MSK Cards

What ligament of the knee prevents anterior translation of the tibia on the femur?

ACL

Which of the following is not a part of the extensor mechanism? - patellar tendon - quadriceps tendon - ACL - patella

ACL

What ligaments of the knee are intra-capsular and extra-synovial?

ACL and PCL

1. L1 vertebral body* 2. spinous processes 3. pedicles 4. transverse processes 5. lamina 6. sacrum/S1 7. L5 vertebral body*

AP L-spine

Compare ACL and PCL tears

ACL tear: - contact, non-contact (more often), hyperextension PCL tear (rarer): - primarily contact injury - land on tibial tuberosity with flexed knee (stabilizer flexed)

Erector spinae mm - location - attachments - action - innervation

"I Love Spaghetti" = lateral to medial Iliocostalis m: posterior ilium to ribs and lower C-spine; lumborum, thoracis and cervicis Longissimus m: from common tenson in L/S to transverse p T and C, and mastoid process temporal skull. Only one with capitis portion (thoracis, cervicis, capitis) Spinalis m: spinous process to spinous process , thoracis and cervicis, cervicis seems to blend with semispinalis capitis m bilateral -> vertebral column extension unilateral -> lateral flex and rotate neck on same side posterior rami

Pes anserinus (not on structure list) - what is it? - what's it made of? - what does it do?

"goose foot" joined tendons of 3 muscles that insert onto the anteromedial surface of the proximal portion of the tibia Say Grace Before Tea sartorius, gracilis, (pes anserine bursa,) semitendinosus increases stability of medial knee

Tensor fasciae latae m. - location? - origin? - insertion? - action? - innervation?

"sbux m" "little verticle m" (palpable when ambulating) lateral hip/superficial gluteal O: ASIS, anterior-most portion iliac crest I: Iliotibial tract Hip abduction & internal rotation Help keep pelvis level when ipsilateral (same side) limb is weight bearing Superior gluteal n

Plantar interossei (3) - location - origin? insertion? - action? - innervation?

(3) Intrinsic foot, plantar group, 4th layer - sides MT 3-5/medial sides proximal phalanges 3-5 - *adducts toes (PAD)* - lateral plantar n

Dorsal interossei - location - origin? insertion? - action? - innervation?

(4) Intrinsic foot, plantar group, 4th layer - adjacent sides of MTs/sides of proximal phalanges 2-4 (1st from proximal MT 1 to proximal phalanx 2) - *abducts toes (DAB)* - lateral plantar n

What's innervated by medial plantar n?

(4): Abductor hallucis, Flexor digitorum brevis, 1st lumbrical, flexor hallucis brevis (motor) Sensory = medial aspect sole, digits 1-4 tibial n (innervates posterior compt leg superficial and deep) courses around medial malleolsu, dives under foot and splits to medial and lateral plantar n lateral plantar n: motor all rest, digits 4-5 sensory laterla aspect sole foot - runs on top of quadratus plantae (from layer 1 to 2) common (MT) plantar digital nn. then proper

Describe the formation of the lumbosacral plexus and its major branches

*Lumbosacral plexus = L1-S4* - innervation to gluteal region + LE Sensory: - Clunial nn. = superior (iliac crest), middle (gluteal region), and inferior (gluteal region) Motor (incl.): - Superior gluteal n. - Inferior gluteal n. - Sciatic n. (common fibular + tibial) - all motor n. exit pelvis via greater sciatic foramen

Describe the origin, course, and function of the sciatic, femoral, obturator, common fibular, and tibial nerves

*Sciatic n: - largest n in body - from anterior rami L4-S3 - innervates *posterior thigh, then leg - tibial and common fibular nn. in 1 sheath - *in popliteal fossa, splits into tibial and common fibular nn. Tibial n: - remains posterior (posterior cmpt leg) - courses around medial malleolus, under plantar surface foot -> medial and lateral plantar nn. Common fibular n: - laterally around fibular head - splits to superficial, deep fibular nn. in leg - superficial fibular n (lateral cmpt leg) -> cutaneous innervation dorsum foot - deep fibular n (anterior cmpt leg) -> cutaneous sensation dorsal web space b/t 1st/2nd digits *Femoral n: - from anterior division lumbar plexus - L2-L4 - *anterior compartment thigh - passes deep to inguinal ligament to exit pelvis *Obturator n: - from anterior division lumbar plexus - L2-L4 - *medial compartment thigh (adductor) - thru obturator canal to exit pelvis

Identify the bursa of the hip joint. What are bursa? What are they for?

*Should not see in lab* Greater trochanteric bursa (b/t gluteus maximus and greater trochanter) Ischial bursa (superficial to ischial tuberosity) Bursa = fluid filled sac to decrease friction (blow up if hit)

Describe the development of the ribs and sternum

*paraxial mesoderm -> somite -> *sclerotome (cells grow out from each costal process of thoracic vertebrae) -> ribs (costal cartilage from *sclerotome cells that migrate across *lateral somite frontier of adjacent lateral plate mesoderm) lateral plate mesoderm -> somatic mesoderm (parietal layer) -> mesenchyme (sides of midline fuse) -> sternum

What results from injury to the superior gluteal n?

+Trendelenburg test: pelvis drops on contralateral side injury (loss ability to maintain level), foot won't clear ground during swing phase Weakened abduction & internal (medial) rotation from loss of gluteus medius and minimus mm. (TFL too)

Describe the origin, course, and function of the terminal branches of the brachial plexus, as well as their sensory distribution

- 5 terminal branches Musculocutaneous n: anterior cmpt arm* Median n: thru arm, most anterior forearm* (most flexors) Ulnar n: thru arm, posteriorly around medial elbow, 1.5 muscles anterior forearm, most hand muscles* (posterior to medial epicondyle) Axillary n: posteriorly humeral surgical neck -> teres minor m, deltoid m (abductor) Radial n: posteriorly down, extensor cmpts arm and forearm* (posterior cmpt arm and forearm)

What is the most sensitive and specific physical exam finding for diagnosing an Achilles tendon complete rupture? - Lack of ankle plantarflexion with squeeze of gastroc-soleus complex musculature - Increased passive anterior translation of talus on tibia with tibia stabilized - Excessive passive ankle inversion with ankle in 0 deg plantarflexion - Excessive passive ankle inversion with ankle in 20 deg plantarflexion - Lack of ankle dorsiflexion with squeeze of gastroc-soleus complex

- Lack of ankle plantarflexion with squeeze of gastroc-soleus complex musculature

Describe the (pathogenesis) pathophysiology and causes of RA/JIA (including the relationship between RA and HLA-DR-4) List the major symptoms and clinical presentation of RA/JIA (including extra-articular manifestations) List the classic radiographic findings of RA/JIA Recognize the association of RA with DR4 and (list the) the most common laboratory findings of RA/JIA List the most common extra-articular manifestations of RA Recognize the approach to treatment of RA/JIA and how that overlaps with the most common medication therapies

- RA Caucasian, 3F>M - risks RA: smoking, HLA-DR4 epitope, silica - JIA less common, most common rheumatic disease childhood - chronic autoimmune disease - age 16+ dx, lasting 6+ weeks - affect 3+ joints (usually 5+) - symmetric, usually involves hands - elevated acute phase reactants = markers inflam like ESR (sedimentation), C-rp - assoc w serum rheumatoid factor (RF) or anti-cyclic citrullinated peptide (CCP) antibody - r/o infection, malignancy JIA - age < 16 dx, 6+ wks, more heterogeneous (multiple types) - assoc w uveitis - both genetically complex - RA assoc w HLA-DR4 allele = shared epitope - triggers = cig smoke, silica, other? - pro-inflam cytokines like TNF, IL-6 upreg in serum and synovium, B T cell dysreg, macrophage neutrophil DCs -> angiogenesis within synovium - activated fibroblasts -> more synovium -> activated osteoclasts erode bone - proteases damage and deplete cartilage eye: scleritis, keratoconjunctivitis sicca tendons: tendonitis, degeneration tendons ligaments *pleura: pleural effusion, pleuritis *lung: pulmonary nodules, interstitial lung disease *heart: atherosclerosis, pericardial effusion *cv: atherosclerosis, vasculitis (can -> cutaneous ulcer), Raynaud's syndrome bone marrow/hematologic: anemia of chronic disease, thrombocytosis, leukocytosis, Felty's syndrome (in setting longstanding disease, granulcytopenia + low WBC + splenomegaly = hi risk infection) *bone: osteopenia, osteoporosis (inc risk fx) lymph node: reactive lympadenopathy kidney and gut: amyloidosis muscle: myopathy dermatologic: rheumatoid nodules, vasculitis with ulcers* nervous system: peripheral neuropathy uveitis: 10% children JIA - most comon in oligoarticular JIA subtype - risk factors: F, younger, ANA+ - can -> cataracts, glaucoma, visual impairment - often asx - screened by slit lamp 3-12 mos for all JIA kids, freq depends on subtype, ana status, age - comlications unique to JIA -- micgronathia from JIA involvement of TMJ joints -- limb length iscrepancy - from asymmetric - affected leg longer systemic-onset jia - more ill, other assoc features like *fever (2+ wks, quotidian), rash (evanescent within hours, usually w fever), hepatosplenomegaly, lympadenopathy, serositis - lab: leukocytosis, anemia, thrombocytosis, elvated esr, crp, elevatd ferritin, rf/anti-ccp, ana usually absent joint pain/stiffness, daily and chornic, worse after rest, better with activity/hot shower/nsaid - limp, fatigue - usually absent fever wt loss unless systemic onset jia pex: - complete joint exam for swelling, tenderness, loss rom, rhematoid nodules, enthesitis - other clues: psoriatic skin or nail changes, --lympadenopathy, signs of serositis which could suggest systemic onset jia or other condition - patterns: usually symmetric polyarthritis - oligoarticular jia diff, usually asymmetrical advanced ra/jia - ulnar deviation, joint swelling, joint subluxation - rheumtoid nodules (uncommon in jia, esp sites trauma) - enthesitis - swollen tendon, tender, pain rom Labs in RA: - inflam (ESR, crp), hemat (anemia, thrombocytosis, leukocytosis /branulocytopenia in Feltys), immunologic (RF 80%, anti-CCP 80%, ANA not useful except excluse lupus), synovial fluid (elev WBC, neg culture, no crystal) Labs in JIA: - similar (feltys unlikelye), RF <10%, Anticcp <10%, ANA helpful to assess uveitis risk Rheumatoid factor: - IgM or IgA ab binds to IgG - + in 80% pts in RA, uncommon JIA (if polyarticular JIA or RA = worse prognosis) - other causes + RF: infection (TB, hep C, endocarditis), other inflam disease, chronci liver disease, malignancy Anti-cyclic citrullinated peptide (CCP) antibody - ab to citrulline-containing proteins - present in 80% RA pts - sensitivity = RF in RA - specificity > RF in RA (false + less likely) - anti-CCP ab not fully known in JIA Radiogaphic imaging findings in RA/JIA - periarticular osteopenia (dec bone density surr joints, then ulnar deviation) - erosions: loss cortex bone most commonly in MCP, PIP, MTP and ulnar styloids - joint space narrowing - subluxation joint - - subluxation C1 on C2 = atlantoaxial instability - can -> spinal cord dmg DDx symmetric polyarthritis: - lupus, other rheumatic, infection, post-infectious arthritis, leukemia (children), gout/pseudogout, OA, psoriatic, hemochromatosis Tx: NSAIDs, glucocorticoids (PO or intraarticular - can retard growth in kids, hypergly, htn, wt gain), analgesics (acetaminophen, tramadol, narcotics), DMARDs (disease modifying anti-rheumatic drugs; hydroxychloroquine (inhibit signaling thru TLR 7, 9-- retinal pigmenttion, hemolytic anmiea), sulfasalazine, methotraxate [inhibit dihydrofolate reductase], leflunomide [inhibit dihydroorotate dehydrogenase), Biologics (anti-TNF, abatacept [binds to cd80 prevent t cell costim/ful activation], rituximab [monoclonal ab binds cd20 marker on b cell for b cell deplation], tocilizumab [mab for depleting circulatin il-6], anakinra [recominant protein, R antagonist, competitively binds to il1 Rs, prevent bindg IL1 to R on cell surface]), analgesics, pt and ot, surgery NSAID - liver/kidney fn, BP glucocorticoids: bone densitometry (age), glucose, lipids hydroxychloroquine (visual fields, fundoscopic exam methotrexate, leflunomide, sulfasalazine - blood count, liver fn biologics: blood cts, liver fn, lipids (tocilizumab), tb screen, cxr synovectomy: inflamed synovium meds fail joint replacement/recon - sx and qol consider: perioperative med mgmt to reduce risk infection, risk adrenal insuff if on glucocorticoids, c-spine instability RA and JIA: chornci, progressive, autoimmune -> joint inflammation, damage, extra-articular manifestations -- AM sittnfess - pex shows arthritis with polyart ymmetric or varying lika JIA RA: rhematoid nodules, RF, anti-CCP, and assod HLA-DR4, cig smoking JIA: heterogenous substypes, risk uveitis (worse if F, young, ANA+, oligoarticular subtype), risks related to growing child (micrognathia, limb length discrepancy) Tx involves NSAIDs, glucocorticoids, DMARDs (methotrexate, leflunomide, sulfasalazine, hydroxychlroquine) and biologic therapies

Oblique popliteal ligament

- expansion of semimembranosus tendon - reinforces capsule posteriorly = oblique

Clavicle fx

- fall on outstretched arm - overlap of fragments = shortening of clavicle - usually in middle 1/3 of bone - lateral aspect of medial portion gets lifted up

Arcuate popliteal ligament

- fibular head, over popliteus m, to joint capsule - strengthens capsule posterolaterally

Select which of the below are contents of the carpal tunnel: - flexor digitorum profundus x 4 - flexor pollicis brevis - palmaris longus - median n - flexor pollicis longus - ulnar n - abductor pollicis longus - flexor digitorum profundus to 4th/5th - flexor digitorum superficialis x 4

- flexor digitorum profundus x 4 - median n - flexor pollicis longus - flexor digitorum superficialis x 4

Match the different radiographic densities with the corresponding tissue/material types: gas fatty tissue connective tissue/muscle/blood bones heavy metals/hip replacements intermediately radiolucent moderately radiopaque very radiolucent moderately radiolucent very radiopaque

- gas = very radiolucent - fat = mod radiolucent - CT/muscle/blood = intermediately radiolucent - bone/Ca = mod radiopaque - heavy metal = very radiopaque

What population of pts is the most common group to sustain an Achilles tendon rupture? - women 30-60 - men 30-60 - women <30 - men <30

- men 30-60

What are the cardinal features that you would expect to see on radiographs of a pt with hip osteoarthritis? (choose all that apply) - perarticular cyst formation - destructive bone loss - subchondral sclerosis - osteophytes - joint space narrowing

- perarticular cyst formation - subchondral sclerosis - osteophytes - joint space narrowing

Image showing measurement of patella alta

- predisposes to dislocation - measured by ratio of height of patella above tibia (A) to patellar length (B) = Caton-Deschamps index - >1.2 suggests PA

What are the different densities seen on plain radiographs (x-ray)?

- rays blacken film - high density tissue = radiopaque = bright - low density tissue = radiolucent = dark - x-ray of nothing = black = all rays pass thru - gas = very radiolucent - fat = mod radiolucent - CT/muscle/blood = intermediately radiolucent - bone/Ca = mod radiopaque - heavy metal = very radiopaque

Describe the TL fascia what does it cover?

- thoracolumbar fascia - covers all deep back muscles, separating from intermediate in thoracic region - attaches medially to spinous processes of T and L vertebrae - easily visible in low back - posterior layer: thickest, L spinous p and S, covers erector spinae m - middle layer: L transverse p and posterior iliac crest - anterior layer: L transverse p, covers quadratus lumborum m posterior and middle meet at lateral boundary erector spinae mm at lateral border qudratus lumborum m, anterior joins to make aponeurotic origin of transverse abdominins m

Describe scapulohumeral rhythm

2 deg humerus abducts (GH), scpaula should abduct 1 deg (scapulothoracic articulation)

Diagram of sensation and muscles innervated by ulnar nerve

3.5-5 digits Flexor carpi ulnaris, Flexor digitorum profundus (IV, V), flexor carpi ulnaris, Lumbricals (III, IV), flexor pollicis brevis (deep), adductor pollicis, palmaris brevis, abductor digiti minimi, opponens digiti minimi, flexor digiti minimi, palmar & dorsal interosseur m, palmar & dorsal interosseous m

During motor testing of the left bicep of your pt you notice that he is able to perform flexion of the elbow against gravity. You would grade him as: 3/3 4/5 4/3 5/5 3/5

3/5 strength is motion against gravity

What's piriformis syndrome, and what places people at higher risk of it?

= sciatica = shooting pain, numbness down posterior aspect thigh/leg Sciatic can split into tibial and common fibular to have 1 pierce piriformis 1 can go over piriformis = much higher risk Having tight piriformis also inc. risk = mechanical stress

What's Tom Dick And Nervous Harry?

= tarsal tunnel From closest to medial malleolus (anterior) to posterior (to calcaneal tendon side) *only works if at medial malleolus level (assume vein with artery) *T*ibialis posterior m Flexor *d*igitorum longus m Posterior tibial *a*rtery (and vein) Tibial *n*erve Flexor *h*allucis longus m Held in by flexor retinacula (holds down structures form deep post compartment as course around medial malleolus

Which of the following is a long term complication unique to JIA (not seen in RA)? Limb length discrepancy Micrognathia Uveitis C-spine instability All above A, B, C

A B & C C-spine instaiblity can be seen in both RA and JIA micrognathia, limb length discrepancy are consequences of arthritis in a growing child and uveitis occurs in JIA not RA

What is a myotome?

A muscle supplied by motor fibers from a single spinal n.

What is the Trendelenburg test for the hip? What does a positive mean?

A positive means weak abductors. The pelvis is not level when pt standing on affected leg, and dips down to that side where foot lifted.

AP: talus is shifted laterally with fibula, but still see contact b/t talus and tibial plafond Lateral: see contact b/t talus and tibial plafond, and talus is shifted posteriorly Confirm some contact b/t joint surfaces on 2 views

AP and Lateral view x-rays showing ankle subluxation

1. tibia 2. lateral malleolus (on fibula) 3. navicular 4. subtalar joint, talocalcaneal joint* 5. medial malleolus (on tibia) 6. talus

AP ankle

Sartorius m - group/location? - origin? - insertion? - action? - innervation?

Anterior thigh - crosses hip & knee, diagonal down O: ASIS I: Proximal anteromedial tibia *Know all actions for sartorius* Hip flexion, external rotation, abduction; Knee flexion Femoral n

What ligament of the knee is the main stabilizer in extension?

ACL

Which of the following joint sx is the most suggestive that a pt may have RA or JIA? AM stiffness of >30 min Pain in knees only with climbing stairs "Cracking" of joints Low back pain after lifting heavy boxes

AM stiffness of >30 min

Iliopsoas m. - group/location? - origin? - insertion? - action? - innervation?

Anterior thigh - from posterior abd wall, entering proximally - run under inguinal ligament Psoas major m. O: bodies and TP (transverse processes) of T12-L5 vertebrae Iliacus m. O: Iliac fossa I: lesser trochanter femur Main hip flexor Psoas major innervation = anterior rami L1-L3 Iliacus m. = Femoral n

Rectus femoris m - group/location? - origin? - insertion? - action? - innervation?

Anterior thigh / quadriceps femoris m - only quad that crosses hip! O: AIIS I: quadriceps tendon Knee extensor + hip flexion Femoral n

Vastus medialis m - group/location? - origin? - insertion? - action? - innervation?

Anterior thigh/quadriceps femoris m O: Linea aspera I: quadriceps tendon Knee extension Femoral n

Vastus intermedius m - group/location? - origin? - insertion? - action? - innervation?

Anterior thigh/quadriceps femoris m O: anterior femur I: quadriceps tendon Knee extension Femoral n

Vastus lateralis m - group/location? - origin? - insertion? - action? - innervation?

Anterior thigh/quadriceps femoris m - largest of 4 quads O: Greater trochanter, linea aspera I: quadriceps tendon Knee extension Femoral n

1. medial epicondyle 2. femorotibial joint* 3. medial condyle 4. tibia 5. fibula 6. fibular neck 7. head 8. tibial spine* 9. lateral condyle 10. lateral epicondyle 11. patella

AP view knee Name all structures

Where does the inguinal ligament run to and from?

ASIS to pubic tubercle

1. 1st distal phalanx 2. Sesamoids 3. Cuneiforms (1-3)* 4. Navicular 5. Talus 6. Calcaneus 7. Cuboid 8. Metatarsals (1-5) 9. Proximal phalanges (1-5) 10. Distal phalanges (2-5) 11. Middle phalanges (2-5)

AP Foot

Spine PEx

Access legs for piting edema or venous stasis Skin overall Back skin overall alignment, muscle bulk legs arms back balance incl side profile level shoulders pelvis angle feet - ext rotated or not gait: far apart heels, antalgic gait, slack foot, foot progression angle, LE strength with gait - walk on toes (gastroc sol), on heels (tib ant), tandem gait - upper motor neurons heel toe, down spine, joints si, iliac crests l4-5, paraspinal muscles (spasm, asymetry, atrophy); ROM -bend fwd legs straight look for prominence. extend; lateral bending; fle neck fwd back, rotate to ea side. ear to shoulder w/o elevating shoulder stregnth deltoid c5, biceps c6 and wrist extensor, wrist flexor c7, lift knee off table w resist, quad l3, tib ant - dorsiflex ankle l4, ehl l5 = great toe extensors, fhl s1 w gastroc-ssoleus, hip ab-ductors, ad-ductors sensation: symmetric: - c8 into medial forearm t1 medial arm lat thigh calf l5 plantar calf post calf s1 reflexes: palpate biceps tendon, brachioradialis, triceps; along patella; back heel, Hoffman's sign: stabilize middle finger ? spurlings exam: babinski: asses great toe stroke along lat border foot, medially along arch - watch for flexion which is nl SLR: pt in supien, repro of pain - document how high lift - in seated have dorsiflex foot FABER: flexion abduction, external rotation hip -

What is the name of the fibrocartilage that adds depth to the hip joint and cushions the femoral head, increasing articular surface area by ~10%?

Acetabular labrum

List the primary medications used in the tx of gout and understand complications/toxicities involved in their use For the bone-homeostasis pharmacotherapies, describe: - primary mechs of action - indications/uses - common toxicities - cross-reactions with other meds

Acute gout drugs: - NSAIDs (like ibuprofen, ketoprofen, indomethacin, ketorolac, naproxen, meloxicam, acetaminophen; inhibit prostaglandin synth and urate crystal formation; non-selective reversible COX1/2 inhibition; gastric erosions & bleeding due to dec PGE2 and prostaglandin, renal insuf due to deg prostaglandin, hypersensitivity urticaria rxn; NO ASA b/c renal retention uric acid) - colchicine (*PO*/IV, acute and chronic taking allopurinol, binds intracellular tubulin -> polymerizes microtubules -> inhibits leukocyte migration and phagocytosis, inhibits formation leukocyte B4, *NVD, abd p*, hepatic necrosis, acute renal failure, DIC, seizure, peripheral neuritis, myopathy; long-term use adverse effects = bone marrow suppression *agrnulocytosis* and suppression of hair follicle growht (alopecia)) - corticosteroids (occasionally used for severe symptomatic gout; shorter-acting = prednisone/cortisone [PO], hydrocortisol [PO, top, inj], prednisolone/methylprednisolone [PO, inj]; longer-acting = triamcinolone, betamethasone, dexamethasone [PO, inj, top]; *intracellular regulation genes -> anti-inflam = dec production prostaglandins and inflam cells like T/B cells, macros, baso/eosinophils*; widespread intracellular regulation of genes has catabolic/anti-anabolic effects, immunosuppressive effects, can adrenal insufficiency; long-term use can -> osteoporosis) Chronic gout drugs: - uricosuric agents (probenecid, sulfinpyrazone; *inhibit uric acid reabsorption in kidneys -> accelerated excretion urate*; adverse effects include *formation of uric acid renal stones*, GI irritation, inhibit renal excretion of PCN, indomethacin, sulfonylureas) - xanthine oxidase inhibitors [*allopurinol* = purine = standard b/t episodes, febuxostat (non-purine), rasburicase/pegloticase (recombinant of urate oxidase), *inhibit production of uric acid by inhibiting xanthine oxidase*, *allergic skin rxn*, allopurinol alone can *precipitate acute gouty arthritis* so usually given with colchicine; need decreased doses of mercaptopurine/azathioprine/theophylline by 75% while on] - colchicine

Describe epidemiology of fibromyalgia Explain and list pharmacologic and nonpharmcologic tx fibromyalgia Recognize and define neurotransmitter abnormalities in fibrimyalgia Recog hx and pex findings in fibrmylagia

Adults: F 6x> M 2-3% F, 20-55 in US all races/ethnicities Children/adolescents: - up to 1% in US - F 3-7x > M - most common onset in early adolescence, usually 11-15 - more common Caucasian in US Central (non-nociceptive) chronic pain - central disturbance in pain processing and autonomic regulation - behavioral factors more prominent - fibromyalgia, irritable bowel syndrome - usually sx after trigger (infection, acute illness, physical/emotional trauma) - possible genetic: 1st deg relative, human serotonin xptr gene, catecholamine methyltransferase genes, polymorphisms of adrenergic Rs NT abnl: in CSF - substance P, glutamate, nerve growth factor, opioid = increased (opiod Rs in CNS and PNS upreg) - norepinephrine, serotonin, dopamine = decreased - detect pain at lower pain threshold - upreg opiod Rs too - inc activity in CNS pain-sensing areas - ANS dysfunction: often orthostatic hypotension, tachycardia and variability *not immune-mediated, but 2ry in context of autoimmune, also must exclude other rheumatologic conditions pain chronic (3+ mos), widespread, worse with activity/weather/stress, other sx (fatigue, AM stiffness, subjective joint swelling, HA, abd p, sx IBS, pelvic pain and sx interstitial cystitis, ocular dryness, intermittent palpitations, lightheaded, intermittent paresthesia (nondermatomal), brain fog/memory issue, change taste, mood disorder (dep/anx 50%) PEx: diffuse tender points, hyperalgesia (inc response to painful stimulus), allodynia (painful response to normally innocuous stimulus) - tender point exam - thumb 4 kg/cm Tx: - pt education, expectations - non-pharm: sleep hygiene, exercise, CBT = combo, multidisciplinary - pharm (30%): tricyclic antidepressants (amitriptyline, nortriptyline), muscle relaxant (cyclobenzaprine), serotonin-norepi-reuptake inhibitors (duloxetine, milnacipran), GABA agonists (gabapentin, pregabalin = dec glutamate), acetaminophen, NSAIDs, generally avoid narcotics (may consider tramadol, may worsen)

List key components of the MSK hx Differentiate b/t an acute injury and chronic complaint Recognize the importance of ID'ing acute MSK conditions, via an accurate hx, and be able to discuss the ramifications of missing them

Age, Sex, Occupation, Hand dominance if UE, Body part affected, Complaint (pain, sitffness, instability, NV), Onset (trauma?), Length, Worse/better/same, Characterize pain (where, quality), What makes hurt/better, At rest?, At night?, Neuro, Tx (med, inject, tx, img) How much bothering/interfering, Could live with it?, PMH (meds, surg, fam, soc) Missing an impt area in hx of PE but billing same = fraud

Describe the role of synovial tissue and synovial fluid: The synovial fluid: Aids in nutrition of cartilage: T/F Removes debris from joint: T/F Heals cartilage injury: T/F

Aids in nutrition of cartilage: T Removes debris from joint: T Heals cartilage injury: F

What is a dermatome?

An area of skin supplied by sensory fibers from a single spinal n. Lots of overlap (stick to clinical map)

What's the angle of inclination? What is a change in the angle of inclination important? What are two terms for abnormal knee postures resulting from abnormal angle of inclinations, and what are their numerical cutoffs?

Angle made b/t neck and shaft of femur Changes affect gait (change over lifetime, can -> wear/tear/abnl knee posture, near 90 with age) coxa vara = angle <120 coxa valga = angle >135

What is the most commonly injured joint in the body?

Ankle

The outer portion of the intervertebral disk is called the? Nucleus pulposus Anulus fibrosus Posterior longitudinal ligament Intervertebral disk Ligamentum flavum

Annulus fibrosis: outer portion of intervertebral disk

The spinal n forms when what structures merge together in the same area? Posterior (dorsal) roots and rami Anterior (ventral) and posterior (dorsal) horns of the spinal cord Anterior (ventral) and posterior (dorsal) roots Anterior (ventral) roots and rami Anterior (ventral) and posterior (dorsal) primary rami

Anterior (ventral) and posterior (dorsal) roots

What is the most common direction of shoulder dislocation? inferior anterior posterior superior

Anterior = most common (posterior = most missed!)

Think about the cutaneous nn. of the UE

Anterior arm: intercostobrachial n medial cutaneous n of arm medial cutaneous n of forearm posterior cutaneous n of forearm lateral cutaneous n of forearm (cutaneous branch of musculocutaneous n) radial n, superficial branch ulnar n (medial, to hand) median n (palmar) Posterior arm: intercostobrachial n radial n, superficial branch radial n ulnar n median n (digits)

Match each of the major knee ligaments to its primary role: ACL PCL MCL LCL MPFL Prevent lateral dislocation patella Resist valgus load applied to knee Resist varus load applied to knee Resist posterior translation of tibia relative to femur Resist anterior translation of tibia relative to femur

Anterior cruciate ligament (ACL): Resists anterior translation of the tibia relative to the femur Posterior cruciate ligament (PCL) resists posterior translation of the tibia relative to the femur Medial collateral ligament (MCL) resists valgus loads applied to the knee Lateral collateral ligament (LCL) resists varus loads applied to the knee Medial patellofemoral ligament (MPFL) prevents lateral dislocation of the patella

Extensor digitorum longus m - group/location? - origin? - insertion? - action? - innervation?

Anterior leg O: *Proximal 1/2 fibula*, lateral tibial condyle I: Distal and middle phalanges of digits 2-5 *Extends digits 2-5*, Ankle dorsiflexion, Weak eversion Deep fibular n

Fibularis tertius m - group/location? - origin? - insertion? - action? - innervation?

Anterior leg O: Distal fibula I: Base of 5th MT Dorsiflexion, eversion Deep fibular n (not present on all bodies)

Extensor hallucis longus m. - group/location? - origin? - insertion? - action? - innervation?

Anterior leg O: Medial fibula and interosseous membrane I: Base of distal phalanx of great toe (dorsal surface) Great toe extension and ankle dorsiflexion Deep fibular n (b/t extensor hallucis longus and tibialis anterior, along w anterior tibial a/v)

Tibialis anterior m. - group/location? - origin? - insertion? - action? - innervation?

Anterior leg O: Proximal, lateral tibia and IM (intraosseous membrane) *I: Medial cuneiform, base of 1st metatarsal* Ankle dorsiflexion, inversion; helps support medial arch of foot Deep fibular n

Which of the following ligaments prevents vertebral column hyperextension? Interspinous ligament Supraspinous ligament Anterior longitudinal ligament Ligamentum flavum Posterior longitudinal ligament

Anterior longitudinal ligament (only ligament of vertebral column that prevents hyperextension)

What are all major somatic plexuses formed by?

Anterior rami

The ankle anterior drawer test performed with the ankle in plantarflexion tests what ligament?

Anterior talofibular ligament In neutral dorsiflexion tests calcaneofibular ligament

What's the weakest ankle ligament? Where is it?

Anterior talofibular ligament Lateral Most commonly sprained ankle ligament

Correlate the pathophysiology of disc degeneration and disc herniation with pt presentation w cervical and lumbar radiculopathies Describe the pathophysiology and clinical findings of spinal stenosis ID the clinical presentation, differential diagnosis and common tx options for low back pain

Anterior vertebral body + posterior neural arch C7, T12, L5, S5 (fused), coccyx (4) Disc = outer annulus, inner nucleus pulposus Neural arch: 2 pedicles, 2 lamina, 1 spinous process, 2 transverse processes - contains spinal elements Pedicles are attached to body to lamina Lamina are attached to pedicle and spinous process Spinous process is intersection b/t 2 lamina Transverse processes are attached to lamina and pedicle Each vertebral level = 3 joint complex = 1 intervertebral disc (anterior) and 2 facet joints (posterior) C3-C7: - smaller bodies; transverse > AP diameter - superior lateral edges of vertebral body have joint = uncinate process - neural arch has 2 pedicles, 2 lamina, 1 bidi spinous process (not C7), 2 transverse processes, 2 transverse foramen *** REVIEW *** cervical spondylosis: most common cause of progressive spinal and nerve root deterioration spinal stenosis = tricompartmental - intervertebral disc collapse - annular bulging - end plate ridging - facet joint hypertrophy - +/- ligamentum flavum hypertrophy - typically bilateral from L3-4 and L4-5

How do bones widen during growth?

Appositional growth (along surface) Osteoblasts secrete bone matrix at external surface of bone just below periosteum (there is a deep osteogenic layer assoc w periosteum) Osteoclasts breakdown bone matrix at endosteal surface bone Rates shuld be equal

What's the blood supply to the hip joint? What do these branch from? Describe their directions

Artery to the head of the femur (From obturator a.) = thru fovea capitus Retinacular aa. from circumflex femoral aa. (mostly medial) = hug neck and go up head *NOT SEEN IN LAB*

Define the components of the axial and the appendicular skeleton

Axial: skull, vertebral column, ribs, sternum Appendicular: limb bones, pectoral & pelvic girdles

Arrange the following structures from smallest size to largest size: Microfibrils, Fibrils, Fascicles, Subfibrils, Collagen Molecules, Tendons

Collagen mc Microfibrils Subfibrils Fibrils Fascicles Tendons

What type of joint is the hip? Describe important ligaments and cartilages at the hip. Describe bony prominences of pelvis and femur How do you orient the pelvis?

Ball and socket. iliofemoral ligament = anterolateral upside-down Y, strongest pubofemoral ligament = anteromedial ischiofemoral ligament = posterior acetabular labrum = @rim of acetabulum, dense fibrocartilage ring increases depth and adds stability Incl: Greater trochanter, Lesser trochanter Ischial tuberosity, ischial spine, greater sciatic notch, lesser sciatic notch, ASIS, AIIS Locate sciatic notch posteriorly Line can be dropped from ASIS to ischium Draw a perpendicular: posterior superior quadrant should have iliac wing = safest place for acetabular screws

Anterior compartment of arm - list muscles - innervation - blood supply - action

Biceps brachii m, Coracobrachialis m, Brachialis m Musculocutaneous n Brachial a Flexor compartment of arm

What are the posterior thigh muscles? What is another (colloquial) name for the muscles of the posterior thigh?

Biceps femoris m Semimembranosus m Semitendinosus m Hamstrings

Describe the blood supply to the femoral head and describe the clinical significance and ramifications of this Recognize the MOI, presentation and initial management of hip dislocations Describe the anatomic locations of hip fractures and how this impacts their tx options Recognize the clinical and radiographic presentation of hip arthritis Describe the clinical and radiographic findings with quadriceps contusions Describe the extensor mechanism and describe the MOI and pt presentation of the most common tendon injuries in the knee (quadriceps and patella) Describe the MOI, clinical presentation and dx of the most common ligamentous knee injuries (including ACL, PCL, LCL, MCL) Compare and contrast the presentations of degenerative vs acute meniscal injuries and describe the factors that affect tx principles Recognize the clinical and radiographic presentation of knee arthritis Recognize the anatomy, presentation and initial management of patella dislocations Describe the anatomy, MOI and clinical presentation of the most common ankle sprains and describe how the grades of injury affect tx Describe the MOI and presentation of Achilles tendon ruptures

Blood supply to hip - pediatric (3): medial circumflex femoral a, a of ligamentum teres, branch of obturator - adult (1): lateral ascending branch of medial femoral circumflex - AVN: like from medial circumflex a to femoral head; end-stage AVN -> collapse of articular surface, requiring replacement [MRI can detect edema in femoral head of earlier stage AVN, before XR can] Hip dislocations - hi-speed MVA, contact, fall - posterior = most common (85%) bc MOI more frequent and anterior ligaments stronger, hip and knee flexed and anterior blow to knee (knee on dashboard or fall and force on top); flexed, internally rotated, adducted = pain, can't move/be moved - anterior = pain/can't move; externally rotated, abducted - PEx + NV, XR, reduction (long delay can affect blood supply -> risk osteonecrosis or avascular necrosis (AVN) femoral head) Hip fx - <50% pts return to prior mobility, impacting independence elderly -> inc mortality by 25% within year following - neck fx: more serious bc disrupt blood supply bc branches of medial circumflex travel up neck to head; can survive maybe if nondisplaced, but if displaced no chance, expect head die so replacement - intertrochanteric fx: greater to lesser, hip abductors insert on greater, iliopsoas inserts on lesser, blood to fem head ok since distal to vessels, proceed w fixing Hip arthritis (like DJD) - weight-bearing so can present earlier than shoulder for example - gradual onset deep aching pain - typically worse as day progresses (unlike inflammatory arthritis) - stiffness, loss mobility; in advanced - catching, grinding - inspect (might not see anything bc deep joint), palpate (may be nl), ROM (loss active and passive), strength (abductors often weak so can't hold pelvis level when standing on only affected leg - hip dips toward side where foot lifted), gait (assistive device? Trendenlenburg gait/sign = pelvic drop to foot lifted side and shoulder comp to foot down side vs. antalgic gait upper body leaning but pelvis level) Quadriceps contusions - common in sports, direct blow - bleeding in branches of femoral a (excessive in hemophiliacs/bleeding condition/on thinners) into muscles - tx: ice/heat, flexion splint (keep quad stretched out, in extension quad is shortest so if scar down in extension when quad shortest this can limit flexibility of knee -> limitation AROM PROM), anti-inflammatories & PT for ROM work - myositis ossificans = complication; bleeding into muscle partially ossifies (b/t muscle fibers, proliferation precursor cells which mature into OBs); quad hard, can limit ROM affected knee incl full knee flexibility adn flexion due to scarring; avoid by starting PT early; see ossification on XR; can be mistaken for osteosarcoma (but remember signs of bone tumors in XR and hx) Ankle sprains - most common sport injury (40%, bball, soccer, running, dance, 10% ER, 30k/day) - 75% involve lateral ligaments - 80% full recovery w conservative tx, rest instability (oft w fibular/peroneal tendon) - medial ligaments = deltoid = posterior tibiotalar, tibiocalcaneal, tibionavicular, anterior tibiotalar), broad, fan-shaped, superficial and deep layers - syndesmosis ligaments: anterior inferior tibfib lig, posterior inferior tibfib lig, interosseous membrane - lateral ligaments (3): posterior talofibular, calcaneofibular, *anterior talofibular (weakest)* - PEx: inspection (swelling, ecchymosis, blisters, deformity), palpation (anterior talofibular ligament, calcaneofibular ligament, posteiror talofibular ligament, syndesmosis, deltoid; fibula, tibia, talus, 5th MT, calcaneus; peroneal tendons, PT tendons), AROM/PROM - anterior drawer test: pt seated w flexed leg hanging off; stabilize distal tibia w 1 hand, grasp heel and pull foot forward; in neutral dorsiflexion (test calcaneofibular) and plantarflexed (anterior talofibular) & compared with other ankle -- may get false - due to involuntary guarding or pain -- inc translation of 3 mm compared to uninjured side or absolute value > 10 mm = anterior talofibular incompetence - in complete anterior talofibular tear, talus subluxates anteriorly and dimple appears over anterolateral joint due to suction - std XR: AP, lateral, mortise/oblique views (weight bearing) - stress XR: not routinely necessary in acute setting-- accuracy compromised by pain, peroneal spasm, but valuable in chronic cases - initial (24-48 h) tx: rest/crutches w gradual return to wt bearing as tolerated, immobilization (fx boot/splint), ice (~20 min/hr if swelling), elevation (above heart level while reclining to decrease swelling), NSAIDs - nonop tx: early mobilization (prevent stiffness), support (tape, semi-rigid brace, lace-up brace, rehab (strengthen esp fibularis brevis and longus), proprioception training (balance and NM ctrl like trampoline and tilt board), coordination - sequelae: loss staiblity, disruption mechanoreceptors and subsequent loss afferent nerve fn and ankle motor coordination may -> chronic ankle instability which may need surg Achilles ruptures - strongest largest tendon in body - 10-15 cm long, gastroc + soleus tendons - antecedent tendinitis/tendinosis in 15% - 75% of sports-related ruptures in pts 30-60 y - most in area of least blood supply (watershed) 2-6cm proximal to calcaneal insertion - Hx: like kicked in leg, eccentric loading (running backwards in tennis)/sudden unexpected dorsiflexion ankle/direct blow or lac, usually 30-60 y/o m - PEx: palpable defect, +Thompson test (pt prone, knee flexed, squeeze calf muscles and normally foot will plantar flex), bruising/swelling, weakness w plantar flexion - Tx: surg = early wt-bearing, lower re-rupture rate / non-op = no surgical risk/expense but longer protected time - surg depends on surgeon and pt pref; surgery = for athletes, young pts, delayed rupture -- acute rupture in non-athletes can do non-op (cast in plantar flexion, if too hi-risk for surg) Ligamentous injuries (of knee) - quadriceps = extend knee = rectus femoris, vastus intermedius, vastus lateralis, vastus medialis - quads insert into quad tendon onto patella onto patella tendon to tibial tubercle - quad and patellar tendon rupture: due to forceful quads contraction like forced knee flexion against active quad like in fall: highest risk = M 40+, pre-existing degeneration predisposes; no prodrome, palpable defect either above or below patella, severely impaired knee extension (may weakly have thru intact retinaculum); patella migrated in imaging; MRI confirms; r/o intra-articular (ACL and patellar tendon sometimes); non-op -> chronic weak extensor knee (only if poor surg candidate); surg within few days - ACL: from lateral wall femoral notch to central anterior portion tibial plateau; distal and posterior to lateral intercondylar ridge; lateral bifurcate ridge separates antermedial and posterolateral bundles ACL not always visible; posterolateral attaches more distally and is smaller; anteromedial bundle larger and attaches more proximally;; ACL inserts onto anterior intercondylar fossa on tibia; 1ry fn ACL = prevent anterior translation tibia from femur (helped by posterior horn medial meniscus, MCL and posteromedial capsule, tibial slope, hammies); 2ry fn = prevent knee hyperextension, resist varus/valgus angulation esp if collaterals injured, PL primarily resists internal tibial rotation relative to femur near extension; ACL contact are 1/4 of cases oft with direct blow and concurrent injuries; most noncontact during stop/cut/landing; poss quad contraction/dec relative hamstring strength; axial compression; knee abduction (valgus); wll inc tibial internal rotation and anterior translation; Hx ?s = contact? pop? swelling - immediate? how much? could play? (acute hemarthrosis in o/w healthy knee think ACL; post-injury locking/catching? feel unstable?; PEx - strength ROM NV gait, can be similar to patellar dislocation, exam ligaments, anterior drawer with knee flex 90 translate tibia anterior relative to femur -- if ACL intact feel firm endpoint -- Lachman better; Lachman knee 20-30 hamstrings relaxed- excursion and endpoint; ACL oft with articular cartilage and menisci injuries, can also b with other ligaments like collaterals, PCLs - unhappy triad = ACL MCL medial meniscus ; need XR to r/o (may see tibial tubercle avulsion in skeletally immature - small fleck = pathognomonic); injury -> inc incidence OA which is much higher risk with associated meniscus injury; reconstruction improves knee stability and fn but may not reduce risk of OA - PCL: resist posterior translation tibia; anterolateral and posteromedial; anterolateral bundle larger, resists posterior tranlation tibia with knee flexed 90 deg; medial condyle to posteromedial tibia, blow to anterior tibia with knee flexed (fall, mvc), assoc w femur fx and post hip disloc; posterio rdrawer - usually black continuous band in MRI - disruption and inc intensity = injury - MCL: broad long ligament from femur to tibial metaphysis; connects medial femoral condyle to medial plateau; resists valgus force; posterior oblique ligament = part of posteriomedial, works with MCL to resist posteriomedial rotation of tibia - MCL: resist valgus force - MCL = most commonly inured ligament of knee, force valgus to lateral knee - Pex: TTP on medial knee - above or below joint line could be; pain with valgus stress knee joint; check opening in full extension and 30 deg flexion (isolates MCL by relaxing joint capsule), eval for other ligaments, meniscus - grade I: partial tear, no laxity or minimal laxity on PEx, pain with valgus stress - grade II: inc valgus laxity at 30 deg flexion, no laxity in full extension - grade III: complete tear, double positive - XR useful to r/o other, valgus stress XR can help - Hx and Pex, MRI = gold std LCL (fibular collateral ligament): - lateral femoral condyle to fibula = varus force resistor - popliteus tendon part of complex = dynamic (muscle from lateral femoral epicondyle to posterior tibia) - popliteofibular ligament too - injury by forceful adduction knee joint - isolated injury rare - associated w posterolateral corner of knee = typical, incl popliteus tendon, popliteofibular ligament - PEx: ttp at origin at lateral femoral epicondyle or fibular head where inserts - pain w varus stress at extension and 30 deg flexion (isolate); also exam other posterolateral injuries - XR (varus stress), MRI confirms injury -- very sensitive and may overcall - arcuate sign: avulsion of proximal fibular head (w LCL inj) Meniscus injuries - degenerative (inc common w age, oft asx) vs non - non-degenerative: oft young athletic, no OA/DJD, usually injury, poss pop, lock/catch, some rest ice NSAID activity change but oft surg - arthroscopy some fix some partial meniscectomy - chronicity, orientation, location tear - vascular supply from periphery (healing will not happen in central) - degenerative: oft OA, +- trauma, arthroscopy adds nothing (tho does not include pts with large tears or those w mech sx), all try non-op 1st, probably not in really degenerated Patella dislocations - almost always laterally out of groove - traumatic usually nl knee after contact, patella pushed laterally out of trochlear groove - atruamatic: underlying abnl like high patella, flat trochlear groove or lateral positioning of tibial tubercle - distal most fibers of vastus medialis / VMO = medial force, keeping patella centered - length patellar tendon, bony anatomy groove, medial patellofemoral ligament, and VMO musculature - medial patellofemoral ligament MPFL key for lateral translation - attached border to medial femoral condyle - to dislocate patella this must be torn - surg include recontrustion MPFL - patella alta = high patella: predisposes to dislocation, measured by ratio of the height of the patella above the tibia to the patellar length (Caton-Deschamps index) - trochlear dysplasia = flattening of trochlear groove predisposes - can usually reduce by straightening knee - patellar apprehension after redution: fear of re-dislocation with lateral translation of patella - reduction, brace with lateral patellar buttress to prevent lateral recurrent dislocation, imaging XR, MRI - r/o fx and eval for osteochondral injury w loose bodies - often if 1st time if no sig osteochondral or loose bodies - nonsurg - surg : recurrent or those other 2

Understanding Fractures: Clinical, Radiologic, Basic Science Describe a displaced vs nondisplaced fx ID comminuted vs simple fx. Describe mech of injury (low or hi E) for both List and apply ***

Bone 2 main fns: - skeletal stability/frame - Ca bank Fx: loss of mechanical integrity and continuity Inspect: loss contour, opening/wound/blister/burn/dysvascularity palpate: crepitation/turgor motor/sensory/vascular eval above/below joint imaging/xr Xr: orthogonal views - entire bone, joit above and below epiphysis really only in skeletally immature

What's a sesamoid bone?

Bone within a tendon

What to watch out for on an x-ray

Bone: - trabecular lines intact? (lattices of bone spicules aligned in direction of load) - cortex disrupted? - joint located? narrowed/disrupted? Soft tissue planes - blurred? - fullness/fluid collection? - calcifications? (can develop inside soft tissue tumor, clue for tumor but not dx) (- gas could indicate severe infection)

Describe and demonstrate knowledge of the origin of the brachial plexus and its general function in the upper limb

Brachial plexus: - anterior rami *C5-T1* - innervates UE - 5 terminal branches

Where does posterior tibial a run?

Branches from popliteal a (anterior tibial a thru interosseous membrane) Gives off fibular a (most of lateral leg) Courses around medial ankle to enter plantar foot

What are the two structural subdivisions of the nervous system?

Central nervous system (CNS) - brain + spinal cord - coordinate signals Peripheral nervous system (PNS) - cranial nn, spinal nn, and ganglia - conduct impulses (to and from CNS) - 12 pr cranial nn (11 from brain); 31 pr spinal nn (from spinal cord) - C8 (7 vertebrae, 1 superior), T12 (starting here, nn all exit below vertebrae #), L5, S5, C1

The greater occipital n and suboccipital n are named dorsal primary rami of which spinal nerves, respectively? C3, C1 C2, C1 C1, C2 C1, C3 C2, C3

C1 = suboccipital n (which is with vertebral a in suboccipital triangle; provides motor innervation to muscles of suboccipital triangle) C2 = greater occipital n (provides sensory to back of head)

Think about dermatomes of the upper limb

C5: upper lateral arm (abduction UE) C6: palmar thumb (flexion forearm) C7: pad index finger (extension forearm) C8: pad pinky finger (flexion fingers) T1: skin on medial aspect elbow (abduction/adduction index/middle/ring fingers)

How many vertebrae are there?

C7, T12, L5, S5 (fused), and C4 (fused) 33 in kids, 26 in adults

What is the correct grouping of structures that runs through the adductor canal? A. obturator a, obturator v, femoral n B. femoral a, femoral v, femoral n C. femoral a, femoral v, saphenous n D. popliteal a, popliteal v, sciatic n E. obturator a, obturator v, obturator n

C: femoral a, femoral v, saphenous n

Which of the following ligaments is not a part of the syndesmosis complex? - interosseous membrane - anterior inferior tibiofibular ligament - posterior inferior tibiofibular ligament - calcaneofibular ligament

Calcaneofibular ligament is not syndesmosis ligament but lateral

What's the adductor canal?

Canal bordered by - Sartorius - Adductor longus - Vastus medialis Contains - Fem a, fem V, SAPHENOUS N (not fem N) Adductor hiatus (at end, within add magnus) allows fem a/v to move posteriorly, while saphenous n stays anterior

Which of these might be considered as a potential therapeutic to treat osteoporosis? IGF-1 antagonist Sclerostin TNFa Cathepsin K inhibitor

Cathepsin K inhibitor: would permit formation of osteoclasts but inhibit their ability to resorb bone.

Absolute indication for surgical intervention is pts with cervical spondylotic radiculopathy is: - failure after 4-6 wks conservative care - burning pain referrred to abdomen - cauda equina syndrome - chronic pain

Cauda equina syndrome = surgical emergency

What's the endosteum?

Cells of stroma of marrow or resting osteoblasts = line cortical haversian canals = inside all cavities, lines all trabeculae ~ b/t marrow cavity and compact bone

Describe the anatomical features of a typical vertebra. Describe the characteristic features that distinguish vertebrae in the cervical, thoracic, lumbar, and sacral regions. Describe the range of movements of the vertebral column as a whole. Then, describe the regional anatomy of the vertebral column, i.e., the structures and the movements allowed in each region. Explain what makes spinal injury stable or unstable. Describe the anatomy of the intervertebral facet joints and the intervertebral disks. Explain the role of the disks in weight-bearing and give examples of lesions to the disks and the consequence of disk lesion to the spinal nerve, the nerve roots, and the spinal cord itself. Identify the extrinsic and the intrinsic muscle groups of the back. Demonstrate the surface anatomy of these muscles and their role in stabilizing and moving the vertebral column. Describe the anatomical basis of back pain. Describe the anatomical relationships of the meninges to the spinal cord, and the ventral and dorsal roots, particularly in relation to cord and root compression. Describe the anatomy of lumbar puncture, and placement of epidural and subdural injections.

Child: 33 vertebrae Adult: 26 vertebrae (fuse w/age) C7, T12, L5, S5 (fused), C4 (fused) 1ry curvatures - T, S = kyphotic 2ry curvatures (after birth) - C, L = lordotic lordosis - excessive anterior tild pelvis kyphosis - excessive anterior curve T, elderly osteoporosis compression fx on anterior, hunched scoliosis: lateral C curve, T region vertebrae: body, posterior vertebral arch - often pedicle, transverse process, lamina, spinous process, spinal canal, sup/inf articular processes, sup/inf vertebral notches - body smallest in C-spine, largest in L C vertebrae: smallest, small body, relatively large spinal canal, foramen in transverse processes = tranverse foramen (for vertebral a) C1 = atlas, articular surfaces for occipital condyles skull = atlanto-occipital joint (nod head up and down); no vertebral body or spinous process but anterior arch and tubercle and posterior arch and tubercle C2 = axis; dens/odontoid process = vertical projection of bone - makes atlanto-axial joint for shaking head no - transverse ligament of atlas holds dens to c1 bifid spinous process = C certebrae superior articular processes show how orientation changes based on level of c-spine T: more heart-shaped body, long slender inferiorly pointing spinous processes - costal facets L: large ovoid bodies, shorter spinous processes which are more horizontally oriented spinus processes of sacrum = median sacral crest (midline) holes on sacrum = anterior and posterior sacral foramina craniovertebral joints = joints that attach head to c1 and c2 = atlanto-occipital and atlanto-axial atlanto-occipital joints: b/t occipital bone skull and atlas c1 = nodding head = synovial atlanto-axial = 3 joints b/t atlas c1 and axis c2, lateral atlanto-axial joints bt lateral masses of C1 and superior articular facets C2, 1 median atlanto-axial joint b/t dens C2 and anterior arch C1 cruciate ligament (transverse holds dens, longitudinal sup and inf, and alar diagonally) tectorial membrane = superior extension of posterior longitudinal ligament covering alar and transverse ligaments joints of spine: usually 6 (4 synovial, 2 symphysis) synovial joints = zygapopphysial joints/facet joints of inferior and superior articular facets symphysis joints = b/t adjacent vertebral bodies movements of spine: flexion, extension, lateral flexion, rotation, circumduction spine ligaments: (continuous? segmental? what motion prevented?) - anterior longitudinal: continuous along anterior vertebral bodies from base skull to anterior sacrum, prevents hyperextension* - posterior longitudinal: continuous, prevents hyperflexion, much thinner than anterior - ligamenta flava - segmental from lamina to lamina, prevent hyperflexion - interspinous ligament: segmental from spinous process to next, prevent hyperflexion (superficial to LF) - supraspinous ligament: continuously along tips cpinsous processes C7-sacrum, prevent hyperflexion - ligamentum nuchae: posterior thickening of supraspinous ligament from C7 to skull. prevent hyperflexion AND site for muscle attachment pars interarticularis: common place for fx; part of posterior arch vertebrae = region posterior to transverse processes and superior articular process and anterior to inferior articular processes and spinous process stress fx here = spondylolysis - oft in adolescents of those in repetitive activities - scotty dog w collar = fx line spondylolisthesis - anterior shift of vertebral body, typically this and spondylolysis in L-spine esp at L5

You can see atrophy: - left: normal muscle contours around scapula - right: prominent scapular spine due to supraspinatus and infraspinatus atrophy (harder with deeper muscle groups, esp in shoulder and hip joint) Why atrophy?

Chronic disuse Chronic tendon tear Neurogenic causes (nerve palsy/compression syndrome; spinal/disc disease; neurogenic disease)

Shin splints = ?

Commonly used to describe leg pain Causes: - typically overuse - strain tibialis anterior m and/or tibialis posterior m - tears/inflammation tibial periosteum May -> stress fx if not treated properly

Incomplete (mostly children): - bowing - torus/buckle (of cortex) - greenstick (fx 1 cortex) Complete - simple = clean line - comminuted = shatter-y

Complete vs incomplete fx types

How do meniscus tears typically occur? What's the "unhappy triad"?

Compression & rotation Usually medial Common w/ MCL injury ACL + MCL + medial meniscus

What does the anterior root do?

Contains motor neuron fibers

What's the metaphysis?

Region b/t epiphysis and diaphysis

What's the periosteum?

Covers outer surface bone Vascularized, has osteoprogenitor cells Outer fibrous portion (need attachment muscles), inner osteogenic cells (osteoblasts, clasts)

List components of nl synovial fluid: Match the synovial fluid finding with the pathology. Crystals WBC > 50k Clear pale yellow fluid Infection Gout/pseudogout Nl

Crystals = gout/pseudogout WBC > 50k = infection Clear pale yellow fluid = Nl

Where are PT and DP pulses?

DP: foot PT: behind med mall

Surgery for lumbar spinal stenosis without instability typically consists of: - decompression with fusion - vertebrectomy - epidural steroid injections - decompression with laminectomy alone

Decompression with laminectomy alone - if surg for L-spine stenosis w/o instability Laminectomy will decompress the spinal stenosis

What branches off the femoral a in the thigh? What does it turn into?

Deep a of thigh branches off Medial and lateral circumflex of femoral a branch of from this very proximally Passes thru adductor hiatus, -> popliteal a lateral circumflex femoral: 3 branches deep to rectus femoris = ascending, descending and transverse branches

Transversospinales mm - location - attachments - action - innervation

Deep back, deep to erector spinae = semispinalis, multifidus, rotatores mm - connect and stabilize vertebrae segmentally semispinalis: GREAT EXTENSOR NECK - palpable posteriorly at midline skull just below external occipital protuberance - capitis, cervicis, thoracis - *great extensor neck*, rotate head - capitis: transverse p upper T and lower C to occipital bone; cervicis and thoracis on transverse processes T to spinous processes upper T/lower C and C2-C5 - capitis more superficial than cervicis and thoracis - attachment cervicis on spinous process C2 = impt landmark for suboccipital mm multifidus: transverse process to spinous process every 2-4 vertebrae, most developed in L region, often deficient in those with low back pain; extend spine/rotate spine to opposite side rotatores: deepest, transverse process to spinous process every 1-2 vertebrae, same actions as m

Splenius m - location - attachments - action - innervation

Deep back, just deep to trapezius & levator scapulae, running superolaterally Splenius capitis attaches to mastoid process and superior nuchal line Splenius cervicis attaches to transverse processes C1-C3 (from T spine ish) Bilateral contraction -> head/neck extension Unilateral contraction -> head/neck rotation on same side posterior rami

Gemellus superior m. - group/location? - origin? - insertion? - action? - innervation?

Deep gluteal m O: Ischial spine & tuberosity I: Trochanteric fossa w/obturator internus tendon Hip external rotation N to obturator internus

Quadratus femoris m - group/location? - origin? - insertion? - action? - innervation?

Deep gluteal m O: Ischial tuberosity I: Intertrochanteric crest Hip external rotation N to quadratus femoris

Gemellus inferior m. - group/location? - origin? - insertion? - action? - innervation?

Deep gluteal m O: Ischial tuberosity I: Trochanteric fossa w/obturator internus tendon Hip external rotation N to quadratus femoris

Obturator internus m. - group/location? - origin? - insertion? - action? - innervation?

Deep gluteal m O: Obturator membrane I: Greater trochanter Hip external rotation N to obturator internus (going to see tendon; above = gemellus superior which piggybacks on to attach to greater trochanter)

Flexor hallucis longus m: - group/location? - origin? - insertion? - action? - innervation?

Deep posterior leg - most lateral of deep posterior leg - originates lowest of group - relatively large O: posterior fibular and interosseous membrane I: distal phalanx great toe Flexes great toe (also plantar flexion, inversion) Tibial n

Flexor digitorum longus m: - group/location? - origin? - insertion? - action? - innervation?

Deep posterior leg - most medial of deep posterior leg O: posterior surface tibia I: distal phalanges of lateral 4 toes (plantar surface) Flexes lateral 4 toes (also plantar flexion, inversion) Tibial n

Popliteus m: - group/location? - origin? - insertion? - action? - innervation? - vasculature?

Deep posterior leg - most superior of deep group = floor of popliteal fossa - does not cross ankle - runs inferomedially (oblique) O: lateral femoral condyle (almost toward epicondyle) I: posterior surface proximal tibia (broadly) Medially rotates tibia; "unlocks knee" from standing Tibial n ??

Tibialis posterior m: - group/location? - origin? - insertion? - action? - innervation?

Deep posterior leg - resting on interosseous membrane O: Posterior tibia, interosseous membrane, fibula I: Navicular tuberosity, medial cuneiform Inversion, plantarflexion Helps support medial arch Tibial n

Match the following meniscal tears to the best association Degenerative meniscus tears Traumatic meniscus tears Peripheral meniscus tears Central meniscus tears Irreperable, occur more commonly as pts age, often respond to nonoperative mangement Often require surgery, generally occur in knees without significant underlying osteoarthritis. May be either central or peripheral May be amenable to repair Generally irreparable, often require partial meniscetomy

Degenerative meniscus tears: Irreperable, occur more commonly as pts age, often respond to nonoperative mangement Traumatic meniscus tears: Often require surgery, generally occur in knees without significant underlying osteoarthritis. May be either central or peripheral Peripheral meniscus tears: May be amenable to repair Central meniscus tears: Generally irreparable, often require partial meniscetomy

List the medial ankle ligaments

Deltoid aka - posterior tibiotalar - tibiocalcaneal - tibionavicular - anterior tibiotalar

How do you describe alignment of angulated displaced fractures?

Describe apex of fx: - apex pointing medially = medial angulation - apex pointing laterally = lateral angulation

transverse = horizontally across oblique = diagonally across spiral = waving up intra-articular = in joint space segmental ? longitudinal = vertically up

Describe the direction of fx lines

How do you describe displaced translated fractures?

Describe the fragment that is distal to the fx - medial? lateral? (find landmark that lets you tell, like fibula)

Place the following steps of endochondral ossification in the correct order: Retention of hyaline cartilage of articular cartilage and the epiphyseal plate Development of the primary ossification ctr in the diaphysis Epiphyseal plates ossify and form the epiphyseal lines Development of the 2ry ossification ctrs Bone collar forms around diaphysis and cartilage of shaft begins to calcify Development of the fetal cartilage model

Development of the fetal cartilage model Bone collar forms around diaphysis and cartilage of shaft begins to calcify Development of the primary ossification ctr in the diaphysis Development of the 2ry ossification ctrs Retention of hyaline cartilage of articular cartilage and the epiphyseal plate Epiphyseal plates ossify and form the epiphyseal lines

How do chondrocytes receive nutrients?

Diffusion

What do you need to describe for dislocations/what's pertinent?

Direction: location of body part distal to dislocation If ball/socket joints (shoulder/hip), must know if ball anterior/posterior to socket, or even superior/inferior Must know position! Pressure on NV structures?

Define dislocation vs subluxation

Dislocation: occurs when the two articular surfaces of a joint are no longer in contact; puts more stress on surrounding soft tissues and NV structures and is more likely to cut off blood supply to 1 of the joint surfaces bc of the severe pressure that can be put on the surrounding vessels Subluxation: occurs when there is only partial contact between articular surfaces. There is still disruption of the nl joint alignment, but not as serious as dislocation

The anterior tibial a continues distally on the dorsum of the foot as what artery? Lateral plantar a Medial plantar a Posterior tibial a Popliteal a Dorsalis pedis a

Dorsalis pedis a

What does the anterior leg do? What innervates the anterior leg? What supplies blood to the anterior leg?

Dorsiflexion Deep fibular n Anterior tibial a

Extensor hallucis brevis - group/location? - origin? - insertion? - action? - innervation?

Dorsum foot O: Superolateral surface calcaneus I: Proximal phalanx great toe Extend metatarsophalangeal joint of great toe Deep fibular n

Extensor digitorum brevis - group/location? - origin? - insertion? - action? - innervation?

Dorsum foot O: Superolateral surface of calcaneus I: Tendons EDL (extensor digitorum longus) and extensor hoods Extension toes 2-4 Deep fibular n

Name and describe the 3 meninges of the spinal cord

Dura mater: outermost, thickest/strongest Arachnoid mater: attached to inner dura mater, not seen Pia mater: directly on top of spinal cord and brain b/t pia and arachnoid = subaracnoid space with CSF denticulate ligament = lateral extensions of pia mater which laterally anchor spinal cord to dura mater Spinal cord inside vertebral foramen from foramen magnum to ~L2 vertebral column lengthens faster than spinal cord in development dural sac extends to sacrum ~S2 end cord at L2 = conus medullaris cauda equina = roots at end most distal anchor spinal cord = filum terminale = distal extent of pia mater that continues off conus medullaris and attaches to coccyx

Which of the following mechanisms is most likely to lead to tendon rupture? Concentric loading Eccentric loading

Eccentric loading

Which of the following is not a safety concern for anti-TNF therapy in RA or JIA? Histoplasmosis infection Elevated cholesterol Tuberculosis infection Demyelination

Elevated cholesterol

What's the epiphysis?

Ends of long bone Lots spongy/cancellous bone surrounded by compact bone

Recognize the anatomic reasons why bone and joint infections occur List the main organisms that are responsible for septic arthritis in children and adults Recognize the clinical signs of a joint infection Describe the pathophysiology of bacterial infections of joints and bone List three factors that contribute to diabetic joint infections Describe the general treatment strategy for joint infections

Epidemiology: - hematogenous spread (most common) - direct inoculation (like trauma) - contiguous spread - hospital-acquired (nosocomial) Nosocomial: - most common complication affecting hospitalized pts - 5-10% of all admitted pts - surgical site infection 3rd most common type, UTI, lines/ports; 29% MRSA SSI: 1. Superficial incisional infection; 2. Deep incisional infection (to investing fascia); 3. Organ space infection; 4. Defined as within 30 days surgery or 1 year if implant placed Most prevalent locations: - bone (osteomyelitis), native joint or prosthetic joint (septic arthritis), diabetic ulcers - check multiorgan PEx: - temp (compare sides), pain (w micromotion!), swelling (permeability), redness (blanching blood flow) Lab: - CBC (white), ESR (stays up), CRP (acute phase elevate early and respond early) Tx: - Tx MSK infection = surgical emergency: irrigation & debridement, then 6-8 wks IV abx Osteomyelitis: - bone and medullary space - 80% staph aureus, 30-50% MRSA - varying severity - lab: ESR >70 suggests, systemic WBC may be nl, need bone biopsy - tortuous venous sinusoids at metaphyses -> acute hematogenous osteomyelitis - hematogenous seeding, direct inoculation, contiguous spread all routes; hematogenous 85% in children, post-trauma in adults usually - risks: penetrating trauma, IV drug abuse, DM, immunocompromise, vascular insufficiency, open fx - in children see strep, pyogenes (staph aureus all around; infants group b strep & e coli, children pyogenes, elderly gram neg rods, IV device candida, IVDU p aeruginosa) - DM ulcer (*gram -, anaerobes), human bite (*bacteroides, *elkenella), dog/cat bite (paseturella multocida), exposure to water (salt fibrio vulnificus, fresh aeromonas species, fish/shellfish mycobacterium marinum) Native Joint Infection: - more common in rheumatoid joint - 50% lose fn - risk factors: chronic systemic disease, immunocompromise, trauma, IVDU, endocarditis, DM - red, swollen, painful joint, *pain with micromotion (diff from trauma or OA) - septic arthritic caused by bacterial invasion of synovial space - host responds with acute inflammatory reaction and phagocytosis by PMHs - toxins and enzymes released by bacteria and stimulated T cells -> destruction cartilage, LOF - Labs: ^ESR, ^CRP, systemic WBC may be nl, *synovial fluid aspiration* most impt - for WBC ct, gram stain, culture, crystals (arthrocentesis) - WBC ~75,000+ with >90% neutrophils - usually hematogenous, can be direct inoculation from trauma/surg, contiguous - MEDICAL EMERGENCY: needs surgical debridement and usually 6-8 wk IV abx - in septic arthritis (<5 step, flu; Neisseria gonorrhoeae common in sex active, 60+/IVDU/immunocompromised incl gram neg bacillli; prosthetic joint = coag-neg staph, P acnes if indolent; SCD salmonella risk; S aureus for all) Prosthetic joint infection: incidence <2%, 60% = direct inoculation at time surg, most others *hematogenous seeding (bacteremia) - may not be as painful as native joint - Lab: ESR, CRP, WBC (>6000 suggests infection), aspiration - host factors: older, poor nutrition, inflam joint disease, DM, obesity, remote infection, HIV - revision surg w increased risk - common orgs: coag-neg staph, S aureus, mix -- no org ID'd in ~10% - *** Tx protocol? Diabetic infections - infected foot ulcer = 25% admissions for DM pts, neuropathy = common predisposing factor, also poor vasc and nutrition - leading cause LE amputation - 25-50% -> minor (foot-sparing amputation) - 10-30% with ulcer -> amputation - inc mortality, precedes 2/3 amputations - new approaches: revascularization (angioplasty, stenting, bypass grafting (need early recognition, aggressive surgical drainage of sepsis then revasc to maximally salvage), poss recombinant G-CSF, HBO - most common locations for musculoskeletal infections include bone (osteomyelitis) and joint - main tx = H&P (pain, swelling, erythema, warmth), lab (CBC, ESR, CRP), surgical intervantion followed by pathogen specific abx - routes include hematogenous (due to bacterial seeding and vascular anatomy), direct inoculation (trauma, surg), and contiguous spread - most common org = staph aureus

ID the regional zones and describe the function of these zones in epiphyseal cartilage and their role in bone formation.

Epiphyseal plate can be divided into different zones 1st zone: next to epiphysis, last zone: closest to diaphysis Zone 1: Resting cartilage Zone 2: Proliferating cartilage Zone 3: Hypertrophic cartilage Zone 4: Calcified cartilage Zone 5: Ossification 1: Resting/reserve - closest to epiphysis - chondrocytes alone/v small groups - no active matrix production, no mitosis 2: Proliferation/Proliferating - chondrocytes in lacunae in mitosis, stacking up in line with long axis bone = isogenous groups = actively producing matrix - pushes epiphysis away from diaphysis -> bone lengthening 3: Hypertrophy/Hypertrophic - chondrocytes grow, cytoplasms accumulate glycogen, matrix is compressed/thinned due to cellular expansion 4: Calcified - form hydroxyapatite crystals -> basophilic staining calcified cartilage matrix - chondrocytes can no longer receive nutrients needed via diffusion, die 5: Ossification/Resorption/Remodeling - direct contact with marrow tissue, right next to diaphysis - small blood vessels, blood cells, osteoprogenitor cells, osteoclasts enter into spaces previously occupied by chondrocytes - 1ry/woven bone laid down by osteoblasts onto leftover calcified cartilage spicules -> eosinophilic - eventually much eroded by osteoclasts -> 2ry bone/more space to medullary cavity

Which of these soluble factors is inhibitory to OC activity? TNF-a RANKL M-CSF Estrogen

Estrogen is inhibitory to OCs and its loss in older women promotes bone resorption

When bilaterally contracting, the erector spinae muscle group acts to ___ the vertebral column; when acting unilaterally this muscle group acts to ____. Flex; laterally flex to the contralateral (opposite) side Extend; laterally flex to the ipsilateral (same) side Extend; has no add'l effect on the vertebral column Flex; laterally flex to the ipsilateral (same) side Extend; laterally flex to the contralateral (opposite) side

Extend; laterally flex to the ipsilateral (same) side Erector spinae mm responsible for extension (bilaterally) and lateral flexion (unilaterally)

What's the patellar retinacula?

Extensions of aponeuroses (fascia) from medial and lateral vasti mm. that pass on each side of the patella Patellofemoral articulation alignment (attach margins of patella and patellar ligament anteriorly, collateral ligaments posteriorly, and tibial condyles distally; form anteromedial and anterolateral portions of fibrous capsule of knee)

Which muscles are on the dorsum of the foot? What innervates them?

Extensor digitorum brevis Extensor hallucis brevis Deep fibular n

List the deep back muscles What are they all innervated by?

Extensors and rotators of head and neck - splenius capitis, cervicis Extensors and rotators of vertebral column - erector spinae gp, transversospinales gp Short segment muscles - interspinales, intertransversari Posterior (dorsal primary) rami

Describe and demonstrate the origin, course and distribution of the major arteries and their branches that supply the lower limb Demonstrate the locations at which the femoral and popliteal arteries can be felt

External iliac a -> femoral a (starts as crosses under inguinal ligament) -> deep a of thigh branches in proximal thigh - lateral and medial femoral circumflex aa typically branch from deep a thigh *femoral a moves to posterior aspect passes thru adductor hiatus, becomes *popliteal a splits to *posterior and *anterior tibial aa posterior tibial aa gives off fibular a posterior tibial aa courses posterior to medial malleolus (pulse)-> medial and lateral plantar aa anterior tibial a thru interosseous membrane -> anterior cmpt leg crosses ankle, becomes dorsalis pedis a (pulse) superior and inferior gluteal aa Palpate femoral a @femoral triangle Palpate popliteal a @popliteal fossa (both hands holding knee, bent)

An intertrochanteric hip fx disrupts the blood flow to the femoral head, especially if the fx is displaced: T/F

F

Experts agree that disability is incompatible with health: T/F

F

If you took an x-ray of nothing, the film would be bright white: T/F

F

It it not important to differentiate b/t an acute MSK injury and a chronic injury: T/F

F

Water is bright on T1-weighted MRI images: T/F

F

When evaluating a pt with a MSK complaint, focus on their joint complaints. Don't spend time on the PMH as that is not relevant and you can leave that to the pt's PCP: T/F

F

When evaluating any joint in the MSK system - one radiographic view is adequate. T/F

F

You can easily detect bone infection in radiographs in the early stages: T/F

F

As colchicine is indicated only for the treatment of acute gout, patients with chronic gout are normally not treated with colchicine between gouty episodes, especially if they are receiving the chronic gout medication allopurinol. T/F

F Colchicine is a first-line tx for acute gout. Allopurinol, a chronic gout medication, is given b/t gouty episodes for pts with chronic gout. As allopurinol can precipitate an acute gout attack, colchicine should be given to all pts receiving allopurinol.

An active 35 y/o M acutely tears his pectoralis major when weight lifting. He tells you the Arnold Classic is coming up in 3 mos. He asks - can I rehab this and have surgery in 3 mos - and expect the same outcome. You should tell him - no worries - there is no difference in the repair and outcomes if you do the surgery now or wait even up to 6 mos T/F

F Any traumatic tendon rupture anywhere in body will atrophy/scar down/retract and become very very difficult to fix if wait too long. For pec major rupture, if you wait 3-6 mos to address it, you might not be able to repair it

Chronic, attritional tears of tendons are generally treated with prompt surgery to prevent further tendon degeneration T/F

F First line of tx for chronic attritional tears, as opposed to acute traumatic tendon tears, is nonoperative management

Supraspinatus = most commonly injured RTC tendon and injury to this tendon affects ability of pt to externally rotate arm T/F

F Infraspinatus, teres minor responsible for external rotation. Supraspinatus = fwd elevation

Pts with an untreated type III AC separation (complete rupture AC and CC ligaments) will have a slight permanent loss of active elevation of the shoulder, but it should not be symptomatic T/F

F Instability of coracoclavicular joint has no effect on forward elevation of shoulder

Intra-articular ligaments have greater healing potential than extra-articular ligaments because they are nourished by synovial fluid inside the joint. T/F

F Intra-articular ligaments have much lower innate healing potential because the intra-articular environment does not promote healing

The ACL has a higher healing potential than the MCL because it is intra-articular and is nourished by synovial fluid: T/F

F Intra-articular ligaments such as the ACL have poorer healing capacity. The intra-articular environment is quite hostile to ligament healing. Extra-articular ligaments such as the MCL have high healing potential

The majority of RTC tears in pts >60 are traumatic in nature. T/F

F Most pts in 50s, 60s have degenerative tears of the RTC.

An athlete with a complete separation of the AC joint (AC and CC ligaments torn) should urgently proceed with surgery: T/F

F Nearly always try rehab if grade III AC. Many do well w/o surg. Unlike traumatic tendon tears (short window time for good repair). Can't repair CC ligaments - (always reconstruct with some donor graft so surg is the same immediately vs 1 yr later.)

Complete patellar tendon ruptures can generally be treated nonoperatively without significant functional loss T/F

F Nonoperative mgmt generally yields poor functional outcome and is reserved for poor surgical candidates

Urgent surgical intervention is common for ruptures of the long head of the biceps T/F

F Ruptures of LHB are common. LHB has almost no effect on strength of shoulder, so main ramification of tear is popeye deformity and most of these tears are degenerative so no surgical fix

An active 50 y/o pt presents with a large, acute, traumatic RTC tear after falling down the stairs. Tx should always start with PT T/F

F Treat acute/traumatic/large RTC tears aggressively, often proceed quickly to surgery or the tendon can atrophy/retract and scar down -> unfixable Degenerative tears start with rehab/PT

Inflammatory cells are present in lateral epicondylitis T/F

F tendinosis = degenerative condition of tendon so no inflammatory cells bc this is not tendinitis (in lateral epicondylitis)

The Americans with Disabilities Act only applies to people who are born with a disability: T/F

F:

trigger fingers or "stenosing tenosynovitis" is most commonly seen in the finger extensors: T/F

F: trigger fingers occur due to discrepancy in flexor tendons, vs A1s pulleys: the flexor tendons thus get caught on the pulley when a pt flexes their finger and they have trouble getting them back out to extension

The majority of the dry weight of tendons is type II collagen: T/F

F: 86% of the dry weight of tendons is type I collagen

Research has shown that disability confers better health due to improved access to healthcare: T/F

F: disparities, barriers, seek more healthcare but have greater unmet needs in nonelderly with disabilities, 25% difficulty finding professional who understood their disability

Is this an accurate description of a fracture pattern? "This is an AP view of the femur. There is a spiral fracture of the diaphysis, it is non-displaced." T/F

F: need to describe if pt skeletally mature or not

The radial artery courses down the medial forearm: T/F

False

Reloxifene (prototypical SERM) acts at estrogen Rs to inhibit bone resorption and hyperplasia of breast and endometrial tissue. T/F

False SERMs (selective estrogen R modulators) like raloxifene, interact with estrogen Rs to inhibit bone resorption WITHOUT stimulating estrogen breast or endometrial Rs (inc risk thromboembolism)

Bisphosphonates (alendronate, pamidronate) inhibit bone resorption via regulation of gene transcription via the vit D R. T/F

False. Bisphosphonates (alendronate, pamidronate) inhibit bone resorption via suppression of osteoclastic activity by inhibiting farnesyl pyrophosphate synthesis; Calcitriol acts via regulation of gene transcription via the vit D R

Please pick out the features of benign tumors: - blurred borders of the tumor - cortex intact - periosteal rxn - sharply defined borders of the tumor - no periosteal rxn - cortex disrupted - soft tissue masses - matrix inside lesion

Features of benign tumors: - cortex intact - sharply defined borders of the tumor - no periosteal rxn Features of malignant tumors: - blurred borders of the tumor - periosteal rxn - cortex disrupted - soft tissue masses - matrix inside lesion

What nerve supplies motor innervation to the anterior compartment of the thigh? Where can this be found? How does this n terminate?

Femoral n (L2-L4) Deep to inguinal ligament Terminates as *saphenous n (sensory to medial leg)

What are the contents of the femoral triangle?

Femoral n. + Femoral sheath = inguinal lymph nodes + Femoral vein + Femoral a NAVL = lateral to medial (saphenous vein enters femoral vein thru opening in fascia within triangle)

What are common injuries to the hip?

Femoral neck fx (osteoporotic, stress) (common hip fx sites are neck, intertrochanteric, subtrochanteric) Osteoarthritis Dislocation (posterior most common; limb appears shorter & internally rotated; not seen much in MVC but with loading on flexed hip like fall)

Where does the tibial n run?

From sciatic n, which splits at superficial popliteal fossa area Centrally, b/t deep and superficial posterior compartments of leg Around medial ankle Onto foot

What muscles make up the superficial group of the posterior compartment of the leg?

Gastrocnemius m Soleus m Plantaris m

What inserts into the trochanteric fossa with the obturator internus tendon?

Gemellus superior m. Obturator internus m. Gemellus inferior m.

Describe what's happening with bowleg and knock-knee.

Genu varum = bowleg - inc weight onto medial knee - LCL stretched Genu valgum = knock-knee - weight on lateral knee - MCL stretched

What are the superficial muscles of the gluteal region? What is their function?

Gluteus maximus m. Gluteus medius m. Gluteus minimus m. Extend & abduct hip

Tensor fasciae latae m. shares innervation with..?

Gluteus medius and gluteus minimus mm.

What are your hip abductors? Where do they insert? How are they important in gait?

Gluteus medius and minimus Greater trochanter Hold pelvis level when contralateral foot is off ground. Firing puts compression across hip joint

Gout can likely be associated with all except one of the following: reversible liver damage (hepatitis) uric acid crystallization leading to renal damage arthralgia hyperuricemia uric acid crystals in the joints

Gout is associated with hyperuricemia (high levels of uric acid in the blood), leading to formation of acid crystals. These can cause significant problems in the joints (arthralgia, crystals) and kidneys (renal damage) Not associated with reversible liver damage/hepatitis

Hallux = ?

Great toe

Where is true hip pain? What must you do with pt reporting hip pain?

Groin Where hurt? What makes hurt? What makes better? May grab low back or lateral aspect hip over trochanter Back (like spinal stenosis) can present as hip pain Always examine spine when eval pt for hip or knee pathology!

***A 33 y.o. pt is in an MVA and c/o arm pain and inability to extend elbow. Without knowing any other part of his exam at this point what are your possible options for why he can't extend his elbow? (Pick all correct) He has a brachioradialis rupture He has an injury to the radial n in the spiral groove He has a high injury to the radial n He has an acute disc herniation affecting the C5 nerve root He has a triceps tendon rupture Weakness from disuse

He has a high injury to the radial n He has a triceps tendon rupture Triceps = sole/major extender of elbow, so rupture of tendon would eliminate the ability to extend the elbow. High radial nerve injury would affect the triceps as the radial nerve sends its branch to innervate the triceps very proximal. When the radial nerve is in the spiral groove, it has already innervated the triceps, so injury here would not affect triceps fn. Just had MVA indicates acute not chronic C5 does not affect elbow extension but elbow flexion.

Healed ligaments are generally __ than their pre-injured state. Prettier Smaller Stronger Weaker

Healed tendons are generally larger, but weaker than the same ligament pre-injury

Using the following terms, construct a case example using the ICF framework: Health Condition Impairment Activity limitation Participation restriction blind voting with a secret ballot diabetes reading ballot to vote

Health condition = diabetes = illness, injury, physical or mental disorder Impairment = blind Activity limitation = reading ballot to vote Participation restrition = voting with secret ballot

epiphysis top, diaphysis bottom resting zone/reserve proliferation (stacked coins, active mitosis and matrix production -> lengthening) hypertrophy (compress matrix) calcification ossification

Histological image epiphyseal plate. ID zones

Describe the developmental origins of musculoskeletal birth defects What's Holt-Oram Syndrome? Describe OI. What are brachydactyly, syndactyly, polydactyly, and cleft foot?

Holt-Oram Syndrome: broad spectrum of upper limb abnl and <3 defects - TBX5 mutation Osteogenesis Imperfecta (OI): - shortening, bowing and hypomineralization of long bones of limbs; broad range; blue sclera -> fx (usually AD in COL1A1 or COL1A2 which -> collagen I) Brachydactyly = short digits Syndactyly = fused digits (mesenchyme apoptosis between digits fails) Polydactyly = extra digits (extra digits often lack muscle connection, usually bilateral) Cleft foot = 3rd metacarpal missing, rest toes fused (experimental duplication ZPA -> mirror image digit formation)

Which class of drugs act via GPCRs? Hormones (Teriparatide, Calcitonin) Ca R Agonist (cinacalcet) RANKL Inhibitors (Denosumab) Bisphosphonates

Hormones (Teriparatide, Calcitonin)

ID and describe the morphological and functional differences between hyaline, elastic and fibrocartilages in histological images

Hyaline cartilage - most common - ECM = 75% H2O, proteoglycans, hyaluronic acid, type II collagen - @articular surfaces (no perichondrium but instead synovial fluid), nose, larynx, tracheal rings, epiphyseal plates, fetal bone models (lots pressure) - fewer chondrocytes in lacuna than elastic - huge isogenous groups (vs elastic) - perichondrium mostly present - looks translucent/blue-white appearance (fresh) / basophilic matrix and indiscernible collagen fibers Elastic cartilage - similar to hyaline + some elastic fibers - more chondrocytes in lacuna than hyaline - very small isogenous groups (comp to elastic) - @auricle/pinna, auditory canal, auditory tube/pharyngotympanic tube, epiglottis - perichondrium present - yellowish / prominent elastic fibers if special stain Fibrocartilage - ECM: collagen I, less proteoglycans - NO perichondrium - @intervertebral discs, pubic symphysis, major tendon-bone anchorages (lots pulling stress) - tissue b/t dense reg CT and hyaline cartilage; chondrocytes in long rows separated by collagen fibers; more acidophilic matrix = eosinophilic - chondrocytes in lacuna + visible dense fibers like dense CT - may see fibroblasts in there table 7.1 p 202

the cloudy area at 12 o clock

ID area of myositis ossificans on the axial CT

Normally a black line the ACL from left bottom ro right top

ID the tear of the ACL in this sagittal MRI image

A: part epiphysis (see bone marrow b/t eosinophilic bone spicules) B: Zone reserve (see quiescent hyaline) C: Zone proliferation (see chondrocytes in isogenous gps like stacked coins) D: Zone hypertrophy (chondrocytes in lacunae getting bigger and matrix thinning) E: Zone calcification (chondrocytes no longer in lacunae, spaces opening up, matrix usually gets more basophilic) F: Zone ossification (see new eosinophilic 1ry bone vs basophilic calcified cartilage)

ID zones of epiphyseal plate

Which hip joint ligament is the strongest? What does it do?

Iliofemoral ligament Y-shaped Prevents hip hyperextension, reinforcing anterior superior capsule

What are the bones of the pelvis?

Ilium, ischium, pubis

Compartment syndrome

Increased pressure in compartment can -> m and n damage and restrict blood flow Acute and chronic forms May see decreased sensation over dorsal web space between 1st and 2nd digit (What n innervates this area? DEEP FIBULAR N?) So Fasciotomy = cut open

Describe the spinoglenoid notch

Inferior transverse scapular ligament allows innervatino same for supraspinatous and infraspinatous Suprascapular a and n go underneath

Place the stages of tendon healing in chronological order: Fibroblastic stage, Remodeling stage, Inflammatory stage

Inflammatory Fibroblastic Remodeling

Understand deep and surface soft tissue anatomy List basic steps of exam of any MSK joint. (Know normals, abnl) List primary cause of deformities, atrophy, skin changes on exam Differentiate b/t active and passive ROM List reasons why only active ROM is lost List reasons why active and passive ROM lost List reasons for muscle strength deficits

Inspection - always *disrobe - @rest? @movement? observe - skin changes (swelling, ecchymosis, erythema), atrophy (chronic disuse, chronic tendon tear = gradual, neurogenic cause like palsy/compression syndrome or disc diseases other), deformity (fx, dislocation, acute tendon disruption if superficial all, malunion old fx, other like contracture or rheumatologic) (skin dimple over left PSIS) Palpation (know landmarks) - pain (localized, diffuse) - defects (tendon, crepitus = fx, mass, cellulitis v abscess, pulse) ROM - 1st AROM then PROM - opposite sides - loss AROM (pain, tendon disruption, neuro) - loss AROM and PROM (mechanical block like DJD, fx/disloc acute/malunion, stiffness, intraarticular effusion) Strength - neuro, tendon disruption, pain, disuse Instability/special - loose use instability (not if stiff) - check other joints too *both sides - symmetry? *pain is often referred-- neck pain can radiate to shoulder, back pain/lumbar can radiate to hip, hip pain can refer to knee (if knee exam nl, eval HIP) *NECK*

PEx Foot/Ankle

Inspection - atrophy/deformity/skin change (callouses = areas of high pressure) - bony contour/relationship - resting position; arch; standing Palpation: - lat mal - lat ankle ligaments - med mal - deltoid ligament - Achilles tendon, insertion on calcaneus - Fibular tendons - Posterior tibial tendons - Base of 5th MT - 1st MTP joint - base calcaneus - DP (base 1-2 MT)/PT pulse (behind med mal) ROM: A then P - ankle dorsiflex (0-20) - ankle plantar flex (0-50) - ankle inversion (5-20 deg) (finger on talus) - ankle eversion (5-20 deg) - toe extension/flexion (nl flex 45 deg, ext 70) Strength: - resisted dorsiflexion ankle (1ry tib anterior) - resist plantar flex ankle (Achilles tendon 1ry) - resist eversion ankle (peroneal tendons) - resist inversion ankle (PT) - resist toe flex/exten (EHL, FHL) Special: - Achilles tendon disruption - Thompson testing: squeeze calf lying down (bball, kicked in back feeling) - ankle instability: anterior drawer (anterior talogibular lig) & inversion stress test (calcaneofibular ligament) - NV exam

PEx Knee

Inspection - atrophy/deformity/skin changes - nl knee countours: quads, patella, patellar tendon, tibial tubercle, medial and lateral joint line, effusion in supra-patellar pouch? - alignment - resting position (stance) Palpation: - quads insertion - patella - patella tendon - tibial tubercle - medial and lateral joint line - medial and lateral epicondyle - MCL/LCL origin/insertion - pes anserinus insertion - fibular head ROM: (A then P) - flexion (0-135) - extension (0 nl) - hyperextension? Strength: (supine or seated) - resisted knee extension (testing quads) - resisted knee flexion (testing hammies) Special: - ligamentous: (MCL valgus stress 0/30; LCL varus 0/30; ACL Lachmans/anterior drawer 20/30; PCL posterior drawer) - meniscus: joint line ttp, McMurray's (pain or click = +) - patella ballottement for effusion - SLR: part of active knee extension to 0 - Patella apprehension: if hx dislocation always laterally bc MPFL tear. Lateral pressure on patella -> apprehension dislocation *check hip, sometimes hip pain refers to knee *check NV arthritic knee - varus - slight bow - gait staying on bad leg more - skin, rash, down to foot; swelling - push along joint line, tenderness - not fully extended - snap crackle pop flexing and extnding - ligaments - NV, 1-2 = DP, behind medial mal = PT - wiggle toes, point toes up, ankle up, push down - strength - reflex

Arrange the order in which you will examine a MSK complaint of say - the knee. Palpation Inspection ROM Strength testing Special testing/instability testing

Inspection Palpation ROM Strength testing Special testing/instability testing

PEx Hip Notes

Inspection: - atrophy, deformity, skin change - position @rest - alignment pelvis (iliac crest level bilat?) - bony contours: greater trochanter, iliac crest - hip contracture? (gait w hip/shoulder, side to side, to and fro) (antalgic gait = short phase, coxalgic gait = nl abductor so level pelvis, Trendelenburg gait = weak abductor, lurching) Palpation: - level iliac crest - PSIS - ASIS - sartorius insertion - AIIS - rectus femoris insertion - SI joint - greater trochanter - hip abductors - lesser trochanter - can't feel, but psoas attach - ischial tuberosity - hammies - adductors - cordlike in groin - quads (follow sciatic n, DP/PT, med/lat sens) ROM: (A then P, easier if supine) - flexion (0-130 nl) - extension (easier if prone or on side) - abduction (stabilize pelvis, nl 0-45) - adduction (stabilize pelvis, nl 0-20/30) - internal rot (hip flex to 90, knee flex to 90, 0-35) - external rot (hip flex to 90, knee flex to 90, 0-45) Strength: - resist hip flexion (can sit) - resist hip extension (seat or prone) - resist hip adduction (seat or prone) - resist hip abduction (may be easier pt lying lateral on unaffected side) Special: - posterior dislocation = adducted, internally rot - anterior dislocation = abducted, externally rot - Trendelenburg test: + = weak abductors, pelvis not level when standing on affected leg, pelvis dips down to side where foot lifted - FABER test: flexion/abduction and external rot hip = pain at SI joint if path @SI joint - *test L-spine/NV- back pain hard to diff hip pain

Serratus posterior superior and inferior - location - origin? insertion? - action? - innervation?

Intermediate back - very thin, deep to superficial group superior: elevate ribs 2-5, inferior depresses ribs 9-12 intercostal nn

How do you describe rotated displaced fx?

Internally or externally: distal extremity rotates thru fx site

Compare and contrast endochondral bone formation with intramembranous bone formation (ossification/osteogenesis)

Intramembranous ossification - osteoblasts differentiate from mesenchyme, produce osteoid -> flat bones skull, bones face - ~W8 - 1 development ossification center -> basophilic from rER; 2 Calcification -> osteocytes; 3 Woven bone and Periosteum development -> 1ry bone, apposition growth, vessels; 4 Replacement Woven Bone -> woven by lamellar for compact and spongy Endochondral ossification: - mesenchyme (condense) -> hyaline cartilage model -> ossification - most short and long bones, including limbs and skull base - 1st in W6, centers in all limbs by W12 - 1 Fetal cartilage model (mesenchymal cells -> chondroblasts which secrete matrix like type II collagen, interstitial and appositional growth w perichondrium); 2 Bone collar (periosteum) forms around diaphysis and shaft begins to calcify (collar impedes diffusion, chondrocytes swell up hypertrophy accum glycogen and make alkaline phosphatase lead fo calcify cartilage which is blue/purple/basophil not pink/red/eosinophil like new bone then chondrocytes die and matrix breaks down to porous cartilage left); 3 Development of 1ry ossification center in diaphysis (capillaries in, 1ry/woven bone); 4 2ry ossification ctr after birth, in epiphyses, similar to 3; 5 - Retention of Hyaline cartilage as articular cartilage and epiphyseal plate; 6 - Epiphyseal plates ossify and form epiphyseal lines

List the intrinsic muscles of the foot & its groups What supports the plantar surface of the foot?

Intrinsic dorsal group (2): - extensor hallucis brevis - extensor digitorum brevis Intrinsic plantar group (14 in 4 layers): [1st layer]: abductor hallucis m, flexor digitorum brevis m, abductor digiti minimi m [2nd layer]: quadratus plantae m, lumbricals (4) [3rd layer]: flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis [4th layer]: dorsal interossei (4), plantar interossei (3) Intrinsic intermediate group (4): Plantar aponeurosis (plantar fascia)

Flexor digitorum brevis m - location - origin? insertion? - action? - innervation?

Intrinsic foot, plantar group, 1st layer - calcaneus to middle phalanges 2-5 - flexes MTP & PIP 2-5 - *medial plantar n* (straight down foot, mini version flexor digitorum longus)

Abductor digiti minimi m - location - origin? insertion? - action? - innervation?

Intrinsic foot, plantar group, 1st layer - calcaneus to proximal phalanx 5th digit - abducts 5th digit - lateral plantar n

Abductor hallucis m - location? - origin? insertion? - action? - innervation?

Intrinsic foot, plantar group, 1st layer - tendon comes up very medial on side great toe - calcaneus to proximal phalanx great toe - abducts great toe - *medial plantar n* (medial-most m)

Quadratus plantae m - location - origin? insertion? - action? - innervation?

Intrinsic foot, plantar group, 2nd layer - calcaneus (either side), inserts onto tendons of flexor digitorum longus - assist FDL (helps stabilize tendons, anchor, support arch help) - lateral plantar n

Lumbricals - location - origin? insertion? - action? - innervation?

Intrinsic foot, plantar group, 2nd layer - tendons of flexor digitorum longus to medial side of extensor expansions - FLEXES MTPs, EXTENDS IP 2-5 - *1st = medial plantar n*, 2-4 = lateral plantar n

Flexor digiti minimi brevis m - location - origin? insertion? - action? - innervation?

Intrinsic foot, plantar group, 3rd layer - 5th MT to proximal phalanx 5th - flexes MTP 5th - lateral plantar n (*superficial branch*) (no longus)

Flexor hallucis brevis m - location - origin? insertion? - action? - innervation?

Intrinsic foot, plantar group, 3rd layer - deep to tendon of FHL - cuboid & lateral cuneiform to proximal phalanx great toe (containing sesamoid bones) - flex MTP of great toe - *medial plantar n* - 2-headed

Adductor hallucis m - location - origin? insertion? - action? - innervation?

Intrinsic foot, plantar group, 3rd layer - tranverse head O: capsule of MTP 3-5 - oblique head O: bases MT 2-4 - I: proximal phalanx great toe - adducts great toe - lateral plantar n (*deep branch*) - 2-headed

Compare intrinsic and extrinsic muscles of the back

Intrinsic muscles of back - originated developmentally in dorsum of back and remained - innervated by DORSAL (posterior) primary rami - deep - vertebral column and head Extrinsic muscles of back - migrated from ventral surface body, carrying innervation with them - innervated by VENTRAL (anterior) 1ry rami (or CN XI [accessory n]) - superficial / appendicular - upper limb/respiratory = trapezius, latissimus dorsi, (largest, most superficial, upper limb mostly) rhomboid major, rhomboid minor, levator scapulae (scapula mvmt)

What muscle(s) do you classically see atrophy in when one has a long standing cubital tunnel syndrome? hypothenar muscles flexor carpi ulnaris thenar muscles FDP to the 4th and 5th digit intrinsics

Intrinsics. Not much bulky msucle in dorsum of hand, so if intrinsics are atrophied and waste away, extensor tendons will really stand out and that is why this is so esily spotte don PEx. Even if FCU was atrophied, in your volar forearm, you really could not pick this up. But, can't hide intrinsic atrophy

1 - no periosteal rxn 2 - no matrix inside 3 - cortex intact 4 - sharp borders 5 - no masses BENIGN

Is this benign or malignant? Why?

1 - periosteal rxn 2 - bone made inside lesion (matrix) 3 - cortex disrupted 4 - blurred borders / not well seen MALIGNANT

Is this benign or malignant? Why?

Why do you need 2 different view of the joint?

To determine if it is dislocated and in what direction

What makes up the bone/muscle ROS?

Joint crepitus/grinding Joint instability Joint locking Joint pain (arthralgia) Joint redness (erythema) Joint stiffness Joint swelling (edema) Muscle pain (myalgia) Muscle weakness

Explain the changes in cartilage with age: Describe how the concentration of the following proteoglycans changes with aging. Keratan sulfate Chondroitin-4 sulfate Chondroitin-6 sulfate

KS Inc C4S Dec C6S Inc as well

Since back pain can be hard to differentiate from hip pain, what else gets tested in the event of hip complaints?

L-spine and neurovasculature

Think about dermatomes of lower limb

L1: over inguinal ligament L2: lateral thigh L3: lower medial thigh L4: medial leg-*medial great toe L5: lateral leg to *medial digit II-IV S1: back thigh S3: buttcheek/skin over gluteal fold

A pt has decreased sensation along his medial leg over the tibia. What dermatome does this correspond to? L3 L4 L5 S1 L2

L4

The iliac crest is at the level of what vertebrae? T7 S2 T12 L2 L4

L4 is at level of iliac crests

Which ligament is not attached to the meniscus/which has deep attachments to the meniscus: lateral or medial

LCL is not attached to lateral meniscus MCL has deep attachments ON the medial meniscus

Which ligament protects from varus force? LCL or MCL?

LCL protects from varus force (which = medial blow)

What are signs of an anterior hip dislocation?

LE abducted, externally rotated

What are signs of a posterior hip dislocation?

LE adducted, internally rotated

bone = opaque muscle = intermed radiolucent fat = mod radiolucent black = all rays passed thru = no tissue = nothing

Label the substances/densities by the arrows

1. vertebral bodies T12-L5 2. disc spaces 3. sacral promontory* 4. sacrum 5. facet joints 6. spinous processes 7. pedicles

Lateral L spine

1. tibia 2. medial malleolus* 3. lateral malleolus* 4. talus 5. talocalcaneonavicular joint* 6. navicular 7. calcanealcuboid joint (*name order) 8. cuboid 9. calcaneal tuberosity* 10. calcaneus 11. talocalcaneal joint* 12. fibula

Lateral ankle

What compartment of the leg does not have its own a? What happens instead?

Lateral compartment of leg Receives blood supply from perforating branches of fibular a and anterior tibial a

Fibularis brevis m (peroneus) - group/location? - origin? - insertion? - action? - innervation?

Lateral leg O: Distal 2/3 lateral fibula I: Base of 5th MT Eversion, weak plantar flexion (Distal attachment fibularis brevis = common site for avulsion fx)

Fibularis longus m (peroneus) - group/location? - origin? - insertion? - action? - innervation?

Lateral leg (very deep) O: Proximal, lateral fibula I: Plantar surface of base of 1st MT and medial cuneiform Eversion, weak plantarflexion; helps support medial arch Superficial fibular n

What are most muscles of the plantar surface of the foot innervated by? What do these muscles do?

Lateral plantar n (4 by medial plantar n) Resist loads/maintain arch in support phase; stabilize foot in push-off phase, maintain balance

1. Capitellum 2. Radial head 3. Coronoid 4. Olecranon 5. Olecranon fossa

Lateral view elbow

1. Femoral neck 2. Greater trochanter 3. Ischium* 4. Acetabulum 5. Femoral head

Lateral view hip Name all structures

1. patella 2. medial epicondyle* 3. femorotibial joint* 4. tibial tuberosity* 5. tibia 6. fibula 7. fibular neck 8. fibular head 9. intercondylar fossa 10 femur (shaft)

Lateral view knee Name all structures

Note: - talus (entire talar dome) sitting posterior to tibial plafond

Lateral view x-ray showing ankle dislocation

Describe the development of limb buds including bones, joints, musculature, motor innervation, sensory innervation What do limb buds develop from? What are they composed of? What is the AER? How are digits formed Describe the development origins of ms innervation Describe the role that limb rotation plays in sensory and motor innervation of the limbs

Limb buds develop from *ventrolateral body wall*, ~ end W4 Composed of *parietal/somatic lateral plate mesoderm* derived mesenchymal core and surface ectoderm (hindlimb lags behind forelimb) AER = apical ectodermal ridge = distal border of limb that regulates limb outgrowth by secreting FGFs - develops ~W5 - induces mesenchyme to remain proliferative = *progress zone* W5-6: - limb bud mesenchyme condenses - cells differentiate to chondrocytes = hyaline cartilage models W6: - terminal portion of limb bud flattens; cell death separates AER to 5 digits that continue to grow - joint formation begins in joint interzone: mesenchyme condenses to form dense fibrous CT -> articular cartilage/synovial membranes/menisci/ligaments -> joint capsule W7: - limbs rotate in opposite directions - upper limb rotates 90 laterally (extensor on lateral and posterior surface, thumb lateral) - lower limb rotates 90 medially (extensor on anterior surface, big toe medial) W12: - endochondral ossification starts Birth: - diaphysis ossified, epiphyses cartilaginous - - - - - Limb musculature: - from *dorsolateral somite cells* that migrate in - initially segmental: extensor (dorsal) and flexor (ventral) groups of somites - splitting and fusing -> single muscles often from multiple somite segments - upper limb = C4-T2 - lower limb = L2-S2 Limb motor innervation: - from ventral (anterior) primary rami, which -> dorsal and ventral branches -> extensor (dorsal) and flexor (ventral) compartments, which unite to large dorsal and ventral nerves - radial nerve = extensors = dorsal branches - ulnar nerve = flexors = ventral branches - median nerve = flexors = ventral branches - back muscles = epaxial muscles - body wall, extensor limb, flexor limb = hypaxial muscles Limb sensory innervation: - dermatomes: follow growth and rotation limbs - sensory and sympathetic nerves from migrating neural crest with cell bodies in dorsal root ganglion (sensory) and postganglionic sympathetic nerves in sympathetic chain ganglion

Describe the key molecular pathways that regulate limb development and the formation of the various axes associated with the limb

Limb patterning/growth = series of interconnected molecular inductions with feedback loops Cranial-caudal axis: HOX genes - limb location, boney org limb Limb outgrowth: TBX5/FGF10 forelimb and TBX4/FGF10 hindlimb Proximal-distal axis: - AER formation = BMP signaling thru MSX2 - AER restriction = radical fringe/SER2/Engrailed-1 - Progress zone = FGF4 & 8 by AER Anterior-posterior axis: ZPA (zone of polarizing activity -> vit A); RA, SHH (-> patterning) Dorsal-ventral axis: BMP, EN-1/WNT7a*/LMX1 Bone shape: HOX gene expression dependent on combo expression of FGF/SHH/WNT7a

Describe blood supply of spinal cord

Longitudinal vessels: - anterior spinal a (from vertebral a) and paired posterior spinal aa (from branches of posterior inferior cerebrallae aa = branches vertebral a) down posterior surface cord on posterolateral aspects Segmental vessels: - segmental spinal aa (enter each level thru intervertebral foramen and split into anterior and posterior radicular aa), also give off segmental medullary aa which communicate with longitudinal aa

The lumbosacral plexus is the combination of the lumbar and sacral plexuses and supplies the innervation to the lower limb. What are the spinal levels that comprise the lumbosacral plexus? L2-S3 L4-S4 L1-S1 L1-S4 C5-T1

Lumbosacral plexus = L1-S4

Which ligament protects from valgus force?

MCL protects from valgus force (lateral blow)

The most sensitive imaging test for detecting an anterior cruciate ligament (ACL) injury is: - valgus stress x-ray - plain x-ray - MRI - CT _ US

MRI

What imaging modality is best to detect RTC tear? MRI bone scan plain radiograph US CT scan

MRI = gold std. Even though some ability to detect with US, CT, not best.

What is the primary blood supply to the adult hip? - lateral circumflex femoral artery - medial circumflex femoral artery - obturator artery - superior gluteal artery

Medial circumflex femoral a = 1ry blood supply to adult hip

List and describe the arches of the foot

Medial longitudinal arch Lateral longitudinal arch Transverse arch

Adductor magnus m - group/location? - origin? - insertion? - action? - innervation?

Medial thigh O: ischiopubic ramus, ischial tuberosity I: linea aspera, adductor tubercle Adducts Obturator n + *Tibial div sciatic n* (Hamstring part which extends hip) *adductor hiatus = opening for NV to leg

Adductor brevis m - group/location? - origin? - insertion? - action? - innervation?

Medial thigh - deep to pectineus and adductor longus O: Body of pubis (deep to O longus) I: linea aspera (proximal 1/3) Adducts Obturator n

Gracilis m - group/location? - origin? - insertion? - action? - innervation?

Medial thigh - long thin, *only adductor to cross knee O: body of pubis, inferior pubic ramus I: Proximal anteromedial tibia Adducts hip, flexes knee

Pectineus m - group/location? - origin? - insertion? - action? - innervation?

Medial thigh - most proximal, very high groin muscle O: Pectineal line (pubis) I: Proximal medial femur (posterior) Medial fibers: adduct hip (Obturator n, like rest of medial thigh) Superficial fibers: flex hip (Femoral n) *dually innervated

Adductor longus m - group/location? - origin? - insertion? - action? - innervation?

Medial thigh - superior to brevis O: Body of pubis I: Linea aspera (middle 1/3) Adducts Obturator n

Compare medial vs lateral menisci of the knee joint

Menisci: - function to deepen articulation (improve stability) - shock absorption Medial meniscus: - C-shaped, little wider - not mobile: attached to tibial plateau via coronary ligaments Lateral meniscus: - circular, mobile (shifts to allow movement) Posterior meniscofemoral ligament

What tissue does bone develop directly from in intramembranous ossification? Dense regular connective tissue Epithelial tissue Elastic cartilage Hyaline cartilage Mesenchyme

Mesenchyme

Describe the cell lineages derived from mesenchyme and the role in cartilage and bone formation

Mesenchyme = loose embryonic CT (elongated, undifferentiated spindle-shaped cells, prominent nucleoli in round nuclei) -> hematopoietic stem cell (-> monocyte -> macrophage, *osteoclast = break down) -> fibroblasts -> lipoblasts (-> adipocyte) -> endothelium -> mesothelium -> *osteoblast -> *chondroblast* All CT from mesenchyme

Degenerative joint disease of the hip would cause a loss of active and passive hip ROM: T/F

T Loss AROM and PROM can be due to DJD. Also fx/dislocation, stiffness, intra-articular effusion

Which of th following exam findings is not suggestive of the dx of RA? Monoarthritis Polyarthritis Effusions and tenderness of MCP and PIP joints in hands Rhematoid nodule

Monoarthritis

Bankart lesion is?

Most common tear with traumatic anterior shoulder dislocation Young pts Tear of anterior/inferior labrum

Lack of preventive care for people with disabilities is largely explained by their low rate of having a primary care physician. T/F

Most people with disabilities have a PCP making their lack of preventive care, such as ca screening, especially troubling F

What do the ligaments of the vertebral column do?

Mostly prevent hyperflexion (anterior longitudinal ligament = exception, prevents hyperextension)

What do tendons attach?

Muscle to bone

All except one of the following are NSAIDs appropriate for the treatment of acute gout: keterolal indomethacin aspirin ibuprofen naproxen

NSAIDs are a mainstay of acute gout pharmacotherapy. However, aspirin should NEVER be used to treat gout as it causes renal retention of uric acid, leading to uric acid crystals in kidneys.

Epiphysis = joint/intra-articular = upper circle and lower circle Metaphyseal = junction of diaphysis and epiphysis Diaphysis = in shaft of bone

Name the segments of the bone, as in how you would describe a fracture location

AP view of the pelvis 1. SI joint 2. Acetabulum 3. Greater trochanter 4. Intertrochanteric line 5. Lesser trochanter 6. Inferior pubic ramus 7. Pubic symphysis (symphysis pubis) 8. Ischial tuberosity 9. Teardrop* 10. Femoral neck 11. Femoral head 12. ASIS 13. Iliac crest 14. Sacrum 15. Superior pubic ramus

Name this view and all structures

List some common dislocations. What do you need to have to decrease the chance of missing a dislocation?

Need at least 2 x-ray views shoulder, elbow, finger, hip, patella, ankle, foot

A 23 y/o, otherwise healthy sexually active male presents with 1 d hx of painful, red swollen knee concerning for infection. An aspiration is performed and gram stain shows gram neg diplococci. The organism responsible for the infeciton is: - E Coli - Clostridium difficile - Strep group B - Neisseria gonorrhea

Neisseria gonorrhea

List the differential diagnosis for a monarticular arthritis List the differential diagnosis for a polyarticular arthritis List and differentiate between the most helpful laboratory studies utilized in the work-up of an arthritic condition Describe which tests are useful in following disease activity Describe which tests are indicative of a good or poor prognosis Identify joint fluid as normal or inflammatory and given a simple case and joint fluid data - student will be able to match it with the most likely diagnosis. In particular - differentiate between different conditions based on the WBC count. List the characteristics of effusions depending upon the conditions Define arthrofibrosis and list the situations in which this may occur and describe the clinical presentation.

Not tested on all meds: know in -depth: - Gout therapyL probenicid, colchicine, allopurinol, febuxostat, pegolated, uricase - Glucocorticoids - Leflunomide - Sulfasalazine - Hydroxychloroquine Arthralgia: pain in joint (v common) Arthritis: Joint poss with pain, loss ROM, swelling, warmth, tenderness (pain + PEx finding, less common) Arthrocentesis: taking fluid from joint Effusion: swelling in joint Hemarthrosis: bleeding in joint Enthesitis: inflammation at inertion ligament or tendon into bone Monarticular: only 1 joint affected Oligo" = <5 Polyarticular: 5+ CMC = carpometacarpal joint DIP = distal interphalangeal joint MCP = metacrapophalangeal joint MTP = metatarsophalangeal joint PIP = proximal interphalangeal joint RA = rheumatoid arthritis JIA = juvenile idiopathic arthritis CPPD = calcium pyrophosphat depoition disease pt w arthrlagia might not have arthritis - Pex / radiographs v important in distinguishing classifcy: - based on hx, Pex - duration, # involved joints, distribution joint involvement, timing - based on synovial fluid analysis acute = <6 weeks arthritis - infection, trauma, or initial manifestation chronci inflammatory arthritis (RA, JIA< psoriatic, etc) - most infectious processes resolve @ 6 wks chornic: >6 wks - chornic inflam arthritis, osteoarthritis, indolten infections (like TB..), tumors monoarticular arthritis: acute: - *infection* bacterial - crystal-induced.. hemorrhagic effusion - chronic - infection fungal/mycobacterial/lyme; osteoarthritis, inifitla hornic inflam, FB synovitis, pigmented villonodular synovitis, malignancy - *acute monoarticular and INFLAMMTORY* = infection until proven otherwise, need synovial fluid exam oligoarticular - acute: infection or crystal - chronci: osteo, psoriatic, JIA, initial RA polyarticular: - acute: viral (parvovirus), gonococal arthritis; crystal induced (acute gout, CPPD), inflam (early chronci inflam), rxn infection (Acute rheumati fever) - chronic: infeciton (viral like hep C, whipplies), crystl (chronci tophaceous gout, chronci cppd), inflam (RA, JIA, psoriatic), osteoarthri esp hands, sarcoidosis, systemic lupus erythematosus distribution joint involvement: - symmetric, asymmetric, axial (c t l spine), peripheal - DIP = osteoarthritis, psoriatic arthritis - PIP = osteo, psoriatic, RA, JIA - MCP = RA, JIA (most classic RA) - CMC: osteoarthritis (thumb) timing: - migratory: *acute rheumatic fever, early Lyme* - intermittent: gout, reactive arthritis - additive: RA, JIA, systemic lupus erythematosus synovial fluid: - secreted by synoviocytes, fibroblasts - lots hyaluronic acid - lubes joints, xpts nutritional substance to joint - nl clear/pale yellow, viscous, doesn't clot, loe volume arthrocentesis: fluid characteritis; color, clarity, viscosity, wbc, rbc (noninflam -more yellow, inflam = yellower and cloudier, septic = purulent v dark cloudy, hemorrhagic lot blood, not clotted) "string test", synovial WBC rises, inflam cells nad proteins break down hyaluronic acid so viscosity decreases - fluid analysis: - nl wbc <200, inflam 2000-75k, septic 75k+ non-inflam: osteoarthritis, endocrine (hypothyroid), avascular necrosis, amyloidosis, neuropathic arthritis (charcot joint), metabolci disorder (alkaptonuria, hemochromatosis) inflam: inflam arthritis, crystal indued (*septic joints can present with wbc in this range) hemorrhagic fluid: clotting disorder (hemophilia, anticoagulants), trauma, *pigmented villonodular synovitis* benign neoplasia synovial gram stain, culture - r/o infection, may need to add fastidious bacteria, fungi, mycobascteria, virusse (bacteria routinely done) - crystal analysis synovial biopsy - moreoccult infections (tb mycobacteria, fungi), rare malignancy and pigmendted villonodular synovitis bloodwork: cbc, liver/kidney/UA, uric acid marker inflam: ESR, Crp ESR (Wintrobe, westergren); stand in tube, ESR = rate at which rbcs settle- inflam proteins stick to rbc and make them settle faster Crp: pentameric protein made by liver circulating in blood, triggered by pro-inflam cytokines - acute phase reactant - rises and falls more quickly than ESR auto-abs in arthritis: - rheumatoid factor (ab to IgG, 80% pts RA, 10% JIA, worse prognosis) - anti-cyclic citrullinated peptide ab (ab citrullinated proteins, 80% pts RA, worse prognosis = anti CCP); - anti-nuclear ab (ab to nuclear contents, in JIA inc risk uveitis, helps dx other thigns like lupus) - xr can assess joint dmg, loss jt space (loss cartilage), signs inflammation mediate damage (periarticular osteopenia, erosions) - US/MRI: can detect abnl earlier and in finer detail Hx ?: which joints, length sx present, chornicity (constant/intermittnet), morning stiffness? how long? constitutioanl or extra articular sx?, family hx, injury/occupation am stiffness: - inflamed joint "gelling" stiffer after inactivity; chornic inflam arthritis morning stiffness 30+ minutes; mechanical arthritis like osteoarthritis = <30 min mechanical: minimal am stiffness, sx worse w activityy, sx improve w rest inflam: am stiffness 30+ min, sx worse w inactivity better w activity edxtra articular cues: fever, ee involvement, rash/nail finding, oral ulcer, gi sx fevers up n down (systemic jia), uveitis (jia, anklosing spondylitis, psoriatic arhtitis), oral ulcers (inflam bowel disease, lupus, behcets), nail abl/scaly plaques (psoriasis) deformities: loss rom, bony enlargement, subluxation joint (due to tendon lig dmg) bony enlargement, overgrowth (children in large bc growht pltes not fused) no need memorize defomrities arthrtofibrosis: -> scarring, adhesions, limited rom - joint effusion - complciation of injury, trauma, surg, bleeing in joint pt case: - r knww, 2 days, swelling, v painful - no fever, r knee red/warm/swollen/tender/dec rom, other joints wnl - acute monoarticular arthritis - poss infection depist eno fever so arthrocentesis - synovial fluid yelow, transulucent/mildly opaque, dec viscosity, wbc 40k = inflammatory - do culture, crystals - culture/gram stain neg; see cyrstals = gout hands, 2 mos, feet 1 mo, 1 hr am stiffness, trouble bending fingers esp am, better with activity, fatigue - chronci, additive, polyarticular, symmetric, real? systemic inflam? - effusion tenderness dec rom all mcp pip fingers and ttp mtp - real arthritis, polyarticular, symmetric, chorcni - could be chornic viral (dont need to know Whipples elderly men), chornci crystal, ra, psoriatic, sarcoiosis, lupus - xr: periarticular osteopenia mcp and pip and erosions of 2 mcps -- damage seen caused by inflam arthritis - labs: esr, crp elevated suggest systemic inflam - cbc, liv/kid, uric acid nl - no hep c/b - ana neg - x lupus - RF, anti-CCP positive = RA 67, pain thumb/giners, worse 3 yrs, worse r dom hand, worse when using (garden type), 15 min am stiff chronic, worse activity, not much am stiff - not sounding inflam - goes on Key pts: Pattern recognition helps to classify arthritis Arthritis = pain with ROM, swelling, warmth or loss of ROM Assess joint symptoms for: number, chronicity, symmetry, timing, distribution Assess exam for: effusions, enthesitis, extra-articular clues, range of motion, deformities Morning stiffness points to inflammatory process Synovial fluid analysis can help to determine if process is inflammatory, non-inflammatory, likely to be septic and can assess for crystals. Synovial fluid analysis necessary in acute, inflammatory monoarticular arthritis to exclude infection. Laboratory studies can be helpful, especially routine blood work, uric acid, inflammatory markers, RF, anti-ccp, ANA. X-rays can be helpful.

Motor and sensory distribution of median n: diagram

Note: if median n out, no sensation in pink areas (tip digit 1-3.5 and anterior palmar of that Muscles affected: pronator teres, flexor carpi radialis, palmaris longus, flexor digitorum superficialis, flexor digitorum profundus, flexor pollicis longus, pronator quadratus, abductor pollicis brevis, flexor pollicis brevis, opponens pollicis, lumbricals

Which muscle(s) do(es) the nerve to the obturator internus innervate?

Obturator internus m. Gemellus superior m.

What nerve supplies motor innervation to the medial compartment of the thigh? How does this n terminate?

Obturator n (L2-L4) Splits to anterior and posterior branches around adductor brevis m - posterior br -> adductor magnus m - anterior br -> all other medial thigh m Terminates with cutaneous branch (sensory to medial thigh)

Which JIA subtype is most likely to develop uveitis? Oligoarticular JIA Polyarticular RF + JIA Enthesitis-related arthritis Systemic JIA

Oligoarticular JIA

Describe the origins and differentiation of the four major types of bone cells Identify and describe the major soluble factors that promote bone formation and resorption Describe the interactions among bone cells that lead to bone formation and resorption Identify and describe several types of therapies used to improve bone mass in humans

Osteoblasts: (bone building, cuboid) - from mesenchymal stem cells - can -> osteocytes, lining cells, or apoptose - regulated by soluble factors released from other cells or degraded matrix (WNT, sclerosin, BMP, TGF-b, IGF-1, PTH/PTHrP) / cell-cell contact (ephrin) - form matrix (collagen I, osteocalcin, osteonectin), ctrl mineralization (hydroxyapatite = Ca, phosphate, H2O; express alkaline phosphatase) - also reg OC activity (via soluble factors RANKL/OPG and ephrin signaling) Osteocytes: - from OB buried/diff in bone; body in lacuna, processes in canaliculi - most abundant, flat, long-lived - regulated by mechanical signaling (fluid shear stress -> 2nd msgrs), damage, other cells (apoptose by microcracks, RANKL) - regulate OB (act: IGF-1, NO; inh: sclerostin) - regulate OC (act: RANKL; inh: OPG) - regulate minerals (osteocytic osteolysis if preg/lact, FGF23 = kidney phosphate excretion) Osteoclasts: - from hematopoietic stem cells (marrow), related to monocyte/m-phage, formed by fusion -> large, multi-nucleated - short-lived - need M-CSF, RANKL; OPG can inhibit RANKL - very motile; crawl on surface leaving pits; dynamic cytoskeleton (inhibited by bisphosphonates in anti-resorptive tx) - soluble pro regulators: M-CSF, RANKL, PTH (Ca release), TNFa, IL-1, IL-6 (inflammatory cytokines) - soluble anti regulators: OPG, estrogen (loss in older F -> excessive OC), calcitonin (polypeptide hormone, used to inhibit resorption) - *sealing zone: integrin-mediated, actin-rich ring seal to matrix - *ruffled border (apical membrane) thru which secrete HCl, proteases like cathepsin K, onto bone - tumor vicious cycle: amplify each other - also reg by cell-cell contct via ephrin signal - usually inhibited form/fn for osteoporosis tx, like bisphosphonates (Actonel, FOsamax, are taken up by OC after tightly binding to bone, though can hrm any cell) inteferes with Rho GTPase signaling, and denosumab (Prolia) inhibits RANKL (circulates, but only OC use RANKL) **but need functional OC for OB Lining cells: former osteoblasts, flattened, no longer build bone, line entire bone surface Signals include soluble mc, like those trapped in/released from matrix during resorption, and from cell/cell contact ephrin ligands = membrane-bound on differentiating OCs, Eph Rs on differentiating OBs - diff combos -> form 1 type of cell inhibiting others - RANKL: stimulates OC differentiation and fn (R activator of NF-kB ligand) OPG: by OB and OC = osteoprotegerin inhibits RANKL fn (bind) Factors that promote bone formation: - WNT: secreted glycoproteins, stim beta-catenin [when not available, beta-catenin associates with complex for degradation so cannot promote diff etc; but if not degraded/+WNT, BC -> nucleus to promote transcription; *sclerostin = impt inhibitor, made by osteocytes, antagonist of WNT binding to that R] - BMPs/bone morphogenetic proteins: TGF-beta family, trigger Smad, some used to promote bone healing - TGF-beta: - IGF-1/insulin-like growth factor-1: - PTH and PTHrP: anabolic or catabolic depending on dosing and context; only approved anabolic therapy for osteoporosis

All bone cells are of mesenchymal origins except: bone lining cells OCs osteocytes OBs

Osteoclasts are of hematopoietic origin

Which of these statements about osteocytes is true? Osteocytes regulate bone formation, but not bone resorption Osteocytes are short-lived cells Osteocytes regulate bone resorption, but not bone formation Osteocytes are responsive to mechanical stresses

Osteocytes are responsive to mechanical stresses Fluid shear stresses on osteocytes regulate their activity

ID component parts and describe organization of the osteon in histological images

Osteon / haversian system in compact bone center of osteon = central canal (contains artery, vein, nerve fiber) Around = lamellae, concentric Between concentric = osteocytes/chondrocytes -> collagen fibers which run parallel to each other in twisting fashion = alternating = strength cement line = outer portion osteon Volkmann's canals bring in blood vessels to central canals New osteons carved between old, and parts of old left behind = interstitial lamella

Associated injury to the ___ should be considered when treating a pt with a posterior hip dislocation due to a "dashboard injury" PCL, ACL, MCL, LCL

PCL

Which ligament is stronger: ACL or PCL?

PCL

Which ligament of the knee is the main stabilizer in a flexed knee?

PCL

Which ligament of the knee prevents posterior translation of the tibia on the femur?

PCL

The most common clinical finding on PEx in a native joint infection is: - no effusion (joint swelling) - no pain - pain with micromotion - elevated systemic WBC

Pain with micromotion

Which of the following bones develops through intramembranous ossification? Femur located in thigh Humerus located in arm Parietal bone of skull Phalanges of fingers Tibia in leg

Parietal bone of skull

What does the acetabular notch allow for?

Passage of neurovascular structures

What's the largest sesamoid bone in the body?

Patella of knee

Match the appropriate PEx test to the injury it is designed to detect: Patellar apprehension test Lachman test Posterior drawer test Varus stress test Valgus stress test PCL LCL Patellar instability ACL MCL

Patellar apprehension test- Patellar instability Lachman test- ACL Posterior drawer test- PCL Varus stress test- LCL Valgus stress test- MCL

What muscles make up the medial thigh compartment? What do they do? What innervates them? What supplies blood to them?

Pectineus m Adductor longus m Adductor brevis m Adductor magnus m Gracilis m Obturator externus m (likely unseen in lab, v deep) Hip adductors (*obturator externus does hip external rotation) Obturator n Obturator a

Match origins/insertions with muscles Pectoralis major insertion Latissimus dorsi insertion Distal biceps insertion Proximal long head biceps origin Short head biceps origin Floor/medial aspect of bicipital groove Coracoid process Bicipital tuberosity on the radius Supraglenoid tubercle of glenoid Lateral aspect bicipital groove

Pectoralis major insertion = Lateral aspect bicipital groove Latissimus dorsi insertion = Floor/medial aspect of bicipital groove Distal biceps insertion = Bicipital tuberosity on the radius Proximal long head biceps origin = Supraglenoid tubercle of glenoid Short head biceps origin = Coracoid process

Which of the three meninges adheres directly to the spinal cord? Pia mater Dura mater Arachnoid mater CSF Denticulate ligament

Pia mater adheres to the surface of the spinal cord and is the innermost meningeal layer

Scoliosis (lateral curvature, typically of T spine)

Pictured here is what condition of the spine? Scoliosis Kyphosis Hunchback deformity Sway back deformity Lordosis

What are the deep muscles of the gluteal region? What is their function?

Piriformis m.* Superior gemellus m. Obturator internus m. Inferior gemellus m. Quadratus femoris m. External rotator hip

Describe the ligaments of the joints of the foot

Plantar calcaneonavicular - "spring" ligament - imp in supporting medial arch (support head of talus to maintain longitudinal arch on medial side) Long plantar ligament - deep to muscles - calcaneus to cuboid & MT bases (creates tunnel for fibularis longus tendon) - helps maintain longitudinal arch Plantar calcaneocuboid ligament - "short plantar" - deep to long plantar (just medial) - helps support arch

What does the lateral leg do? What innervates it? What supplies blood to it?

Plantar flexion, eversion Superficial fibular n Fibular a & anterior tibial a

What muscles make up the deep group of the leg?

Popliteus m Tibialis posterior m Flexor hallucis longus m Flexor digitorum longus m

Semimembranosus m - group/location? - origin? - insertion? - action? - innervation?

Posterior thigh m (hamstrings) - deep to semitendinosus m. O: Ischial tuberosity I: Posteromedial tibia Extend hip, flex knee, internally (medially) rotate leg Tibial division of sciatic n

Biceps femoris m. - group/location? - origin? - insertion? - action? - innervation?

Posterior thigh m (hamstrings) - lateral O: Ischial tuberosity (long), Linea aspera (short) I: Fibular head Hip extension, Knee flexion, Leg lateral/external rotation *Long head = tibial division sciatic n Short head = common fibular division sciatic n* *=great test question*

Semitendinosus m - group/location? - origin? - insertion? - action? - innervation?

Posterior thigh m (hamstrings) - medial to biceps femoris O: Ischial tuberosity I: Medial proximal tibia Extend hip, flex knee, Internally (medially) rotate leg Tibial division of sciatic n

Differentiate the structural characteristics of woven and lamellar bone, and cancellous (spongy, trabecular) and compact (cortical, dense) bone

Primary bone tissue = woven/immature - 1st made, very disorganized Secondary bone tissue = lamellar/mature - highly organized, put after 1ry broken down by osteoclasts - concentric circles Cancellous = spongy Compact = cortical, both = secondary bone tissue in adults Compact & Spongy histologically look same - both secondary/lamellar bone - compact has osteons, spongy don't (no central canal) - but both have concentric circles - osteocytes in spongy bone have canaliculi to obtain from red/yellow marrow, passing inward (opposite of compact bone)

Why is an accurate x-ray description important?

Proper x-ray description sets the tone for the urgency of tx, the type of tx, and allows the initial physician to initiate proper tx plan and guide pt expectations

List the functions of the human skeleton

Protection Support Mechanical basis for movement Storage Blood cell formation (hematopoiesis)

A valgus force is one that pushes the distal limb segment away from the midline: T/F

T Valgus pushes distal portion of limb away from midline Varus force distal portion toward midline

What are the two weaker hip joint ligaments? Which is the weakest? What do they do?

Pubofemoral, ischiofemoral Ischiofemoral = weakest Pubofemoral: reinforces anterior-inferior capsule prevents hyperabduction Ischiofemoral: Reinforces posterior capsule prevents hyperflexion (hug as tight as possible to chest)

Which muscle(s) do(es) the nerve to the quadratus femoris innervate?

Quadratus femoris m. Gemellus inferior m.

A 55 y/o businessman wiped out skiing and dislocated his shoulder. You perform a closed reduction. His NV exam is intact. What pathology must you make sure you check him for? biceps tendon tear axillary n injury rotator cuff tear bankart lesion glenoid fx

RC tear 40+ y/o can traumatically tear their RTC with a dislocation (though often not, is severe and often missed)

Approximately 80% of pts with RA will have which of the following positive blood tests? Positive ANA High ferritin Rheumatoid factor Positive HLA-B27

RF

Some imaging modalities are better to evaluate certain problems than others. Match the clinical problem with the imaging modality that best corresponds to it. A pt with a 1-year hx of L knee pain A pt with an intra-articular fx of the hip Bone marrow abnl Tendon tears Evaluation of which bones are affected in a pt with metastatic bone disease MRI radiographs nuclear medicine scan CT scan

Radiograph good for pt with 1y hx L knee pain CT scan good for pt with intra-articular hip fx MRI good for bone marrow abnormalities and tendon tears Nuclear medicine/bone scan good for evaluation of which bones are affected in pt with mets bone disease

List the quadriceps muscles

Rectus femoris Vastus medialis Vastus lateralis Vastus intermedius

List the muscles of quadriceps femoris m Which cross the hip? Where do they insert? What is their action? What is their innervation? Which is the largest of these 4?

Rectus femoris m Vastus lateralis m Vastus medialis m Vastus intermedius m Only rectus femoris crosses hip ALL insert via quadriceps tendon, crossing knee via patellar ligament to tibial tuberosity All = knee extension (Rectus femoris also hip flexion) Femoral n Vastus lateralis = biggest of 4

What is a nerve plexus? Name the 4 major plexuses and their levels. What's different about the thoracic region?

Region where anterior primary rami of multiple spinal nerve levels merge and interchange fibers, before forming a peripheral nerve Cervical plexus: C1-C5 Brachial plexus: C5-T1 Lumbar plexus: L1-L4 Sacral plexus: L4-S4 Thoracic region = no plexus = segmental region

Which of the following is not a methotrexate safety concern in JIA and RA? Hepatitis Immunosuppression Bone marrow suppression (cytopenis) Retinal hyperpigmentation

Retinal hyperpigmentation

The rhomboid major m attaches proximally on which of the following bones? Spinous process T2-T5 Spinous process L1-L2 Transverse process T2-T5 Transverse process C7-T1 Spinous process L2-L5

Rhomboid major m attaches proximally to spinous processes T2-T5

*ID most common conditions/injuries, etiology, clinical characteristics, eval, tx, ramifications - age and activity level affects* Describe the mechanism of injury and patient presentation of the most common tendon tears in the shoulder (acute and traumatic rotator cuff tear, long head of the biceps and pectoralis major tears) Describe the mechanism of injury and presentation of anterior versus posterior glenohumeral joint dislocations Recognize the clinical presentation, evaluation and pathogenesis of an acromioclavicular joint injury Recognize the clinical and radiographic presentation of glenohumeral joint arthritis Describe how the age and activity level of the patient affects the pathology of shoulder injuries and the treatment plans. Recognize the presentation and treatment of distal biceps ruptures Recognize the treatment and presentation of tennis elbow "lateral epicondylitis" and medial epicondylitis Recognize the most common nerve compression syndromes in the arm, contrast between injury or compression at a high level versus low and understand the pathophysiology Recognize the most common connective tissue disorders in the hand (Dupetryns, trigger fingers, Dequervains) and describe their pathophysiology and etiology.

Rotator cuff injury - acute/traumatic (surg) vs *degenerative tears (most) - SITS: supraspinatus (onto greater tuberosity, suprascapular n), infraspinatus (onto greater buerosity, suprascapular branch to infraspinatus travels thru spinoglenoid notch), teres minor (greater tuberosity, axillary n thru quadrangular space), subscapularis (*lesser tuberosity, internal rotation, prevent anterior instability humerus) - muscles stabilize humeral head against glenoid, compressing into fossa - impingement/tendonitis: pinches acromion when *raising arm (tx = rest/ice/activity change/NSAID/PT) - partial rotator cuff tear: usually fibers on joint side (same, PT most imp, sometimes cortisone, surg if 3-6 mos tx failed) - full rotator cuff tear: torn away from insertion (urgent esp in younger, wait maybe no repair, rec surg esp if weakness) - acute, traumatic tears: fall/slip/dislocation - pts older than 40 more likely to tear rotator cuff if they dislocate shoulder - degenerative, attritional tear: aging - impingement/tendonitis: can be age related or overuse, esp if overhead athlete/laborer - mostly 40+ (if younger usually traumatic) - trauma = acute pain after fall, degenerative gradual pain w/o trauma - can be quite painful, mostly lateral over deltoid - dull tooth ache, can be sharp - *night pain v common - overhead activities/reaching activities painful, poss weakness here - PEx: poss ecchymosis in acute, poss atrophy supra/infraspinatus in chronic; poss ttp over greater tuberosity, oft other and pain over AC joint/biceps groove; passive ROM should be intact w poss pain, active ROM oft lost in acute but chronic maintain -- check fwd elev/ext/int rot - test fwd elev, int/ext rot - strength limitations depend on tear; impingement test, drop arm test + if lg *supraspinatus tear - XR: AP, outlet/scapular lateral, axillary views - MRI = gold std for rotator cuff tear - US may be screener, depending - chornic might not enlarge w time, acute do - degenerative, pain, worse overhead, night pain, supraspinatus, PROM ok AROM gone, weak, MRI std, PT, if acute-- urgent surg Biceps injuries - long head biceps ruptures vs distal biceps - long head usually degenerative, conservative - distal biceps ruptures/pec major ruptures -> loss strength w/o surgery - oft tears due to eccentric contraction of biceps while lifting - almost always traumatic, rare in F - long head biceps inserts on supraglenoid tubercle, inside GH joint, travels up bicipital groove - short head biceps inserts on coracoid, along w coracobrachialis (conjoined tendon) - distal biceps = short + long head biceps, inserts on radial tuberosity of proximal radius - musculocutaneous n - LHB: proximal pain, some ecchymosis poss - distal biceps; pain/swelling/ecchymosis, oft weakness with supination/lifting - PEx: poss ecchymosis, swelling - LHB: popeye deformity: LHB retracting inferior - distal biceps rupture = reverse popeye - whole biceps retracting superior - ROM intact tho painful - strength WNL for LHB rupture - distal biceps rupture: substantial supination weakness (at elbow, biceps = 1ry supinator!), flexes elbow w brachialis but this won't be v weak - LHB tx: conservative, rest/ice resume when comfort, no surg - distal biceps: very active pts usually want surgery for full supination strength, less active pts may accept some weakness to avoid surg - LHB: no functional ramifications but always "popeye" deformity - distal biceps: lose supination strength w/o surg. if surg success, need to do soon otherwise pt will have rev popeye and permanent supination strength loss Pectoralis major/tendon tears - bench press/heavy lifting, M, overload - pec major = 2 heads = larger/stronger sternal head, smaller clavicular head - lateral and medial pec nn - strong internal rotator and adductor of GH joint - often only sternal head tears off - from insertion on lateral aspect of bicipital groove - remember lat dorsi inserts on medial aspect/floor bicipital groove - "pop", sudden give, bruising, deformity, weak - PEx: deformity (pec major retracts from insertion on humerus and balls up in chest), substantial ecchymosis, ttp at pec insertion and pec, ROM intact though painful poss, internal rotation strength may be limited - younger/active = urgent surg - longer = more retracted/scarred/harder - older/less active can consider rehab (but then also less likely to even have - if missed/late = perm deform and loss IR strength Acromioclavicular joint injuries - clavicle meets acromion, small joint surrounded by thick capsule/ligaments - stability from coracoclavicular ligaments; conoid and trapezoid ligaments hold down - can sprain ligaments or tear (complete tear = grade III) - most from direct blow- athletes, bikers - pain over AC joint - PEx: clear deformity/prominent distal clavicle if ligaments torn, none if sprained; TTP over joint; only limited due to pain; actual joint injury = no detectable loss strength or motion - usually dx from hx/PE - radiograph: will show prominent distal clavicle-- if CC ligaments torn, clavicle loses its vertical stability and you see it elevated compared to acromion on XR - initial rest/ice/activity, mod w pain change, PT - if completely torn can't heal - most can avoid surg- only consider if sx despite care - cosmetic deformity; some manual/overhead c/o rare weakness/pain - if all ligaments torn = grade III injury - "shoulder separation" Shoulder instability - static stabilizers: glenoid labrum, GH ligaments (thickened at joint capsule) - dynamic stabilizers: RC muscles keep HH centered on glenoid; periscapular muscles position scapula and glenoid to support HH - not much bony support = instability - anterior disloc: HH anteriorly oft with inferior component; more common; oft contact sports/fall/load to arm that is abducted and externally rotated - posterior disloc: HH posterior; more commonly missed; electrocution/seizure/trauma/fall/MVA - severe pain, inability to use arm; feel locked/out of place; poss numb/ting (more with anterior); some can see deformity (esp anterior) w fullness of dislocated HH - PEx: may see fullness anteriorly or posteriorly, often globally tender in acute dislocation, global loss AROM PROM due to mechanical blockage of HH, posterior (hard dx) classically w severe loss AROM and passive external rotation; strength hard to assess: check NV and document, esp axillary n - always start w XR (true AP, scapular lateral, axillary view (MUST axillary bc very easy to miss posterior on 2 views, v commonly missed in ER); MRI for tendon/ligament/capsule/labral pathology after shoulder is reduced - anterior dislocation: Bankart lesion: classic; tear of anterior/inferior labrum; ~95% dislocations, never heals in correct position: pt loses stabilizing (bumper) effect of labrum; prone to recurrent dislocations - anterior dislocation: RC tears: older (40+) pts prone to sustaining traumatic RC tear; must eval for this after shoulder is reduced, or will miss; more likely to tear subscapularis (which is anteiror structure stressed by anterior dislocation) - tx: reduce shoulder after documenting NV exam and direction dislocation with XRs; recheck NV; sling w rehab when comfortable - long-term tx: pts <20 = high rate recurrent dislocation; pts >40 low rate recurrent dislocation but more likely tear RC, often large due to trauma, oft tear subscapularis (DON"t MISS FIX URGENTLY) - if >40 and RTC ok, rehab, do well - if dislocation missed, damage to joint can be severe - can lead to complex surg and perm functional change - in older: if RTC ok, ok - in younger: esp if still sports, likely dislocate again if labrum not fixed. recurrent dislocations can -> further damage of joint and onset arthritis at early age - PEx post-dislocation: RTC testing esp in 40+, in young do apprehension test - std lift-off test: isolated subscapularis (which is powerful internal rotator, solely responsible for lifting hand off back) - belly press exam: subscapularis integrity - can hurt too much to do lift-off so this is another; place hands on belly, press in and bring elbows out, cannot do if subscap torn - anterior apprehension test (for younger): abduction and external rotation (as position of risk for anterior shoulder dislocation) - concern for anterior instability - relocation test (after apprehension): push posteriorly on shoulder, push HH back into joint so pt feels better = + Glenohumeral arthritis - similar to OA, DJD other joints, but not as common as hip or knee - usually no inciting event though occasionally years after trauma like fx/disloc - c/o pain, stiffness, loss fn, crepitus-- seek help when interfere with activities - PEx: inspection usually nl, palpation often ttp along joint line, limited AROM/PROM oft with crepitus (pop/click), strength intact but poss limited due to pain - XR: fold std = joint space narrowing, osteophytes (on HH), subchondral cysts, sclerosis - Tx: activity modification, NSAIDs, heat, PT, cortisone injections, shoulder replacement surg Lateral and medial epicondylitis - lateral = "tennis elbow": tendinosis of ECRB (extensor carpi radialis brevis) at its origin at lateral epicondyle; no inflammatory cells present; "angiofibroblastic dysplasia"; pinpoint ttp @ lat epicondyle, pain with resisted wrist extension; c/o lateral arm pain worse with repetitive activity esp wrist ext; median age 41, M = F; ice, NSAIDs, activity mod, PT, counterforce brace (unloads muscle/tendon unit - just distal to elbow), corticosteroid injection, time, surg after >9-12 mos sx (debridement of pathologic tissue - medial = "golfer's elbow"; tendinosus of pronator teres and FCR (flexor carpi radialis); medial elbow pain worse activity esp forceful wrist flexion/pronation; ttp medial epicondyle; pain w resisted wrist flexion/forearm pronation; may have concurrent cubital tunnel syndrome (irritation ulnar n since cubital tunnel sits just posterior to medial epicondyle); same tx Nerve compression syndromes in the UE - dysfunction of peripheral n caused by pressure - sensory, motor, autonomic - signal conduction along n altered due to: ischemia and impaired venous return, intraneural edema, decreased axoplasmic transport, membrane instability, fibrosis - risk factors: F, endocrine disorder like DM/hypothyroid/MPS, RA, gout, infection, inc age, obesity, EtOH, occupational, repetitive use, idiopathic? - most common = median n, ulnar n, radial n, suprascapular n, axillary n (think thru consequences of compression) - high vs low compression: *when compression n, all muscles innervated by n distal to site are affected, so any muscles above are ok* - ex compression radial n at mid-humeral level - all radially innervated muscles distal to that are affected (wrist/thumb/finger extensors) but triceps is spared as branches from radial n to triceps come off above site of compression - carpal tunnel syndrome: numb/ting/pain assoc w compression of median n @wrist; median n = C6-T1 from medial and lateral cords of plexus, - carpal tunnel (affects median n): digit 1-3, numb/ting, night/activity, hand/wrist/forearm pain, when flexed, weakness, dropping things; classic signs = median n compression test, Tinel's test (tapping on n reproduce sx), Phalen's test (max flex wrist = pressure on median n and sx, if chronic then thenar muscle wasting, 2 point discrimination, monofilament, vibration, dx w nerve conduction study (sensory/motor latency), EMG, tx splint to extend, cortisone injection, surg to release transverse carpal ligament and remove pressure - cubital tunnel (affects ulnar n): less common than carpal, similar - ulnar n @elbow: C8-T1, terminal continuation of medial cord of plexus; - ulnar n sits in cubital tunnel, just behind medial epicondyle - elbow flexion numb/ting, Tinel's, max flexion test, intrinsic muscle atrophy abduction adduction, tx similarbut no inject - surg w or w/o transposition n Connective tissue disorders in the hand (aggravating but not bad): Trigger Finger - "stenosing tenosynovitis" or finger flexor tendone; discrepancy in size b/t tendon and flexor tendon sheath -> thick and tendon can't slide well gets caught; flex can't extend, pain at A1 pulley, locking, most common thumb - risk factors F, DM, hypothyroid, gout, renal but anyone - tx corticosteroid injection (50-90% success), surg release A1 pulley - can be painful de Quervain's Tenosynovitis - stenosing tenosynovitis of 1ts dorsal compartment = abductor pollicis longus and extensor pollicis brevis (APL, EPB) ** think of other dorsal compartments** - radial sided wrist pain worse by thumb motion/ulnar deviation, swelling; Finkelstein's test (ulnar deviation wrist with thumb in palm reproduces) - 1st dorsal compartment can be subdivided in 2, EPB in own compartment in up to 34% population - tx: thumb spica splint (extending), corticosteroid injection, surgery - = release of 1st dorsal compartment and subcompartment -

42 y/o m, basketball, pushed off foot while playing d, fell to ground. Felt pop. Couldn't stand up on trying. Ttp over distal gastroc and calcaneal tendon. Palpable divot, +Thompson test. What's wrong?

Ruptured Achilles tendon

The most common pathogen seen in MSK infections is: - Strep group B - E coli - Staph aureus - Clostridium difficile

S aureus

The lateral border of the femoral triangle is the? Sartorius m Inguinal lig Adductor magnus m Adductor longus m Pectineus m The actions of this muscle at the hip are? What structures run through the femoral triangle?

Sartorius Hip flexion, abduction, external rotation NAVL: femoral n, femoral a, femoral v, lymph nodes

List the muscles of the anterior compartment of the thigh What are the general actions of the anterior thigh? What is the innervation?

Sartorius m *1st and most superficial* Quadriceps femoris mm (Rectus femoris, Vastus medialis oblique, Vastus lateralis oblique, Vastus intermedius) *BE VERY COMFY WITH* Iliopsoas m (really from posterior abd wall, but enters into anterior thigh proximally) Hip flexion and knee extension Femoral n (L2-L4) *Psoas major innervation = anterior rami L1-L3

Deltoid m: - location - O? I? - action - innveration

Scapular/shoulder O: anterior = lateral 1/3 clavicle, middle = acromion scapula; posterior = spine of scapula I: deltoid tuberosity of humerus major *abductor shoulder, anterior fibers also flex, posterior fibers also extend Axillary n (C5, C6)

Which of these soluble factors inhibits bone formation? BMPs WNT IGF-1 Sclerostin

Sclerostin inhibits WNT/b-catenin signaling, which is critical to bone formation

Which muscle is considered the great extensor of the head and neck? Longissimus capitis m Semispinalis capitis m Trapezius m Semispinalis cervicis m Splenius capitis m

Semispinalis capitis m attaches to head. With its vertical line of pull and overall size, it is the strongest and most efficient head and neck extensor

What's the epiphyseal plate/growth plate?

Separates metaphysis and epiphysis during growth Responsible for lengthening of long bone Noted by epiphyseal line in adults

What's the diaphysis?

Shaft of long bone = marrow cavity surrounded by compact bone

How do you describe distracted or shortened displaced fx?

Shortened = bones overlapped Distracted = bones pulled apart

What does the limb look like in a posterior hip dislocation?

Shorter and internally/medially rotated

1408 Describe and demonstrate the anatomical landmarks of the clavicle, scapula, humerus, radius, and ulna. Identify the bones of the wrist and hand and their relative positions. Identify wrist bones that are commonly injured (scaphoid and lunate) and predict functional impairment following such injury. Secondary Learning Objective 1409 Demonstrate the relationship of bones and joints of the upper limb with soft structures and describe how fractures and dislocations can injure these soft structures. Predict the functional consequences of such injuries. Secondary Learning Objective 1410 Describe and demonstrate the fascial compartments of the upper limb and the muscle groups that are contained within these compartments. Explain the functional importance of these fascial compartments. Secondary Learning Objective 1411 Describe and demonstrate the origin, course, and distribution of the major arteries and their branches that supply the shoulder, arm, and forearm. Explain the importance of anastomoses between branches of these arteries at the shoulder and in the upper limb. Secondary Learning Objective 1412 Demonstrate the sites at which pulses in the brachial, radial, and ulnar arteries can be assessed. Secondary Learning Objective 1413 Describe and demonstrate the course of the major veins of the upper limb. Define and contrast the function of deep and superficial veins. Identify common sites of venous access and describe key relationships. Explain the relationship between venous and lymphatic drainage. Secondary Learning Objective 1414 Describe and demonstrate the organization of the brachial plexus, its origin in the neck, and continuation into the axilla and upper limb. Secondary Learning Objective 1415 Describe the origin, course, and function of the terminal branches of the brachial plexus. Name the muscle groups and individual muscles that these nerves supply as well as their sensory distribution. Predict the consequences of injury to these nerves and describe how to test their functional integrity. Secondary Learning Objective 1416 Describe the boundaries and contents of the axilla. Describe the anatomy of the axillary lymph and explain their importance in the lymphatic drainage of the breast, the skin of the trunk and upper limb, and in metastasis. Secondary Learning Objective 1417 Describe the anatomy of the shoulder girdle and joint and describe the movements of the pectoral girdle. Identify the muscles responsible for these movements and summarize their attachments and nerve supply. Secondary Learning Objective 1418 Describe the factors that contribute to the stability of the shoulder joint and explain functional and possible pathological consequences of its dislocation. Secondary Learning Objective 1419 Describe the anatomy of the elbow joint. Demonstrate the movements of flexion and extension and identify the muscles responsible for these movements. Summarize the bony attachments of these muscles and their innervation. Secondary Learning Objective 1420 Describe the anatomy of the superior and inferior radio-ulnar joints. Demonstrate the movements of supination and pronation and identify the muscles responsible for these movements. Summarize the bony attachments of these muscles and their innervation. Secondary Learning Objective 1421 Describe the anatomy of the wrist. Describe and demonstrate movements of the wrist and identify muscle groups responsible for these movements. Describe the relative positions of tendons, vessels, and nerve at the wrist in the context of injury to these structures. Secondary Learning Objective 1422 Describe and demonstrate the movements of the thumb and the fingers. Describe the location, function, and nerve supply of the muscles and tendons involved in these movements, differentiating between muscles of the forearm and intrinsic muscles of the hand. Secondary Learning Objective 1423 Explain the main types of grip (power, precision, and hook) and the muscles and nerves involved in executing them. Secondary Learning Objective 1424 Describe the location and function of the retinacula of the wrist and the tendon sheaths of the wrist and hand. Explain carpal tunnel syndrome. Explain how infection can spread within the tendon sheaths. Secondary Learning Objective 1425 Describe the arterial supply of the hand. Demonstrate the Allen test and the anatomical structures that contribute to collateral circulation in the hand.

Shoulder PEx: Inspection: - disrobe - skin changes -

Flattened deltoid = key clinical sign for ...?

Shoulder dislocation - oft in anterior direction so anterior inferior component

1. Glenohumeral joint 2. Humeral head 3. Acromioclavicular joint 4. Scapular spine 5. Glenoid 6. Coracoid

Shoulder: Axillary view

1. Scapular spine 2. Skin/fat 3. Deltoid 4. Humeral head 5. Humerus 6. Coracoid 7. Clavicle 8. Acromioclavicular joint

Shoulder: lateral view

Explain how muscles attach to bone Explain the types of muscle contractions ID and differentiate b/t skeletal, cardiac and smooth muscle tissue and the connective tissue layers associated with muscle fro histological images Describe the general hierarchy of muscle organization, form organ thru the major fibrous protein components of sarcomeres (the contractile units) ID the ultrastructural structural components of the sarcomere in electron micrographs and describe the major protein components of the A band, Z line, H band, I band and M line Describe the differences b/t the sarcomere in the relaxed and contracted state and the molecular basis of contraction and the sliding filament hypothesis ID the t-tubule - sarcoplasmic reticulum complex in electron micrographs, and describe their general function in excitation-contraction coupling Differentiate b/t muscle fiber types and the utilization of metabolic energy Define the distinct morphological characteristics of smooth muscle, the differences in organization of contractile proteins in smooth muscle cells in comparison to striated muscle, and the distribution of smooth muscle cells in the body> Define the distinct morphological characteristics of cardiac muscle, functional properties of the intercalated disc and distribution of cardiac muscle in the body

Skeletal - voluntary - strong quick contractions - striated - longitudinal = striping pattern - large elongated cylindrical cells - syncytial (multinucleated) cells - 10-100 micrometers dm - length depends on size muscle organ - nuclei @periphery, right underneath plasma membrane Cardiac - involuntary - only in myocardium - strong quick contractions - striated but lil broken up - not as many myofibrils in there - (elongated) branching cells also breaks up striations - uni-nucleated in center cell - 15 micrometer dm cell - 85-100 microm length - cells connected an pulling each other, and CT - where connected, must stay also gap junctions for communciations, so see darker staining intercalated disks - functional syncytium Smooth - involuntary - weak slow contractions - mostly walls hollow organs (gi, resip, urinary, repro) and change shape/size passawways blood vessels iris eye - striated pattern gone - nonstriated - fusiform (wide in middle, tapered at both ends - at widest area = nucleus = uninucleate - depends - like to line up in sheets in which all same direction Characteristics muscle tisue: excitability/irritability thermogenesis bc inefficient conversion

Which superficial v courses posterior to the lateral malleolus before ascending up the posterior leg? Basilic v Great saphenous v Small saphenous v Median cubital v Cephalic v

Small saphenous v

In the advanced stages of osteomyelitis, the changes in the bone can be very similar to those of a tumor: T/F

T

The "unhappy triad" consists of injury to the ACL, medial meniscus, and MCL: T/F

T

What are the two functional subdivisions of the nervous system?

Somatic nervous system (SNS) - somatic sensory system carries sensation (afferent fibers via posterior root and horn) - somatic motor system innervates skeletal muscle (voluntary) (efferent via anterior horn to root) Autonomic nervous system (ANS) - innervates smooth muscle, viscera, glands - sympathetic + parasympathetic

Why is a LP considered a safe procedure at L3-L4 or L4-L5 levels? - Bc spinal cord ends at L5 - L2 S2 T10 T12

Spinal cord typically ends at L2, making LP safe below termination of spinal cord at L3-L4 or L4-L5

Describe the origin from spinal roots, formation, and initial branching of a typical spinal nerve using thoracic spinal nerve as an example Describe the anatomical relationships of the meninges to the spinal cord, and the ventral and dorsal roots, particularly in relation to cord and root compression

Spinal n: - just lateral to dorsal root ganglion - *posterior (dorsal) root + anterior (ventral) root* - forms and exits vertebral column thru intervertebral foramen - splits into posterior ramus (innervate deep/intrinsic back mm [epaxial], assoc. skin) and *anterior ramus (innervate limbs, trunk = hypaxial) - contents: somatic sensory neuron, visceral sensory neuron, somatic motor neuron, autonomic motor neuron (all afferent and efferent together)

Where do you do intragluteal injections and why?

Split posterior thigh vertically in half Split posterior gluteal region into lower third (lower 1/2 buttock down), middle third (upper 1/2 buttock), and third above that Inject into supero-lateral quadrant/upper lateral quadrant = gluteus medius m Don't want to hit sciatic n Or, index finger on ASIS, thumb to AIIS, hand splayed Safe site b/t 2nd and 3rd digit = gluteus medius

Patellar ligament

Strengthens joint anteriorly

Describe and demonstrate the origin, course, and distribution of the major arteries and their branches that supply the upper limb.

Subclavian a -> (cross 1st rib) *Axillary a -> (past teres major m) brachial a *Brachial a gives off Deep a of arm in proximal arm Brachial a continues to proximal forearm, splits at head radius in cubital fossa -> radial and ulnar aa *Radial a deep to brachioradialis m, leaves anterior cmpt wrist -> deep palm hand *Ulnar a: down medial forearm -> palm hand

1. lateral facet of patella 2. trochlear groove 3. lateral femoral condyle 4. fibula (lateral side) 5. medial femoral condyle 6. medial facet of patella

Sunrise view of knee

Levator scapulae m - location - origin? insertion? - action? - innervation?

Superficial back superior angle scapula to transverse processes C1-C4 (splits into 4 slits, may be covered by splenius?) elevates scapula dorsal scapular n & a (seen on deep surface muscle on ditsal portion closer to scapula)

Latissimus dorsi m - location - origin? insertion? - action? - innervation?

Superficial back (large, v superficial, lower posterior back, courses superolaterally, ypertrophied in swimmer) O: spinous processes T7-T12, thoracolumbar fascia and iliac crest I: anterior proximal aspect humerus GH adduction, medial rotation, extension thoracodorsal n thoracodorsal a

Trapezius m - location - origin? insertion? - action? - innervation?

Superficial back (most superficial, superomedial portion in diamond pattern/shoulder) O: external occipital protuberance, nuchal ligament, spinous processes of C7-T12 I: upper = lateral 1/3 of clavicle; middle = acromion, inferior: spine scapula upper: elevates scapula / bilateral contraction helps neck extension middle: retract scapula inferior: depress scapula accessory n (CN XI) (proprioception from anterior rami C3, C4) transverse cervical a accessory n and superficial branch transverse cervical a run on anterior surface muscle (just deep)

Rhomboid major & minor mm - location - origin? insertion? - action? - innervation?

Superficial back muscles - deep to trapezius, minor more superior Minor: inferior portion ligamentum nuchae and spinous process C7-T1 Major: just inferior on spinous processes T2-T5 i: medial border scapula (minor above spine, major below) retract (adduct) scapula, assist in scapular elevation dorsal scapular n & a (like levator scapulae)

Gluteus minimus m - group? - origin? - insertion? - action? - innervation?

Superficial gluteal m O: External surface ilium (inferior) I: Lateral aspect greater trochanter femur Hip abduction & internal (medial) rotation Superior gluteal n (deep to medius)

Gluteus medius m. - group? - origin? - insertion? - action? - innervation?

Superficial gluteal m O: External surface ilium (superior) I: Lateral aspect greater trochanter femur Hip abduction & internal (medial) rotation) (keep pelvis level while walking, palpable) Superior gluteal n

Gluteus maximus m.: - group? - origin? - insertion? - action? - innervation?

Superficial gluteal m. O: posterior ilium & sacrum, sacrotuberous ligament I: Iliotibial tract, gluteal tuberosity of femur Action: Hip extension (especially when flexed), Hip external (lateral) rotation Innervation: inferior gluteal n *EXCEPTION*

What does the posterior leg do? What innervates it? What supplies blood to it? What muscles are in the posterior compartment of the leg?

Superficial group = plantar flexion Deep group = (weak) plantar flexion + inversion Tibial n Posterior tibial a & fibular a Superficial group: gastrocnemius, soleus, plantaris Deep group: popliteus, tibialis posterior, flexor hallucis longus, flexor digitorum longus

Gastrocnemius m: - group/location? - origin? - insertion? - action? - innervation? - vasculature?

Superficial group of posterior leg O: medial head = posterior surface, superior to medial condyle of femur; lateral head = posterior surface, superior to lateral condyle of femur *both heads cross knee joint* *crosses ankle* I: calcaneal (Achilles) tendon onto posterior calcaneus Powerful plantar flexor, weak knee flexor Tibial n Posterior tibial a

Soleus m - group/location? - origin? - insertion? - action? - innervation? - vasculature?

Superficial posterior leg - deep to gastroc O: soleal line (posterior tibia) [and also fibular head] I: calcaneal tendon to posterior calcaneus Plantar flexion Tibial n Posterior tibial a "fish" fillet

Plantaris m - group/location? - origin? - insertion? - action? - innervation? - vasculature?

Superficial posterior leg - muscle belly starts just superior to lateral head gastrocnemius - runs inferomedially between gastrocnemius and soleus O: supracondylar ridge of femur (just superior to lateral head gastroc) I: calcaneal tendon to posterior calcaneus Weak knee flexor, weak plantar flexor ~ size thumb but much flatter - "fools nerve" "freshman nerve", mostly tendon Tibial n Posterior tibial a

When evaluating a joint, especially the hip and shoulder, often 3 views of the joint are necessary. T/F

T

Describe and demonstrate the course of the major veins of the upper limb. Define and contrast the function of deep and superficial veins. ID common sites of venous access and describe key relationships. Demonstrate the sites at which pulses in the brachial, radial, and ulnar arteries can be assessed.

Superficial veins: *Cephalic v: up lateral UE, drains into axillary v in deltopectoral triangle *Basilic v: up medial forearm, dives thru deep brachial fascia in arm -> axillary v Medial cubital v: branch b/t cephalic and basilic, in cubital fossa, venipuncture Brachial pulse @elbow Radial pulse @lateral wrist Ulnar pulse @medial wrist

Describe and demonstrate the course of the major veins of the lower limbs. Define and contrast function of deep and superficial veins. ID common sites of venous access and describe key relationships

Superficial veins: Great saphenous & Small saphenous vv. - great saphenous v: dorsal venous arch, anterior to *medial malleolus, up medial leg/thigh; drains into femoral v in femoral triangle - small saphenous v: from *lateral side dorsal venous arch, posterior to lateral malleolus, up posterior leg, dives deep in popliteal fossa, drains into popliteal v

What are the 3 groups of back muscles and what do they do?

Superficial, intermediate, deep Superficial & intermediate affect scapula, humerus, aid in respiration Deep acts directly on spine and/or head (innervated by posterior rami)

Describe the relationship of nearby aa. and nn. wrt piriformis m.

Superior gluteal a. and n. = superior to piriformis Inferior gluteal a. and n. = inferior to piriformis Sciatic n = inferior to piriformis

Describe the borders of the femoral triangle

Superior: Inguinal ligament Lateral: Sartorius m Medial: Adductor longus m Floor: Iliopsoas & pectineus m

What are the boundaries and contents of the popliteal fossa?

Superomedial: semimembranosus, semitendinosus Superolateral: biceps femoris m Inferior: medial and lateral heads gastrocnemius Tibial n (usually most superficial), common fibular n (along boundary biceps femoris tendon), popliteal v (superficial to a) & a (usually little medial), small saphenous v should course b/t heads, dive deep into popliteal v

A 42 y/o carpenter sustains a distal biceps rupture. What elbow strength will he primarily lose if he does not have this surgically fixed? supination extension pronation flexion

Supination Biceps = primarily supinator, more so than elbow flexor, so supination loss will be detectable

Describe the knee joint: - type of joint - which bones involved? - joint capsule consists of? - what movements possible? - what does its strength depend on - what does patella articulate with? list ligaments - what's the blood supply to the knee - what's the innervation to the knee - bursae?

Synovial, (modified) hinge joint Between distal femur and proximal tibia Joint capsule = fibrous + synovial Movements: knee flexion/extension, internal & external tibial rotation *not true hinge, like elbow *capsule excludes anterior and posterior cruciate ligaments (excluded from synovial membrane = intra-capsular but extra-synovial) - depends on surrounding mm & ligaments from femur to tibia (quadriceps femoris m) patellar retinacula = vastus medialis & lateralis aponeuroses; helps with articulation (patellofemoral) patella + femur (not with tibia at all) knee joint = femur + tibia Patellar ligament: anteriorly LCL, MCL ACL, PCL Oblique popliteal ligament Arcuate popliteal ligament - genicular anastomosis (superior lateral genicular a, superior medial genicular a, inferior lateral genicular a, inferior medial genicular a, all from poplitel a after adductor hiatus from femoral a) - obturator & saphenous nn - 12+ bursa around knee, incl infrapatellar, prepatellar, suprapatellar - prepatellar bursitis = most common

What kind of joint is the hip joint? What bones make up the socket joint? What is the joint capsule made of? What movements does it do?

Synovial, ball & socket Head of femur, acetabulum of pelvis Fibrous (outer), synovial (inner) Flexion/extension, Abduction/adduction, External (lateral) rotation/internal (medial) rotation, circumduction

Following injury, muscle repair begins with a degenerative stage and proceeds into a regenerative phase. T/F

T

Because the pectoral muscles and biceps muscles are superficial, the deformity of the muscle when there is an acute tendon tear is easy to see on a pt: T/F

T Biceps ruptures: classic popeye deformity Pec ruptures; retract medially w bunched up muscle belly on chest wall

A fracture pattern that is a comminuted fracture pattern shows multiple pieces of bone at the break site T/F

T Comminuted fx pattern more often from high E injury. Higher force = more bone shattering when force applied. Lower E injury often simple fx, often non-displaced.

Because ibuprofen attenuates prostaglandin synthesis and PGE2 activity, chronic use can be associated with gastric erosions and bleeding. T/F

T Gastric erosions and bleeding can be associated with chronic use of ibuprofen

Typically when one presents with a RTC tear, they can lose AROM but not PROM T/F

T Losing PROM typically mechanical block cause. So rare in RTC pt.

Pts under 20 are at high risk for recurrent instability after they have had an initial dislocation: T/F

T Ramifications of dislocation in younger pts is not only will they have a bankart lesion, but they will keep dislocating

Symptomatic RTC tears often cause pain at night time: T/F

T This is a classic finding of RTC tears. Lack of sleep is often what drives many pts to finally seek tx

Medial epicondylitis is tendinosis of the FCR and pronator teres: T/F

T remember medial anatomy at elbow

What's the difference b/t T1 MRI and T2 MRI?

T1: water dark (fat white, water gray) T2: H2O bright, fat gray

A pt presents with R shoulder dislocation. When you perform your PEx, you would expect a loss of AROM and PROM as he has a mechanical blockage to ROM due to dislocation T/F

T: if pt dislocated = mechanical blockage = block both AROM and PROM

What does the posterior root do?

Takes sensory n to CNS

Describe the true ankle joint

Talocrural joint - synovial hinge joint (plantar and dorsi flexion) - tibia, fibula, talus Lateral ligaments (injured the most, *inversion ankle sprain* w plantar flexion) - *anterior talofibular ligament*: resists anterior translation of talus relative to tibia - calcaneofibular ligament: resists excessive inversion - posterior talofibular ligament: (posterior lateral malleolus to posterior talus) resists posterior translation talus Medial ligament = deltoid ligament - ant & post tibiotalar part - tibionavicular part - tibiocalcaneal part - from medial malleolus - injury by eversion ankle sprain (bruising and pain but swelling atypical) Blood supply: branches of fibular and ant/post tibial aa Innervation: tibial n, deep fibular n Pott fx: forceful eversion

Match terms to definitions: Tendinopathy Tendinitis Tendinosis Tenosynovitis General term including any condition involving tendons Degenerative process within the substance of tendons Inflammation of the synovial lining of tendons Inflammation of a tendon associated with partial tearing

Tendinopathy - General term including any condition involving tendons Tendinosis - Degenerative process within the substance of tendons Tenosynovitis - Inflammation of the synovial lining of tendons Tendinitis - Inflammation of a tendon associated with partial tearing

Match the following terms to definitions Tendons Ligaments Strain Sprain Collagen-based structures connecting muscles to bones Collagen-based structures connecting bones to other bones Injury to a ligament Injury to a muscle or tendon

Tendons - Collagen-based structures connecting muscles to bones Ligaments - Collagen-based structures connecting bones to other bones Sprain - Injury to a ligament Strain - Injury to a muscle or tendon

The anterior spinal artery ____ - is a branch off the vertebral a - runs circumferentially around the spinal cord - is paired - supplies only the cervical portion of the spinal cord - is responsible for supplying the entire spinal cord

The anterior spinal a is a branch off the vertebral a Anterior spinal a descends out foramen magnum and down anterior median fissure of spinal cord

What does the ligament of the head of the femur contain?

The artery to the head of the femur

Pedicle (bony pillars that attach vertebral arch to vertebral body)

The black arrow in the picture is pointing to what portion of the vertebra? Transverse process Superior articular process Lamina Vertebral foramen Pedicle

What happens to the width of the epiphyseal plate during growth?

The epiphyseal plate remains the same width during the growth of an individual So cartilage growth must = bone tissue replacement (amt new cartilage made in zone proliferation must = activity in zone ossification OR activity chondrocytes needs to = activity bone cells) As bone lengthens, epiphysis pushed further away, like chondrocytes chased by osteoclasts At epiphyseal plate closure, hormones signal for end of chondrocyte division and bone replaces all of the cartilage -> epiphyseal line (bone cells have caught up)

Describe the tibiofibular joints

The proximal fibular does not articulate with the femur syndesmosis joints Proximal tibfib joint - proximal ant/post tibfib ligaments - not much movement or injury Distal tibfib joint - distal ant & post tibfib ligaments, crural interosseous ligament - "high ankle sprain": MOI of forcced dorsiflexion w in or eversion = spreading apart tib/fib - usually anterior tibfib lig - painful, not much swelling - stressed with each step

Developmentally speaking, what are vertebrae formed by?

The upper and lower halves of two successive sclerotomes and intersegmental tissue Myotomes bridge intervertebral discs

Pt presents with inability to plantarflex ankle and flex toes. Inversion of ankle also weak. What n could be involved in this pathology? Sciatic n Deep fibular n Femoral n Tibial n Superficial fibular n Where would this injury likely be located? Hip / ankle / thigh / knee / not enough to know

Tibial n (all plantar flex, post compat by tibial n) Knee

What's the sciatic n consist of?

Tibial n + common fibular n

What provides dynamic support to the foot? What provides passive support to the foot?

Tibialis posterior, tibialis anterior, flexor hallucis longus, fibularis longus, intrinsic plantar muscles Planar aponeurosis, long plantar ligament, short plantar ligament, plantar calcaneonavicular ligament

Which portion of the stress-strain curve represents the straightening of crimped collagen fibers during loading? Toe, Linear, Failure?

Toe: marks time in which the crimps in the fascicles are being straightened. The later linear region occurs when the collagen molecules themselves are being tensioned

List the muscles of the posterior compartment of the arm What innervates them? What do they do?

Triceps brachii, Anconeus mm Radial n (C5-T1, C6-8 for Triceps only) Extend elbow

Cinacalcet is used to treat hyperparathyroidism; it inhibits PTH secretion; it can be associated with nausea. T/F

True

Denosumab is a monoclonal antibody (MAB) indicated for tx of osteoporosis; however, it may result in an increased risk of infections. T/F

True

What are tendons mostly made of?

Type I collagen

A pt comes to your clinic with severe back pain and leg pain in the LLE. He has weak quadriceps (3/5 motor grade) on the left as well as absence of the quadriceps reflex. He is unable to dorsiflex his foot and c/o parethesias in his perianal region. He has had difficulty with his urination over the last 3 days. The next step is: - refer to neurology - give him a Medrol dose pack (steroids) and ask him to f/u in 3 weeks - send him for PT and epidural injections - get an urgent MRI - reassure and see him in a few hours

Urgent MRI - sx concerning for cauda equina needs to be dx with MRI

Name a way to determine bone age in development

Use bone ossification sites for information about fetal growth and gestational age

What is the primary function of the transverospinales muscle group (semispinales, multifidus, rotatores mm) if contracting bilaterally? Vertebral column lateral flexion Head flexion Vertebral column extension Vertebral column stabilization Head rotation

Vertebral column extension Based on the posterior location and line of pull, when contracting bilaterally this group of muscles will assist with vertebral column extension

List the primary medications that affect bone metabolism and describe their mechanism of action and therapeutic rationale. For bone-homeostasis pharmacotherapies, describe: - primary mechs of action - indications/uses - common toxicities - cross-reactions with other medications prototypic member, indication, mech, toxicity - vit D; bisphosphonate; hormone; SERMs; RANKL i; Ca R agonist, minerals

Vitamin D, Metabolites, Analogs - ex: *calcitrol* (PO), paricalcitol (PO, parenteral), ergocalciferol/*cholecalciferol* (PO) - for osteoporosis, osteomalacia, malabsorption, renal failure, vit D-dependent Rickets 1 & 2 - mech: ^ intestinal Ca2+ absorption, bone resorption and renal Ca2+ and PO43- reabsorption, raising serum concentrations of both *Ca2+ and PO43-*; dec PTH - side effects: *hypercalcemia and/or hypercalciuria* Bisphosphonates - ex: *risedronate, alendronate (PO)*, pamidronate (parenteral) - for osteoporosis, tx hypercalcemia associated with malignancy or Paget's - mech: *potent inhibitors of bone resorption* by inhibiting farnesyl pyrophosphate synthesis -> suppresses osteoclast activity - bad eff: *gastric & esophageal irritation with PO, adynamic bone*, poss renal failure, rarely osteonecrosis jaw, rarely femoral sub-trochanteric fx Calcitonin (hormone; parenteral, nasal spray) - for osteoporosis, hypercalcemia; first-line for Paget's with bisphosphonates - mech: *binds GPCRs -> suppresses osteoclastic bone resorption, dec serum Ca2+ and PO43- by actions at kidney and bone* - bad: *gastric erosion/bleeding* (PGE2 dec and prostaglandin synth dec) Teriparatide, recombinant PTH (SQ) (hormone) - for osteoporosis - mech: *stim bone turnover* - bad: *hypercalcemia, hypercalciuria* SERMs (selective estrogen R modulators) - ex *raloxifene (PO)* - for osteoporosis - mech: interact with estrogen R -> inhibit bone resorption w/o stimulating estrogen breast or endometrial Rs - *increased risk thromboembolism* RANKL inhibitors - Denosumab (parenteral) - for osteoporosis - mech: MAB binds to RANKL, prevents from stimulating OC differentiation and fn -> dec bone resorption - inc risk infection Ca R agonist - ex *cinacalcet (PO; concentrates in parathyroid gland)* - treat *2ry hyperparathyroidism (chronic kidney disease or parathyroid carcinoma)* - mech: *activates Ca-sensing Rs -> inhibits PTH secretion* - nausea Minerals (Ca, phosphate = PO, parenteral) - for osteoporosis or osteomalacia from deficiencies, as needed for mineralization - hyperphosphatemia -> ectopic calcifications (osseous tissue in various soft tissues) - hypercalcemia -> milk-alkali syndrome, renal failure, CV problems - IV PO43- fastest, but need careful monitoring in case of hypocalcemia, ectopic calcification, acute renal failure - slow IV Ca2+ for hypocalcemia, but too rapid -> cardiac arrhythmias

Quadriceps and patellar tendon rupture image

What does this XR show?

What you should know in radiographs of fractures: How to describe a fx

What is x-ray of? What view is it? What is broken? (which bones?) Describe x-ray, what you see, fx pattern Any other studies needed? Skeletal maturity Do NOT need to know: definitive tx, surgical fixation Fx pattern in detail: - location: epiphysis (near joint, intra-articular), metaphysis (jn of diaphysis and epiphysis) or diaphysis (shaft) - complete or incomplete (bent/cracked like in kids)? if complete, simple (clean break) or comminuted (shattered) - orientation fx line: transverse, oblique, spiral or more longitudinal - non-displaced? displaced? (translation, angulation, rotation, distraction, shortened) - open or closed?

Comminuted (shattered, higher E), complete

What kind of fx is this?

Complete Adult bones break! humerus

What kind of fx is this?

Incomplete Pediatric bones bend! Radius/ulna in child

What kind of fx is this?

Simple (clean break), complete AP of skeletally mature humerus Complete transverse fx of diaphysis Simple (non-comminuted) Slight apex lateral angulation

What kind of fx is this? Describe this X-ray

What needs to be considered in deciding is a tumor is bad or good in a radiograph?

Where? Which bone? What is tumor doing to bone? What is bone doing to tumor? Any type mineralization in lesion? Periosteal reaction Pattern of destruction Borders Matrix Soft tissue masses

DMD vs Becker's MD

X-linked R, M >> F mutation in gene for dystrophin (cytoplasmic protein that forms a dystrophin-associated protein complex linking the cytoskeleton to the ECM) DMD: no functional dystrophin, disease moresevere w earlier onset (<5 y vs 8-25)

Why is it important to adequately evaluate dislocations with proper x-rays so that you know the direction of the dislocation? (pick all that apply) a) so you know what NV structures may be compromised by the dislocation b) it is not important to know the direction of the dislocation - brute force will reduce any dislocation c) so you don't break off the humeral head when using the wrong reduction technique d) so you know which technique to use to reduce the dislocation

a, c & d

Brachialis m

anterior arm O: anterior humerus I: tuberosity ulna powerful elbow flexor (small contribution from radial n to distal lateral portion not imp) - to see do pronated elbow flexion musculocutaneous n brachial a

Coracobrachialis m

anterior arm O: coracoid process I: mid-medial humerus flexes and adducts shoulder musculocutaneous n brachial a

Radiographic evaluation is not as good for: a. detection of osteoporosis b. assessment of fx c. initial bone tumor evaluation d. evaluating arthritis e. initial evaluation of a painful joint

a. detection of osteoporosis Radiographs are always the initial choice, and are great for bone lesions, fx, dislocation, tumors, and arthritis. They aren't great for detecting bone density loss, soft tissue/fluid issues, osteomyelitis, or detailed 3D fx understandings

Identify a conceptual framework of disability in the context of human diversity, illness, life span, and the social and cultural environments. Integrate concepts of patient functioning, environment, and disability

activity limitations: difficulties an individual may have in executing activities Americans with Disabilities Act (ADA): prohibits discrimination against people with disabilities in employment, transportation, public accommodation, communications, government activities, telecom (Office of Disability Employment Policy in Dept of Labor helps not enforces, so Equal Employment Opportunity Commission, Dept of Transportation, and Fed Communications Commission, DOJ enforce) disability: physical/mental impairment that substantially limits 1+ major life activities; record of such; being regarded as such (Major Life Activities = caring for self, manual tasks, see, hear, eat, sleep, walk, stand, lift, bend, speak, breath, learn, read, concentrate, think, communicate, work; Major bodily function = immune, cel growth, digest, bowel, bladder, neuro, brain, resp, circ, endo, repro; ) - impairment, activity limitations, participation restrictions environmental factors: physical social attitudinal environment in which people live and conduct lives health: state of complete physical mental social well-being, not merely absence of disease or infirmity; resource for everyday life, not objective of living impairments: problems in body fn or structure that affect person's ability to engage independently in aspects of day to day life International Classification of Functioning, Disability and Health (ICF): health and related domains from body, perspectives by list of body fns and structure and list of domains of activity and participation - also list of environmental factors Natl Survey of Children with Special Health Care Needs: also info on access to quality health care, care coordination of services, access to a medical home, transition services for yough, impact of chronic conditions on family participation restrictions: problems individual may experience in involvement in life situations Surgeon General's Call to Action: healthcare that enables persons with disabilities to live fully - providers treat whole person, educators teach, public see abilities, community to help - incentivize *peopel with disabilities have healthcare nedds like everyone else - pts say either overfocus on disability losing CC or fail to take into account - need holistic and resepct -- 25% difficulty WHO: in UN, global health - provider assumes disability as tragedy - social issues and factors - each individua value ICF: - provides framework to describe - disability = universal (all can experience) *- disability = umbrella term denoting mimpairment, activity limitations, participation restrictions* *~20% americans = have diability *- shift focus from cause to impact* 50 mill Americans, most at some time 15% children and yough have special need 15^% worl pop - inc with age - lack preventive care - esp children

Biceps brachii m - location - origin, insertion - action - innervation

anterior compartment of arm O: short head = coracoid process, long head = supraglenoid tubercle I: radial (bicipital) tuberosity flexes and supinates forearm, assists in shoulder flexion (strongest supinator) musculocutaneous n brachial a

ACL

anterior cruciate ligament - intra-capsular, extra-synovial - prevents anterior translation of tibia on femur - main stabilizer in extension - weaker than PCL (named for where it ends up, acl ends inferior portion anteriorly)

Subclavius m - location - origin, insertion - action - innervation

anterior thorax 1st rib to inferior clavicle depresses clavicle subclavian n not seen on all bodies

Pectoralis major m - location - origin, insertion - action - innervation

anterior thorax O: clavicular head = medial clavicle; sternocostal head = sternum, costal cartilages of ribs 1-7 I: intertubercular (bicipital) groove shoulder flexion, adduction, internal rotation lateral & medial pectoral nn

Pectoralis minor m - location - origin, insertion - action - innervation

anterior thorax, deep to pec major O: ribs 3-5 I: coracoid process of scapula action: protract (like pulling fwd) & depress scapula medial pectoral n2

A 22 y/o football player dislocated his R shoulder in the game Friday night. What structure did he most likely injure? superior labrum rotator cuff anterior/inferior labrum shoulder capsule subscapularis long head biceps

anterior/inferior labrum: younger pts injure labrum and sustain bankart lesion. Older pts more often injure RTC

Think about the cutaneous nerves of lower extremity: Describe the origin and sensory distribution of the sural and saphenous nerves

anterior: genitofemoral n (anterior) lateral cutaneous n of thigh lateral cutaneous nerve of thigh anterior cutaneous branches of femoral n cutaneous branch of obturator n (medial) lateral sural cutaneous n (from common fib n) saphenous n (from femoral n) superficial fibular n -> dorsal digital n lateral dorsal cutaneous n of foot (termination of sural n) deep fibular n posterior: superior clunial n (posterior rami) medial clunial n (posterior rami) lateral cutaneous n of thigh (posterior branches) inferior clunial n lateral cutaneous n of thigh posterior cutaneous n of thigh saphenous n (from femoral n) medial sural cutaneous n (from tibial n) sural n medial plantar n lateral plantar n Sural = more lateral Saphenous = more medial

What are the boundaries of the axilla pyramid? How do you amke it disappear? What are its contents?

anterior: pectoralis major, pectoralis minor lateral wall: intertubercular sulcus medial wall: serratus anterior ~ 4th rib posterior wall: teres major, latissimus dorsi, subscapularis, scapula Disappears with arm abduction Axillary sheath - axillary a & branches - axillary v, etc - nerves of brachial plexus - lymphatics

Serratus anterior m - location - origin, insertion - action - innervation

anterolateral thorax O: lat aspect ribs 1-9 I: medial border anterior scapula *protracts scapula*, holds scapula against thoracic wall long thoracic n major scapular protractor, if weak, scapula pops up against thorax

What is the most crucial x-ray view of the shoulder to obtain when evaluating shoulder pain after any traumatic injury to the shoulder? clavicle views true AP AC joint views scapular lateral axillary view

axillary true AP and scapular lateral sometimes don't show dislocations well, but an axillary will show it every time

What does the cephalic vein drain into?

axillary v located in lateral upper limb

You are repairing the distal biceps in one of the most famous weight lifters. Therefore, you don't want to accidentally cut any anatomic structures that you should not. So, what is the correct order, MEDIAL TO LATERAL, of the contents of the antecubital fossa? a) medial epicondyle, pronator teres, brachial artery, median n, distal biceps, brachioradialis, lateral epicondyle b) medial epicondyle, pronator teres, median n, brachial a, distal biceps, brachioradialis, lateral epicondyle c) medial epicondyle, flexor carpi ulnaris, median a, median n, distal biceps, ECRL, lateral epicondyle d) medial epicondyle, pronator quadratus, median n, distal biceps, supinator, lateral epicondyle e) medial epicondyle, pronator teres, brachial a, median n, distal biceps, brachioradialis, supinator, lateral epicondyle

b) medial epicondyle, pronator teres, median n, brachial a, distal biceps, brachioradialis, lateral epicondyle

When describing a hip dislocation, you should describe: a) the direction of hip flexion b) the location of the femoral head relative to the acetabulum c) the direction the knee is pointed, relative to the acetabulum d) the location of the acetabulum, relative to the femoral head

b) the location of the femoral head relative to the acetabulum

relatinoship b/t lateral plantar n & a and foot?

b/t FDB quadratus plantae mm (1st and 2nd layers) deep br plantar n courses around with plantar arch

Where's safe for an LP?

below L2, since spinal cord ends there place pt in flex to help open space b/t L vertebrae L3-L4 or L4-L5

With a hematoxylin & eosin (H&E) stain, calcified cartilage stains ___, while newly formed bone stains ___. blue/purple; pink/red blue/purple; sage/green pink/red; blue/purple pink/red; sage/green sage/green; pink/red

blue/purple; pink/red

What maintains the structural integrity of the hip joint?

bony integrity capsular & ligamentous integrity (iliofemoral, ischiofemoral, pubofemoral) muscular strength (medial & lateral rotator mm.)

Describe the deltopectoral triangle

cephalic v thoracoacromial a lateral pectoral n

Describe the organization of hyaline cartilage- including cell types involved in generating and maintaining the tissue and the composition of ECM

chondroblasts make ECM (more elliptical) chondrocytes also make ECM (can undergo mitosis) (chondroblasts surrounded by ECM) (lacunae = cave space they're in) (more rounded) ECM = GAG, proteoglycans - 95% ECM, lots H2O perichondrium - assoc w some, dense CT, surrounds cartilage , lots vessels nerves (for growth maintenance cartilage) catailge = avascular how cartilage grows: appositional growth (add to extant surface, new chondroblasts made) interstitial growth (internal expansion growth, proliferation chondrocytes, formation isogenous groups) isogenous groups = recent mitosis = growing cartilage

Describe the organization of hyaline cartilage, including cell types involved in generating and maintaining tissue, and composition of ECM. Explain the changes in cartilage with age. Describe the role of synovial tissue and synovial fluid. List the components of normal synovial fluid.

chondrocytes: produce and maintain ecm ecm = water (80% at surgac, 65 deep zone, compression moves), proteoglycans (chondroitin sulfate = most > keratan sulfate > dermatan sulfate; most are aggrecans -- change w age increase keratan sulfate and condroitin 6 instead of 4), collagen (50% dry weight, most *type II collagen in articular*) superficial tangential zone trnsitional/middle zone deep zone: proteoglycan conc - stacked in columsn calcified zone *characteristis of synovial fluid in diff type effusions table *know nl.

Define tendonitis, tenosynovitis, and tendinosis and differentiate between them on the cellular level Define tendon rupture Differentiate between an acute (traumatic) tendon rupture versus a chronic (degenerative/attritional) tear; compare and contrast the different principles of treatment List the phases of and concepts in tendon healing Describe the mechanism of injury for ligament injuries List and describe the types of injuries/sprains (Grade 1-3) Contrast intra versus extra-articular ligament tears and healing potential List the key characteristics of the phases of ligament healing Describe the main forms of muscle injury Describe the process of degeneration and regeneration in injured muscle

collagen > microibril subfibril fibril fascicle with crimps then tendon tendinitis: tendon inflammation; partial tear/healing response (inflam cells, granultion tissue, evidence prior degenerative change freq seen) tendinosis: tendon degeneration; much more common than tendinitis; more with inc age; no healing response but focal necrosis, collagen disorg, mucoid ground substance appearance, +- neovascularization, no inflam cells tenosynovitis: inflammation of synovial sheath surrounding a tendon; can be aseptic or infected; numerous inflam cells invade lining, tendon minimally invovled tendon rupture: often overload; tendon less crimping than ligament can stretch less w/o injury; - toe: crimps straighten - linear: measure stiffness thru this slope - failure: ultimate load seen here - rupture usually preexisting degenerative change acute tear: biceps, triceps, pectoralis, achilles, usually operative repair; end to end repari of direct reinsertion of avulsions to native bony attachments is frequently possible chonic tears: chornic degenrative change can -> gradual loss tendon integrity without acute trauma, most common in rotator cuff tendons, often asx if other muscle have adpated to perform function asx usually no tx. if sx focus on compensation nonop (like deltoid after tear supraspinatus). if fails, surfical maybe but often compromised by lack of nl quality tissue for repair. healing; - inflammaotry (3-5 day, fibrin clot made); some fibroblasts present - fibroblastic (1-6 weeks, production collagen and matrix to form disorganized tendon "callus"), bridges, then more paralell by 3 wks - remodeling (6 wk-9 mos, reorg collagen into x-linked org pattern) - immobilize joints in inflamm period and early remodling to let new collagen made and prevent injury - load progress increased ligament: - connect bones, stabilize joints esp at extreme of motion - joints in weird directions like w dislocation - injury = sprain / strain = msucle/tendon ligamemt grade: - 1 = damaged not apreciabley stretched, no joint laxity, yes pain 2: damaged, streatched but continuous, laxity, pain 3: completely ruptured poss dislocation, laxity w/o endpoint extra articular ligmanets can heal better - commonly injured extra articular ligaments = collateral ligaments knee, collateral ligaments elbow, ankle ligaments - intraarticular worse healing bc fibrolyti and anticoagulative environment in joint - commonly injured intraarticular ligaments: ACL PCL (cruciate) and scapholunate ligaments wrist - usually no heal w/o surgery etraarticular ligament 4 healing phases: inflam response, cell proliferation, remodeling, scar maturation - healed ligaments more bulky, less strong indirect muscle injury: outside force, acute strain and delayed onset muscle soreness - more common, loaded oddly, from microscopic to partial tea to complete rupture, crosing 2 joints esp prone like hammies, rectus femoris, gastrocnemius - delayed muscle soreness 24-72 hours following intense exercise, 1-5 days, rsponds nsaids direct injury: direct lac or contusion to muscle skeeltal muscle relatively stable, low turnover, but can repair repair: degenerative stage (necrosis, inflam, , regenerative stage (growoht fusion new myogenic cells - smaller central nuclei new fibers myositic ossificans - calcification within muscle tissue -> bone formation outside nl bone = heterotopic ossification - assoc w trauma to muscle

What innervates the short head of the biceps femoris m?

common fibular division of sciatic n

What happens in notches?

compression posterolateral shoulder pain atrophy of supraspinatus and infraspinatus mm

What ligaments provide vertical stability to the AC joint? coracoclavicular (conoid and triangular) coracohumeral coracoacromial coracoclavicular (conoid and trapezoid) pectoralis major

coracoclavicular (conoid and trapezoid)

Corticosteroids (prednisone, cortisone, etc.) are often used for severe, symptomatic gout. Which one of the following statements regarding corticosteroid-use for tx of chronic gout is incorrect? a) The widespread gene regulation (via corticosteroid pharmacotherapy) causes catabolic and anti-anabolic effects as well as immunosuppressive effects and potentially can cause adrenal insufficiency with chronic corticosteroid pharmacotherapy. b) Triamcinolone, betamethasone and dexamethasone are longer-acting corticosteroids c) Corticosteroids have anti-inflammatory properties due to their intercellular regulation of genes d) A "side benefit" of corticosteroids is improvement in osteoporosis development and symptomology e) The shorter-acting corticosteroids (prednisone, cortisone) are available in PO formulations

d) A "side benefit" of corticosteroids is improvement in osteoporosis development and symptomology = INCORRECT Chronic use of steroids can lead to osteoporosis development or worsening

If fx is described as an incomplete fracture, what is the most likely reason for that? a) the patient has very osteoporotic bone and thus - the bone is more ductile and bends rather than breaks b) the break is due to a low energy injury and thus only broke part of the bone c) the patient did not fall hard enough to break the bone all the way through d) the break most likely occurred in a child, who is more likely to bend/buckle or only break one cortex

d) the break most likely occurred in a child, who is more likely to bend/buckle or only break one cortex

What is adductor hallucis innervated by?

deep branch of lateral plantar n

*Piriformis m.* - group/location? - origin? - insertion? - action? - innervation?

deep gluteal m. O: Anterior sacrum (thru greater sciatic foramen) I: Greater trochanter Hip external rotation *& abduction* Nerve to piriformis - largest of deep lateral rotators

Describe the suboccipital triangle

deep muscles extension/rotation of atlanto-axial joints innervated by suboccipital n (posterior rami C1) medial border: - rectus capitis posterior major: from C2 spinous process to occipital bone, extends atlanto-occipital and atlanto-axial joints (and rotate same side) - rectus capitis posterior minor: from posterior tubercle C1 to occipital bone; extend/rotate ONLY atlanto-occipital joint (head only) lateral border: - obliquus capitis superior: from transverse p C1 to occipital bone, extend and laterally flex atlanto-occipital joint Inferior border: - obliquus capitis inferior: from spinous process C2 to transverse process C1, rotate atlanto-axial joint Contents: - suboccipital n - deep to this = vertebral a

where's fibularis longus tendon?

deep! on bone

What's spongy bone called in flat, irregular, short and sesamoid bones?

diploe, which is sandwiched between compact bone have endosteum, periosteum then red marrow or yellow marrow b/t

When should you document your NV exam when you are the physician treating a pt with a shoulder dislocation (or any joint dislocation for that matter) in the ER? a) on arrival and after reduction b) on arrival to ER and every 10 minutes after until you reduce joint c) don't document - then you can't get sued if axillary n is not firing after reduction d) document NV exam on arrival and pre-reduction

document your NV exam on arrival and after reduction With any reduction maneuver of any joint, document NV exam prior to reduction and then again after you have reduced the joint

Anterior leg: - what does it do? - what innervates it? - what artery supplies it? What are the muscles of the anterior compartment of the leg?

dorsiflexion deep fibular n anterior tibial a (and v) Tibialis anterior Extensor digitorum longus m Extensor hallucis longus m Fibularis tertius m

When describing a fracture pattern, you describe the position of what? a. describe the position of the bone proximal to the fracture b. describe the angulation of the proximal bone c. describe the rotation of the bone at the fracture site d. describe the position of the most displaced bone fragment e. describe the position of the bone that is distal to the fracture

e. describe the position of the bone that is distal to the fracture

Lateral epicondylitis is tendinosis of which tendon?

extensor carpi radialis brevis "mobile wad of 3" = wrist extensors at elbow = brachioradialis/ECRL and ECRB, but only ECRB is involved in tennis elbow (lateral epicondylitis)

Pick the tendons that are classically involved in deQuervain's tenosynovitis extensor pollicis brevis abductor pollicis brevis adductor pollicis longus flexor pollicis longus abductor pollicis longus extensor pollicis longus

extensor pollicis brevis & abductor pollicis longus = tendons in the 1t dorsal extensor compartment

AC sprain / separated shoulder

fall on outstretched arm hit tip shoulder?

What innervates the anterior compartment of the thigh?

femoral n

Marfan syndrome mutations

fibrillin FBN1 tall slender, lon thin limbs and face pectus excavatum or carinatum joint hyperflxibility dilattion/dissection aorta ascending, dislocation lens of eye

Describe the key roles and fn of the meniscus Describe the vascular anatomy and zones of the meniscus Describe the funciton of the intervertebral disc Describe the affect of aging on the intervertebral disc

fill gap b/t tibia femur, maintain fluid film for lube, cyclic compression for nutrient distribution - type i coll most meniscus avascular

What's pes planus?

flat foot can be from injury, overstretching spring ligament (fallen arches: 2ndry to dysfunction of tibialis posterior m, spring ligament fails to support talar head, loss of medial longitudinal arch, lateral deviation of forefoot)

When a pt sustains a direct blow to the quadriceps and you are concerned they are at risk for developing myositis ossificans, it is better to splint them in ---?

flexion

What is the FABER test and what does a positive test indicate?

flexion/abduction and external rotation @hip pain @SI joint if pathology @SI joint

The acetabulum is lined with:

hyaline cartilage

Summarize gout

hyperuricemia -> uric acid crystals In joints: -> pain, swelling, stiffness, deformity, impaired movement In kidneys: -> damage/scarring, poss renal insufficiency, ultimately failure

Describe epidemiology of crystal-induced arthritis conditions. Recognize historical and physical exam characteristics of gout and calcium pyrophosphate deposition disease (CPPD). List predisposing factors for gout and CPPD. Recognize testing or imaging necessary for the diagnosis of gout and CPPD. Compare basic treatments for gout and CPPD.

hyperuriemis - >7.5-8 mg/dl at 37C, solubility urage in plasma is 7 mg/dl (solubility dec as T dec) productin uric acid req xanthine oxidase* humans don't have uricase, elim thru gi and kidney - urate enter passively bacteri degrade = 1/3 - kindy urate filterd by glomerulus, most reabsorbed in prox tubule, secreted reasorbed, excreted into urine, only 8-12% ultimatedly excreted *Urate tranporters req in tubuel; URAT1, Glut9 immune systems primed against uric acid - underexcretion = most common pathophy for gout - cause under: renal insuff, diuretics, low dose asa, htn, cyclosporine, ketoacidosis, lead nephropathy, idiopathic (estrogen uricosuric so premenopausal women less likely to develop gout) over: congental enzyme abnl (lesh nyhan w HGPRT def, PRPP synthetase overactive); lymphoprolfierative, hemolysis psoriasis, glycogen storage disease, Etoh, hypoxia, idiopathic classic acute gout: acute onset (hrs) usually mono or oligoarthritis red hot exquisitely painful joitn any joitn can be involved Podagra = classis = big toe fever, leukocytois will eventuallyr esolve w/o tx but prefer shorten period triggers- surgery, etoh, inc purine in diet, fluctuation uric acid level intercritical gout: sx free period b/t epiodes - w/o tx, probably mroe freqeutn , longer, polyarticular, chornci tophaceous gout: - uric acid deposit - tophic in other tissues - ear colder than rest body - synovium, subchondrla bone, olecranon bursae, infrapatellar tendon, achilles tendon, ear pinnae - can look like RA, freq attacks, bone destruction and degenerative arthritis common in adcanced cases

What's the shoulder girdle?

incomplete bony ring scapulae, clavicles, sternum (no humerus!)

Winged scapula

injury to long thoracic n or weakness see medial border lift up despite doing same action with both arms

List the syndesmosis ankle ligaments

interosseous membrane (+ crural interosseous ligament) anterior (inferior) tibiofibular ligament, posterior (inferior) tibiofibular ligament

What can tibialis anterior and posterior mm do together?

invert ankle

What ligament in the hip is the primary restraint to posterior dislocations? - ischiofemoral ligament - transverse acetabular ligament - pubofemoral ligament - ligamentum teres - iliofemoral ligament

ischiofemoral ligament = primary restraint to posterior dislocations. Weaker than iliofemoral, so more posterior dislocations in part bc of this

What is the triangle of auscultation bordered by?

lat dorsi trap rhomboid major center @ 6th intercostal space

LCL

lateral (fibular) collateral ligament - tendon of popliteus m separates it from lateral meniscus - splits biceps femoris tendons - protects from a varus force (medial blow)

Describe the developmental origins of the axial and appendicular skeleton

lateral plate mesoderm -> appendicular skeleton paraxial mesoderm + neural crest -> axial skeleton (vertebrae, ribs, part skull / face, part skull)

In a patellar dislocation, the patella generally dislocates ___ relative to the femur - superiorly - medially - laterally - inferiorly

laterally

MCL

medial (tibial) collateral ligament - superficial and *deep* attachments on tibia and medial meniscus - protects from valgus force (lateral blow)

relationship b/t medial planter n & a?

medial plantar n bigger than laterl plantar n medial plantar a is smaller than lateral plantar a deep to abductor hallucis m

Name contents of carpal tunnel *KNOW*

median nerve FDP x 4 FDS x 4 FPL median n

Where do clavicle fx usually occur?

middle 3rd

What is trabecular bone responsible for?

mineral homeostasis

Describe epidemiology of osteoarthritis (OA). Recognize history and physical exam characteristics of OA. List predisposing factors for OA. Recognize testing or imaging needed to diagnose and manage OA. Describe basic approach to treating patients with OA.

most common, 20+ million in us, by 75, all radiographic most common cause adult disat in us primary/idiopathic - no predisposing, often assoc w aging secondary: tend affect youger, end result alternate 9like truama, inflam arthri, cyrstl, infeciton, metab disor) oa cartilage - frayed, fibrillated, chrondrocytes biger: imbalanced matrix catabolism by chondrocytes na dfialure to heal cartilage damage agign: more senescent secreoty cels, oxidative stress, less GF and GF response so less synth/repair matrix, more formation advanced glycation end products - inc fatigue failure, red size aggrecan and cartilage hydration inc olagen cleavage - red resiliciency and tensilse strength - inc calcification matrix - PEx: - 1-few jts, has typicl locations oft asymmetric, small effusions, low lvel synovitis, bony anlargement joint, pain on rom joint, loss AROM PROM, crepitus on ROM joint, deformity, absnce extra-articular signs disease - most common loacations: hand CMC/PIP/DIP, hip, knee, foot, spine (C, L) lab - exclude other, w inflam, synovial fludi lowwbc - radiographic; joint space narrowing, ostephyte formation, subchondral scleorisis, subchondral cysts, goal: alleviate pain, improve fn nonparm, pharm, surg NONPHARM: WEIGHT LOSS, lifestyle mod, PT (gait), OT, splint/brace, decives like cane/walker, tai chi, exrcies pharm: - topical (capsaicin, nsaid) - po: acetaminophan, nsaid, tramadol, narcotic - intraarticular - glucocorticoid, viscosupplementaiton with hyaluraonic acid *glucosamien chondroitin no clear benefit - no drugs retard/revers progression OA OA txs

What's another name for a muscle cell?

muscle fiber or myofiber

Common dorsal digital vs proper dorsal digital nn?

nerves split up either side toe/MT adjacently = common dorsal digital n (MT = common) up to toe = proper dorsal digital n (a or n around toe, more distal)

Understand the clinical implications of nl and abnl ms development in tx of pts Describe the embryologic development of the ms system Describe the specific embryologic mechs utilized during ms development

nl fertilization outside uterus in outer 1/3 tube zygote migrates and divides morula (D4), then compaction trophoblast (outer) and embryoblast (inner, at one end) and blastocyst cavity = blastocyst - hatching? then within embryoblast = epiblast (dorsal, covered by hypoblast and growing from cytotrophoblast) and hypoblast (ventral, middle, covering) - migrates to uterus - trophoblast -> outer syncytiotrophoblast (embeds in) and inner cytotrophoblast (ring around) by D6 - embeds in endometrium by end of D6 = implantation - *epiblast* develops amniotic cavity, *hypoblast* (cupping that) develops 1ry umbilical vesicle (aka former blastocyst cavity), with extraembryonic mesoblast cupping this - epiblast -> embryo, hypoblast -> part of extraembryonic appendages Week 3: - mesoblast made from ectoblast cells cells flowing over primitive streak - then epiblast/derm becomes ectoblast/derm (dorsal) with mesoblast/derm (middle/3rd germinal layer) and endoblast/derm (replacing hypoblast, ventral) - epiblast cells form ectoblast, mesoblast and intraembryonic endoblast, while hypoblast cells give rise to extraembryonic endoblast (umbilical vesicle and allantois) - mesoblast: paraxial (somites), intermediate (urogenital), lateral plate mesoderm = enclose intraembryonic coelom - notochord induces neuroblast differentiation = neurulation; median epiblast thickens, grooves, forms neural tube -> CNS longitudinal direction: cephalo-caudal folding transversal direction: lateral folding (rolling up)

The majority of ACL tears (75%) result from ___ injuries - non-contact - motor vehicle - firearm-related - contact

non-contact

What innervates the medial compartment of the thigh?

obturator n (medial thigh = area medial to femoral v)

Describe the sternoclavicular joint What does it include What are its ligaments?

only articulation b/t UE and axial skeleton sternal end clavicle, manubrium sternum, 1st costal cartilage synovial saddle joint articular disc anterior & posterior sternoclavicular ligaments = capsular; interclavicular ligament: strengthen superiorly costoclavicular ligament: limits elevation medial clavicle

ID and describe the morphological characteristics of osteoblasts, osteocytes, osteoclasts in hitsological images

osteogenic cells = in endosteum and periosteum bone = very vascularized osteoblasts: cuboidal/short columnar, like epithelial cells along surface, v basophilic cytoplasm bc producing lots proteins osteocytes: osteoblast stuck in matrix, maintain don't form matrix, cytoplasmic extensions thru canaliculi or via chondrocytes osteoclasts: v large, multinucleated, motile cells, ruffled border, bunch monocytes fuse together, v acidic

What's in bone?

osteogenic cells, osteoblasts, osteocytes, osteoclasts ECM = osteoid = type I collagen, BMP (bone matrix protein like GAGs), glycoprotein, osteocalsin (vit K dep, promotes calcification bone), osteonectin + hydroxyapatite crystals

Describe early vs chronic osteomyelitis. How might this appear in x-rays?

osteomyelitis = bone infection early stage: - will not see bone rxn - may see soft tissue swelling chronic osteomyelitis: - bone resorption - radiolucent lesions (cystic changes) - cortical resorption/periosteal changes x-ray of (advanced) osteomyelitis might look like a tumor. - must use hx, PEx, etc.

Describe the development of the vertebral column. What are the primary and secondary curvatures, and when do they develop?

paraxial mesoderm -> somite -> sclerotome -> vertebral column Week 4: sclerotome segments are separated by intersegmental mesenchyme Vertebrae formed by upper and lower halves of 2 successive sclerotomes and intersegmental tissue Myotomes bridge intervertebral discs Primary curvatures: thoracic, sacral - form during fetal period Secondary curvatures: cervical, lumbar - form after birth for holding head up and beginning to walk respectively

What does the appendicular skeleton derive from?

parietal layer of *Lateral plate mesoderm* -> appendicular skeleton + sternum

Pick all the correct reasons why a pt would lose active but not passive ROM of a joint: arthrofibrosis acute fx peripheral nerve injury spinal disease/compression of nerve roots dislocation too painful to use own muscles advanced DJD tendon tear

peripheral nerve injury, spinal disease/compression nerve foots, too painful to use own muscles, tendon tear loss AROM (not PROM) = pain, tendon disruption, neuro loss both = mechanical block like DJD, fx/dislocation, stiffness, intra-articular effusion

Triceps brachii m - location - origin - insertion - action - innervation

posterior arm O: long head = infraglenoid tubercle; lateral head = posterior humeral shaft, above radial groove; medial head = posterior humeral shaft, below radial groove I: olecranon of ulna *elbow extension; long = extension, adduction shoulder; lateral = recruited primarily against resistance radial n (C5-T1, C6-8 for triceps m only) *only long head crosses shoulder joint (long head more medial)

Anconeus m - location - attachments - action - innervation

posterior arm lateral epicondyle humerus to olecranon of ulna assists triceps brachii m radial n (C5-T1)

PCL

posterior cruciate ligament - intra-capsular, extra-synovial - prevents posterior translation of the tibia on the femur - main stabilizer in flexed knee

What innervates the deep back muscles?

posterior rami (dorsal primary rami)

A 33 y/o diabetic sustained a diabetic hypoglycemic seizure. When he comes to, he c/o L shoulder pain. What injury must you be sure to check for in this pt? posterior shoulder dislocation bankart lesion glenoid fx inferior shoulder dislocation rotator cuff tear

posterior shoulder dislocation: often occur after pt has had seizure or electrocution injuries

List the lateral ankle ligaments

posterior talofibular, calcaneofibular, anterior talofibular

Infraspinatus m - location - attachments - action - innvervation

rotator cuff O: infraspinous fossa I: middle facet of greater tubercle of humerus lateral (external) rotation of shoulder suprascapular n (C5, C6)

Supraspinatus m - location - attachments - action - innervation

rotator cuff - O: supraspinous fossa - I: superior facet of *greater tubercle* of humerus - initiates abduction arm (assists deltoid m) suprascapular n (C5, C6) - most often injured of all rotator cuff muscles

Teres minor m - location - attachments - action - innervation

rotator cuff O: lateral border scapula I: inferior facet greater tubercle humerus lateral (external) rotation shoulder axillary n (C5, C6) - hard to injure unless nerve impingement?

Subscapularis m - location - attachments - action - innervation

rotator cuff (biggest, only anterior) O: subscapular fossa I: lesser tubercle humerus internally (medially) rotates shoulder upper & lower subscapular nn (C5, C6, C7)

What prefixes mean muscle?

sarco-, myo-, mys-

What's the plasma membrane/plasmalemma of muscle called?

sarcolemma

What's the cytoplasm of muscle called?

sarcoplasm

What's smooth ER of muscle called?

sarcoplasmic reticulum

Teres major m - location - attachments - action - innervation

scapular/shoulder region O: inferior angle scapula I: intertubercular sulcus (bicipital groove) humerus internal (medial rotation, adduction, extension shoulder lower subscapular n (C5, C6) - "lats little helper"

List the intermediate back muscles

serratus posteiror sup and inf

Which muscles insert via the Achilles tendon? - soleus - anterior tibialis - flexor digitorum longus - gastrocnemius - posterior tibialis

soleus & gastrocnemius

List the true articulations of the shoulder complex

sternoclavicular joint (SC) acromioclavicular joint (AC) glenohumeral joint (GH) + scapulothoracic articulation

naming - all orsla and plantr liga - synovial -

subtalar joint: talocalcaneal joint inv and ever transverase tarsal joint - calcaneocuboid + talocalcaneonavicular tarsometatarsal jts intermetatarsal jts MTP jts IP joints

What is flexor digiti minimi brevis innervated by?

superficial branch of lateral plantar n

Posterior leg: - what does it do? - what innervates it? - what artery supplies it?

superficial group = plantarflexion deep group = plantarflexion, inversion tibial n posterior tibial a, fibular a

What goes through the suprascapular notch?

superior transverse scapular ligament - suprascapular n below; suprascapular a above (army navy)

Match the rotator cuff muscle to its innervation: supraspinatus infraspinatus teres minor subscapularis suprascapular n suprascapular n subscapular n axillary n

supraspinatus = suprascapular n infraspinatus = suprascapular n teres minor = axillary n subscapularis = subscapular n

acriomioclavicular joint

synovial gliding joint less movement than sternoclavicular oint articular disc loose fibrous joint capsule *acromioclavicular ligament = thickens joint capsule, strentchen superior aspect AC joint *coracoclavicular ligament* v improtant strencth - anchor clavicle to corcoid process, prevent superior displacement of lateral end of clavicle = conoid and trapezoid ligament - conoid ligament = posteromedial - trapezoig ligament = anterolateral

GH joint

synovial, ball and socket joint - very mobile, unstable large HH, shallow glenoid cavity (fossa), deepend by glenoid labrum loose fibrous joint capsule strengthened by rotator cuff mm -- cavity, surrounded by labrum synovial capsule around and fiborus capsule aorund that SITS supraspinatus, infraspinatus, teres minor subscapularis deltoid above long head triceps brachii into inferior aspect glenoid fossa " short head biceps brachii and coracobrachialis inset onto coracoid process pec major above this ---- glenohumeral ligaments: strengthen anterior aspects = superior, middle, inferior coracohumeral ligament: part of fibrous capsule, strengthen superiorlY transverse humeral ligament: holds long head briceps brachii tendon in place coracoacromial ligament: STRONG superior support - supraspinatus is underneath - can lead to wear and tear of that supraspinatus scapulohumeral muscles: deltoid, supraspinatus, infraspinatus, teres minor, subscapularis, teres major

What is the cortex of the bone responsible for?

thick outer coating skeletal homeostasis

What innervates the long head of the biceps femoris m?

tibial division of sciatic n

What inserts to navicular?

tibialis posterior m (and tib ant? though tib ant more medial cuneiform, base of 1st metatarsal)

What's in the quadrangular space? What borders this?

transmits: axillary n & posterior circumflex humeral a superior: teres minor inferior: teres major medial: long head triceps lateral = humerus

List the superficial back muscles

trap, lat dorsi, lev scapulae, rhomboid maj/min

What are key components of an X-ray description?

view (AP/lateral?) body part skeletally mature (adult or child) condition (fx, arthritis, nl, etc)

Lateral leg: - what does it do? - what innervates it? - what artery supplies it? What are the muscles of the lateral compartment of the leg?

weak plantarflexion, ankle eversion superficial fibular n perforating branches from fibular a, anterior tibial a (*does not have own a) Fibularis longus m, fibularis brevis m

What's in the triangular space? What borders this?

window: circumflex scapular a superior: teres minor inferior: teres major lateral: long head triceps

What's in the triangular interval? What borders this?

window: radial n, profunda brachii a (deep a of arm) (coursing around radial groove) superior: teres major medial: long head triceps lateral: humerus

Which imaging modalities are used in MSK? Describe their indications. What standard views are obtained?

x-ray (plain radiograph, film) - always initial choice, screening - bone lesion, fx/disloc, tumor, arthritic - cheap, ez - can't detect bone density loss well (osteopenia, osteoporosis-- advanced = inc radiolucency, changes in trabecular pattern and shape of vertebral bodies, cortical thinning, insuff fx), soft tissue (tendon tear, herniated disc, soft tissue tumor, subtle cartilage lesions), detailed 3D understanding fx, differentiate abscess/cellulitis/soft tissue edema, or pick up early osteomyelitis (can be subtle, hard to detect) - always: AP (ant-post), Lateral; 2-view min - joints: often need 3rd view, like oblique CT - more complicated fx (like 3D) - bone tumors - subtle changes in bone density/cortical bone - great visualization for complex *intra-articular* anatomy/fx - helpful in pelvis due to dimensions, bowel/gas MRI - soft tissues, *marrow abnl* (cartilage, meniscus, ligaments, tendons, spinal canal/nerve roots like for herniated disc, edema w/in bone (like osteomyelitis), osteonecrosis AVN, infection, stress fx, bone and soft tissue tumor) - coronals = AP / sagital obliques = lateral / axial cut similar to axillary view bone scan/nuclear medicine - radioactive tracer detects abnl areas of bone turnover - very sensitive with low specificity: detects any high turnover but can't tell you what's causing it (?) - bone tumors/mets, infection, occult fx/stress, early degenerative joint disease, fx, post-op changes

ID the spondyloarthropathies (ankylosing spondylitis, reactive arthritis, psoriatic arthritis, enteropathic arthritis) and the clinical features they have in common Describe the relationship between the HLA-B27 antigen and the spondyloarthropathies Relate the general approach to treatment of the spondyloarthropathies

~2% population spine arthropathy Key clinical features for all: - involve axial skeleton, esp SI joints - +peripheral arthritis- asymmetric, oligoarticular, lower > upper limbs - enthesitis - extra-articular features like mucocutenaus, uveitis - male predominance, familial clustering - assoc HLA-B27, absence of other ab SpA vs RA M>F, asymmetric, oligo, lower>upper, usually RF neg (tend not ab), C and LS spine Inflam back pain - before 45 y, chronic, oft more 3 mos, worse in am or rest, better w movement Enthesitis: inflam tendon, ligament, joint capsule at site attachment to bone clinical manifestations: tendonitis, fasciitis, dactylitis, spondylitis -> perioteal new bone formation/thickening Dactylitis Uveitis *anti-TNF agents usually most effective ts for mod to sev spondyloarthrotpathies

How is bone remodeling controlled?

~5-10% remodeled every year 1) Negative feedback loop for Ca homeostasis (in blood) (defines WHEN remodeling occurs) - calcitonin (if too much-- from parafollicular cells in thyroid gland, inhibits osteoclasts and encourages Ca deposition) - PTH (if too little, stimulate osteoclast) 2) Bone's response to mechanical stress and gravity (WHERE)