphosphonates: first line, prevent hip and vertebral fx decrease bone resorption
trabecular/medullary bone is same as
Cancellous/bone marrow
traumatic disruption of the quadriceps tendon-what cant they do?
Cant extend knee/straight leg raise usually requires surgery
Disc spaces and all joints, assess joint width, subchondral bone, symmetry with other side are related to what TABCS of radiological interpretation
Cartilage
specialized type of CT of the bone, does not have vessels or nerves. poor regenerative capacity. cells form isogenous groups
Cartilage (more degeneration)
A joint where bones are united by cartilage. No joint cavity What are the two types/their qualities?
Cartilaginous joints 1. Synchondroses (immovable) 2. Hyaline cartilage covers articulating surfaces and is fused to an intervening pad of fibrocartilage (amiphiarthrosis/partially movable)
Clinical presentation of polyarticular JIA
Children less than 10 Symmetric arthritis Indolent onset, starts with 1-2 joints, spreads rapidly knees, wrists, ankles, hips Older children/adolescents rapid onset in multiple joints fingers, wrists, elbows, hips
Complications of polyarticular
Children with early onset have low chance of spontaneous remission May cause destructive damage uveitis osteoporosis
what may happen after an ankle sprain (chronic condition)? What would be the tx for that?
Chronic lateral ankle instability (10-20% of sprains)-more likely to resprain, recurrent pain, talar tilt, laxity with inversion stress. refer to ortho Tx: ankle brace surgical ligamentous repair
development of deformity of the foot, feet are plantarflexed, heel is in varus, kidney bean shaped foot
Clubfoot
distal radius fx with dorsal angulation, often associated with an ulnar styloid process fx
Colles fracture
A fracture in which there are more than two fracture fragments
Comminuted
what is important to assess with a tibial plateau fracture
Common fibular nerve (peroneal nerve foot eversion, sensory at dorsum of foot, 1st webspace) DO NOT assess ROM
Rifampin what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
Commonly used synergystically with other agents to reduce development of resistance for gram + organisms, intracellular pathogens Bactericidal, inhibit RNA polymerase Caution in hepatic disease PO and IV-Best taken on empty stomach Concentration-dependent orange-discoloration of body fluids, flu-like symptos CYP P450 drug interactions
Relatively solid, found on external surface of bone, dense part of structure
Compact/cortical bone
occurs when blood flow is cut off and pressure builds in compartment between bone and fascia. Pain is most important symptom. Dx-device that measures pressure-not done in clinic.
Compartment syndrome
A type of impaction fx that occurs in the vertebrae, resulting in depression of the end plates.
Compression
Older adults are more susceptible to these types of fractures due to decreased bone health.
Compression, pathologic
Conditions and meds that increase risk for GI toxicity when taking NSAIDs
Conditions: Age, H. pylori infection, heavy alcohol consumption Meds that increase risk of GI bleed: glucocorticoids, antiplatelet agents, anticoagulants (warfarin, apixaban), SSRIs
type of synovial joint that is convex or concave movement of two articulating surfaces not dissociable example: knee, temporomandibular joint
Condylar
tx for patellofemoral pain syndrome
Conservative RICE NSAIDs PT activity modification consider bracing with a sports holiday
Tx for prepatellar bursitis (inflammatory)
Conservative: RICE, activity modification, time and monitoring do not aspirate (high rate of infection)
How would you diagnose SLE?
Constellation or clinical findings Elevated ANA titers (sensitive, not specific. refer to rheumatologist for additional testing)
Spiral groove of humerus: whats special
Contains the radial nerve and deep artery (profunda brachial artery)
an adjacent skin infection that may happen along with nonhematogenous OM
Contiguous infection
Flexing the shoulder is the same action as extending the arm.
Coo
For NSAIDs, why does cox-1 inhibition lead to adverse GI effects?
Cox-1 stimulates gastroprotective prostaglandins. When you inhibit it, there will be adverse GI effects. This is why selective cox-2 inhibitors (celoxib) were created.
test to assess autoimmune muscle condition? dermatomyositis, polymyositis, inclusion body myositis, polyarteritis nodosa
Creatinine kinase elevated: muscle damage
How to evaluate for AC joint arthritis
Crossover test-pain on crossed arm abduction x-ray most important
way to remember difference in action of dorsal and palmar interossei?
DAB (dorsal abduction) PAD (palmar abduction)
controlled substance prescribing tips
DEA. number, patients full name and DOB, MNPMP (prescription monitoring program)
low level ionizing radiation, measures bone mineral density. documents small changes in bone mass. can evaluate for osteoporosis (T score: -2.5 or lower is osteoporosis. spine and hip are most important)
DEXA (dual energy X-ray absorptiometry)
determines bone mineral density, usually in the hip or lumbar spine. radiation exposure
DEXA Scan
Tx for RA
DMARDs (methotrexate-may be indefinite) NSAIDs for pain-do not help with progression of dz Glucocorticoids (oral or injections) Consider surgical intervention if advanced
Diet recommendation for gout: do and donts
DO: vegetables and low fat or non fat dairy products, water, weight control, DONT: some purine rich foods (shellfish, organ meats, beef, lamb, pork-red meat) alcohol (esp beer) high fructose corn syrup beverages
immobility can lead to this hematologic MSK condition where there blood clots too fast
DVT (deep vein thrombosis)
Mechanism of quadriceps tendon rupture. What does it disrupt?
Deceleration injury (jumping from height) The extensor mechanism of the knee
patellar tendon tear MOI
Deceleration injury-jumping down from a height of 3ft or more abrupt stopping
Abx used when organism is known, uses narrowest spectrum agent to prevent abx resistance
Definitive
Exam findings for a distal biceps tendon rupture
Deformity of biceps, diffuse swelling and ecchymosis about the elbow and antecubital fossa Focal antecubital fossa pain and tenderness often cant assess strength due to discomfort high energy mechanism: get an X-ray
A type of impaction fx that occurs in the knee when the femoral condyle strikes the softer tibial plateau.
Depression
Name 3 potential derm manifestations of SLE. There are others if you want to try to name those too!
Derm sx of SLE: Malar rash (days-weeks, spares nasolabial folds) Photosensitivity Discoid lupus-chronic, sun exposed areas Other less common ones: urticaria, telangiectasias, purpura, bullous lesions, etc. Just know that there are other derm sx than malar rash!
patients at higher risk for chronic OM
Diabetic/PVD neuropathy, high blood sugar, poor tissue perfusion
Blood supply to long bones
Diaphysial, metaphysial, epiphysal arteries
Jones fx of 5th metatarsal involves the __ of the 5th metatarsal
Diaphysis; high incidence of non-union chance if it doesnt heal may need surgery
Skin findings for systemic sclerosis (scleroderma)
Digital ulcerations Digital pitting Tightness, swelling, thickening of digits Hyper/hypopigmentation Narrowed oral aperture Scaling of skin SC calcinosis
WHO: Sum or lost years of "healthy life," measures burden of disease across population
Disability adjusted life years (DALY)
Pain with straight leg raise. What are some ddx?
Disc herniation/back and spine pathology Osteoarthritis of the hip/hip pathology
Patellar dislocation
Dislocation of the patella laterally
bones are displaced from their normal joint alignment, out of their sockets, or out of their normal positions
Displaced fracture
Bone fragments shattered
Distracted fracture
should you assess ROM in femoral condyle fractures? how to examine this patient? What is there a risk of?
Do not assess ROM examine as it lies risk for NV injury-check deep, superficial peroneal and sural nerve function
if a drug is time dependent you probably have to do what
Dose multiple times per day
Name of test: Stabilize lower tibia with one hand, with other hand you pull forward with hand behind the heel
Drawer test
Clinical effects of opioids
Drowsiness, GI effects (nausea/vomiting/constipation), histamine release (morphine, flushing, pruritis, hypotension, euphoria, risk of dependence
Because someone with rheumatoid arthritis may have Sjogrens syndrome, what sx do you want to ask them about?
Dry mouth, dry eyes, swollen glands
When is the fetus most radiosensitive?
During the first few weeks of pregnancy
Two inflammatory markers we check, which increase in acute and chronic inflammatory states. Non-specific.
ESR and CRP
useful in monitoring disease activity for rheumatologic conditions
ESR and CRP
cartilage with elastic fibers located in: ear external auditory canal, eustachian tubes, epiglottis and larynx bridge of nose does not calcify
Elastic cartilage
etiology: overuse of extensor muscles of forearm Very TTP over the medial or lateral epicondyle
Elbow overuse: Tennis elbow (lateral epicondylitis) golfers elbow (medial epicondylitis)
Lab findings for polymyalgia rheumatica
Elevated ESR (above 40) Elevated CRP Normocytic/normochromic anemia common Serologic test negative (ANA, RF, CCP) Temporal bx if giant cell arteritis sx are present (tenderness in temple areas, jaw cramping, elevated sed rate, headache) Normal EMG Normal muscle bx
Abx used when organism is unknown, tx covers the most likely organisms causing the infection, may require multiple agents or broad-spectrum agents
Empiric
Connective tissue sheath of skeletal muscle: fine areolar CT surrounding each muscle fiber
Endomysium
With allergies, asthma, parasites, what might be elevated?
Eosinophils
Connective tissue sheath of skeletal muscle: dense regular CT surrounding entire muscle
Epimysium
SLE management
Exercise is important Stress management Sunscreen Team approach
Deep group of extensor muscles of forearm
Extensor indicis, extensor pollicus brevis, extensor pollicus longus, abductor pollicus longus, supinator, anconeus
evaluation of femur fx- what is their presentation? what cant they do? what imaging to get?
Externally rotated, Abducted, Limb shortened (if displaced) AP of pelvis Cross table lateral view unable to straight leg raise avoid frog-leg view
exam for dequervain's tenosynovitis
FINKELSTEINS
What populations in general tend to have higher inflammatory markers?
Females, older people, obesity, chronic disease
Skeletal muscle relaxant: Acts via CNS, reducing motor neuron activity. Approved for short term use only. Contraindications: Patients w/ seizure risk, glaucoma, arrhythmias/CHF/recent MI, avoid w/ tramadol. May cause sedation
Flexeril
flexor carpi ulnaris
Flexes and adducts wrist; ulnar nerve
If prepatellar bursitis is severe, ROM may be affected. What specifically would be limited?
Flexion
PE findings of meniscal tears. what are two special tests
Focal and medial or lateral joint line tenderness McMurray's Appley's
actions to assess nerves of lower extremity?
Foot eversion- peroneal Foot plantar flexion-sural
inflammation, fibrosis, and scarring of joint capsule-- does not involve rotator cuff. insidious onset- female 40-55 years old. Number 1 complaint is pain, stiffness. ROM limited more by stiffness than pain. Pain management and PT are key
Frozen shoulder (adhesive capsulitis)
GI, Kidney, Pulmonary, PV, Neuro and Cardiac Sx of systemic sclerosis---this can be a bad disease.
GI -dysphagia -esophageal reflux due to dysmotility -malabsorptive diarrhea -n/v -weight loss -xerostomia Kidney -Hypertension -Potential for sclerodermal renal crisis: renal failure PV -Telangiectasia Pulmonary -Crackles in lung bases -Dyspnea Cardiac -Conduction abnormalities -Cardiomyopathy -Pericarditis Neuro Peripheral neuropathy Trigeminal neuropathy bells palsy like (paralysis on one side)
Etiology of reactive arthritis
GU or GI infection (diarrhea, STI risk?) Chlamydia trachomatics Camplyobacter C. diff E. coli Salmonella
Lab findings for reactive arthritis
HLA-B27 common (30-50% pts pos) The following only if they have STI or GI concerns: Genital swab may reveal Chlamydia Stool culture: Salmonella, Shigella, Yersinia, Campylobactor, C. diff
ankylosing spondylitis: gene and classic finding
HLA-B27, bamboo spine
Stiffness of MTP joint of great toe, caused by arthritis, local trauma, gout, more common in men pain with walking tender MTP joint, pain with dorsiflexion what is it and tx?
Hallux rigidus curved-sole (rocker-sole shoe), NSAIDs, possible surgery-podiatry/ortho
Allopurinol: Screening for human leukocyte antigen-B*5801 genotype is recommended before initiating treatment in patients of __________
Han Chinese or Thai descent, regardless of kidney function, or in Koreans with chronic kidney disease stage 3 or greater.
Osteoporosis: what you could monitor
Height-old people might get shorter and have higher risk. greater than 1.5cm is significant
What ways is osteomyelitis spread?
Hematogenous (20%): bacteria in blood stream travek to bone nonhematogenous (80%): trauma, injection, surgery, nearby infection (cellulitis, abscess)
failure of ossification of half a vertebra triangular shaped vertebral body instead of a rectangle MC in thoracic spine may produce significant scoliosis
Hemi vertebra *extra one between L5 and S1
Secondary PAN may be related to what causes
Hep B, Hep C, Hairy cell leukemia (rule these out!)
tests for polymyalgia rheumatica
HgB: Decreased (Anemia) elevated ESR Elevated CRP negative ANA, RF, CCP
type of synovial joint that is flat, planar motion: in one plane; flexion, extension Example: Interphalangeal joints of hand and foot, elbow
Hinge
Eldery patients with hip pain (thigh pain, knee pain) should be treated as if they have a __________.
Hip fracture
adjunct to surgery and abx, enhanced bone and soft tissue healing, used in refractory chronic OM
Hyperbarics, increase oxygen to limbs
Growth plate fx: Salter-Harris classification
I (Same): X-ray negative II (Above): Metaphysis through epiphysis III (Lower) Physis through epiphysis IV (Through): Epiphysis, Physis, and Metaphysis V: compression of the Physis
Part where there is only actin filaments appears lighter, this is known as ___________
I band
How to treat felon
I&D(scalpel, irrigation), abx (amox/clav (Augmentin-cover oral flora) OR clindamycin OR cephalexin
Exam findings for distal biceps tendonitis
I: Normal P: focal antecubital fossa pain and tenderness S: Pain in elbow area with resisted supination
Tx for septic arthritis
IV abx followed by PO usually at least 4 weeks target staph, strep, MRSA, gram - IV vanco + 3rd gen cephalosporin cefepime if they have a lot of comorbidities or are immunosuppressed ortho and possible ID consult admission
OM tx- acute
IV antibiotics (usually for 1 week before transition to oral) ortho/podiatry/infectious disease consult admission aspiration, surgical drainage, wound care, amputation, immobilization manage diabetes if needed
Tx for septic bursitis
IV/po abx (vanc and/pr cefazolin; po cephalexin; clinda or doxy) ortho consult if extensive
CK can be elevated after a marathon, a muscle biopsy or even caused by medications like statins. Illness caused by medicine is called ___________.
Iatrogenic
first line NSAIDs
Ibuprofen (advil, motrin) Naproxen (Aleve) (go to- only dose once every 12 hours, may be safer for CV risk)
Inflammation of the ITB is what
Iliotibial band syndrome
Neutrophils may undergo morphologic change during disease. Presence of band means what?
Immature neutrophils; reflect left shift->active infection or severe anemia
Patient education for SLE
Importance of adherence to medications and follow-up appointments Seek medical attention of new sx including fever Increased risk of infection and CV disease Avoid exposure to sunlight and UV light Avoid other triggers Non-live vaccines during stable periods of disease Stop smoking Plan pregnancies
Determines probability of an individual being diagnosed with a disease in a given time period. The number of newly diagnosed cases of disease.
Incidence
This step in pain signaling involves transient vasodilation and increased vascular permeability. The release of chemical mediators such as histamine and 5-Ht result in throbbing, burning, or aching sensation.
Inflammation
What is prepatellar bursitis? types? MOI?
Inflammation of the bursa over the patella-MC May also present as septic prepatellar bursitis inspect the skin-is there anything that could make it infected? Housemaid's knee Kneeling excessively
Pes anserine bursitis hx and PE finding
Insidious onset of medial joint pain Often will point exactly to the Pes Anserine bursa medial aspect of the knee below the joint line Tenderness medial aspect of knee below the joint line
Findings of long head of biceps tendonitis:
Inspection: Normal (the pic is a rupture) Palpation: Focal anterior shoulder pain and tenderness radiating inferior to biceps muscle. Strength: Focal pain with resisted shoulder forward flexion and resisted elbow flexion and resisted forearm supination.
Clinical presentation of talus fx. What must you get to help in dx?
Intense pain, inability to bear weight, localized tenderness and swelling more to the front of the foot, may have loss of normal foot contour, may be misdiagnosed with talus fx, so they need Foot x-rays (ideal, ankle x-rays may also pick up on it)
The fracture line crosses the articular cartilage and enters the joint
Intra-articular
Name of test: Forcibly inverting ankle
Inversion stress test (significantly more movement + , significant disruption of lateral ligaments)
Tx for bite wounds
Irrigating and debriding Prophylaxis with Td, amox/clav (Augmentin) Rabies? Vaccine + immoglobulin exposure labs? XR to look for teeth
Make sure you ask this when someone is having joint pain in one joint
Is there pain in any other joints?
muscle contracts but without appreciable change in length (for example just holding something)
Isometric
What is the gold standard for diagnosing gout?
Joint aspirate
suspect a septic joint, GOUT, RA. what do you do
Joint aspirate diagnostic and therapeutic to evaluate synovial fluid Indications: painful, swollen joint. septic: huge WBC count (over 10,000)
Help with ddx for reactive arthritis?
Joint aspirate: No crystals or abnormal bacteria (septic arthritis gout)
tx for pseudogout
Joint aspiration, NSAIDs, intraarticular steroid injections can reduce symptoms to less than 10 days (allopurinol will not work)
MSK symptoms of SLE:
Joint pain MC-Arthalgia. May seem out of proportion to other sx. myalgia, arthritis of small joints Usually symmetrical, polyarticular Swan neck deformity increased incidence of avascular necrosis
criteria for JIA diagnosis
Joint pain, swelling, and inactivity stiffness Last at least 6 weeks Involves one or many joints Symptoms begin prior to 16 yo
MSK findings for systemic sclerosis
Joints, tendons, bones -Flexion contractures -Friction rub on tendon movement -Hand swelling -Joint stiffness -Polyarthalgias -Sclerodactyly (stiff appendages) Muscles -Proximal muscle weakness
flip to compare Jones and proximal 5th metatarsal avulsion fx. which is worse?
Jones worse
jones and psuedojones management
Jones: high incidence of malunion, ortho consult for operative, lengthy treatment PJ: extrarticular-walking cast or stiff shoe 2-3 weeks intraarticular: non-weightbearing cast 6-8 weeks with ortho f/u in 1 week
NSAIDs are excreted via the _____. So caution in this disease!
Kidney
most commonly involved organ with PAN
Kidney
Most patients with pseudogout have preexisting joint damage from other conditions like OA and RA. What joint is the most commonly affected?
Knee
common joint deformities in OA?
Knees: bony enlargements varus > valgus
rediculopathy common dermatomes lower extremity and what actions they do
L3 (flex hip), L4 (flex quad, straighten knee), L5 (toes to nose), S1 (push the gas) dermatomes
If someone can't squat think
L4
Patellar reflex associated with what nerve?
L4
Damage to this nerve-cannot heel walk
L5
branches of lateral cord of brachial plexus
LML Lateral pectoral nerve Muscluocutaneous Lateral root of median nerve
Other lab findings in RA-CBC and X-ray
Lab Thrombocytosis Anemia CMP normal Serological studies or synovial fluid analysis if uncertain about diagnosis X-ray Joint erosions, displacement
most specific test for an ACL tear
Lachman
special tests for ACL
Lachman's (grab knee, slight flexion, thumb on tibial tubercle, thumb on quad tendon) Anterior/Posterior drawer test
Risk factors for osteoporosis
Lack of estrogen, calcium or vitamin D deficiency; petite body form; immobility; low levels of TSH; diabetes mellitus
The time following the initial radiation event before the first-detectable effect occurs.
Latent period
Vaglus is when the distal joint is more _________ than the proximal joint.
Lateral (vaLgus-Lateral)
Testing for lateral and medial epicondylitis (3 each)
Lateral epicondylitis: resisted wrist extension and forearm supination Arm extended, push long finger down Medial epicondylitis: resisted wrist flexion and forearm pronation Arm extended, push long finger up
Gold standard for skeletal maturation assessment
Left hand and wrist PA x-ray compared to the Greulich and Pyle atlas Risser index more common however (see image)
Presentation for a posterior dislocation of hip
Leg is shortened, hip is fixed in flexion, adduction, internal rotation, sciatic nerve palsies common (check sensation and distal palsies)
Basophils may be increased in what condition
Leukemia
Lab findings in systemic JIA
Leukocytosis Thrombocytosis Anemia low hgb and hct-often exacerbated by GI blood loss due to NSAIDs Elevated ESR and CRP (inflammation markers) ANA and RF negative Mild LFT elevations UA normal (hematuria or proteinuria should prompt alt dx)
complications of PAN
Limb edema is common infarction gangrene of fingers, toes ulceration extending into SC tissue
MC locations for hematogenous OM in children
Long bones-femur, tibia, humerus, fibula
Etiology: Use/overuse (overhead use, swimmers, tennis, etc.) Tendon becomes frayed/worn between lesser and greater tuberosity Anterior shoulder pain with resisted supination/forward flexion of the shoulder Sometimes it ruptures and there is a deformity. Tx: RICE, activity modification, NSAIDs, injection is an option.
Long head of biceps tendonitis (a rupture is also known as popeyes deformity)
Proteins interconnecting myosin filaments
M Line
Complete tear of the MCL or LCL, MOI? What should you also suspect?
MCL, LCL tear Blow to the lateral aspect of the knee often with foot planted (valgus stress to the knee) Always suspect an associated ACL tear (LCL-most common with ACL)
branches of medial cord of the brachial plexus
MMMMU Medial pectoral nerve Medial root of median nerve Medial cutaneous nerve of arm Medial cutaneous nerve of forearm Ulnar nerve
soft tissue detail imaging
MRI
go to for spine/ortho imaging, no ionizing radiation. uses magnets to line up atoms and flips them out of phase, shows good anatomical detail, fat is brightest signal
MRI (magnetic resonance imaging)
Work up for OM-Imaging
MRI test of choice x-ray (Cant fully rely on, may take weeks or months to appear) CT: more useful for chronic than acute less common Bone scan (sensitive but not specific) Ultrasound: subperiosteal fluid collection or abscess adjacent to bone
Common resistant pathogens
MRSA (multidrug resistant s aureus) Vancomycin-resistant enterococcus Pseudomonas Extended spectrum beta-lactamase producing e coli, klebsiella Carbapenemase producing E. coli, klebsiella
pelvic fx can be stable or unstable. Unstable may be associated with _____ loss. What to look for on x-ray for pelvic fx? What can you do to evaluate for pevlis fx?
Massive blood loss; Trace the main pelvic ring and two obturator foramina push on ASIS pt supine
Varus is when the distal joint is more _______ than the proximal joint.
Medial
With a supracondylar humerus fx, what are we worried about for risk of damage?
Median nerve, radial nerve, vascular compromise (5-17% supracondylar fx have: brachial artery injury or compartment syndrome)
lateral femoral cutaneous nerve syndrome aka
Meralgia paresthetica tx: remove cause, neuropathic pan med if needed
nagging forefoot pain over middle metatarsal heads, usually d/t faulty weight distribution
Metatarsalgia
Fx with radial nerve effected wrist drop, numb on back of hand Immediate surgery
Midshaft humerus fx
Difference in potential causes between monoarticular vs polyarticular pain
Mono: could be localized injury, monoarticular arthritis, or infection Poly: Could be inflammatory, immunologic, or neurologic disorder, or infection
Fx of proximal third of the ulna, dislocation of the proximal head of the radius
Monteggia fx
Allopurinol can be started during an acute gout flare if used with ____ and ____.
NSAID, colchinine
tx for polyarticular JIA
NSAIDs
Tx for reactive arthritis
NSAIDs Intra-articular glucocorticoid injections systemic glucocorticoids DMARDs Antibiotics if Chlamydia is present
Tx and screenings for oligoarticular JIA
NSAIDs Intra-articular glucocorticoids DMARDs rarely used Regular eye exams (more frequent if they have a pos ANA)
Tx for systemic JIA
NSAIDs (indomethacin good option, improvement should happen in 1-2 weeks) Oral glucocorticoids DMARDs (disease modifying antirheumatic drugs) Pediatric rheumtaology referral
what can you do with greater trochanteric bursitis
NSAIDs, activity modification, ice, injection of corticosteroid injections
management of stress fx
NSAIDs, restriction of activity, time
Should you test someone that got bit by a tick right away?
Nah, the IgM antibodies to B. burgdorferi take 1-2 weeks and IgG antibodies take 2-6 weeks
Tx for OA
Naproxen first line Topical (if there is only 1 joint involved) and oral NSAIDs (Cox-2 inhibitor) Duloxetine (multiple joints, if they cant be on NSAIDs) Topical capsaicin (if only 1 or 2 joins affected, the above failed) Intra-articular glucocorticoids injections Surgical: if failed conservative measures, hip or knee replacements
common adverse abx effects
Nausea, diarrhea, Rash: hypersensitivity, photosensitivity
Consists of motor neuron, motor end plate, synapse, synaptic cleft, synaptic vesicles, NTs (ACh)
Neuromuscular junction
Dx for Sjogrens
No single diagnostic test, clinical dx to rule other causes out. Salivary gland bx used to confirm suspected diagnosis (not fun) Drugs may be a cause of dryness (anticholinergics) so take a thorough hx
is sx of gout started recently, would the uric acid be elevated?
No, its not always high in a first attack
If someone has an acute illness and a tick bite or exposure in an endemic area (like MN), do you want to get a test?
No, just treat them (doxycycline)
OM that occurs through direct inoculation: happens when there is penetrating wounds, open fractures, invasive ortho procedures, pressure ulcers
Nonhematogenous OM
When you pick up a child typically under 4 by the arms you might pop the elbow out (radial head dislocation). They don't have pain, their
Nursemaid's elbow, reduce it by supinating wrist and extending arm, apply pressure over radial head
Other contraindications for NSAIDs: Kidney injury, eGFR < 30mL/min, cirrhosis/advanced liver disease, ASA-exacerbated respiratory disease, avoid in pregnancy (esp after 32 weeks)
OK
A fracture with angulated fracture line
Oblique
Red flags to watch out for when evaluating a fx
Open fx-refer immediately to hospital Extreme swelling-suspect impending compartment syndrome
Opiate vs opioid vs narcotic
Opiate = in poppy (morphine, codeine) Opioid = includes opiates and similar drugs (we use this term the most) Narcotic = gov't definition: controlled substance
Drug that inhibits pain transmission neurons, causing analgesia best for continuous dull pain, higher doses can be used for acute, sharp pain Respiratory depression
Opioids
Treatment of acute gout should commence within 24 hours. What drugs are used for acute gout flares? What is the first line tx?
Oral corticosteroids, intravenous corticosteroids, NSAIDs, colchinine (CI renal or hepatic impairment; expensive) are equally effective, but NSAIDs are first-line treatment, particularily Indomethacin. Oral NSAIDs are given at maximal dosage and continued for 1-2 days after relief of sx. Single joint-corticosteroid injection
Biggest cause of hip pain
Osteoarthritis Others: rheumatoid arthritis, septic arthritis, fractures of proximal femur or pevlis, dislocation of the femoral head (hip dislocation)
Leptin has also shown to influence bone density, inhibiting _______ and doing what
Osteoblasts, softening the bone
stem cells in periosteum and endosteum that give rise to osteoblasts
Osteogenic cells
the structural unit of bone matrix, laid down in organized manner, laid down in lamellae tubules, haversian canal contains nerve, vein, artery
Osteon/haversian system
T score less than -1 but greater or equal to -2.5
Osteopenia
imaging for scoliosis
PA (Cobb angle, risser sign) and lateral spine films
Two chest views
PA, Lateral
Wrist Views
PA, Oblique, Lateral (scottie duck-no duck droppings, sign of triquetral fx), Scaphoid (distance between scaphoid and lunate important)
Tender erythematous nodules, palpable purpura, livedo reticularis, ulcers, bullous or vescicular eruptions, more frequent on lower extremities
PAN
determine areas that are metabollically active, can detect cancer, heart issues
PET Scan (spine infection-cancer looks exactly the same, have to pair this with other imagine)
Patient education for polymyositis
PT and OT can be helpful Monitor for steroid induced complications Most patients improve w therapy
What hormone regulates the blood Ca level that will stimulate the osteoclasts to degrade bone matrix to release Ca
PTH (parathyroid hormone)
clinical presentation of trochanteric bursitis
Pain and tenderness over greater trochanter, may radiate to knee or ankle or buttock, worse when first rising from sitting, night pain
Osgood Schlatter's disease presentation
Pain at the insertion of the patellar tendon on the tibial tubercle
clinical presentation of osteoarthritis
Pain exacerbated by activity, better with rest Morning stiffness Knees, hips, hands, spine Weight-bearing joints more prevalent in females
presentation of morton's neuroma, tx
Pain in the toes and dorsum of the foot May palpate small nodule in web space Initial tx: steroid/lidocaine tx Potential surgery
flip to see clinical presentation of ankle fx
Pain, swelling, bruising, inability to bear weight. Significant deformity if dislocation present as well
How do fx usually present?
Pain, swelling, decreased function stress-insidious onset, pain during weight bearing
Clinical presentation of ankle sprains, which are usually inversion mechanism
Pain, swelling, may or may not be able to bear weight, foot may be passively inverted (talar tilt), passive inversion related to increased pain
A CBC finding you may get for lupus
Pancytopenia (anemia, neutropenia and thrombocytopenia)
Terminal cisterine?
Part of sarcoplasmic reticulum where calcium is stored
Flip to see an x-ray of a quadriceps tendon rupture deformity--what will look off?
Patella sunken down
A fracture through bone weakened by tumor, metabolic bone disease, or osteoporosis
Pathogenic
collapsed medial arch-may be congenital or acquired from polio, RA, tendon rupture. can be flexible (MC, with weight bearing) or rigid. tx?
Pes planus (flat foot) arch support. if underlying condition may need surgical correction
MOA for patellar dislocation
Pivoting injury or valgus injury (patella valgus) on extended knee Can spontaneously reduce
usually an overuse injury (runners, standing occupations, also RA or gout) Pain over plantar surface Strain of fascial fibers, friction causes periositis of calcaneus
Plantar fasciitis tx: rest, NSAIDs, heel and arch support, if refractory: steroid injection
generalized pain, fever, weight loss painful nodules on legs necrotizing arteritis of medium or small arteries Involvement of renal and visceral arteries is characteristic ocasionally effects small arteries middle or older age adults, male predominance does not involve veins
Polyarteritis nodosa (PAN)
morning stiffness and pain typically lasts at least 30 minutes, shoulder, hips, and neck limited ROM in affected joints subjective weakness inflammatory rheumatic condition occurs in adults over 50 women more affected
Polymyalgia and rheumatica
Both ends of this muscle are insertion and origin, depends on how we move the joint
Popliteus muscle
Tx for gout flares
Potent NSAIDs: Naproxen (500 mg BID) Indomethacin (50 mg TID) Glucocorticoids: Oral-short burst 5 days, then follow up) Colchicine (use w/ NSAID/glucocorticoid intolerance; use within first 24 hours of a flare, lots of drug drug rxns)
When mycobacterium infect thoracic spine, this type of hematogenous OM is also known as
Pott's disease
CT scan contraindications
Pregnancy WT >450lbs allergy to contrast die kidney/liver disorder Huge radiation exposure
Likelihood of having disease, total number of cases in a population
Prevalence
two types of scoliosis
Primary (idiopathic-MC) Secondary (congenital abnormalities, neuromuscular disorders, tumors)
flip to see ulnar drift, what is it related to
RA
risk factors for septic arthritis
RA, Lyme prosthetics
What to do when you see these things on a clavicle fracture/AC separation Midshaft or proximal: Overriding of greater than about 1.5 cm Displaced distal third clavicular fractures. AC separation with skin tenting or unsightly deformity. Polytrauma Floating Shoulder (Rare combination of clavicle and glenoid neck fracture).
REFER!
Tx options for elbow overuse
RICE Corticosteroid injections for short term relief new,wont be tested on:Nitroglycerin patches applied 1/4 daily
Management of talus fx
RICE ortho will usually make call on surgery
Management of ankle sprain
RICE for first 1-2 days immobilize with plastic or plaster splint Consider crutches if moderate or severe
Tx for Osgood Schlatter
RICE, NSAIDs, chopart strap
Tx pes anserine bursitis
RICE, activity modification, NSAIDs, Sports holiday 3-4 weeks
mechanism: fall on outstretched hand (FOOSH), direct blow focal tenderness on radial head
Radial head fracture
Reiter syndrome aka
Reactive arthritis
Pes planus rigid causes, what to do
Refer tarsal coalition (pain with activity, repeated strains, 8-12 years old) vertical talus iatrogenic/posttraumatic ant eater sign seen here
if you suspect RA, what to do
Refer to rheumatologist Pt education (be aware of functional limitations, psychosocial component), PT/OT
Colles' Fx management
Refer, URGENT reduction and immobilization stable: closed reduction and casting unstable: pinning
What is the number 1 cause of work related injuries
Related to lifting, pushing, holding, carrying, holding
Prognosis and complications of systemic JIA
Resolves completely in 40-50% of patients Complications: destructive damage severe growth retardation osteoporosis Macrophage activation syndrome (life threatening-widespread->bleeding, shock)
autoimmune, inflammatory disease chronic synovitis (synovial fluid)-bony erosion and damage to joint Can be systemic
Rheumatoid arthritis
suspect rheumatoid arthritis, what do you check?
Rheumatoid factor (more likely to see in active disease) May also be seen in Sjogren syndrome, lupus, even healthy individuals Way more specific test: Anti-CCP Antibody "positive" in RA
Organism that causes osteomyelitis
S. aureus
Nonhematogenous OM: common organism
S. aureus, frequently multiple organisms
If someone cant toe walk think what
S1
achilles reflex is mediated by
S1
rotator cuff muscles
SITS Supraspinatus Infraspinatus Teres Minor Subscapularis
Multiple myeloma (they have bone pain) test
SPEP UPEP Looking for gamma globulin CBC-Anemia ESR and CRP increased Hypercalcemia
Pts with sickle cell typically have osteomyelitis due to
Salmonella
Sickle cell think about
Salmonella
network of smooth endoplasmic reticulum surrounding each myofibril
Sarcoplasmic reticulum (blue)
common mechanism: FOOSH snuffbox tenderness: axial compression of thumb metacarpal, pronate the wrist and ulnar deviation 10-25% of them are missed on initial radiographs, come back in 10-14 day for repeats
Scaphoid fx
Why should you not miss a scaphoid fx? Why would this be easy to miss? What can you do about that?
Scaphoid fx have a very high rate of non-union (poor blood supply to scaphoid), but they may be occult on x-ray. Get an MRI to be sure.
Screening is an example of _________ prevention.
Secondary
A type of comminuted fracture in which a completely separate segment of bone is bordered by fracture lines
Segmental
Where can you test to make sure the axillary nerve isnt injured? (rare concern for an AC separation)
Sensation/strength of deltoid
A _______ test picks up the disease most of the time, may have false positives.
Sensitive
Step of pain signaling: Occurs with repeated stimulus and/or inflammation Increase in chemically gated and voltage gated ion channels Increases excitability of nociceptor terminals, lowers threshold for activation, especially true w/ visceral nerve fibers. Nerve injury-> burning, shooting, tingling pain
Sensitization
infectious arthritis, usually involves a single joint (can be multiple if they have RA, CT disorder, or spesis), can be hematogenous (MC) or nonhematogenous. Knee>hip>shoulder>ankle>wrist gonococcal (MC) vs nongonococcal worse
Septic arthritis
2 yo limping cant walk, pain with PROM of hip
Septic arthritis put abuse on ddx for kid who cant walk Test: ESR hip: do ultrasound-> effusion XR: hip and knee hip arthrocentesis blood cultures
prosthetic. R knee history of OA, diabetes, Knee is swollen w erythema, decreased and painful flexion. ddx? workup?
Septic arthritis-diabetes prosthetic-nongonococcal
PE findings, differentiating the septic arthritis and gout.
Septic arthritis: Range of motion pain, Toe would be hot, indurated, decreased glucose, elevated protein and WBC Gout: Excruciating pain even when touched gently, toe wouldn't be hot to touch, shiny purplish red, no induration negatively birefringent Imaging to rule out OA and trauma
Dry eyes, dry mouth, swollen glands chronic inflammatory autoimmune disorder characterized by lymphocytic infiltrates exocrine organs More often in women Can be a complication of rheumatoid arthritis, may be associated with scleroderma,SLE,polymyositis,HIV,HepC(immune deficiencies)
Sjogren's disease
What type of muscle is multinucleated
Skeletal
A snapping or popping sensation due to tendons around the hip moving over bony prominences
Snapping hip
Looking at organs, blood vessels, gas patterns, fat, calcifications, fluid levels relates to what TABCS or radiological interpretation
Soft tissues
A ________ test will confirm a diagnosis, may be some false negatives.
Specific
Antibiotic selection considerations
Spectrum Bacteriostatic (halting growth) vs bactericidal (killing organism) Allergies ROA Penetration Dose/Frequency Monitoring
type of synovial joint with convex surface in concave cavity movement:wide-ranging, flexion, extension, abduction, adduction, rotation, circumduction ex. shoulder, hip
Spheroidal (ball and socket)
fever, cant walk, low back pain, decreased anal tone. ddx? test?
Spinal epidural abscess-get MRI
patient with back pain who is leaning forward on a shopping cart pushing it for comfort should make you think about (there is more room for spinal cord and nerves when leaning forward). inflammed ligaments, CSF squeezed out. Think of this as pre-cauda equina, progression is slow. global weakness (not focal), numbing, difficulty walking, cannot stand upright, no hyperreflexia or clonus
Spinal stenosis
A multiplanar and complex fracture line
Spiral
someone comes to you saying they have pain or limited motion while in a cast.. what do you do?
Split the cast or remove and check under the splint
Soft part of bone
Spongy/cancellous/medullary bone
hematogenous osteomyelitis: MC organism
Staph aureus
Organism for felon
Staph, strep, oral flora
damage to bone exceeds the rate of repair, hard to detect (may need a bone scan or MRI). pain, repetitive traumatic activity, plain film might not show anything
Stress fracture
continuous low level stress over time, may not show up on x-ray. usually 2nd and 3rd MT's, which are relatively fixed. if you suspect, what to do?
Stress fx; rest and immobilize. bring back in 2-3 weeks-calcification may form. Tx: RICE
clinical tests to assess the stability of ankle ligaments (done at follow-up, not acutely)
Stress maneuvers drawer test inversion tests
A fracture in the normal bone that has been subjected to repeated or cyclical loads that in and of themselves are not sufficient to cause a fracture
Stress-Fatigue
A fracture in weakened bone that has been subjected to a load insufficient to fracture normal bone
Stress-Insufficiency
Discoid lupus (chronic conditon) are typically on what areas of body
Sun exposed areas
DMARDs action
Suppresses the body's overactive immune system RISK: sepsis Labs (CBC, BMP), screenings, imagine (chest x-ray) before May takes weeks to become effective
FOOSH, elbow pain, swelling, limited ROM. Fracture immediately proximal to the condyle of the distal humerus
Supracondylar humerus fx (common)
presentation of an achilles tendon rupture
Swelling of distal calf, palpable tendon defect, weak plantar flexion, may still be able to flex (can press down weak) Pos thompson test
Patellar fx PE
Swelling, abrasion possible, rarely open, possible depression at mid patella Palpation: anterior tenderness over the patella, possible depression at mid patella DO NOT assess ROM Cannot straight leg raise
Partially movable cartilaginous joint, bones united by fibrocartilage
Symphyses
Systemic sclerosis management/prognosis
Symptomatic and supportive Monitor every 3-6 months for end-organ and skin involvement, medications Ecocardiology and pulmonary tests yearly Prognosis: possible improvement but incurable. Worse if there is early organ manifestations
Cartilaginous joint where bones are united by hyaline cartilage, immovable.
Synchondroses
type of fibrous joint held together by ligament, immovable
Syndesmosis
Joints with maximum amt of movement, more likely to be arthritic, has joint cavity, articulating surfaces lined by hyaline cartilage, lined by synovial membrane that secretes synovial fluid, articulating bones kept in place with fibrous capsule
Synovial. ** most important for us to know
Subsets of juvenile idiopathic arthritis
Systemic JIA (10-20%) Oligoarticular JIA (50%) Polyarticular JIA (35%) Enthesitis related JIA Psoriatic JIA
chronic dz, diffuse fibrosis of skin and visceral organs and vascular abnormalities Stiff Raynauds phenomenon-chief complaint, skin thickening, "puffy hands" pruritis, GERD Most manifestations have vascular features Many organ systems may be involved Can range from mild disease, affecting the skin, to a systemic disease that can cause death in a few months More often in women
Systemic sclerosis (scleroderma) CREST is limited version
clinical presentation of PAN (most important-systemic, MSK, Skin, Renal)
Systemic sx fatigue, weight loss, weakness, fever, arthalgia/arthritis/myalgia Other organ involvement skin lesions (rash, purpura, nodules) hypertension renal insufficiency neurologic dysfunction-cerebral ischemia GI-abdominal pain esp after meals
fibromyalgia presents as pain that involves both sides of the body, above and below the waist. T or F
T (pain may be initially localized however)
invagination of sarcolemma, part of extracellular compartment. penetrates the cell's interior at each A band-I band junction, associated with paired terminal cisternae to form a triad
T Tubule
The number of standard deviations from the bone mineral density in healthy young white women
T-score
MRI image: fat is bright white
T1-weighted image
MRI image: Water is bright, myelographic effect
T2-weighted image
What should be included on an image interpretation?**
TABCS (technical quality, alignment, bone, cartilage, soft tissues) Description DDx Follow-up
worried about back pain in a TB endemic country (it can infect spine), what tests for a latent TB infection?
TB Gold (Active TB infection necessitates a bacterial culture)
compression fractures are usually treated with _____ brace or _____ (injecting bone cement into vertebral body)
TLSO; verterboplasty
physical exam findings for RA
TTP or with movement Swelling Decreased ROM "bogginess" Warmth and redness may be present Joint deformities
fx usually due to foot hyper-plantar flexion (pressing gas pedal). Top of bone may lose blood supply leading to avascular necrosis-must diagnose.
Talar fx
Abx for OM
Target S. aureus including MRSA and gram - Hematogenous/nonheme: vanc + 3/4 cephalosporin (ceftriaxone-gram - or cefepime-pseudomonas)
What are the TABCS of radiologic interpretation?
Technical quality of image Alignment Bone Cartilage space Soft tissue
Diagnostic criteria for fibromyalgia
Tenderness in soft-tissue anatomic locations Widespread pain in all quadrants (they will have pain at least 11 of these points)
PE findings for OA
Tenderness to palpation along the joint line Bony enlargements (osteophytes) typically no swelling, redness, warmth Decreased ROM Crepitus Joint deformities
infection of the synovial sheath, penetrating injury or spread from septic joint, soft tissue, infection or felon. Kanavel's signs may be present
Tenosynovitis
______ prevention focuses on helping people manage complicated, long-term health problems such as diabetes, heart disease, cancer and chronic MSK ain. Goals include preventing further physical deterioration
Tertiary
suspect DVT. what do you test for (if you have a low suspicion for a blood clot?)
Test for D-Dimer, which indicates thrombolysis If its positive, follow up for mores testing If its negative, there is likely NOT a clot
MC location for adult hematogenous OM. What are some common reasons for an infection?
Thoracolumbar spine IV drug users at risk, UTI, respiratory and skin infections
who are tom dick and harry? what are they responsible for?
Tibialis posterior, flexor digitorum, flexor hallicus. Plantarflexion of foot
useful for diagnosing causes of non-specific systemic symptoms after a tick bite. can pick up on: ehrlichiosis, anaplasmosis, babesiosis, maybe Lyme
Tick panel
two ways we look at antimicrobials and pharmacokinetics:
Time-dependent killing Concentration-dependent killing
Break=fracture Treatment principles: RICE first 48 hrs Pain med-tylenol, ibuprofen more often than NSAID Why dont we put fractures in a cast right away?
To prevent compartment syndrome and allow swelling, if injury is recent it may increase swelling.
why can achilles tendon rupture still plantar flex?
Tom, dick, harry tendons (Tibialis posterior, flexor digitorum, flexor hallicus)
An incomplete buckle fx of one cortex, usually from a compression injury (like FOOSH) often seen in children.
Torus
1st step of pain signaling: nociceptors activated by chemical mediators release an electrical signal
Transduction
A fracture that is perpendicular to the shaft of the bone
Transverse
Two types of regulatory proteins on the actin (thin) filament
Troponin (Ca attaches, actin changes its structure, exposing sites where myosin heads attach) Tropomyosin (detaches from the active sites so myosin can bind)
Test and Tx option for metacarpal fx
Tx: ulnar gutter or radial gutter splint for 1 week followed by buddy taping and progressive motion OR buddy taping and range of motion from the onset Examine these with finger flexion and extension. Check motion with fist closed Focal tenderness at fx site
Prognosis and complications for oligoarticular JIA
Typically resolves in 6 months Uveitis-eye inflammation, screen them with eye exams dont want vision loss
branches of posterior cord of the brachial plexus
ULTRA Upper subscapular Lower subscapular Thoracodorsal Radial Axillary
What should you do instead of saying medial or later forearm?
Ulnar aspect or radial aspect (thumb side) of forearm
joint deformities in RA
Ulnar drift Swan's neck Boutonniere deformity (can be hands or feet, feet less common) Subcutaneous rheumatoid nodules (common in wrists, elbows)
what we can use to look for effusion, what best pocket of fluid to go in, how to guide needle for arthrocentesis of joint
Ultrasound
Most common reason for uric acid level to be high in gout?
Underexcretion (overproduction 2nd most)
Types of Fluoroquinolones
Urinary (good for UTIs) Ciprofloxacin Levofloxacin Respiratory Levofloxacin Moxifloxacin New delafloxacin
Osteomylitis tx-Empiric therapy
Vancomycin PLUS a 3rd/4th generation cephalosporin
what is relationship between vitamin D and calcium
Vitamin D is required for calcium to be absorbed
Two haversian canals in the bone matrix are interconnected by
Volkmann's canal
A dreaded sequela of a missed vascular injury in a supracondylar humerus fx
Volkmann's ischemic contracture
Labs that support septic arthritis diagnsosis
WBC of joint aspirate over 10,000 blood culture lyme antibody
When the fibular is fx below syndesmosis, mortise is usually intact. Most distal fx-distal to the ligament. Treated conservatively--no surgery. What is tx?
Weber A; Pt needs a splint, non weight-bearing on crutches.
When the fibular fx at the level of the syndesmosis, often tearing the ligament. May disrupt the mortise. Tx?
Weber B (mortise joint here looks smooth and symmetric.) Needs 6 weeks of immobilization. Splint->Cast. + Crutches Will need surgery only if mortise is injured.
When the fibula fx above syndesmosis, always tearing ligament, disrupting mortise, always instable. tx?
Weber C, surgery ref
What are some questions you can ask to tease out the mechanism of injury for a patient with msk problem
What happened? How did it happen? Accidental or avoidable? When did it happen? What was the joint position when it happened? outstretched or rotated? How have symptoms changed or progressed? Other injuries? Other joints? Associated symptonms?
What is counted in a CBC
White blood cells -Granulocytes (Eosinophil, neutrophil, basophil) -Lymphocytes -Monocytes Red blood cells (RBCs) Platelets
White vs red muscle:
White: fast twitch type II, poorer blood supply susceptible to fatigue leg muscles (more cramps in this area) Red: slow twitch type 1 more myoglobin resistant to fatigue posture muscles
a bone grows and remodels in response to demands placed on it is (ie. my right hand bones are thicker and stronger)
Wolff's law
Polyarticular JIA most common in
Women, bimodal distribution of age of onset (peak sat 2-5 years old and 10-14 years old)
Ottawar ankle rules: Any tenderness on distal fibula or tibia, bony tenderness at base of 5th metatarsal, or inability to bear weight. Do what?
X-ray (ankle sprains not usually tender on the bones- tender just on the ligaments)
Tests for ankylosing spondylitis
X-rays, HLA-B 27
most calcaneus fx need ____
XR foot views, surgery
Maintenance therapy for gout- go to
Xanthine-oxidase inhibitors, prevents conversion of hypoxanthine to uric acid (gout is a urate crystal deposition disease)
can bacteriostatic drugs become bactericidal if there is an increased conc for susceptible organisms? can bactericidal become bacteriostatic for less susceptible organisms?
Yes
can you bruise muscle? bone?
Yes
Proteins interconnecting the actin filaments
Z disc
Similar to the T score but corrected for age and gender of the patient.
Z-score (used less)
Displacement of clavicle greater than one bone width, shortening greater than 1.5 cm, distal clavical fx always warrants
a referral. non union risk
flip to see a peds xray of elbow
a. olecranon b. humerus c. capitulum d. radial head
opening the fingers is an example of _________, while closing the fingers is an example of ______________. (anatomical movement)
abduction, adduction (midline of hand is the middle finger)
Consider that LBP is effected by knee problems, and knee pain is effected by foot problems. This is why you must always consider the joint _____ and joint ____ as there are many contributory factors effecting more than the joint of pain.
above, below
why surgery may be needed for OM
abx alone will not heal infected, necrotic bone
Tx for femoral acetabular impingement
acetaminophen, NSAIDS, activity modification, deep tissue massage potential surgery
usually due to forced dorsiflexion of ankle (initiating sprint, slipping on stair) may see with direct trauma, may be partial or complete MC in middle-aged men sudden pain, trouble walking, pt may hear a "snap" May still be able to flex Positive thompson test
achilles tendon rupture
arises from gastroc and soleus inserts on calcaenus. what is the action?
achilles tendon; plantarflexes foot
overuse of calf muscles, tenderness increased pain with dorsiflexion
achilles tendonitis, RICE, NSAIDs, immobilize chronic: maybe surgery
clinical presentation of flat fooot
aching feet with standing/walking shoes poor fitting medial border of foot almost touches ground when standing
two types of myofibril
actin (thin filament) myosin (thick)
tests for adolescent idiopathic scoliosis
adam's forward bend test, scoliometer
Another less specific and less sensitive test for muscle breakdown
adolase
Non-modifiable risk factors of osteoporosis
advanced age, caucasian or asian ethnicity, female gender, fam history or osteoporosis or atraumatic fx
intrinsic muscles of hand- nerve supply
all muscles supplied by ulnar nerve except thenar muscles and 1st, 2nd lumbricals which are supplied by median nerve adductor pollicis recieves dual nerve supply from ulnar and median nerves
Gentamicin, Tobramycin, Amikacin are all
aminoglycosides
what drugs should you avoid in someone with myasthenia gravis
aminoglycosides, fluoroquinolones
Bacteriodes, cutibacterium/propionobacterium, clostridium, clostridiodes, and peptostreptococcus are all
anaerobes
long bone is angled
angulation
"Bamboo spine" on x-ray, vertebral inflammation, fused spine, genetic (HLA-B27 20% chance if a first degree relative is affected), calcification of the spine ligaments
ankylosing spondylitis
3 ligaments that make up the lateral ankle
ant talo-fibular calcaneo-fibular post talo-fibular
features of patellofemoral pain syndrome
anterior knee pain at the onset of running, subsides during workout insidious onset Pain from the patellofemoral joint often in young active female-distance runners
majority of ankle sprains involve what ligament
anterior talo-fibular
overall profile of antimicrobial susceptibility testing, generally done for a facility, used to aid in antimicrobial selection, also used to track trends, emerging resistance patterns
antibiograms
ligament of elbow not developed until 2 years of age, common dislocation here in children
anular ligament
angulation toward back of hand or dorsum
apex dorsal
segment that has the greatest rotation or furthest deviation from the center of vertebral column
apex vertebra (A)
angulation toward palm (colle's), arrowhead
apex volar
adds shape to the bone
apophysis
secondary growth center in bone aka
apophysis- starts in boys at 16, girls at 14. Takes 2-3 years to fuse down at iliac crest. Fusion is an indication of complete skeletal growth.
osgood-schlatter, sinding-larsen-johansson, sever's disease are all
apophysitis
bone ends are touching
apposition
growth of cartilage: mature cartilage
appositional growth
what type of postnatal bone growth increases thickness and remodeling of all bones by osteoblasts and osteoclasts on bone surfaces
appositional growth
special test for patellofemoral pain syndrome-- most everything else is normal
apprehension test-patellar inhibition test (With the knee in extension, downward pressure just superior to the superior pole of the patella. Ask the patient to straight leg raise - + result is pain or guarding)
deep vein accompany an _______
artery
difference between arthritis and arthralgia?
arthritis: visible swelling, arthralgia: pain, cant see swelling
surgical fixation of joint
arthrodesis
joint replacement
arthroplasty
surgical procedure to open and explore a joint
arthrotomy
what type of cartilage covers bones at joints to protect them
articular cartilage (type of hyaline cartilage)
Aconeus: a weak synergist muscle
assists triceps in extending elbow, radial nerve
rare, pinches brachial plexus, can mimic carpal tunnel, cubital tunnel, radial palsy, or radiculopathy (so r/o those conditions) loss of radial pulse with raising arm over head
athoracic outlet syndrome
flip to see categories of penicillins
augmentin- amoxicillin/clavulanic acid should be under aminopenicillins
Systemic JIA is an __ disease
autoimmune//idiopathic
continuation of subclavian artery, three branches (gives rise to posterior circumflex humeral artery)
axillary artery
Surgical neck of humerus is important bc it is a site that is prone to fracture, it contains two structures:
axillary nerve posterior circumflex humeral vessels
exits axilla via quadrangular space, winds around surgical neck of humerus with the posterior circumflex humeral vessels, innervates deltoid, teres minor, skin over deltoid region and joint capsule of shoulder
axillary nerve (c5, c6)
CRP may rise above normal within 6 hours of an injury. It peaks at 48 hours. Very high levels are associated with _______
bacterial infections
kills organism, 99.9% reduction in viable bacteria density after 24 hours
bactericidal
When to use bactericidal vs bacteriostatic
bactericidal: high concentrations of organisms, CNS infections, neutropenic patients, infections in areas that are difficult to penetrate like bone bacteriostatic: potential for endotoxin surge slow growing bacteria
inhibits growth, keeps organism in a stationary phase of growth
bacteriostatic
fall prevention
balance training (try standing on one foot) muscle strengthening remove hazards in home fall reduction measures remove meds that may cause AMS
evaluation for hip dysplasia
barlow (infant supine, knees flexed to 90 degrees, hands on knees, legs out-> adduct in and push down-will feel hip dislocated) Ortolani (Out, In)-> knees adducted, reduce femoral head back into acetabulum
How to take biphosphonates correctly
be upright for 30min-1hr after you take it, take with full glass of water (make sure pt is competent enough to do this)
ganglion cyst test
big-mushy small-hard transillumination is diagnostic-flashlight on the bump that pops up when you put the index finger down
difference between osteoblasts and clasts?
blasts-build bone clasts-crush bone
Patellar fx MOI
blunt trauma to patella falling directly on the patella unable to ambulate
bone scan aka ___. what is it
bone scintigraphy (helpful to determine areas of metabolic activity in the body, tracers will collect in highly active areas, can see degeneration.. have to pair this with other imaging)
99% of the body's calcium is found in the ___
bones
Fracture of necessity surgery inherently unstable Referal
both bone forearm injury ((one on left-apex volar one on right-slight valgus))
microscopic fx in periosteum, usually in ulna or radius angulation over 20 degrees-refer
bowing fracture
formed by ventral rami of c5-c8 and T1, gives rise to nerves that innervate the upper limb
brachial plexus
Six superficial muscles of extensor forearm (except 1, 2, the rest take a common origin from lateral epicondyle of humerus)
brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris
what to do with 20-45 degrees of scoliosis
bracing consult
concentrations used for interpretation of susceptibility testing
breakpoint
fluoroquinolones what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
broad-spectrum, limited anaerobic activity. resistance is developing in many gram + organisms Bactericidal, inhibitor of dna gyrase avoid in pts with myasthenia gravis or genetic disorders involving blood vessel changes, or cardiac arrhythmia PO-chelation (dont wash it down with milk) IV Widely distributed into body tissues, urine, kidney, lung, etc Concentration-dependent, renally adjust Tendon rupture, aortic dissection, neuropathy, QTc prolongation Photosensitivty
how is cephalic vein formed, terminated
by lateral end of dorsal venous arch, axillary vein
how is basilic vein formed, terminated
by medial end of dorsal venous arch, brachial vein
presentation and MOI of meniscal tear
can be traumatic or atraumatic (degenerative) focal pain over joint line repetitive squatting, twisting, or compression weight bearing pivoting injury
flip to see a salter harris 3 fx
can result in posttraumatic arthritis casted 3-6 weeks x-ray 7 day after casting follow up at 6 and 12 month to reassess for growth arrest refer
PE findings for a quad tendon rupture Special test?
can't ambulate +/- deformity with a depression above patella diffuse swelling often a palpable step off or soft spot above patella low risk of NV injury ROM: patient cannot straight leg raise
pressure on median nerve-motor branch to thenar weakness (chronic-atrophy). numbness.
carpal tunnel syndrome
spinal surgical emergency: complete compression of spinal canal below L2. Saddle anesthesia. Blunted sensory and motor nerve function to legs, bowel, bladder. Back pain, urinary or bowel incontinence. Diminished patellar and achilles reflexes.
cauda equina syndrome
If someone has Salmonella (sickle cell) or psuedomonas, what abx to use?
cefepime
a single muscle fiber is synonymous with muscle____, skeletal muscle fibers can be up to 30 cm long!
cell
when a person comes in looking drunk/imbalanced and has neck pain, extremity weakness, it might be
cervical myelopathy
taken to see the cervical intervertebral foramen, also known as swimmers view
cervical obliques (this is normal-good sized spaces for intervertebral foramen)
downward TPS-> upward TPS->
cervical, thoracic
hematogenous osteomyelitis more common in
children
other manifestations of sjogren
chronic arthritis, interstitial nephritis, rheumatoid arthritis, vasculitis, vaginal dryness, pleuritis, pancreatitis
glycopeptides Main example, when its used, MOA
class vancomycin is in Not a b-lactam but often used in place of b-lactams if resistance is present MOA is similar-disrupts cell wall synthesis
pectoral (shoulder) girdle components
clavicle and scapula
what is the most commonly broken bone in body, was it poorly designed?
clavicle, no. its there to break to protect apex of lung and other vital structures. its like the bumper of a car
diagnosis of PAN
clinical diagnosis with compatible lab results dx should be confirmed by bx whenever possible angiography sometimes identifies microaneurysms
General principles of splinting: 1. remove _____ from fracture area 2. record pulse, ________, and neurological status at site of injury 3. Cover all wounds with a _______ 4. Immobilize joint ______ and ______ 5. Pad rigid splints to prevent local pressure 6. Support site of injury while splinting 7. Gently align areas of deformity if possible 8. When in doubt-splint!
clothing cap refill sterile dressing above, below
never inject steroids after arthrocentesis if fluid appears
cloudy/purulent
serum concentration is the most important parameter for effectiveness
concentration-dependent killing
dorsal dislocation of navicular bone over talus
congenital vertical talus
Triad of reactive arthritis
conjunctivitis urethritis arthritis Cant see cant pee cant climb a tree
alignments we look for in scoliosis
coronal and sagittal alignment
Enzyme of NSAID: Dominant source of prostanoid formation in housekeeping functions, gastric protection
cox-1
Enzyme of NSAID: Dominant source of prostanoid formation in inflammation; upregulated by cytokines, shear stress, growth factors, tumor promoters
cox-2
fracture of the proximal tibia metaphysis that may cause genu valgum
cozen fracture
elbow overuse carpal tunnel of the elbow, affects ulnar nerve etiology: insidious/over use/resting on elbow persistently
cubital tunnel syndrome
usually due to a crush injury pain/swelling/tenderness need foot x-ray
cuboid fx
ACL tear: history
deceleration injury- possibly with pivoting or hyperextension contact or non-contact giving out episode can be: very painful/non-ambulatory (suspect associated injury) can be: mildly painful/ambulatory (some continue playing) May or may not see joint effusion (palpate posteriorly)
supplies muscles of posterior compartment of forearm
deep branch of radial nerve
exam findings for a both bone forearm injury
deformity frequent, significant swelling NV injury is rare diffusely tender at fracture site check radial, median, and ulnar sensorymotor function, 2 point discrimination/cap refill -Allens test to see if artery is disrupted
patellar tendon tear PE findings
deformity of the patella "high riding patella" step off or soft spot on patella avoid ROM Cannot straight leg raise knee gives out-unable to ambulate patella has gone superiorily
What is the medial ligament called?
deltoid ligament
limited rotation on hip abduction, gait asymmetry-get an x-ray to rule out
developmental dysplasia of the hip
Advanced OA is one of the most common causes of ______ in adults, may have issues with falls and living alone.
disability
sciatica AKA
disc herniation
Phalanges fx what to do
dislocated-reduction conservative: buddy taping
usually surgery decision with ankle/foot fx depends on whether it is ___ or not. leave it up to ortho
displaced
bone is "translated", two bone ends are not touching
displacement
common antibiotic mechanisms
disrupt cell wall synthesis or decrease protein synthesis
Always check circulation and sensation ______ to the injury.
distal
what reflex is mediated by c6?
distal biceps tendon reflex
Etiology: overuse (weight lifters) Inflammation of the distal biceps tendon Pain in antecubital fossa Pain in the elbow area with resisted supination. Diffuse antecubital fossa tenderness. Tx: RICE, activity modification, NSAIDs, rare: sling (remind patients not to use it), surgical exploration (brings more blood supply to area)
distal biceps tendonitis
what type of clavicle fx doesn't heal well
distal clavicle fx--refer for surgery
what fx can develop acute carpal tunnel syndrome
distal radius fx
common, volar tilt is lost
distal radius fx (colles)
in a long bone, one end is growing faster, site of entry and angulation of arteries characteristically going away from the ___________
dominant growing epiphysis
how is the ankle unique in terms of anatomical movements
dorsiflexion and plantar flexion
tendons: extensors of ankle aka
dorsiflexors
What is the Cobb method?
draw lines on the VB of the extreme ends of curve, then perpendiculars from these and measure the angle
side effect of the muscle relaxant Flexeril
drowsiness
CI for colchicine
drug-drug interactions (CYP3A4 inhibitors-grape juice), hepatic or renal impairment
Common physical exam findings Sjogren syndrome: eye (slit lamp) and mouth, neck
dry eyes, decreased tear pool in lower conjunctiva, dilated conjunctival vessels, mucous threads filamentary keratosis dry mouth, decreases sublingual salivary pool, tongue may stick to tongue depressor, frequent caries recurrent swollen salivary glands, need to drink liquids to aid in following foods
inflammation of medial end of palmar aponeurosis can lead to what
dupuytren's syndrome
Epiphysis vs. Apophysis
e-secondary growth plate at end of long bone, adds length a-secondary growth plate that adds shape
what organism-fight bite. what is work up for fight bite
eikenella-use augmentin
flip to see movements of elbow
elbow movements
what age group do we need to be most concerned about NSAIDs?
elderly (risk of GI bleed, heptic issues)
6 diff nerves (subclavius, suprascapular, c5, c6, anterior and posterior division of upper trunk) form this
erb's point
Paralysis involving erb's point, weakness of elbow and flexion and shoulder abduction, policeman's tip hand
erb-duchenne paralysis
symptoms of acute OM
erythema, warmth, swelling, pain at site, reduced ROM, fever, sepsis (if patient comes in septic, look them all over!)
Peroneals function, what do they pass?
evertors of ankle, pass posterior to lateral malleolus
reative arthritis is seropositive t or f
false, RF and ANA are negative
risk factors for polymyositis
fam history of autoimmune disease (SLE, myositis) Vasculitis
infection of pulp space in finger is known as
felon
abscess of finger pad pulp, usually d/t biting nails, can spread from paronychia what could this lead to if its not treated?
felon osteomyelitis of phalanx
patient lying prone, rotate legs in-> external rotation of hip patient lying prone, rotate legs out-> internal rotation if IR is greater than ER, what is present?
femoral anteversion (cause of in-toeing)
fracture of both femoral condyles, moi?
femoral condyle fractures-almost always surgery many types High energy injury (fall from height)
MRI scan contraindications
ferro-magnetic objects allergy to contrast dye kidney/liver disorder obesity (above 350)
definitive dx for systemic JIA
fever present for 2 weeks arthritis for 6 weeks tenatve dx can be made however and therapy started
Dense collagenous bundles, extracellular matrix does not contain much water intervertebral discs, meniscus of knee joint, pubic symphysis cant calcify
fibrocartilage
fatigue, "i hurt all over" tender areas in soft tissues often accompanied by cognitive and mood disturbances over 90 percent female chronic widespread noninflammatory msk pain syndrome with multisystem manifestation higher perception of pain than average--central condition. morning particularly hard
fibromyalgia
lumbrical muscles
flex at the MCP joint extend PIP
flexor digitorum profundus
flexes distal interphalangeal joints; lateral: median nerve (anterior interosseous branch) medial part: ulnar nerve
flexor pollicus longus
flexes thumb, median nerve (ant interosseous branch)
how to determine if flat foot is flexible or rigid
flexible-good arch when they get up on tip toe rigid-painful, no arch on tip toe
flip to see swan neck deformity, what is it and what is it related to
flexion at DIP, hyperextension at PIP RA
flexor digitorum superficialis
flexion of proximal IP joint, median nerve
brachialis
flexor of elbow joint; major part: musculocutaneous nerve and radial nerve (small lateral part)
flexor carpi radialis
flexor of wrist, median nerve
Deep muscles of the flexor compartment
flexor pollicus longus, flexor digitorum profundus, pronator quadratus
deep fascia adjacent to carpal bone, tunnel contains digital flexor tendons and median nerve. structures passing superficially: palmaris longus, palmar cutaneous branch of median, ulnar, and radial nerve, ulnar nerve.
flexor retinaculum (implicated in carpal tunnel syndrome
what to do with flat feet
foot orthotics, PT for heel cord stretches
spondylolisthesis
forward slipping of one vertebra over another (note spinal stenosis also on this pic)
results from tendinitis involving rotator cuff
frozen shoulder
fat pad signs around the elbow, always think
fx
fluid filled cyst arising from degeneration of joint capsule or tendon sheath. tx?
ganglion cyst. usually spontaneous. could aspirate, if recurred: surgery
polymyalgia rheumatica may be associated with what dangerous
giant cell (temporal) arteritis-need to catch right away
mechanism: fall with axial load and external rotation history: "i broke my arm" "i dislocated my shoulder" exam: deformity neurovascular: peripheral nerves: axillary, musculocutaneous (bicep strength-supination, sensation on radial border of arm), ulnar
glenohumeral dislocation
ligaments holding the ball and socket shoulder together
glenoid labrum, glenohumeral ligaments, coracohumeral ligament, transverse humeral ligament
vancomycin abx type, what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
glycopeptides only treats gram +, active against MRSA Bactericidal, disrupts cell wall synthesis Poor oral bioavailability, given IV, PO for C-diff only Widely distributed Cumulative dose-dependent killing AUC-guided-careful with renal Renally eliminated Red man syndrome, nephrotoxicity, ototoxicity (loss of hearing-discontinue immediately)
If patient has a lot of lifestyle modifications they need to make, what can you do to not overwhelm patient?
go over changes, get input from the patient. Ask where would you like to start? Schedule follow up to check in
Peg in Socket fibrous joint. Periodontal ligament holds tooth in socket. immovable
gomphosis
typical causes for septic arthritis
gonococcal (MC in 18-30- Neisseria gonorrhoeae) vs nongonococcal (worse- S. aureus)
migratory arthritis and tenosynovitis followed by pain and swelling settling into 1 or more joints. what is it and tx
gonococcal septic arthritis (MC in young adults) Tx: ceftriaxone PLUS chlamydia tx
the most common form of inflammatory arthritis among men, twice as common in Black men
gout
flip to see the Nash-moe method of vertebral rotation of v bodies
grade 3 significant
Aminoglycosides what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
gram - organisms, mycobacteria (not great for anerobes) bactericidal, inhibits protein synthesis only use when necessary d/t toxicities, avoid in myasthenia gravis PO (empty stomach, large glass of water) Widely into body tissues and fluids including bone, abscesses, poor CSF penetration. Concentration-dependent Nephrotoxicity, ototoxicity
bones bend but don't break-pediatric fx bc their bones are more cartilage
greenstick fracture
incomplete fracture on child-what to do
greenstick- refer, x-ray is repeated 1 week after casting
Pain from hip joint can present as
groin pain, anterior proximal thigh pain, knee pain
orthopedic intervention for genu varum/valgum
guided growth, osteotomy
Most common foot deformity great toe angles "inward" (valgus) Obvious deformity-bunion. red, swollen
hallux valgus tx: wide, padded shoes surgical: corrective osteotomy
side by side hammer and mallet toes. What joints are effected in each
hammer: PIP mallet: DIP
PIP joint fixed in flexion, DIP extended. Most commonly affects second toe. shoe pressure may produce callus. tx?
hammertoe, surgery
how is osteomyelitis spread to the bone?
hematogenous (bloodstream infection) nonhematogenous (localized)
How is rate of mortality for elderly pt with pan
high
bursa between calcaenus and achilles tendon another bursa outside of achilles tendon what if they are inflammed
hindfoot bursitis NSAIDs, proper fitting shoes
Big ones- ped fractures, hip dysplasia, scoliosis, SCFE (13-15 male, 11-13 female usually obese), Perfes (3-12 years old) any child with knee pain-look at their _________. if a child has a limp, ______
hips; refer them
type of surgery for grade 3 and 4 AC tears
hook plate (first lets the coracoclavicular ligaments heal, removed after about 6 months, letting AC heal)
flip to see how we evaluate hip x-rays for dislocation
how we determine the acetabular index
bones originate as _____ cartilage (a 2 year old kid will look like they don't have a lot of bones on x-ray, but they just haven't ossified yet)
hyaline
when to refer genu varum/valgum
if you suspect it is pathological
findings for cervical myelopathy
imbalance, hyper reflexes, clonus
Carbapenems: Impipenem Meropenem Ertapenem doripenem What spectrum do these have? What is the warning for doripenem?
imipenem: Moderate Meropenem: Moderate Ertapenem: narrowest, no pseudomonal activity doripenem: Most pseudomonal activity; dont use in ventilator associated pnemonia
Retic account is a measure of
immature red blood cells (high- body is sensing something wrong, will produce more RBCs)
fibrous joints are mostly synarthrotic, meaning they are ______ . what are the three types?
immovable sutures, syndesmoses, gomphoses
Tx for Polymyositis
immunosuppressants/corticosteroids: Prednisone (high dose-40-80g-cconsolidate doses and reduce slowly when enzyme levels are normal) If that doesnt work: Azathiopine or Methotrexate diet and exercise to avoid weight gain from steroids
pinching of supraspinatous tendon over the humeral head and below the acromion; narrow subacromial space can happen from overuse, predisposition, AC arthritis
impingement syndrome
Menopausal women have ______ osteoclastic activity and _______ osteoblastic activity.
increased, decreased
clinical presentation of osteonecrosis, what imaging?
indolent onset dull ache or throbbing pain in the groin/thigh, lateral hip pain with attempted straight leg raise AP of pelvis, frog-lateral view, MRI if needed
three subcategories of adolescent idiopathic scoliosis, which is more common in girls, usually family history
infantile, juvenile, adolescent
Abnormal WBCs indicate
infection or inflammation viral infections-> slight leukopenia, reactive lymphocytes larger Bacterial infections->leukocytosis with left shift Sepsis-high or low WBC meds can interfere: prednisone (increase), chemo (decrease)
complications of open fractures
infection, chronic osteomyelitis, soft tissue problems, chronic pain, limp, non-union, malunion
What types of medical factors may inhibit fx healing?
infection, nicotine use, meds (NSAIDs controversial, phenytoin, ciprofloxacin, corticosteroids, anticoagulants), malnutrition, diabetes, immobility, alcohol abuse, albumin deficiency
osteomyelitis pathogenesis
infectious agent binds to bone, phagocytes attempt to contain infection, releasing enzymes to kill infection and break down bone bacteria difficult to kill when adhered to bone pus pocket created dead bone separates from healthy bone to fragments (sequestra) elevated periosteum deposits new bone (involucrum) sinus tract may form
4 stages of legg-calve-perthes disease
inflammation (pain) fragmentation (mottled femoral head on xray, painless) re-ossification healed
cauda equina physical exam
inspection, palpation, percussion, ROM, reflexes (patellar/achilles seated), strength, rectal exam looking for tone, perianal strength exam_boyyyye how do u do that>??
PE findings: patellar dislocation
inspection: visible swelling relocated or dislocated palpation: tenderness medial side of patella, focal to this area palpate posteriorly for effusion Skip ROM Special: if its in question apprehension test : extend knee, gently push the patella laterally, again recreate the position of injury
Shoulder views
internal, external rotation (look at humeral head to see figure out which one, internal: ice cream sitting on cone-eating ice cream with arm turned in, external: icecream falling off cone-arm facing out), baby arm, scapular Y, acromioclavicular stress view
what type of postnatal bone growth helps in lengthening the bones
interstitial bone growth
growth of cartilage: immature cartilage
interstitial growth
Two types of ossification during development, what are they?
intramembranous ossification (membrane bone develops from fibrous membrane-flat bones-cervicles, cranial bones) endochondral ossification (this is the pic) (cartilage-endochondral bone forms by replacing hyaline cartilage, forms most of the rest of skeleton)
elevated periosteum deposits new bone
involucrum
Joint damage in RA is
irreversible- bony erosions can only be stopped progression wise untreated-joint destruction increased disability and decreased quality of life
generates force by changing muscle length
isotonic
Why is HCTZ (Hydrochlorothiazide) a risk for gout pts?
its a diuretic, which increases serum uric acid
collagenous structure that surrounds the joint like a sleeve; protects cartilage while allowing movement of joint
joint capsule
paralysis that causes a claw hand, effects lower trunk of brachial plexus
klumpke's paralysis
normal infant posture
kyphosis in the sitting position
Sulfamethoxazole-trimethoprim what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent
large spectrum, including MRSA bactericidal, inhibitor of folate synthesis don't use with sulfa allergy or pregnancy PO Widely distributed into tissues and CSF may cause SJS, hyperkalemia, blood dyscrasias
Looking at alignment of verterbral bodies in neck
lateral cervical flexion (this image is normal that it is a little but of forward motion at multiple levels)--important to assess the ADI region-make sure the spinal cord isnt smashed between odontoid process and C1 spinous process
_____ meniscus associated with ACL tear, but ______ meniscus more common over all
lateral; medial
flip to see AP view of the pelvis. Which one is dislocated, how can you tell?
left is posterior dislocated, cant see the lesser trochanter, looks like its adducted
avascular necrosis of the hip present with pain/limping more common in boys 3-12 years old
legg-calve-perthes disease
attach bone to bone
ligaments
what is the ligament connecting the femur and pelvis
ligamentum teres
important components of pt education related to health promotion & screening tests
limitations of screening, screening options, customize risk communication, risks and benefits, potential to help pts avoid preventable morbidity and early death, counsel about behavior and lifestyle
bones are classified by four shapes
long (humerus), short (tarsal), flat (scapula), irregular (sacrum)
typical management of greenstick fx
long arm splint and refer to ortho
features of neuromuscular scoliosis
long c-shaped curve may happen in cerebral palsy or other neuro conditions tend to be in thoracic spine, toward left convex
flip to see the achilles tendon rupture tx
longggg recovery
the leading cause of disability in the world, second most common reason to seek care in a primary care office
low back pain (LBP)
ankylosing spondylitis sx
low back pain, SI joint pain, stiffness. at least 30 minutes every morning to loosen up, weight loss/fatigue, costochondritis, endhesitis-achilles/plantar fascia, heart block)
Tx for polymyalgia rheumatica
low dose corticosteroids (Prednisone 10-20mg/day) most patients require at least 2 years calcium and vitamin D-prevent osteoporosis PT- ROM
pain over lower leg, tender. x-ray may not show anything (would need bone scan to see). pain with activity. tx?
lower leg stress fx try to rest (tibia 6-8 weeks; fibula: 4 weeks). NSAIDs.
Test for lymes
lyme antibody test + western blot to confirm
hx and PE of osgood schlatters
males more often often sports injury with insidious onset complaints of chronic focal pain at tibial tubercle maybe will have prominence of the tibial tubercle
Presentation of tibio-femoral dislocation. what is at risk
may complain of a cool foot or inability to move foot often an ortho emergency-get arteriogram and ortho involved Motor sensory: high association with peroneal or tibial nerve
aligment check for genu varum
measure intercondylar distance, anything above 6 cm is abnormal
how to check for genu valgum
measure the internalleolar distance, greater than 8 cm is abnormal
erythrocyte sedimentation rate (ESR). What is it and whats normal?
measures time it takes for erythrocytes to fall through plasma over a period of 1 hour normal: RBCs settle slowly from plasma inflammation: increased plasma proteins called acute phase reactants cause RBCs to aggregate and settle rapidly->increased ESR
all muscles of flexor compartment nerve are all supplied by median nerve, except
medial muscle of flexor carpi ulnaris, medial muscle of flexor digitorum profundus
Pectoralis major
medial rotation and adduction of shoulder, flexion of shoulder joint; medial and lateral pectoral nerve
How do the basilic and cephalic veins communicate?
median cubital vein (used for drawing blood)
anterior interosseous nerve is a branch of the
median nerve
nerve formed by both medial and lateral cord, lies medial to brachial artery, enters forearm between two heads of pronator teres, enters palm deep to flexor retinaculum
median nerve
thenar muscles are innervated by
median nerve
a tear in the medial or lateral meniscus
meniscal tear (lateral is most commonly associated with an ACL tear, medial is the most common)
common injuries that go with ACL tears
meniscal tears are common with ACL tears PCL tears are often associated with ACL tears
fibrocartilage structure between articular cartilage that provides stability and cushion. Adherent to the synovial membrane.
meniscus
medial deviation of the forefoot, heel is neutral
metatarsus adductus (also evaluate hip [developmental dysplasia] and necK)
if a bone like clavicle is broken in half, you could call it a ________ fx
midshaft
drug concentration required to inhibit growth
minimum inhibitory concentration (MIC)
Step of pain: adaptive processes through which pain impulses may be enhanced (central sensitization) or diminished either centrally or in periphery
modulation
When a muscle fiber is excited, the AP is carried to t tubule, causing an integral protein to detach from sarcoplasmic reticulum, causing Ca to be secreted out. This leads to ______
muscle contraction (the blue is the sarcoplasmic reticulum, the inverted box is the T tubule)
testing the sensorimotor function for musculocutaneous, median, and ulnar nerv
musculocutaneous m: biceps, s: radial aspect of forearm radial s: back of hand, m: wrist extensors median s: thumb index long radial half of ring finger, m: thenar muscles ulnar s: ulnar side of hand m: intrinsics abduction)
derived from lateral cord, below the elbow it pierces the deep fascia and continues as lateral cutaneous nerve of the forearm
musculocutaneous nerve
What can happen in PAN when there is narrowing or occlusion of coronary arteires
myocardial infarction
densely packed, rodlike elements of skeletal muscles, why it is striated
myofibrils
tx for ACL
need MRI and surgery (wont heal on own, bathed in joint fluid which inhibits healing)
Management of Legg-Calve-Perthes
non weight-bearing refer may need PT
tx for patellar fx nondisplaced vs displaced
non-displaced conservative- knee immobilizer displaced (MC) surgery
___________ joint pain has loss of active but not passive range of motion and tenderness. no deformity
nonarticular
Integrity of bone has been disrupted, but the pieces have not been displaced at all
nondisplaced fracture
potential complications of scaphoid fx
nonunion, avascular necrosis. ANY suspected scaphoid fx is treated like one until proven otherwise
tests for carpal tunnel syndrome
normal inspection-possible thenar atrophy and dry skin over median nerve distribution if late Phalen's maneuver and Tinel's test test abductor pollicus longus 2 point discrimination
partial dislocation of radial head in kids, caused by parents grabbing child by the wrist
nursemaid's elbow
what is OLD ACIDS of describing pediatric x-rays (after you describe the age, gender, type of view, MOI)
o (open or closed) l (location) d (degree-complete or incomplete) a (articular) c (comminuted) i (intrinsic bone quality) d (displacement) s (soft tissue injury)
curves 10-25 degrees: curve 25-40 degrees: Curve over 45 degrees:
observation TSLO brace surgery
What to do with scoliosis of 20 degrees or under
observation and conservative management
Be aware of sulfa allergies and celoxib
ok
Opioid pearls: start with immediate release formulation, combine analgesics from different drug classes: targets different pain pathways, synergistic effect allows for lower doses, decreases opioid dependence Prescribe other essentials: Bowel meds, naloxone
ok
Sometimes you may miss a fx. On day 10-16 of bone healing, you can see calcification on x-ray. So if its not getting better in 10-14 days, have patient come back and get another x-ray. if we miss a fracture it will show up (calcium deposits)!
ok
Tx options for herniated disc include: oral steroids epidural steroid injection cervical or lumbar disectomy surgery
ok
causes of internal rotation you should refer to ped ortho: club foot, skew foot, cerebal palsy, and developmental dysplasia
ok
children until age 2 should be checked for developmental dysplasia of the hip at every well child visit
ok
deep elbow flexion test-numb fingers is good for ulnar nerve ulnar nerve abducts fingers (intrinsics)
ok
for CBC w/differential we want to look at the absolute numbers. not percentages.
ok
for fx in kids, closed reduction and casting usually sufficient. non union is rare. be aware of growth plates
ok
growth plate fx may result in premature growth cessation and deformity. Growth problem in types 3,4,5. All types require reduction if significantly displaced, splinting, non-weightbearing status, and orthopedic referral
ok
growth plate is weakest part of bone, especially in hypertrophic zone. periosteum protects the bone.
ok
intermedulary rod through cancellous bone favored over traction
ok
keep in mind: inflamed meninges increase drug penetration eye-use topicals pericadium-transporters biofilms-common in prosthetics-are negatively charged, they bind with positively charged anx and prevent them reaching target
ok
out-toeing causes to refer to ped ortho: external tibial torsion, slipped capital femoral epiphysis, legg-calve-perthes
ok
pars defect have minor trauma and pain, it goes away. Back pain from minor injury. often happens in young athletes
ok
polymyositis most common in women mid-40s
ok
etiology: trauma, slip on ice is common fat pad signs cant extend the elbow treated surgically
olecranon fx
Which end of the muscle is immovable, which is movable?
origin, insertion
intraarticular knee fractures always go to
ortho, usually needs surgery
degenerative joint disease AKa
osteoarthritis
what is the most common form of arthritis
osteoarthritis
osteocytes are matured _____
osteoblasts
cells that break down / reabsorb bone matrix
osteoclasts
inflammation of bone due to infection can be acute vs chronic
osteomyelitis, note bone demineralization on xr
Flip to see some rare pathological fx that could occur when taking biphosphonates
osteonecrosis of the jaw could also happen
Results from death of varying amounts of bone in the femoral head from traumatic disruption of vascular supply, potentially from steroids or other causes. They may develop local osteopenia/osteoporosis. Loses trabeculae, may lead to femoral collapse.
osteonecrosis/avascular necrosis (here you can see sclerosis of bone, head is basically gone/misshapen, subluxed femur)
T score less than -2.5
osteoporosis
low bone density-imbalance between bone resorption and bone formation predominantly over age 60, mostly women (50% post menopausal women get osteoporosis fx) greater risk of mortality after a fx
osteoporosis
number 1 risk factor for compression fractures
osteoporosis
bones are cut and re-oriented, often used in the correction in malunion of fractures
osteotomy
what can make respiratory depression worse when taking opioids
other depressants, sleep, age (infants/older adults), disease (COPD, cardiopulmonary, renal), similar effect in all agents at equianalgesic doses)
clinical presentation of Hip Impingement aka Femoral Acetabular Impingement (FAI)
pain over greater trochanter with associated hip abductor weakness positive C sign (where pt points to the pain)
characterized by chronic thickening of the tendon of the supraspinatus and its impingement against the coraco-acromial arch
painful arc syndrome
deep fascia, central thick part of fascia in palm, triangular in shape, (attached to middle phalanx, inflammation of medial end leads to contracture-dupuytren's contracture)
palmar aponeurosis
This superficial hand muscle improves the grip by steading the skin on the ulnar side, lies across the hypothenar eminence
palmaris brevis
what muscle in the forearm is not always present in people
palmaris longus
c2 is the only cervical verterbrae to have a ______ (can fracture)
pars
what is subluxation
partial dislocation of a joint
A sesamoid bone (a bone formed after birth in a tendon where it passes over a joint) example is..
patella
Adam's test
patient stands in front of you, feet shoulder width apart, hands together, bend forward at waist, arms hanging down
holds hips in flexion and abduction, treatment for developmental dysplasia of the hip
pavlik harness
Muscles of the pectoral region
pectoralis major, pectoralis minor (deep to major), subclavius (inferior to clavicle), serratus anterior
things to look at thoracic AP view
pedicles, TPs, every rib
Flip to see other lab tests to support the RA diagnosis
people can get gout and RA!
flip to see arthrocentesis results
people that have Gout can also have septic arthritis
Thick heavy fibrous envelope of all bones
periosteum
inflammation of tendons passing posterior to lateral malleolus
peroneal tendonitis (tx: RICE, possibly immobilize, possible steroid injection)
flat feet aka ___. often family history
pes planus
what is the end of a long bone in a child that is formed from one or more secondary ossification centers?
physis
Chronic Plantar Fasciitis
plantar fibroma soft insoles, padding cortisone injections surgical
hemoglobin is decreased in
polymyalgia rheumatica
idiopathic polymyositis, idiopathic dermatomyosytis, SLE or Systemic sclerosis associated polymyositis/dermatomyositis myositis associated with malignancy or HIV these are all types of
polymyositis
systemic ct disease characterized by inflammatory and degenerative changes in proximal muscles, sometimes skin rash
polymyositis
clubfoot treatment over 4-6 weeks
ponseti technique (series of casts to bring the foot into the neutral position)
Joint aspiration findings between pseudogout and septic arthritis
positively birefringement rhomboid crystals septic arthritis: pus, high WBC, low glucose, high protein
inflammation of post tibial tendon (a plantar flexor of foot) passes posterior to medical malleolus tx?
posterior tibial tendonitis Rest, NSAIDs, immobilize steroid?
hip dislocation: pain, cant walk what direction is it usually in? what nerve might be affected?
posterior; sciatic
biceps brachii
powerful supinator of forearm, flexor of elbow joint, musculocutaneous nerve
if someone has CI for NSAIDs or elderly/GI problems, you can use ____ for gout
prednisone
septic bursitis--need to differentiate between septic arthritis. It is usually less serious than septic arthritis. MC areas? sx? dx?
prepatellar and olecranon pain, tenderness, erythema, swelling, warmth of bursa bursa aspiration (dont go right into the redness)
pronator quadratus
principle pronator, median nerve (interosseous branch)
a more severe symptom to. look out for with herniated disc
profound weakness (this may become permanent)
Pronator teres
pronator of forearm, weak flexor of elbow joint; median nerve
superficial muscles in flexor compartment of forearm, all origin of medial epicondyle (5)
pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis
serratus anterior
protracts scapula; long thoracic nerve
Pectoralis minor
protracts scapula; medial and lateral pectoral nerve
by far, the most common metatarsal fx. often occurs with lateral ankle sprain- forcibly evert ankle (peroneal brevis can pull the bone off). Avulsion fx
proximal 5th metatarsal (make sure to palpate base of 5th metatarsal!) tx: usually conservative, immobilize, crutches--likely to heal aka psuedojones!
Fx of the humerus in the proximal third (close to surgical neck) Predisposition: Osteroporosis Tx: immobilize with sling PT: pendulums
proximal humerus fracture
how to divide up long bones
proximal, middle, distal third
Deposition of calcium pyrophosphate crystals
pseudogout
spaces between palmar skin and distal phalanges, tight compartments called fibrous septa
pulp space
Be worried about pseudomonas with
puncture wounds of feet IV drug users, immunosuppressed
when ultrasounding a patients hand what should you do
put it in a water bath-pink tray. eliminate scattering
space is important because axillary nerve and posterior circumflex humeral vessels exit from here
quadrangular space
flip to see normal radius x-rays and what to look for
radial inclination should be 30 degrees wrist joint slight tilt toward palm
branch of posterior cord of brachial plexus exits axilla traversing through lower triangular space divides into two branches: superficial (courses anteriorly along with radial artery, supplies skin of lateral dorsum of hand) and deep (runs posterior to forearm, supplies all muscles in posterior compartment of forearm)
radial nerve
sciatica is an umbrella term for all the
radiculopathies
On an X-ray image, things that are more dense will have more ____________ while less dense will be more _______________.
radiopacities (white) radiolucent (dark)
arthritis following an infection *microorganisms cannot be cultured from joints, seronegative (RF and ANA neg) Affects males more, age 20-40
reactive arthritis
in-toeing/out-toeing management
reassurance and observation; refer if it is activity limiting, pain, limping
back pain, leg pain, leg numbness and/or incontinence always warrants a _________
rectal exam (r/o cauda equina-looking for tone)
tx for patellar dislocation
reduce (put it back into extension) knee immobilizer with patellar cutout
growth mostly occurs in the physis, but it is the weakest point. more likely a growth plate fracture than a sprain. what are the classifications?
refer all of them to ped ortho-risk of growth arrest
what to do with SCFE?
refer, non-weightbearing, may need pinning in situ (surgery)
what to do with skeletally immature patients at risk for scoliosis. When to consider surgery?
repeat AP x-rats every 4-6months. A change of over 5 degrees, resulting in a curve magnitude of 20 degrees warrants a spinal surgeon
Presentation of septic arthritis
resistance or significant pain with passive ROM swelling, fever, joint warmth, joint effusion, TTP, pain with weight bearing, fever, sepsis
fibrous bands that hold ankle tendons in place
retinacula
cause of genu varum/valgum (later onset around 4), disease of bone mineralization. may be due to poor diet or vitamin D absorption Tx: medications (see endocrinology), surgical correction
rickets (low bone density)
when to refer pes planus
rigid flat foot, painful flat foot
what finger receives nerve supply from all 3 nerves (median, ulnar, radial)
ring finger
why do you want to reduce the hip right away?
risk of sciatic nerve issues
Presentation: Weakness more so than pain, functional deficits of ADLs, poor ROM in some Examination: no atrophy, minimal tenderness if any, severe:cant hold arm up or reach overhead, may or may not involve trauma, focused strength of supra, infra, spinatous and subscapularis (empty can test-push down they will still be strong) Drop arm (cant hold weight of arm)-> Virtually diagnostic when positive.
rotator cuff tear
organisms involved in tenosynovitis tx (empiric/bite/gonococcal)
s. aureus, strep, gonococcus, oral bacteria (eikenella if human, pasteurella if cat) empiric tx: vanc + 3rd gen cephalosporin pain control splint ortho consult for likely i&d bite wound: ampicillin/sulbactam (unasyn) gonococcal: ceftriaxone and doxy for chalmydia
if a child has tenderness near a growth plate, always suspect
salter-harris fx
what is the key to the Cobb method
same endpoints should be used when comparing curves over time 2-7 degrees difference is considered measurement error
unit of muscle fiber for contraction
sarcomere
tendons that attach to the pes anserine - hamstrings
sartorius gracilis semitendonosis NOT semimembranosis (semi-not a memberanosis)
anatomic snuff box tenderness or diffuse tenderness and guarding with ASB tenderness = ________ until proven otherwise. what to do?
scaphoid fx (MRI, thumb spica, reeval n 1 week or bone scan if cannot do MRI)
anatomic snuffbox tenderness is bascially diagnostic for what
scaphoid waist fx
all rotator cuff muscles attach to the
scapula
when looking for shoulder dislocations, sometimes the AP view is not diagnostic. What other x-rays should you order?
scpaular Y or axillary
right elbow pain and forearm swelling. pos for gon and chlamydia
septic arthritis, septic bursitis arthocentesis: few WBCs gonococcal septic arthritis
dead bone separates from healthy bone to fragments
sequestra
chronic OM features
sequestra usually present sinus tract presence is pathognomonic-may drain pus flare-ups wounds/ulcers overlying bone that does not heal
inflammation of sesamoid bones repetitive force, high feels tx?
sesamoidits
common cause of heel pain, overuse injury, running and jumping sports. self-limited, will stop after growing stops
sever's disease (tx activity modification, NSAIDs, ice, heel cups, CAM boot)
hip fx presentation, what x-rays to get
severe pain in thigh, obvious deformity, unable to move or bear weight hip, knee, and pelvis (AP lateral of femur) x-rays (joint above and below)
buckle fx in kid/distal radius torus fx. what is the treatment?
short arm cast
what to do with a torus fx
short arm cast 2-3 weeks, complications rare. usually little swelling or tenderness, very common
scaphoid fx tx
short-arm thumb spica splint (6-8 weeks) + ortho referral follow up 1 week
bone is displaced and translated longitudinally
shortening/overriding
flip to see shoulder joint movements
shoulder movements
apophysitis of distal pole of patella, jumper's knee, more often males. what is it and tx
sinding-larsen-johannson syndrome' RICE, NSAIDs, activity modification
the tract of infection between bone and skin
sinus tract
What type of muscle is voluntary?
skeletal
What types of muscles are striated
skeletal and cardiac
1 cause of genu varum: long bones are thinner
skeletal dysplasia
Used as adjunctive therapy for muscle spasms, back/neck pain, limit use to 2 weeks, do not work directly on muscles, relief is most likely d/t sedation, avoid in older adults, esp in combo with benzos as it is sedating!
skeletal muscle relaxants
Creatine kinase: CK-MM mostly found in ______ muscle, while CK-MB mostly found in _______ muscle
skeletal; cardiac
the superficial veins typically supply the ____
skin
Tx for radial head fx
sling for 7-10 days ROM exercises as early as day 2 (elbows are terrible about stiffness)
Management of non-displaced, not severly displaced clavicle fx
sling, gentle ROM exercises
anterior and superior displacement of femoral neck, usually after puberty, fracture of femoral neck. obese adolescent, male dull aching, knee pain looks like ice cream falling off of a cone
slipped capital femoral epiphysis (SCFE)
Pain can be described in many ways by patients. what are some examples
soreness, aching, shooting pain, dull, referred pain, numbness
ESR stays elevated longer than CRP Can also be elevated in: anemia, renal disease, obesity.. so it is non-_____
specific
infection spread from vertebral bodies to end plate, pus pocket pushes out on spinal cord, producing neuro deficits and radicular usually back pain. How to diagnose?
spinal epidural abscess need MRI to diagnose
if someone has growth plate tenderness, always
splint it and send to ped ortho
a test to check for disc herniation where you do extension and rotation of neck, will cause numbing of dermatome
spurling's maneuver
compression fracture on AP xray looks like
squished owl face
choosing an abx agent: tips
start with beta-lactam if possible use agent with narrowest spectrum possible patients recent hx of antimicrobial use use facilities antibiogram to avoid agents with growing resistance
subclavius
steadies the clavicle, nerve to subclavius
injury of a muscle or tendon
strain
a bursa located deep to acromion process of scapula, comes in constant tension with supraspinatus muscle
subacromial bursa
bursa under elbow that can be inflammed with friction and be very tender
subcutaenous olecranon bursa
supplies skin on lateral dorsum of hand
superficial branch of radial nerve
fracture above elbow/condyles
supracondylar fracture (does not disrupt triangle)
most common pediatric elbow fx, mechanism, what is the risk? what to check?
supracondylar fx, FOOSH, high risk of NV compromise (check brachial artery, cap refill, check bones above and below elbow including clavicle), watch for compartment syndrome) refer
Apex posterior angulation (radius should normally point to condyle) Have to be perfectly reduced to heal (refer to specialized ortho surgeons) Gunstock deformity: cant extend
supracondylar humerus fx
fat pad signs (which are bleeding) on xray in which fxs?
supracondylar humerus fx radial head fx olecranon fx
gunstock deformity can come from what fx
supracondylar humerus fx--- refer
tx for osteonecrosis
surgery
what to do with 45 degrees of scoliosis
surgical consult
flip to see clinical presentation of stress fractures of the femoral neck (hip). in a young patient it is considered a
surgical emergency--potential for osteonecrosis
uses abx in serially diluted solid agar that contains a culture of the test microorganism to determine MIC and resistance to drug
susceptibility testing
type of fibrous joint only found in the skull, held together with very short interconnecting fibers, bone edges interlock
suture
gout sx
swelling near and beyond affected joint pain redness or shiny skin loss of appetite mild fever or chills
Radial head fracture exam findings
swelling, bruising, careful examination of the skin tenderness over the radial head-focal neuro: sensorimotor to radial, median, and ulnar nerve low risk of nerve injury
exam findings for olecranon fx
swelling, bruising, palpable indentation at the olecranon. don't assess the strength neuro: sensorimotor to radial, median, and ulnar nerve
exam findings for a distal radius fx
swelling, often deformity diffuse tenderness about the wrist check radial, median, ulnar nerve sensorimotor, including 2 point discrimination. median nerve is most at risk can develop acute carpal tunnel syndrome>hematoma into carpal tunnel the bruising in this pic might come overnight
allows you to see cervical thoracic vertebrae region (if you cant find C7)
swimmers view
how are joints classified with movement?
synarthrosis (no movement), amphiarthrosis (slightly moveable), diarthrosis (freely moveable), synovial (freely moveable, enclosed by joint capsule and lined with synovial membrane)
thick viscous fluid inside joint capsules
synovial fluid
Gout is typically diagnosed clinically based on the rapid development of monoarticular arthritis marked by swelling and redness usually involving the first metatarsophalangeal joint. In equivocal cases, what can be used for dx?
synovial fluid analysis collected from joint or tophus
work up for septic arthritis
synovial fluid analysis with culture (athrocentesis-Pus usually happens) high WBCs->infection often greater than 100k if nongonococcal glucose less than 40 (bacteria eat it up) lactate >10 gram stain with bacteria 50% of time WBC, CRP, ESR, Procalcitonin (tells us about bacterial infection) Blood cultures (pos over 50% nongonooccal and 20% gono) XR- soft tissue swelling/effusion
Still's disease aka
systemic juvenile rheumatoid arthritis
a chronic autoimmune multisystem inflammatory disease, relapsing and remitting course, affect any organ system. but most often: skin (CT), joints, kidneys, blood cells, nervous system. sx: triad of fever, joint pain, and rash. fatigue may be most bothersome Other manifestations: pulmonary, MSK, GI, Derm, Cardiac, Renal, Heme, Psych, Neuro management depends on type of organ involvement
systemic lupus erythematous
bacteria can thrive in our joints, they aren't protected by our immune system. t or f
t
entrapment of posterior tibial nerve by flexor retinaculum due to inflammation Pain on sole of foot repetitive activity RA, pregnancy, acute trauma: fx, dislocation, soft tissue swelling
tarsal tunnel syndrome Rest, NSAIDs, immobilization (ankle splint), possible surgery
Lactate dehydrogenase (LDH)
tells us if there is acute or chronic tissue damage investigate variety of diseases involving heart, liver, muscle, kidney, lung, blood monitor changes in tumor burden after chemotherapy disorders of muscle breakdown (dermatomyocitis, polymylocitis, PAN) innaccurate is blood sample is hemolyzed (potassium is also like this, remember?)
Sx to look out for to differentiate polymyalgia rheumatica and giant cell arteritis. What to do if they have the sx of GCA?
tenderness in temple arteries, jaw cramping, elevated sed rate, headache, high fever, lack of response to prednisone, visual loss, high sed rate Immediate: Temporal artery bx
PE for MCL, LCL tears
tenderness over the MCL or LCL Valgus stress testing (knee in slight flexion) Varus stress testing (knee in slight flexion) Lachman: test for ACL integrity Anterior/posterior drawer test (for ACL, PCL integrity)
attach muscle to bone
tendon
elongated bursa that wrap completely around a tendon
tendon sheath
what is injured in a sprain? strain
tendon, muscle or tendon
rotator cuff is the ______ of the SITS muscles (supraspinatus, infraspinatus, subscapularis muscles, teres minor)
tendons
tear of radial collateral ligament causing elbow issue
tennis elbow
inflammation of tenosynovium
tenosynovitis
What are Kanavel's signs?
tenosynovitis - sausage digit (swelled, firm) - digit held in slight flexion - tenderness over flexor tendon sheath - pain with passive extension - flexed posture of finger
the sheath surrounding a tendon
tenosynovium
good test for motor median nerve
testing the abductor pollicis longus; turn palm up, thumb toward push toward index
When someone has congenital scoliosis, monitor what
the progression
subgroups of hand muscles
thenar (flexor pollicis brevis--does not flex the IP joint, abductor pollicis brevis, opponens pollicis-deepest) hypothenar (flexor digiti minimi, abductor digiti minimi, opponens digiti minimi, palmaris brevis-v superficial, SC muscle) midpalmar (adductor pollicis, lumbrical muscles, palmar interossei-deepest muscle in hand, dorsal interossei)
Distal pole scaphoid fractures, which have good blood supply, low non-union rate. what tx?
thumb spica cast
fracture of the proximal tibia is known as
tibial plateau fracture (intra-articular injury)
super rare- dislocation of the knee tibia posterior. what is it and what are the risks?
tibio-femoral dislocation high risk for popliteal artery disruption high risk for peroneal nerve or tibial nerve disruption multiple ligament disruptions
maintains integrity of the mortise joint
tibofibular ligament
what ligament joins the distal tibia-fibula? What is its function
tibofibular ligament maintains integrity of mortisse joint
time above MIC is the most important parameter for effectiveness
time-dependent killing
common in kids 9months-3 years old non-displaced spiral fracture tibial shaft slide with a parent patient will not bear weight on affected leg
toddler's fracture long leg cast
Plantar flexors that pass posterior to medial malleolus aka
tom, dick, and harry tendons
subcutaneous nodules comprised of monosodium urate crystals in a matrix of lipids, protein, and mucopolysaccharides
tophi
tx for femur fracture
traction splint-temporary
Step of pain: Electrical signal moves from site of injury to spinal cord and brain
transmission
Risk factors for osteonecrosis?
trauma, corticosteroids, alcohol, sickle cell anemia
space is important because it has radial nerve and deep artery of arm
triangular interval (lower triangular space)
The posterior compartment of the arm contains what muscle and what is the innervation
triceps brachii, radial nerve
C7 mediates what reflex?
triceps reflex
the Y- shaped epiphyseal plate at the junction of the ischium, ilium, and pubis in the immature skeleton
triradiate cartilage
inflammation and hypertrophy of the greater trochanteric bursa
trochanteric bursitis (beneath IT band
two sets of lymph nodes related to upper extremity
trochlear nodes (by elbow-basilic vein/radial side drains here) and axillary nodes (radial side-drains here)
toe walking is usually idiopathic. t or f
true
neurofibroma, astrocytoma, osteoid osteoma (benign-low back pain in child-aspirin helps) are all ______ that could cause scoliosis
tumors
What is the weber classification of ankle fx?
typically classified at medial end--worry about the syndesmosis
because NSAIDs have GI toxicity, avoid using in someone with an active _________
ulcer
what artery divides into superficial palmar arch and deep palmar arch (a little bit, it is mainly formed by radial artery)
ulnar artery
branch of medial cord, descends down and pierces medial intermuscular septum. hit it--funny bone. accompanied by ulnar artery, enters palm superficial to flexor retinaculum
ulnar nerve
Imaging for developmental dysplasia of the hip
ultrasound of hip x-rays- AP/Frog (children 6mo or older)
space is important because it has circumflex scapular vessels and branches of subscapular vessels
upper triangular space
joint aspiration is gold standard, but not usually done in primary care. usually you could follow up and check ___ levels
uric acid
Lab findings for PAN
urine may show protein or RBC casts CK may be elevated
What testing for tenosynovitis
usually clinical but can get XR, US
intervention for femoral condyle fx
usually surgical, want to prevent osteoarthritis
knock knee
valgus
flip to see risk factors for OM. What are the ones for peds?
varicella, strep, recent URI, animal handling
genu varum vs genu valgum, ages?
varum-6months valgus 2-4 years, slowly going to normal at age 8.
like riding a horse- applies to knee, opposite of valgus
varus
inflammatory disease of the blood vessels destruction of blood vessel walls subsequent thrombosis ischemia bleeding possible aneurysm
vasculitis
MC locations for hematogenous OM in adults
vertebrae, sternoclavicular, pelvic
another term for the palmar aspect of the hand and forearm (btw, the other side is dorsal)
volar
coracobrachialis
weak flexor of shoulder; musculocutaneous nerve
palmaris longus
weak flexor of wrist, median nerve
diagnostic tests for polymyositis
weakness (isolate and test muscle groups) CK (can monitor activity) Lactic dehydrogenase (LDH) Abnormal electromyogram Findings on muscle bx labs/tests to rule out differentials
scoliosis progression: compress on concave side of curve, compression on convex side of curve. the segments will become ___ shaped
wedge
Imaging for OA
weight bearing x-ray look for joint space narrowing, sclerosis, osteophytes
4 W's of documenting an injury
where, when, who (witnesses, other people involved), what (mechanism of injury)
RA most common in
white ppl, female more often
if you suspect scoliosis, refer!
will do
a lesion of long thoracic nerve, paralyzing serratus antertior
winged scapula
children w OM have joint effusion 60-70% of time
wow
radial nerve injury, can happen with fracture of humerus in the region of spinal groove, cant extend wrist
wrist drop