Orthopedics

what is the term for a partial or complete tear of a ligament?

sprain

SHOULDER EXAM - describe how to perform the following: - PE: SCAPULAR movements & ROM

Approximate normal shoulder range of motion: - Abduction: 180º - Adduction: 45º - Flexion: 135º - Extension: 45º - Internal rotation: 70º - External rotation: 45º Image: * Boldface indicates prime or essential mover(s). Numbers refer to figure. • Glenoid cavity moves superiorly, as in abduction of arm. Δ Glenoid cavity moves inferiorly, as in adduction of arm.

Anatomy of the Achilles tendon and superficial posterior calf muscles

- Note that the subtendinous bursa is also referred to as the retrocalcaneal bursa.

How should one read orthopedic x-rays?

1. verify pt. and view 2. systematically inspect soft tissue 3. inspect bones → follow bone capsule for step-offs, "pacman", and changes in density from one side to the other

dislocated shoulder: what nn worried about

?

what is a Boutonnier deformity?

A "boutonniere deformity" is a finger injury that makes the finger joint nearest the finger tip stay straight, and the finger joint in the middle of the finger stay bent.

47. interpret this film - what is the most likely Dx?

AP view of the pelvis demonstrates severe narrowing of the superolateral aspect of the right hip joint with subarticular cyst formation of the acetabulum and femoral head.

- identify the pathology found in this image

Anterior right shoulder dislocation in a young man: Note the prominent acromion, the rounded appearance of the shoulder, and the slightly abducted and externally rotated position of the right arm.

identify the Scaphoid arterial supply and nonunion risk

Arterial flow to the scaphoid, provided by the palmar carpal branch of the radial artery, can be disrupted by a fracture, increasing the risk of nonunion.

Definition of DIAPHYSIS

Definition of DIAPHYSIS: the shaft of a long bone—compare epiphysis

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. MONTEGGIA Forearm Fractures: - Etiology: - Imaging:

Etiology: trauma w/ twisting & tumbling Imaging: Monteggia fracture in a child: Lateral (Panel A) and anteroposterior (Panel B) plain radiographs showing proximal ulnar fracture with dislocation of the radial head (indicated by lack of alignment of the radial head with the capitellum).

a) Describe the spine exam history

Hx: - age: >50y; <20y - general: fever, chills, unexplained weight loss - pain: nocturnal, worse when supine → relieving, aggravating factors? - GI/GU: dysfxn? seen in cauda equina syndrome - trauma: MOI - CA

Croup lateral neck radiograph

Lateral neck radiograph showing subglottic narrowing and distended hypopharynx consistent with acute laryngotracheitis.

what are the 2 common plain radiographic views for identifying lower leg fractures?

Lower leg: - AP, lateral

Odontoid fractures

MOI: flexion loading w/ ant. displacement of dens; or extension loading (e.g forward fall onto forehead) Tx: halo, C-collar

2. what special maneuver is being performed in this image? - what is being assessed?

Neer's test for rotator cuff impingement. The arm is internally rotated, then passively lifted into full flexion with the scapula stabilised.

8. interpret the findings in this x-ray film

OA

Heel Spur

Plain film of the calcaneus bone demonstrates enlargement with inflammation around a spur at the insertion of the plantar aponeurosis inferior to the calcaneus bone (arrow).

- how can internal rotation of the hip be tested?

Prone internal rotation of the hip. This is the most sensitive test for intra-articular hip pathology. In this test, any inflammation of the hip manifests as decreased internal rotation of the hip.

What is a Femoral neck fracture?

Proximal femur fracture between the trochanters and the femoral head

describe how to test MOTOR function of the ULNAR NERVE

Resisted peace sign: Ulnar nerve function can be assessed by having patient make a peace sign and then maintain it against resistance, as shown in the photograph.

Ankylosing Spondylitis AS

SI joint fusion bamboo spine HLAB27+ M>F

how do you perform an Aspiration of shoulder effusion?

Schematic representation of the anterior approach to aspiration of a shoulder effusion

Cervical dermatomes

Schematic representation of the cervical and T1 dermatomes. There is no C1 dermatome. Patients with nerve root syndromes may have pain, paresthesias, and diminished sensation in the dermatome of the nerve that is involved.

a) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Septic Arthritis

Septic Arthritis:

SHOULDER EXAM - describe how to perform the following: PE: ROM (8) motions & involved muscles

Synergists/antagonists: Shoulder

- how is the FABER test performed? - what does it detect?

The FABER test is specific for sacroiliac joint pathology. A positive test causes pain at the sacroiliac joint when the patient lies supine with the ipsilateral ankle placed on the contralateral knee and mild downward pressure placed on the ipsilateral knee. (FABER = hip flexion, abduction and external r otation)

how do you perform a Reduction of patellar dislocation?

The knee is held in mild flexion. The distal thigh is fixed in place by an assistant. While slowly extending the knee, slight pressure is applied to the lateral aspect of the patella to reposition it medially.

Cervical Stenosis: pathophys: Sx: H&P: Tx:

cervical DDD/DJD or cervical arthritis HPI: neck pain w/ progressive difficulty in fine motor; grinding or popping PE: UMN findings w/ upper cervical myelopathy, hyper-reflexia Tx: NSAIDs, steroid injxn, surgical decompression usually w/ dorsal laminectomy Prognosis: pain may improve, goal is to prevent worsening of myelopathy which might require fusion

- **HILL SACHS LESION:

cortical depression in head of humerus; results from forceful *impaction of humeral head* against anterior-inferior glenoid rim when shoulder dislocated

What is a Smith's fracture?

distal radius fracture w/ palmar (apex dorsal) angulation - MOI: fall on a flexed hand

What is a Boxer's fracture?

fracture of distal 5th metacarpal at metaphyseal-diaphyseal junction (head) w/ palmar (apex dorsal) angulation - MOI: most often result of punching a person or wall

What is a Styloid fracture?

fracture of distal radius or distal ulna styloid process

Recognizing fractures and describing them online

http://www.learningradiology.com/medstudents/recognizingseries/recogfxsflashpage.htm

- **BANKART LESION:

injury of glenoid labrum** due to anterior-posterior shoulder dislocation and is usually indication for surgery

Lumbar HNP pathophys: Sx: H&P: Tx:

pt. will not sit normally, will lean, sleep w; bean bag PE: use motor, sensory to determine n. root affected; e.g. L5-S1 HNP causes S1 radiculopahty w/ ankle plantar flexion weakness (*foot drop), decreased sensation on plantar food (+)Straight Leg Raise (SLR) at < 30° Tx: NSAID, epidural steroid injxn, traction, discectomy, laminectomy

What is a Jersey finger?

rupture of distal flexor tendon that may involve avulsion fracture of distal phalanx

L-S spine

spondylolysis = fx in pars interarticularis; usu. L5; *scotty dog sign spondylolisthesis = displacement; most commonly L5-S1;

O'Donahue's

unhappy triad

tx for compression syndrome/

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Spine anatomy overview

(A) This anterior view shows the isolated vertebral column. (B) This right lateral view shows the isolated vertebral column. The isolated vertebrae are typical of each of the three mobile regions. Note the increase in size of the vertebrae as the column descends. (C) This posterior view of the vertebral column includes the vertebral ends of ribs, representing the skeleton of the back. (D) This medial view of the axial skeleton in situ demonstrates its regional curvatures and its relationship to the cranium (skull), thoracic cage, and hip bone. The continuous, weight-bearing column of vertebral bodies and IV discs forms the anterior wall of the vertebral canal. The lateral and posterior walls of the canal are formed by the series of vertebral arches. The IV foramina (seen also in part B) are openings in the lateral wall through which spinal nerves exit the vertebral canal. The posterior wall is formed by overlapping laminae and spinous processes, like shingles on a roof.

**15. interpret the findings from this x-ray image - from what view was this image taken?

**Bankart lesions occur when the **glenoid labrum is disrupted with dislocation. Most involve soft tissue but a small percentage involve the avulsion of bone fragments, as seen in this AP radiograph (black arrow).

Benson

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Explain the mechanism of injury and presentation of FRACTURES:

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Lisfranc x-ray

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flexor injury

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Causes of Midfoot pain (3)

- OA: dorsal osteophytes - plantar fasciitis - fibromas

Cauda Equina Syndrome pathophys: Sx: H&P: Tx:

Hx: like HNP + bladder dysfxn PE: saddle parasthesias/anesthesia; decr. sphincter tone radiograph: compression Tx: emergent surgical decompression

7. use the fracture identification practice tool format to describe the findings in this x-ray film - what is approximate age of this patient?

A transverse fracture of the proximal diaphysis of the femur. The fracture shows shortening and medial-posterior (?) displacement. - pediatric pt. due to open growth plates

- what are the Radiographic variations of the elbow fat pads? - how does a FAT PAD SIGN appear on x-ray?

A) Normal relationships of the two fat pads. B) Displacement of both fat pads (arrows) with an intraarticular effusion. C) In some cases, the effusion may displace only the anterior fat pad (arrows). D) In extension, the posterior fat pad is normally displaced by the olecranon. E) An extraarticular fracture may lift the distal periosteum and displace the proximal portion of the posterior fat pad. F) An x-ray showing displacement of both fat pads (arrows) from an intraarticular effusion.

1. what special maneuver is being performed in this image? - what is being assessed?

Hawkins' test for rotator cuff impingement. The arm is flexed to 90 degrees, adducted across the chest, then internally rotated forcefully by the examiner, who stabilises the scapula with his other hand.

What is a Jones Fracture?

Acute fracture in the metaphyseal-diaphyseal area (base) of the proximal 5th metatarsal (often confused with avulsion or stress fractures) - MOI: frequently caused by pull of peroneus brevis tendon

what are the 3 common plain radiographic views for identifying ankle fractures? - what does the 1 unique view provide?

Ankle: - AP - lateral - mortise: requires 10-20° of internal rotation and allows the tibia and fibula to be viewed without superimposition - image: AP radiograph of ankle shows widening of ankle mortise. Note ↑space between medial malleolus and adjacent talus → strongly suggests a tear of distal tibiofibular syndesmosis, an injury that is referred to as a syndesmotic sprain or, in layman's terms, as a high ankle sprain

- how can abduction of the hip be tested? - what does it detect?

Asymmetric abduction suggesting developmental dysplasia of the hip or any condition irritating the hip.

- interpret this bone scan on a 3-year-old with a 2 week history of limp

Bone scan in a three-year-old girl with a two-week history of limp and no localization by history or physical. The scan helped identify a stress fracture (arrow) of the cuboid. This child was treated successfully with a short leg walking cast for four weeks.

Clinical signs and symptoms in typical solitary cervical root lesions Root: - Pain - Numbness - Weakness - Reflex affected

C5: - Neck, shoulder, scapula; - Lateral arm (in distribution of axillary nerve) - Shoulder abduction, external rotation, elbow flexion, forearm supination - Biceps, brachioradialis C6: - Neck, shoulder, scapula, lateral arm, lateral forearm, lateral hand - Lateral forearm, thumb and index finger - Shoulder abduction, external rotation, elbow flexion, forearm supination and pronation - Biceps, brachioradialis C7: - Neck, shoulder, middle finger, hand - Index and middle finger, palm - Elbow and wrist extension (radial), forearm pronation, wrist flexion - Triceps C8: - Neck, shoulder, medial forearm, fourth and fifth digits, medial hand - Medial forearm, medial hand, fourth and fifth digits - Finger extension, wrist extension (ulnar), distal finger flexion, extension, abduction and adduction, distal thumb flexion - None T1: - Neck, medial arm and forearm - Anterior arm and medial forearm - Thumb abduction, distal thumb flexion, finger abduction and adduction - None

a) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Child abuse

Child abuse:

a) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 6. Common fractures (clavicle, radius, tibia)

Common fractures (clavicle, radius, tibia)"

42. interpret the findings from this x-ray image - Dx:

Transverse fractures are at greater risk of displacement. Widening of the fracture line (as seen here) may indicate entrapment of the nail bed. Dx: Transverse distal phalanx fracture

Definition of EPIPHYSIS

Definition of EPIPHYSIS: a part or process of a bone that ossifies separately and later becomes ankylosed to the main part of the bone; especially: an end of a long bone—compare diaphysis

Definition of METAPHYSIS

Definition of METAPHYSIS: the transitional zone at which the diaphysis and epiphysis of a bone come together

Definition of NEURAPRAXIA

Definition of NEURAPRAXIA: an injury to a nerve that interrupts conduction causing temporary paralysis but not degeneration and that is followed by a complete and rapid recovery

Definition of SCINTIGRAPHY

Definition of SCINTIGRAPHY: a diagnostic technique in which a two-dimensional picture of internal body tissue is produced through the detection of radiation emitted by a radioactive substance administered into the body

Definition of SPONDYLOSIS

Definition of SPONDYLOSIS: any of various degenerative diseases of the spine

Definition of VOLAR

Definition of VOLAR: relating to the palm of the hand or the sole of the foot; specifically: located on the same side as the palm of the hand <the volar part of the forearm

identify the Flexor tendons, common flexor sheath, fibrous digital sheaths, and synovial sheaths of the digits

Dissection of the palm of the hand illustrating the tendons and fibrous digital tendon sheaths. The fibrous sheaths of the digits are strong coverings of the flexor tendons, which extend from the heads of the metacarpals to the base of the distal phalanges. They prevent the tendons from pulling away from the bones of the digits. They attach along the borders of the proximal and middle phalanges, to capsules of the interphalangeal joints, and to the surface of the distal phalanx.

a) Describe the elbow and forearm examination, including special tests.

Elbow & Forearm PE: - Active ROM: - flexion/extension of 0-140/150° - pronation/supination (P/S) of 80° - Functional ROM: can you brush your teeth? - post-traumatic elbow is commonly stiff and min FROM is flex/ext of 30-130° and P/S of 50° S/Sx: - pain w/ flexion/extension is most likely from ulnohumeral joint - pain w/ P/S most likely from radiohumeral joint Special Tests:

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Ankle fractures: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: S/Sx: - AP, lateral, mortise views - palpate for tenderness over deltoid ligament and proximal tibia (MAISONNEUVE fx): rip of syndesmoses - lateral malleolus fx - Pilon Fx: - Calcaneus fx: also check L spine and verify MOI Tx: - ORIF

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 5. Plantar fasciitis - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - S/Sx: - hindfoot pain - image: plantar fascia is a tough band of tissue that connects the heel bone to the toes - Tx: - non-surgical management: takes 6-12 months for sx to resolve

what are the 2 common plain radiographic views for identifying femur fractures?

Femur: - AP, lateral

McMURRAY TEST: - how is it performed? - what does it assess?

McMurray test: Passive flexion and extension of the knee is used to assess the motion of the joint and the presence of meniscal injury. With the examiner's thumb and index fingers placed on the medial and lateral joint lines, the knee is passively maneuvered. - test is positive when there is pain at the joint line, with or without a "thunk," and limited range of motion. A positive test implies meniscal injury.

How do ACL and Meniscus injuries differ in presentation?

Meniscus: not bleeding b/c not well profused, can make it down slope ACL: bleeds a lot, cannot bear weight, feels like giving away, cannot make it down ski slope

Lisfranc fracture:

Open tarsometatarsal (Lisfranc) fracture: Complex open Lisfranc injury in a 14-year-old sustained in an ATV accident. A-C) Initial x-rays showing total incongruity pattern.

a) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Osgood-Schlatter Disease

Osgood-Schlatter Disease:

how do you perform the Patellar apprehension test? - what does it assess?

Patients with patellar dislocation and/or subluxation have pain in the medial patellar retinacular area and are apprehensive when the examiner tries to push the patella laterally.

on a Strength examination of the elbow, list the joint actions and muscles being tested

Perform w/ shoulder in neutral position with elbow flexed at 90° and touching iliac crest - Joint action → Position and action for examination → Muscles tested - Extension → Resisted extension → Triceps - Flexion → Forearm supinated - resisted flexion → Biceps brachii - Flexion → Forearm neutral- resisted flexion → Brachioradialis - Flexion → Forearm pronated- resisted flexion → Brachialis - Supination → Hand in neutral, perpendicular to ground → Biceps, supinator - Supination → Resisted rotation of "palm up" → Biceps, supinator - Pronation → Hand in neutral, perpendicular to ground → Pronator teres, quadratus - Pronation → Resisted rotation of "palm down" → Pronator teres, quadratus

- what is the name for the pathologic finding in this image? - what does it indicate?

Podagra: Gout

Tibia Fractures: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

S/Sx: - check for signs of compartment syndrome - Tx: - ORIF: complications may include genu varus deformity or non-union - image: An anteroposterior (A) and lateral (B) radiograph of an unstable fracture of tibial shaft are shown; A fibular shaft fracture is also present; tibial fracture was treated successfully with a locked reamed intramedullary nail (C and D). Yellow arrows indicate callus at site of fracture healing.

- How do you perform the Schober test? - what does it measure?

Schober test to measure the forward flexion of the lumbar spine in a patient with suspected or proven ankylosing spondylitis. With the patient standing erect, make a mark over the spinous process of the fifth lumbar vertebra or on the imaginary line joining the posterior superior iliac spine. Make another mark 10 cm above it in the midline. When the patient bends maximally forward, the distance between the two points normally exceeds 15 cm.

12. interpret the findings from this x-ray image - from what view was this image taken?

Shoulder fracture dislocation: The plain radiograph above shows a fracture-dislocation of the glenohumeral joint. The humeral head is clearly dislodged from the glenoid fossa and the dislocation is accompanied by a fracture at the surgical neck.

ANTERIOR DRAWER TEST: - how is it performed? - what does it assess?

The anterior drawer test is performed with the patient lying supine and the knee flexed at 90 degrees. The proximal tibia is gripped with both hands and pulled anteriorly, checking for anterior translation. Often the clinician sits on the foot while performing the test to provide stability. It is helpful to compare the degree of translation with the uninjured knee.

what is the procedure for Local injection for Dupuytren's contracture?

The hand is placed in the palm up position. Ethyl chloride is sprayed on the skin for anesthesia. A 5/8 inch, 25-gauge needle is inserted vertically adjacent to the nodular thickening in the midline over the flexor tendon, to a depth of 1/4 to 3/8 inch. 1/2 mL lidocaine and 1/4 mL triamcinolone acetonide (40 mg/mL) are injected.

43. interpret the findings from this f/u x-ray image ID: 15 y/o female CC: wrist pain following FOOSH 2 wks ago HPI: presented 2-weeks ago to ED, x-rays normal, wrist still hurts - what is the Dx?

This 15-year-old suffered acute pain and swelling in the wrist after a fall on an outstretched arm. Initial x-rays were normal, but this film taken two weeks after the injury demonstrates a fracture line through the middle third of the scaphoid.

which bone is fractured and which bone is dislocated in a: Monteggia fracture/dislocation?

- fracture of ulna shaft - dislocation of radial head

what is the mechanism of extension injury to the olecranon with valgus stress?

(A) A fall on an outstretched hand with the elbow extended places a valgus stress on the forearm. (B) This stress can cause a greenstick fracture of the olecranon with or without a radial neck fracture or medial epicondylar apophysis avulsion. (C) Radiograph of a valgus extension fracture of the olecranon with an associated radial neck fracture.

identify the Bones and ligaments of the pelvis

(A) The joints of the adult pelvic girdle include the sacroiliac joints and the pubic symphysis. The lumbosacral and sacrococcygeal are joints of the axial skeleton directly related to the pelvic girdle. (B and C) The ligaments of the pelvis are shown. * Inferior pelvic aperture.

**16. interpret the findings from this x-ray image - from what view was this image taken?

**Hill Sachs lesion: A Hill-Sachs deformity is a cortical depression (black arrows) in the **humeral head made by the glenoid rim with dislocation. They occur in 35 to 40 percent of anterior dislocations and are seen on the AP radiograph with the arm in internal rotation.

patella position

- alta: - baja:

- how do you perform an Aspiration of the olecranon bursa? - what are the expected contents of the aspirate? - what should you do order for the contents?

- patient is supine with elbow flexed to 90° and forearm lying over chest; - Ethyl chloride or a comparable agent is applied to skin for anesthesia. - A 1.5 inch (3.75 cm), 16-gauge needle is inserted distally at base of bursa, nearly parallel to ulna. - 0.5 mL of lidocaine is injected subcutaneously prior to aspiration of bursal fluid - contents: pus, blood, serous fluid w/ crystals possibly, might look like cottage cheese - purple top tube: CBC, ESR, CRP, gram stain, culture & sensitivity, crystals

34. identify the finding in this image - what is the most likely Dx/etiology?

- patient presented with three days of increased swelling, redness, and severe pain of the fingertip. - Dx: Felon of the fingertip

25. interpret the findings from this x-ray image ID: 67 y/o female CC: anterolateral shoulder pain and stiffness for several years PMH: denies hx of fracture, dislocation, or severe injury SocHx: works on her family farm - what is your Dx?

- patient states: "People say I've always done man's work. It doesn't surprise me that it is arthritic since arthritis runs in my family." - On plain x-ray, glenohumeral osteoarthritis is characterized by loss of articular cartilage between humeral head and glenoid, osteophyte formation extending from inferior portion of humeral head, and humeral head sclerosis. The combination of the loss of cartilage and the osteophyte creates the club-like deformity.

- how do you perform the MODIFIED ALLEN TEST? - what does it assess?

- patient's hand is initially held high while fist is clenched and both radial and ulnar arteries are compressed (A); this allows blood to drain from hand - hand is then lowered (B) and fist is opened (C). - After pressure is released over ulnar artery (D), color should return to hand within six seconds, indicating a patent ulnar artery and an intact superficial palmar arch

24. use the fracture identification practice tool format to describe the findings in this x-ray film

A fracture of the middle third of the clavicle with complete displacement is shown. Note the typical upward displacement of the proximal fragment caused by the pull of the sternocleidomastoid muscle. Displacement is approximately two and one half times the width of the clavicle, greater than is typically seen.

identify the numbered markings on this lateral radiograph of normal elbow alignment

A line extended along the anterior border of the humerus (8) or through the middle of the shaft of the radius would bisect the capitellum (2). The structures shown include: humerus (1), olecranon (3), coronoid process (4), radial head (5), radial neck (6), radial tuberosity (7), and the olecranon fossa (9), which is not well seen on the lateral view.

- what measurement is used to predict likelihood of patellar instability? - how is it measured? - what is the normal value?

Although the Q angle is often mentioned, research suggests its role in conditions such as patellofemoral pain syndrome and patellar instability is of little importance. - normal Q: 15-20°

- interpret these AP and frog-leg views of an adolescent pelvis

An anteroposterior view (left) of the pelvis in an adolescent with slipped capital femoral epiphysis. Note that the left hip has a slightly wider physis (large arrow), and slightly less femoral head is visible lateral to Kline's line (the line drawn along the lateral femoral neck). On the frog-leg view (right), the posterior slippage of the femoral head is more obvious (arrow).

A 6 year-old child falls onto his right arm. An x-ray demonstrates a buckle in the cortices of the distal radius, proximal to the growth plate, without angulation. What is the term used to describe this fracture? A Salter-Harris Type III B Salter Harris Type IV C Salter Harris Type V D torus E greenstick

Answer: D, torus Question 18 Explanation: Torus or buckle fracture is most common in a child. This is proximal to the epiphyseal plate and so is not a Salter-Harris issue. Greenstick fracture is also common in children in long bones and is a fracture which "bends" the bone without fracturing it.

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Common shoulder fractures: MID SHAFT HUMERUS FRACTURE: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - usually direct blow such as MVA S/Sx: - *must assess neurovascular fxn b/c radial n. at highest risk for injury: thumb abduction "thumbs-up/ hitchhiking sign" Tx: - Sarmiento brace - if neurovascular compromise: open up and pull out radial n.

b) Understand the treatment of the following conditions: 3. Shoulder Instability & Disclocations - Tx:

Closed Reductions: *+neurovascular assessment* - longitudinal traction w/ gradual abduction and external rotation until a clunk is heard and felt - gravity-assisted reduction (STIMSON) w/longitudinal traction w/ 5-15 lbs - *always check neurovascular fxn before and after reduction: thumb up, spread fingers and resist, hook fingers and hold it; check for sensation over deltoid + firing of muscle fibers; *document in note - conscious sedation

a) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 5. Developmental Dysplasia of the Hip

Developmental Dysplasia of the Hip:

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 6. Diabetic foot - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Diabetic foot: - neuropathy → osteomyelitis S/Sx: - filament sensation test Tx: - better DM control - foot check w/ mirror while on toilet

- which maneuver is used to detect a slipped capital femoral epiphysis?

Diagnosing slipped capital femoral epiphysis. Obligate external rotation of the hip is noted while the hip is passively flexed.

SHOULDER EXAM - describe how to perform the following: SCAPULAR WINGING: - what is it used to find? - how is it performed? - how are the results interpreted?

Dx: Long thoracic nerve palsy; muscular dysfunction Winging of scapula w/ movement, "wall push off": - patient should be viewed from behind to assess scapular positioning - can be done with patient's arms at their sides or in a push up position with their hands against a wall - scapular position is described as elevated, depressed, retracted (rotated back on the chest wall), or protracted (rotated forward on the chest wall) → elevated, protracted scapula is most common dysfunctional position and is described as "winging" → Although scapular winging is classically associated with dysfunction of long thoracic nerve, muscular dysfunction, rather than true nerve injury, is usually cause

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Cruciates and collateral ligaments injuries - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - common mech: trauma w/ twisting or hyperextension force w/ foot planted - 50% of pts w/ ACL tears also have meniscus, MCL, or LCL injury too S/Sx: -* bleeds a lot, cannot bear weight, feels like giving away, cannot make it down ski slope - *bone-kissing-bone pathognemonic for ACL - Image A shows a normal ACL (arrowheads). Image B shows a full thickness tear (arrow) and fraying of proximal and distal components (arrowheads). Image C is a sagittal image of knee using T2 weighted, fast spin echo technique and shows complete avulsion of ACL at its insertion on to tibia (arrow), and normal proximal ligament (arrowhead) Tx: - surgical reconstruction: - bone-tendon-bone graft: - hamstring tendons (semitendinosus, gracilis) - allograft: from cadaver if yours is too wimpy

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. GALEAZZI Forearm Fractures: - Etiology: - Imaging:

Etiology: trauma w/ twisting & tumbling Imaging: Pediatric Galeazzi fracture and dislocation (A) View of the entire forearm of an 11-year-old boy with a Galeazzi fracture-dislocation. (B) Close-up of the distal forearm shows that there has been disruption of the distal radioulnar joint (arrows). The distal radial fragment is dorsally displaced (apex volar), making this a supination type of mechanism. Note that the distal ulna is volar to the distal radius. (C) In this second patient, the AP view shows some shortening of the distal radius (arrow) in relation to the distal ulna, which has a small greenstick component. (D) The pronation component (white arrow) is better appreciated on this lateral view. The distal ulna lies dorsal to the distal radius (yellow arrow).

what are the 3 common plain radiographic views for identifying foot fractures? - which 2 are typically ordered first? - when would the 3rd be ordered?

Foot: - AP, lateral - Oblique: if fracture seen on AP or lateral

SHOULDER EXAM: - list the components of the SHOULDER PE + Special tests:

INSPECT: for deformity or atrophy NEUROVASCULAR assessment: thumb up, spread fingers & resist; hook fingers & hold; palpate REGIMENTAL PATCH of axillary n. over deltoid, ask if can feel touching deltoid, feel it fire; PALPATE: move from most proximal and posterior to distal and anterior structures, these sites include: Cervical spine; Scapular spine and adjacent musculature; Acromion and subacromial space; Bicipital groove, and greater and lesser tuberosities of humerus; Clavicle, including sternoclavicular (SC) and acromioclavicular (AC) joints AROM and PROM *SULCUS SIGN for inferior instability; head out of socket creates sulcus APPREHENSION, RELOCATION tests for multidirectional instability = provacative tests O'BRIENS test for anterior labrum tear NEERS, HAWKINS, DROP ARM, test for rotator cuff injuries CROSS ARM TEST for AC joint pain

SHOULDER EXAM: - PE: what are some GENERAL RECOMMENDATIONS for getting a good exam

PE: GENERAL RECOMMENDATIONS: - Observe pt: noting posture; watch how they carry and move affected arm - Make pt comfortable helps to ensure natural arm motion and ↓likelihood of guarding during exam - Compare shoulders - Perform shoulder exam systematically - Assess scapulothoracic fxn - Use patient demographics and hx to guide fxnl exam - Remember referred pain: Is shoulder really causing pain, or is it cervical spine, gallbladder, spleen, heart?

what are PET scans and how are they used in orthopedics?

PET scanning performed with FDG provides qualitative and quantitative metabolic information b/c FDG is a radiopharmaceutical analogue of glucose that is taken up by metabolically active cells such as tumor cells; PET scans are capable of demonstrating abnormal metabolic activity before abnormal morphologic changes have occurred and can be helpful in distinguishing benign from malignant tumors - PET-CT scanning is typically used in the detection and follow-up of tumors such as solitary pulmonary nodules, non-small cell lung carcinoma, lymphoma, melanoma, breast cancer, and colorectal cancer - may be used to detect mets in bones

how is the Zanca view performed?

The patient in the photograph above is positioned for a Zanca view. Note the upward angle of the x-ray beam.

how do you perform the Talar tilt test? - what is it used to assess?

The talar tilt test is for integrity of the calcaneofibular ligament. With the ankle in the neutral position, a gentle inversion force is applied to the affected ankle, and the degree of inversion is observed and compared to the uninjured side.

Anteroposterior radiograph of the shoulder

This anteroposterior radiograph of a normal shoulder demonstrates a congruent humeral head and glenoid fossa. The accromion and the acromioclavicular joint are not not well visualized in this example due to overpenetration.

Which term most accurately describes the pathology in this image? - SPRAIN - STRAIN

Type II acromioclavicular joint sprain

Odontoid fracture type II

Type II odontoid fractures are the *most common type (>60%) and occur at the base of the odontoid process where it attaches to the body of C2. They are considered unstable.

18. interpret the findings from this x-ray image

Type III AC injuries represent complete rupture of both the AC and CC ligaments. This radiograph clearly shows the clavicle elevated above the normal plane of the AC joint (arrow) and an increase in the coracoclavicular distance (arrowhead).

VARUS VALGUS TEST: - how is it performed? - what does it assess?

Valgus and varus stress tests of the knee: The valgus stress test (photo A) is used to assess the integrity of the medial collateral ligament, while the varus stress test (photo B) is used to assess the lateral collateral ligament.

Ventral (anterior) cord syndrome

Ventral cord or anterior spinal artery syndrome usually includes tracts in the anterior two-thirds of the spinal cord, which include the corticospinal tracts, the spinothalamic tracts, and descending autonomic tracts to the sacral centers for bladder control (figure 10). Corticospinal tract involvements produce weakness and reflex changes. A spinothalamic tract deficit produces the bilateral loss of pain and temperature sensation. Tactile, position, and vibratory sensation are normal. Urinary incontinence is usually present.

4. what special maneuver is being performed in this image? - what is being assessed?

Yergason test for biceps tendinitis. With the elbow flexed at 90 degrees, the patient's maximised site of tenderness is elicited as the examiner resists the patient's attempts to supinate his forearm.

a) Describe the spine examination, including special tests

general: posture, gait, symmetry, sitting position (tripod posture?) GI: rectal exam tone (DDx: cauda equina, trauma, tumor) MSK: spinal alignment; bony tenderness; *straight leg raising w/ discogenic sx; gait, posture; symmetry; *stress hip and SI joints if needed Neuro: CN exam + sensory along dermatomes; motor fxn; DTRs; *walk on heels (L4-5), *walk on toes (S1), *squatting (L2,3,4)

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Hallux valgus deformity (bunions) - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - lateral deviation of great toe at first MT joint - F:M 10:1 S/Sx: - dx x-ray - photograph above shows a bunion and valgus shift with redness and mild swelling over medial first metatarsophalangeal joint of the left foot. Tx: - wear wrap

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Pelvic Fractures - Etiology: - S/Sx: - Imaging: - Dx:

Etiology: - low energy: elderly - high energy: multisystem trauma S/Sx: - assess neurovascular status STAT b/c common injuries to peripheral nn. sometimes damage spinal n. roots - STAT x-rays and CT scan - immediate surgery or external fixation until stable

Knee Degenerative Joint Disease/ Arthritis: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - most common cause of disability in US S/Sx: - pain w/ use - x-ray shows narrowed joint space, OA Tx: - total knee arthroplasty (TKA)

48. interpret this film from a patient just pulled from a MVA - what is the most likely Dx?

This open-book pelvis fracture was sustained in a motor vehicle collision. The fracture was associated with a posterior urethral injury.

OPEN FRACTURES: - how should open fractures be managed? - what are the risks of inadequate tx?

- *true orthopedic emergency → okay to call ortho consultant @ night for this* - Dx: ↓infxn rate if dx accurately → get to OR - Rx: broad spectrum IV abx ASAP + tetanus - initial Tx: -- stabilization: skeletal stabilization w/ splints or external fixation ("ex-fix") -- coverage: wound vac for large soft tissue defect - final Tx: I&D surgery as soon as possible; used to be 4-6hr window to OR but now longer w/ abx

m x-ray

-

stress fractures: - which ones are more dangerous? - what do they look like?

-

4 knaval signs? of?

- KANAVEL'S 4 CARDINAL SIGNS: flexed resting posture; tenderness over flexor sheath; fusiform swelling; severe pain on passive extension - infectious flexor tenovitis -

Herpetic Whitlow: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - herpes virus hand infxn - occupational hazard w/ orotracheal secretions S/Sx: - clinically confused w/ felon - painful cytolytic lesion 2-14 d - vesicles mature over 14 days - self-limited dz, clearing in 7-10 days - image: In addition to erythema, swelling, and pain, herpetic whitlow is characterized by presence of vesicular or pustular lesions. Patients may also experience fever, lymphadenitis, and epitrochlear or axillary lymphadenopathy Tx: - prevent from 2° infxn; keep clean

52. interpret the films ID: 54-year-old woman CC: presents with pain and a prior history of meniscal surgery. - Dx:

Image A is a cross-table lateral examination of the knee following injection of contrast into the joint under fluoroscopic guidance, and it shows a popliteal cyst (arrow). Image B is a sagittal projection using a fat-saturated T1 sequence, and shows the contrast-filled popliteal cyst (arrow). Image C is an axial projection using fat-saturated T1 sequence, and shows the popliteal cyst (arrow) communicating with the knee joint (arrowhead).

Syndromes of sensory loss: complete spinal and anterior cord injury: Brown-Sequard syndrome: central cord syndrome: brain stem injury: thalamic or cerebral hemisphere injury:

In these figures, the blue shading indicates hypalgesia (loss of pain and temperature sensation) and the arrows indicate limbs with significant accompanying weakness. In the Brown-Sequard syndrome (hemisection of the cord, top row, right) there is often diminished tactile sensation on the side of weakness and opposite the side with hypalgesia.

What is an Intertrochanteric fracture?

Proximal femur fracture extending between the greater and lesser trochanters

a) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Slipped Capital Femoral Epiphysis

Slipped Capital Femoral Epiphysis:

Explain the mechanism of injury and presentation of STRAINS

- - STRAIN: partial tear of a muscle

How can internal rotation of the hips be assessed in adults?

- FADDIR (Femoral ADDuction and Internal Rotation) test is used to help identify pathology within hip acetabulum.

26. interpret the findings from this x-ray image ID: 4 y/o girl CC: fell on R. arm Dx:?

- This 4-year-old girl fell on her right arm and was diagnosed with a nurse-maid's elbow. Close review of the radiograph shows the presence of a posterior fat pad (arrowheads) that is due to an effusion and suggests a high likelihood of a fracture. In addition, a subtle cortical defect is visible (arrow) on the anterior surface of the distal humeral metaphysis. Dx: Undisplaced supracondylar fracture

22. interpret the findings from this x-ray image - what is your Dx?

- This anteroposterior radiograph shows a signficantly displaced fracture of the humerus at the surgical neck. In the Neer classification system this is categorized as a two-part fracture. The superior displacement of the distal fragment was clinically apparent as shortening of the upper arm.

what is the Anatomy of the triangular fibrocartilage complex?

- triangular fibrocartilage complex is comprised of the triangular fibrocartilage, ulnar collateral ligament, dorsal and palmar radioulnar ligaments, ulnolunate and ulnotriquetral ligaments, and the extensor carpi ulnaris tendon sheath. This figure shows the dorsal surface of the wrist.

29. interpret the findings from this x-ray image ID: 4 y/o boy CC: fell off his bike Dx: ?

- ulna is fractured and angulated, and a line through the radius clearly does not pass through the center of the capitellum. Dx: Monteggia fracture/dislocation

RHEUMATOID ARTHRITIS: - Etiology: - Clinical Presentation: -- primary joints affected: -- joint deformities: -- joint characteristics: -- stiffness: -- lab findings:

ETIOLOGY: Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder of unknown etiology that primarily involves synovial joints; typically symmetrical; if uncontrolled leads to destruction of joints due to erosion of cartilage and bone, causing joint deformities CLINICAL PRESENTATION: - Primary joints affected: Metacarpophalangeal (MCP), Proximal interphalangeal (PIP) - Joint deformities: ulnar deviation or Bouchard's nodes; "ulnar drift", swan neck, Boutonniere deformities of fingers; "bow string" sign (prominence of the tendons in extensor compartment of hand) - Joint characteristics: Soft, warm, and tender - Stiffness : Worse after resting (eg, morning stiffness) - Laboratory findings: (+)rheumatoid factor; (+)anti-CCP antibody; ↑↑ESR and CRP - image: Bilateral swelling of MCP joints is evident in this patient with RA; Note mild swan neck deformities present in several fingers, particularly left middle and fifth fingers.

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Femur Fractures: Femur Shaft - Etiology: - S/Sx: - Imaging: - Dx:

Etiology: - high-energy trauma w/ possible multi-system injuries, bleeding, compartment syndrome S/Sx: - assess NV status and ipsilateral knee Tx: - splint for comfort and transport → skeletal traction until surgery

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Shoulder Instability & Dislocations - etiology: - S/Sx: - Imaging: - Dx:

Etiology: - *Anterior-Posterior dislocations most common w/ external rotation and abduction motion as MOI (throwing); head not in Y; - Posterior dislocations: head of humerus lateral "light bulb", outside medial space; rare w/ probable long term instability; v. difficult to repair; *red flag for ↑comorbidities - could be secondary to seizures, electrical shock, sport related trauma, or MOVA S/Sx: - SULCUS SIGN: (+) indicates glenohumeral instability - APPREHENSION, RELOCATION, release tests: (+) instability X-RAY IMAGING: - **BANKART LESION: injury of glenoid labrum** due to anterior-posterior shoulder dislocation and is usually indication for surgery - **HILL SACHS LESION: cortical depression in head of humerus; results from forceful *impaction of humeral head* against anterior-inferior glenoid rim when shoulder dislocated

Popliteal / Bakers Cyst: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - A Baker's cyst is a benign fluid-filled sac that forms at the back of the knee - assoc. w/ degenerative meniscal tears and systemic inflammatory conditions such as RA Tx: - not pathologic but if gets bigger may compress

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Acromio-clavicular injuries: - Etiology:

Etiology: - AC joint separations: most common cause is falling on shoulder, e.g. off bike - image: Injury to acromioclavicular (AC) joint usually occurs from direct trauma to superior or lateral aspect of shoulder with arm adducted, such as falling onto shoulder; Greater force ↑risk of injury

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 6. Hand Fractures: Metacarpals & Phalanges - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - Boxer's fx: of 5th MC most common - Distal phalanx intra-articular fx S/Sx: - Malrotation due to unstable metacarpal fracture - Image: axes of the fingers normally converge when metacarpophalangeal and proximal interphalangeal joints are both flexed. In this photograph, while 2nd, 3rd, and 4th fingers converge as they should, 5th does not; divergence of the 5th digit is result of a 5th metacarpal shaft fracture complicated by malrotation. Tx: - closed reduction w/ hematoma block or - sedation + splint/ casting or - ORIF *put no malrotation in note

Infectious Flexor Tenosynovitis: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - flexor sheath is a closed space thus allows spread of penetrating wound infxn: sheaths of thumb contiguous w/ ↔ radial bursa and in 50% of people communicates w/ ↔ ulnar bursa which is contiguous w/ ↔ small finger sheath - S. aureus most common - Hematogenous spread of gonococcal infxns S/Sx: - KANAVEL'S 4 CARDINAL SIGNS: flexed resting posture; tenderness over flexor sheath; fusiform swelling; severe pain on passive extension - image: photographs illustrate fusiform swelling of finger and partially flexed posture of finger Tx: - incision, irrigation, IV abx

Paronychia: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - infxn beneath eponychial fold usually by S. aureus S/Sx: - image: skin infection that causes a painful, red, swollen area around a fingernail or toenail. Some people also get pus-filled blisters, as shown in this photo. Tx: - early: abx, warm soaks - most reliable: drainage; elevation of nail fold

what is the mechanism of injury in a Greenstick fracture?

Forearm shaft fractures typically have a rotational mechanism. Panel A) A supinating force accompanies an apex-volar midshaft fracture (blue circular arrow). During reduction, this rotary force is reversed by pronating the thumb and hand towards the deformity (red circular arrow) while stabilizing just proximal to the fracture site (large red arrow). Panel B) A pronating force accompanies an apex-dorsal midshaft fracture (blue circular arrow). During reduction, this rotary force is reversed by supinating the thumb and hand (red circular arrow) while stabilizing just proximal to the fracture site (large red arrow).

a) Describe the general principles of the orthopaedic examination - HPI: (6) - PSH: - PMH: - Meds: - ROS:

HPI: LPQRST - Location: pin-point if possible - Pain: ↓palliative, ↑provacative - Quality: sharp, dull, stabbing - Radiation: - Severity: 1→10, mild, moderate, severe - Time: timing of injury, duration of sx; what, when where PSH: past relevant surgeries PMH: e.g. gout, sickle cell, carcinomas? Meds: ROS:

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Hip fractures + Hip & Proximal Femur Fractures: - Etiology: - S/Sx: - Imaging: - Dx:

Hip Fracture Etiology: - most common fracture in elderly - incidence doubles past age 50; F>M - **¼ pts w/ a hip fracture die w/i 1 yr after fracture - ½ of pts w/ hip fracture never return to previous level of ambulation and independence - 95% caused by falling, most often sideways Hip + Proximal Femur Fracture Etiology: - intra-capsular (femoral neck): usu assoc w/ high risk for non-union secondary to AVN - extra-capsular: intertrochanteric or above lesser trochanter: requires stronger fixation, has better chance of healing

PIVOT SHIFT TEST: - how is it performed? - what does it assess?

The pivot shift test is sensitive only in a fully relaxed patient. The test is performed with the knee starting in extension. The clinician holds the lower leg with one hand and internally rotates the tibia, while placing a valgus stress on the knee using the other hand. While maintaining the forces described, the clinician flexes the knee. In the ACL-deficient knee this causes a reduction of the subluxed tibia, which the clinician senses as a 'clunk,' and which constitutes a positive test.

POSTERIOR DRAWER TEST: - how is it performed? - what does it assess?

The posterior drawer test is used to assess the integrity of the posterior cruciate ligament. With the knee flexed to 90º and the foot stabilized (often the examiner sits on the patient's foot), the proximal tibia is grasped firmly with both hands and the tibia is forcibly pushed posteriorly, noting any laxity compared with the other side.

describe how to test MOTOR function of the RADIAL NERVE

Thumb's up sign: This thumb motion indicates intact radial nerve motor function.

- Toe Deformities (3)

Toe Deformities: - Claw toe: - Hammer toe: - Mallet toe: most distal joint

what are clinical and lab signs of gout?

- podagra - urate

- what is the name for the pathologic finding in this image? - what condition does this represent?

- Swelling of the MCP joints, moderate MCP flexion, and swan neck deformities are evident in this patient with rheumatoid arthritis; MCP: metacarpophalangeal.

what are the 2 types of incomplete fractures that are often seen in children?

- TORUS: incomplete buckle fracture of one cortex, often seen in children - GREENSTICK: incomplete fracture w/ angular deformity, seen in children

Location of foot and ankle pain

(A) Posteromedial ankle and heel pain. (B) Posterior ankle and heel pain. (C) Anterolateral ankle, midfoot, and forefoot pain. (D) Plantar foot pain.

identify the bones, ligaments, and articular surfaces in the Elbow and proximal radio-ulnar joints

(A) The thin anterior aspect of the joint capsule has been removed to reveal the articulating surfaces of the bones inside. The strong collateral ligaments were left intact. (B) Radiograph of the extended elbow joint. (C) The fibrous layer and synovial membrane of the joint capsule, the subtendinous and subcutaneous olecranon bursae, and humero-ulnar articulation of the elbow joint. (D) Radiograph of the flexed elbow joint.

30. interpret the findings from these x-ray images ID: 11 y/o boy CC: fell off his bike Dx: ?

(A) View of the entire forearm of an 11-year-old boy with a Galeazzi fracture-dislocation. (B) Close-up of the distal forearm shows that there has been disruption of the distal radioulnar joint (arrows). The distal radial fragment is dorsally displaced (apex volar), making this a supination type of mechanism. Note that the distal ulna is volar to the distal radius. (C) In this second patient, the AP view shows some shortening of the distal radius (arrow) in relation to the distal ulna, which has a small greenstick component. (D) The pronation component (white arrow) is better appreciated on this lateral view. The distal ulna lies dorsal to the distal radius (yellow arrow). - Dx: Galeazzi fracture-dislocation.

SHOULDER EXAM - describe how to perform the following: CROSS ARM TEST: - what is it used to find? - how is it performed? - how are the results interpreted?

- Cross-arm test for *acromioclavicular joint pain* - The arm is extended to 90°, then adducted across the chest.

37. identify the finding in this image - what is the most likely Dx/etiology?

"Cord" or advanced Dupuytren's

OSTEOARTHRITIS - Tx:

*Inflammatory arthritis is evidenced by history of swelling, night pain, morning stiffness greater than 30 minutes; active synovitis on physical examination; chondrocalcinosis on radiographs; rhomboid, positively-birefringent crystals from arthroscentesis; or visualization of crystalline material upon arthroscopy. •Including education regarding joint protection, dietary modification for weight loss (if appropriate), temperature modalities, hydrotherapy, rubifacients, physical/occupational therapy for supervised exercise program to preserve strength and range of motion and to provide orthoses as needed. Nonpharmacologic interventions should be continued together with pharmacologic therapies.

c) Demonstrate an understanding of Osteo-arthritis, Rheumatoid arthritis, Septic arthritis and Gouty arthritis

-

SHOULDER EXAM - describe how to perform the following: NEER TEST: - what is it used to find? - how is it performed? - how are the results interpreted?

- "passive painful arc maneuver" Neer test used to assess the degree of *shoulder impingement* - involves passively flexing glenohumeral joint while simultaneously preventing shoulder shrugging; voluntary guarding by patient often manifests as shoulder shrugging - severity of impingement and rotator cuff tendinopathy is determined by angle at which arc becomes painful: - Pain at 90° is consistent w/ mild impingement; - Pain at 60-70° is consistent w/moderate impingement; - Pain at ≤45° is consistent w/ severe impingement

- how do you perform the ALLEN TEST? - what is it used to assess?

- In the Allen test, the patient is instructed to make a fist, which will empty blood from hand and fingers (A) → examiner's thumbs are then pressed down across thenar and hypothenar eminences to occlude radial and ulnar arteries → patient then opens hand, making sure not to overextend fingers → pressure on ulnar artery is then released while radial artery is still compressed (B). → hand does not fill with blood. Note paleness of hand on right compared with hand on left, indicating occlusion of ulnar artery distal to wrist (abnormal test result). → If there is prompt return of color to hand (indicating a normal test result), test is repeated except this time pressure on radial artery is released while ulnar artery remains compressed

What is a MOI of Mallet finger?

- Mallet finger injuries involve disruption of the insertion of the extensor tendon, usually caused by a direct blow to the fingertip. - rupture of distal extensor tendon may involve avulsion fracture of distal phalanx

Basic vertebral anatomy

A "typical" vertebra, represented by L2. (A) Functional components include the vertebral body (bone color), a vertebral arch (red), and seven processes: three for muscle attachment and leverage (blue) and four that participate in synovial joints with adjacent vertebrae (yellow). (B, C) Bony formations of the vertebrae are demonstrated. The vertebral foramen is bounded by the vertebral arch and body. A small superior vertebral notch and a larger inferior vertebral notch flank the pedicle. (D) The superior and inferior notches of adjacent vertebrae plus the IV disc that unites them form the IV foramen for the passage of a spinal nerve and its accompanying vessels. Note that each articular process has an articular facet where contact occurs with the articular facets of adjacent vertebrae (B-D).

- How is the Galeazzi test performed? - what does it detect?

A Galeazzi test suggesting developmental dysplasia of the hip or a leg-length discrepancy. The test is positive when the knees are at different heights as the patient lies supine with ankles to buttocks and hips and knees flexed.

Pellegrini disease

A calcific density in the medial collateral ligament and/or bony growth on the medial aspect of the medial condyle of the femur. (synonym Pellegrini-Stieda disease)

5. use the fracture identification practice tool format to describe the findings in this AP view x-ray film

A comminuted fracture of proximal femur. This fracture shows medial angulation and displacement This anteroposterior radiograph shows a comminuted intertrochanteric fracture with displacement of the lesser trochanter.

6. use the fracture identification practice tool format to describe the findings in this x-ray film - what is approximate age of this patient?

A comminuted fracture of the distal femur. The fracture shows no displacement or angulation. This is likely a pediatric pt b/c growth plates are not fused Significantly comminuted fractures of the distal femur that do not involve the growth plate (A) are often best stabilized with plate fixation (B).

6. use the fracture identification practice tool format to describe the findings in this AP view x-ray film

A comminuted fracture of the medial diaphysis of the femur. The fracture shows valgus angulation. This anteroposterior (AP) radiograph shows a comminuted, angulated midshaft femur fracture prior to operative repair.

how do you perform The squeeze test? - what is it used to assess?

A provocative test for syndesmotic injury. The examiner compresses the tibia and fibula above the ankle. Pain in the region of the distal syndesmosis (area of pain indicated by the tip of the arrow) confirms distal syndesmotic injury.

1. use the fracture identification practice tool format to describe the findings in this x-ray film

A spiral fracture of the diaphysis of the tibia. The fracture shows no displacement or angulation.

Thoracic spine: Adult Kyphosis: Adolescent Kyphosis: Scoliosis:

Adult kyphosis: osteoporotic compression fx, DDD, arthritis, spondylolisthesis; screen w/ DEXA Scheuermann kyphosis: defined as anterior wedging of ≥5º in at least three adjacent vertebral bodies, as measured on lateral spine radiographs; Schmorl's nodes, representing herniation of the nucleus pulposus into the adjacent end plate; difficulty breathing; adolescent males Scoliosis: spine curved; *most commonly adolescent idiopathic scoliosis; sometimes assoc. w/ other conditions; Dx: w/ Cobb angle Ankylosing Spondylititis: *bilateral fusion of sacroiliac joints; *bamboo lumbar spine on x-ray; >90% are HLAB27+, RF-;

3. use the fracture identification practice tool format to describe the findings in these AP and oblique view x-ray films

An oblique fracture of the distal diaphysis of the left 5th metatarsal. An oblique fracture (arrow) of the distal shaft of the fifth metatarsal is seen in two plain radiographs, one using an anteroposterior view (left side image) and the other an oblique view (right side image) of the foot.

4. use the fracture identification practice tool format to describe the findings in this lateral view x-ray film

An oblique fracture of the distal fibula. The fracture shows no displacement or angulation. This lateral plain radiograph shows an oblique fracture (black arrow) through the distal fibula above lateral malleolus.

Which of the following is not typically associated with polyarticular CPPD crystal deposition disease? Hyperparathyroidsim Hemochromatosis Hyperthyroidism Trauma or surgery

Answer: The correct answer is C. Calcium pyrophosphate dehydrate deposition (CPPD, pseudogout) typically presents with inflammation in one or more joints lasting for several days to 2 weeks. Most commonly, CPPD is associated with hyperparathyroidism, hemochromatosis, hypothyroidism, amyloidosis, hypomagnesemia, trauma/surgery, and hypophosphatemia. Hyperthyroidism is not typically associated with this condition.

a) Describe the general principles of the orthopaedic examination - Assessment: - Plan: (4)

Assessment: be specific, do not use "rule out" or "possible/probable" Plan: - Physical Therapy - Medications (NSAIDs, pain meds, abx) - Injections (cortison, viscous supplementation) - Surgery

Spine Exam: Neuro Motor landmarks: C5: C6: C7: C8: T1: L2: L3: L4: L5: S1:

C5: deltoid - shoulder abduction C6: biceps - arm flexion C7: extensor carpi radialis - wrist extension C8: finger flexors - grip T1: finger intrinsics - finger abduction L2: ilio-psoas - hip flexion L3: quadriceps - knee extension L4: tibialis - anterior - ankle dorsiflextion L5: extensor hallucis longus - 1st toe flexion S1: gastrocnemius - ankle plantar flexion

Spine Exam: Neuro Sensory landmarks: C5: C6: C7: C8: T4: T10: L3: L4: L5: S1:

C5: deltoid region of shoulder C6: 1st & 2nd fingers C7: middle finger C8: 4th & 5th fingers T4: nipples T10: umbilicus L3: knee L4: lateral dorsal portion of foot L5: medial dorsal portion of foot S1: plantar portion of foot

36. identify the finding in this image - what is the most likely Dx/etiology?

Cat bites often result in multiple small puncture wounds and are likely to cause infection because cats have sharp teeth that inoculate bacteria deeply in the tissue. The photographs demonstrate a subcutaneous abscess of the right thumb following a cat bite. The arrows point to the puncture wounds.

- What are contributing factors that increase the risk for developing hand infections? - build a DDx for hand infections: (7)

Contributing Factors: - diabetes: - immuno-compromised patient: - environment: - occupation: - smoking: b/c ↓vasc. health Hand Infxn DDx: - cellulitis: - paronychia/ Felon: - deep space infxns: - herpetic Whitlow: - flexor tenosynovitis: - human bites: - animal bites:

Definition of PHYSIS

Definition of PHYSIS: growth plate

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Degenerative Disc Disease, Bulging disc and herniated disc

Degenerative Disc Disease: inter-vertebral discs become dehydrated w/ age → less efficient in shock absorption → bone changes primarily related to altered facet alignment leading to: - subchondral sclerosis - joint space narrowing - osteophytes - stenosis Bulging disc: Herniated disc:

What is the name for dorsal angulation distal radius fracture?

Due to the dorsal displacement of the distal fragment, COLLES' type fractures are often said to have a "dinner fork" appearance.

OSTEOARTHRITIS - Etiology: - Clinical Presentation: -- primary joints affected: -- joint deformities: -- joint characteristics: -- stiffness: -- lab findings:

ETIOLOGY: OA results from a complex interplay of multiple factors, including joint integrity, genetic predisposition, local inflammation, mechanical forces, and cellular and biochemical processes CLINICAL PRESENTATION: - Primary joints affected: Distal interphalangeal (DIP); Carpometacarpal (CMC) - Joint deformities: Heberden's nodes - Joint characteristics: Hard and bony - Stiffness: If present, worse after effort, may be described as evening stiffness - Laboratory findings: Rheumatoid factor(-); Anti-CCP antibody(-); Normal ESR and CRP - image: plain film demonstrates complete loss of articular cartilage at all four DIP joints, large osteophytes, and ankylosis of DIP joint of middle finger

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Rotator Cuff Injuries/Impingement Syndrome: - etiology: - S/Sx: - Dx:

Etiology: supraspinatus most commonly injured; - degenerative changes of rotator cuff normal aging process manifests ~50-60y; - acute trauma: *first-time anterior shoulder dislocation pts ≥40y have 40-60% incidence of rotator cuff tears; - related to impingement, tear, proximal head of biceps tendon rupture, or secondary to instability; Sx: - pain anterior, lateral, superior; *lateral pain over deltoid most common; - pain worse w/ motion at or above shoulder level; - tenderness over sub-acromial space, greater tuberosity or AC joint - can't lift arm, can only get ~45° abduction Dx: - NEER (passive painful arc) impingement sign: pain/tenderness w/ forward flexion at 90° - HAWKINS KENNEDY: pain/tenderness w/ abduction + internal rotation - DROP ARM: to assess supraspinatus fxn - *SUBACROMIAL LIDOCAINE INJECTION: 10cc local (combo long & short acting) + corticosteroid can be used to alleviate pain and to distinguish between rotator cuff tendinopathy and tear; Examination with adequate analgesia following injection provides more accurate assessment of muscle strength; Patients with tendinopathy exhibit normal strength with pain relief; those with large tear have persistent weakness

what are the 2 common plain radiographic views for identifying forearm fractures?

Forearm: - AP, lateral

a) Describe the knee and lower leg examination, including special tests - Hx: - PE: - Special Tests:

HPI/PMH: - acute vs. chronic pain - acute or delayed swelling or effusion - sx of locking or giving away - what makes pain better/worse - previous surgery, injections, PT - meds: use of NSAIDs, pain meds PE: - gait eval - inspect for deformity or muscular atrophy: vastus medialis oblique VMO, swelling or effusion - palpate: tenderness over joint line, patella - AROM, PROM ** pain is usually localized, tends not to refer Special Tests: - patellar tracking (lateral) and instability - ligaments instability testing: -- collateral ligaments: valgus/varus stress -- cruciate ligaments: lachman's, pivot shift, anterior/posterior draws - menisci injury: McMurrays - Patellar apprehension test for laxity/ instability Imaging: - usually AP and lateral + others as needed - for OA get "weight bearing"

- what is the Eponym for the pathologic finding in this image? - what condition does this represent?

Heberden's nodes of DIP in OA

33. identify the finding in this image - what is the most likely Dx/etiology?

Image of a patient with a partial ulnar nerve paralysis who is asked to extend the digits. Hyperextension of the metacarpophalangeal (MCP) joints of the ring and small fingers occurs with the loss of intrinsic ulnar-innervated MCP flexors. The index and middle fingers have median innervated intrinsics (lumbricals) that allow the extrinsics to extend the interphalangeal (IP) joints. Dx: Claw hand deformity from ulnar neuropathy

how do you perform the Hyperpronation technique to reduce a radial head dislocation?

In this method, the examiner supports the child's arm at the elbow and places moderate pressure on the radial head with one finger. The examiner grips the child's distal forearm with the other hand and hyperpronates the forearm. A click may be felt by the finger over the radial head when the subluxation is reduced.

what are the findings identified with white and black arrows in this x-ray image?

In this radiograph, the anterior and posterior fat-pads are elevated away from the humeral surface as a result of joint effusion or hemarthrosis (white arrows). This "fat pad sign" is associated with a subtle impaction fracture of the radial neck, manifested only by a sharp, angular change in the contour of the ventral cortex (black arrow).

Jones:

JONES Fracture: Acute fracture in the metaphyseal-diaphyseal area (base) of the proximal 5th metatarsal (often confused with avulsion or stress fractures) - MOI: frequently caused by pull of peroneus brevis tendon

what is the special term for an acute fracture of the metaphyseal-diphyseal area of the proximal 5th metatarsal?

JONES Fracture: Acute fracture in the metaphyseal-diaphyseal area (base) of the proximal 5th metatarsal (often confused with avulsion or stress fractures) - MOI: frequently caused by pull of peroneus brevis tendon

What are Kanavel's 4 cardinal signs? - if present, what do they indicate?

KANAVEL'S 4 CARDINAL SIGNS: flexed resting posture; tenderness over flexor sheath; fusiform swelling; severe pain on passive extension - Dx: infectious flexor tenosynovitis

what are the 4 common plain radiographic views for identifying knee fractures? - what can be seen in the 2 unique views?

Knee: - AP - lateral: *patella should line up straight w/ femur, if ↑alta, if ↓baja - oblique, internal or external rotated: provides a different projection of femoral condyles and tibial tuberosities as well as a cleaner view of medial and lateral margins of patella - Sunrise/Merchants view (axial, tangential): patellar injury, should have nice aligment, equal space

Cervical vertebral body fractures: *Flexion tear drop fracture*

MOI: A flexion teardrop fracture results when severe flexion causes a vertebral body to collide with the one below, leading to anterior displacement of a wedge-shaped fragment (resembling a teardrop). *most severe lower C-spin injury; assoc. w/ Ventral cord syndrome (anterior spinal artery syndrome) → Loss of pain and temperature sensation, weakness, bladder dysfunction

RHEUMATOID ARTHRITIS: - Tx:

NONPHARMACOLOGIC Tx: - Patient education - Psychosocial interventions - Rest, exercise, and physical and occupational therapy - Nutritional and dietary counseling - Interventions to reduce risks of cardiovascular disease, including smoking cessation, and of osteoporosis - Immunizations to decrease risk of infectious complications of immunosuppressive therapies PHARMACOLOGIC Tx: - Rapidly acting antiinflammatory medications, including nonsteroidal antiinflammatory drugs (NSAIDs) and systemic and intraarticular glucocorticoids - Disease-modifying antirheumatic drugs (DMARDs), including nonbiologic (traditional small molecule or synthetic) and biologic DMARDs, and an orally-administered small molecule kinase inhibitor, which all have the potential to reduce or prevent joint damage and to preserve joint integrity and function

28. interpret the findings from these x-ray images

Nondisplaced olecranon fracture: (A) Anteroposterior view of the elbow. (B) Lateral view of the elbow. A linear greenstick fracture line is evident on both views (arrows).

a) Describe the general principles of the orthopaedic examination - PE: (7) - Studies: (2)

PE: - vitals: - gait: - posture: - deformity: - tenderness: - ROM: - special tests: Studies: - imaging: - labs:

49. interpret this film - what is the most likely Dx?

Plain radiographs cannot be used to diagnose ACL tears. In some cases, an avulsion fracture of the anterolateral tibial plateau (ie, Segond fracture) is identified at the site of attachment of the lateral capsular ligament. - Dx: Segond avulsion fx w/ ACL tear

OPEN FRACTURES: - what is the clinical presentation of open fractures? - how are they classified and treated?

Presentation: - bleeding longer than other lacs b/c bone is still bleeding - shiny blood b/c also contains fat from bone Gustilo, Mendoza, Williams Classification: - Grade I: wound <1cm, low energy MOI; 1st gen cephs (Ancef) + tetanus - Grade II: wound <10cm, moderate energy MOI; 1st gen cephs + gentamycin + tetanus - Grade III: wound >10cm, high energy MOI; 1st gen cephs + gentamycin + anaerobic abx (pens, clinda, flagyl) + tetanus - Grade IIIa: adequate tissue coverage; emergent OR - Grade IIIb: massive contamination; emergent OR - Grade IIIc: vascular injury; emergent OR

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Femur Fractures: Proximal Femur - Etiology: - S/Sx: - Imaging: - Dx:

Proximal Femur Fracture S/Sx: - displaced: injured limp is externally rotated, abducted, shortened - non-displaced fracture presents w/ ↑pain w/ gentle rotation and extension; unable to do straight leg raise Proximal Femur Tx: - surgical fixation

Hangman Fx / Traumatic Spondylolisthesis of Axis

Radiographic features: bilateral lamina and pedicle fracture at C2; usually associated with anterolisthesis of C2 on C3; Extension of the fracture to the transverse foramina should be sought, raising the possibility of vertebral artery injury.

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Acromio-clavicular injuries - S/Sx: - Dx:

S/Sx: - mild tenderness felt over joint (ligament sprain) ↔ intense pain of complete separation - visible deformity at AC joint usually indicates at least Type III Acromioclavicular (AC) injury classification: - Type I: AC ligament sprain; AC joint intact - Type II: AC ligament torn, coracoclavicular (CC) ligament intact; AC joint subluxed; swelling - Type III: AC and CC ligaments torn; complete dislocation of joint; swelling; *may feel popping sensation due to shifting of loose joint; *usually noticeable deformity on shoulder - Type IV: Complete dislocation with posterior displacement of distal clavicle into or through trapezius muscle - Type V: Superior dislocation of joint of one to three times normal spacing, ↑CC ligament distance 2-3x normal; disruption of deltotrapezial fascia - Type VI: Complete dislocation with inferior displacement of distal clavicle into a subacromial or subcoracoid position Dx: - X-rays: weighted vs. non-weighted w/ ↑CC distance - Image: drawing depicts a type two acromioclavicular (AC) injury; AC ligament is completely disrupted, but there is only a partial tear or stretching of coracoclavicular ligament; Superior displacement of clavicle, if present at all, is minimal.

Patella Fracture - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

S/Sx: - sunrise view of knee demonstrates a comminuted fracture of patella (arrow) with associated soft tissue swelling; Patella not equally positioned evenly Tx: ORIF

identify the piece of equipment in this image

SAM pelvic sling: includes a buckle that limits the amount of force applied to the pelvis.

Spine Radiographic studies: X-ray: CT: MRI: Bone Scan:

X-ray: - AP: - lateral: - oblique: - C-spine: *never accept w/o seeing C7 - odontoid: to view dens of C2/axis through C1/atlas - swimmer's view: for cervico-thoracic jxn CT: scan for bone details in fx or infxn MRI: for disc pathology, infxn, tumors Bone Scan: tumors, infxns

27. interpret the findings from these x-ray images

Supracondylar fracture line orientation: A) typical transverse fracture line originates just above epicondyles and courses through supracondylar area (arrows). B) In lateral projection, fracture line is usually also transverse

Cobb angle measurement

The Cobb angle (arrow in radiograph) is formed by the intersection of a line parallel to the superior end plate of the most cephalad vertebra in a particular curve, with the line parallel to the inferior end plate of the most caudad vertebra of the curve. The intersection of these lines may occur outside the border of the actual film. Therefore, by convention, perpendiculars to the parallels are drawn, and the angle between their intersection is measured. The Cobb angle in the above radiograph is 63°. The most cephalad vertebra is the vertebra that has the greatest tilt from horizontal of its superior end plate (red line). The most caudal vertebra is the vertebra that has the greatest tilt from horizontal of its inferior end plate (blue line). Drawing lines along several vertebrae near each end of a curve (dashed lines) is helpful in determining that with the greatest tilt.

5. what special maneuver is being performed in this image? - what is being assessed?

The arc of elevation manoeuvre. When a patient with shoulder pain elevates the extended arm from a relaxed, at-the-side position to completely overhead and parallel to the long axis of the trunk, a 180° arc is formed. Movement through the first 20-40° (labelled part '1' of the arc) is generally not painful or only minimally symptomatic with rotator cuff tendinitis/tendinosis and impingement, but throughout the portion of the arc designated '2' in the diagram (i.e. the 'middle third', approximately 40-120°), pain will occur with active motion. Movement through the terminal 30-60° (labelled '3') of the arc is generally much less painful with rotator cuff pathology and typically affected by acromioclavicular arthritis/ pathology. The exception is when acromioclavicular arthritis and hypertrophic degenerative change are the cause of rotator cuff impingement, in which case both the second and the third labelled portions of the arc will be painful. Patients with glenohumeral arthritis, adhesive capsulitis, acute calcific tendinitis and subacromial bursitis often have pain throughout all the portions of the arc.

C2 'pedicle' fractures: *Hangman's fracture*

Traumatic spondylolysis of C2 (so-called "hangman's fracture") is an unstable injury MOI: occurs when cervicocranium (skull, atlas, and axis functioning as a unit) is thrown into extreme hyperextension.

Scapular Y-view of the shoulder

This radiograph utilizes a scapular Y-view of the shoulder to assess the location of the humeral head. Anterior or posterior dislocation are excluded by a normal position of the humeral head (HH) relative to the coracoid (C) and the acromion process (A). The inferior portion of the "Y" is formed by the body of the scapula (S).

how do you perform the Anterior drawer test? - what is it used to assess?

The test is performed with patient's foot in neutral position. The lower leg is stabilized by the examiner with one hand. With the other hand, the examiner grasps the heel while the patient's foot rests on the anterior aspect of the examiner's arm. An anterior force (direction of the arrow) is applied to the heel while holding the distal anterior leg fixed. Excessive anterior displacement suggests ligamentous injury.

Axillary radiograph of the shoulder

This axillary radiograph of the shoulder shows a normal relationship of the humeral head to the glenoid (short black arrow), acromion (short white arrow) and the coracoid process (white arrow). This view is valuable in assessing for shoulder dislocation.

38. interpret the findings from this x-ray image - what is the Dx? ID: 11 y/o

This common pediatric fracture is described as follows: 100 percent dorsally displaced distal radius and ulna fracture with volar angulation. - Dx: Complete distal radius and ulna fracture (Colles fracture)

identify the Structures involved with carpal tunnel syndrome

This is a depiction of the volar surface of the right hand showing the relationship of the median nerve to the transverse carpal ligament (flexor retinaculum). The ligament attaches to the carpal bones, including the hamate, pisiform, trapezium, and scaphoid tuberosity (navicular).

C1 arch fractures: *Jefferson fracture*

This odontoid or open-mouth view shows a Jefferson fracture. Note the step-off of the lateral masses (white arrow), which normally are in alignment. *bilateral fx of both anterior and posterior arches of C1 MOI: vertical compression

SHOULDER EXAM - describe how to perform the following: ADSON MANEUVER: - what is it used to find? - how is it performed? - how are the results interpreted?

Thoracic Outlet Syndrome:

Charcot arthropathy

This person with diabetes has joint and bone damage called Charcot arthropathy. The arch of the person's foot has collapsed and been replaced by a bony growth (see arrow). Several factors contribute to this painless condition, including the loss of muscle, decreased sensation, and inappropriate weight distribution.

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Rotator Cuff Injuries/Impingement Syndrome: - Tx: Algorithm for management of rotator cuff tear: * Regular reevaluation is appropriate for those patients who would be surgical candidates were significant pain or shoulder dysfunction to develop. Refer to text for details. Δ Age below 50 is a general guideline and not mandatory to be considered a surgical candidate.

Tx: Non-Surgical Management: - NSAIDS - RICE - cortisone injxns - activity modifications - PT: at least 3 mo; ultrasound; phonophoresis; motion and RC strengthening Tx: Surgical Management: - subacromial decompression (arthroscopic or open) w/ bursectomy - distal clavicale resection (MUNFORD procedure) - rotator cuff repair

19. interpret the findings from this x-ray image - from what view was this image taken?

Type IV AC injuries are uncommon and involve forceful posterior displacement of the distal clavicle (arrow) from the acromion (arrow-head). The injury and posterior displacement are easier to see on this axillary view. The humoral head and glenoid are in normal anatomic position.

32. identify the finding in this image - what is on the most likely Dx?

With the elbow flexed at 90 degrees, the bursa is palpated for ballotable cystic swelling, the degree of associated soft tissue reaction (redness, heat, induration), and in the case of chronic bursitis, the degree of bursal wall thickening.

Shoulder Instability lesions

X-RAY IMAGING: - **BANKART LESION: injury of glenoid labrum** due to anterior-posterior shoulder dislocation and is usually indication for surgery - **HILL SACHS LESION: cortical depression in head of humerus; results from forceful *impaction of humeral head* against anterior-inferior glenoid rim when shoulder dislocated

when is MRI imaging preferred for orthopedic purposes?

although MRI is superior for soft tissue contrast [20]. - Magnetic resonance imaging (MRI) depicts internal structures as cross-sectional images based upon their chemical composition; A major advantage of MRI is its ability to evaluate noncalcified body tissues. For example, menisci, articular cartilage, cruciate ligaments, and joint fluid, which would be indistinguishable on a radiograph, are readily distinguished on MRI. Thus, MRI is particularly useful for the evaluation of soft tissue changes such as internal derangement, articular cartilage integrity, and synovitis. - Extremity MRI is more sensitive than radiography for the detection of **joint erosions; Thus, conditions such as avascular necrosis, transient regional osteoporosis, early infections, subtle trauma, ischemia, and infiltrative processes are best visualized using MRI. - **periarticular soft tissues such as the ligaments, tendons, muscles, synovium, and cartilage are directly visualized and are readily evaluated with MRI. - An infinite number of reconstruction planes allow for the sagittal, coronal, and axial displays of these complex structures - There are several contraindications to MRI, including the presence of ●Orbital metallic foreign bodies ●Cardiac pacemakers or implanted defibrillators ●Cochlear implants

Patella laxity/ Instability - what is the Q value? - what are normal values?

an increased angle between the force vector of the quadriceps and the patellar tendon, also known as the Q angle, is also mentioned as a risk factor for lateral patellar dislocation, this angle varies based upon the degree of quadriceps muscle contraction or knee extension and has been shown to not reliably identify patients with patellar instability relative to other validated standards (eg, the tibial tuberosity-trochlear groove [TT-TG] distance) - normal Q angles 15-20°

SPINE: LOW BACK PAIN: epidemiology: pathophysiology:

low back pain affects 60-80% of adult population at some time; - 80%+ no specific dx possible; usually self-limited - if does not resolve, get CXR DEGENERATIVE DISC DISEASE (DDD): inter-vertebral discs become dehydrated w/ age → less efficient in shock absorption → bone changes primarily related to altered facet alignment leading to: - subchondral sclerosis - joint space narrowing - osteophytes - stenosis Cauda Equina Sciatica radiulopathy Neoplastic Infection Inflammatory

Spine Radiograph indications w/ corresponding views: non-trauma c-spine: spine/neck pain: radiculopathy: aspirated FB: retropharyngeal cellulitis: croup:

non-trauma c-spine: determined by clinical indications; e.g. RA pt before intubation spine/neck pain: AP, open-mouth/odontoid, lateral radiculopathy: AP, open-mouth/odontoid, lateral, oblique aspirated FB: AP, lateral, swallowing fxn, endoscopy retropharyngeal cellulitis: lateral radiograph + MRI to r/o abscess croup: AP → *steepling, pencil-point of subglottic area; lateral → *distended pharynx image: AP view demonstrates tapering of upper trachea, known as "steeple sign" of croup

Cervical Radiculopathy: pathophys: Sx: H&P: Tx:

pathophys: neurogenic pain related to cervical herniated nucleus pulposus (HNP) w/ antrapment of cervical nerve root Sx: neck pain w/ numbness, paresthesias in UE; sharp pain btw shoulder blades; PE: motor & sensory to ID affected nerve root; e.g. C5-6 HNP causes C6 radiculopathy w/ biceps weakness and ↓sensation to thumb and index finger Tx: spontaneous resolution, NSAIDs, PT; no narcotics, no manipulation of C-spine

what is the term for a partial tear of a muscle?

strain

45. identify the finding in this image

- Ganglion cysts (see arrow) often form on the wrist. Cysts like these are filled with a clear, jelly-like fluid.

what is the mechanism of flexion injury causing an olecranon fracture?

(A) In the flexed elbow, force develops on the posterior aspect of the olecranon (small double arrow) because of the pull of the brachialis and triceps muscles (large arrows). (B) Failure occurs on the tension side, which is posterior as a result of the muscle pull or a direct blow to the prestressed posterior olecranon.

Explain the mechanism of injury and presentation of SPRAINS

- - SPRAIN: partial or complete tear of a ligament

a) Describe the 5-8 components that should be included when writing an orthopaedic procedure note

- *PROCEDURE: - *PERMIT: procedure, benefits, risks, alternatives explained to pt. who voiced understanding of info; their questions were sought and answered; pt. agreed to proceed w/ procedure; permit signed and on chart (if so); - INDICATION: suspected... - PROVIDER(S): - *DESCRIPTION: area prepped and draped in a sterile fashion; (type, local, spinal, etc.) anesthetic administered w/ (cc med); describe technique including instruments, body location, occurrences, etc. - COMPLICATIONS: - ESTIMATED BLOOD LOSS: amount in cc - *DISPOSITION: pt. alert, oriented, resting; breathing nonlabored; extremities neurovascularly intact; incision clean, dry and intact, etc. - *PLAN:

SHOULDER EXAM - describe how to perform the following: HAWKINS KENNEDY TEST: - what is it used to find? - how is it performed? - how are the results interpreted?

- Hawkins Kennedy test is used to assess *shoulder impingement*; rotator cuff tendonitis, tendinosis?? - In this test clinician stabilizes shoulder with one hand and, with patient's elbow flexed at 90°, internally rotates shoulder using other hand - Shoulder pain elicited by internal rotation represents a positive test

39. interpret the findings from these x-ray images ID: 40 y/o man CC: wrist pain following FOOSH - what is the Dx?

- Image A is an AP radiograph of right wrist demonstrating an intraarticular fracture of distal radius (arrow). - Image B is a lateral radiograph demonstrating an intraarticular radial fracture with dorsally-displaced radial bone fragments (arrow) and dorsal dislocation of the carpal bones with respect to the radius (arrowhead), - Dx: consistent with a Barton's fracture/ dislocation

SHOULDER EXAM - describe how to perform the following: O'BRIEN'S TEST: - what is it used to find? - how is it performed? - how are the results interpreted?

- This test examines the *integrity of the glenoid *labrum and the *acromioclavicular joint (provides location) - With patient seated or standing, instruct patient to raise their arm into 90° of forward flexion with their elbow extended, and then adduct their arm 10-15°. Have patient internally rotate their arm and point their thumb down to ground. Apply a downward force to arm. Then instruct the patient to externally rotate their arm and point their thumb towards the ceiling. Again, apply a downward force. - Positive findings for labral pathology occur when first test reproduces pain, while second test ↓or eliminates pain - pain associated with labral tears is described as being *deep in shoulder - Pain situated over acromioclavicular joint is associated with acromioclavicular joint pathology such as osteoarthritis or a shoulder separation, rather than labral pathology. - Pain in AC joint is usually equal with palm down or palm up

Thompson test: - how use - when

- Thompson test is performed with the patient's feet hanging over the edge of the examining table. When the examiner squeezes the calf muscle, on the uninjured side there is normal plantar flexion of the foot; on the side with a complete Achilles tendon rupture, there is no plantar flexion. It is important to note that in patients with significant but incomplete rupture of the tendon, the patient may still demonstrate a normal Thompson test as well as substantial strength.

How can leg-length discrepancy as an indicator of dysplastic hip be detected?

Galeazzi test: The patient is positioned as shown. The knee is lower on the affected side because of posterior displacement in the developmentally dysplastic hip (arrow).

51. interpret this film ID: 61 y/o male CC: knee pain after injury - what is the most likely Dx?

Lateral radiograph of the left knee showing superior dislocation of the patella held by interlocking osteophytes in a 61-year-old man who received a direct blow to the inferior patella during knee flexion. Dx: Superior patellar dislocation

9. interpret the findings in these x-ray films, L. is non-weight bearing; R. is weight bearing

OA

- where are Heberden's nodes found? what do they indicate? - where are Bouchard's nodes found, what do they indicate?

OA: Heberden's nodes on DIPs RA or OA: Bouchard's nodes on PIPs

how do the nodes on hands of pt's w/ OA and RA differ?

OA: Heberden's nodes on DIPs RA: Bouchard's nodes on PIPs

13. interpret the findings from this x-ray image - from what view was this image taken?

Posterior shoulder dislocation: Note the "light bulb" appearance of the humeral head on the AP view and the greater than normal overlap between the anterior glenoid rim and medial aspect of the humeral head.

Swimmers view

Swimmers view is xray of cervico-thoracic junction that helps demonstrate upper thoracic and C7 vertebrae; swimmer's view is important for evaluating relationship of cervicothoracic junction and upper thoracic vertebrae C7 through T3. Basic purpose of swimmer's view is to clear the humeral head out of cervico-thoracic junction visualization. Swimmer's view xray positioning is difficult and requires high dosing; w/ trauma patients, this xray becomes even more difficult. Due to this and better imaging with CT and MRI, swimmer's view is not frequently done nowadays.

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: Terminology used in back pain

Spondylosis: arthritis of the spine. Seen radiographically as disc space narrowing and arthritic changes of the facet joint. Spondylolisthesis: anterior displacement of a vertebra on the one beneath it. A radiologist determines the degree of slippage upon reviewing spinal x-rays. Slippage is graded I through IV: • Grade I - 1 percent to 25 percent slip • Grade II - 26 percent to 50 percent slip • Grade III - 51 percent to 75 percent slip • Grade IV - 76 percent to 100 percent slip Generally, Grade I and Grade II slips do not require surgical treatment and are treated medically. However, Grade III and Grade IV slips, and some milder grade slips, may benefit from surgery if persistent and disabling symptoms are present. Spondylolysis: a fracture in the pars interarticularis where the vertebral body and the posterior elements, protecting the nerves are joined. In a small percent of the adult population, there is a developmental crack in one of the vertebrae, usually at L5. Spinal stenosis: local, segmental, or generalized narrowing of the central spinal canal by bone or soft tissue elements, usually bony hypertrophic changes in the facet joints and by thickening of the ligamentum flavum. Radiculopathy: impairment of a nerve root, usually causing radiating pain, numbness, tingling or muscle weakness that corresponds to a specific nerve root. Sciatica: pain, numbness, tingling in the distribution of the sciatic nerve, radiating down the posterior or lateral aspect of the leg, usually to the foot or ankle. Cauda equina syndrome: loss of bowel and bladder control and numbness in the groin and saddle area of the perineum, associated with weakness of the lower extremities. This condition can be caused by abnormal pressure on the bottom-most portion of the spinal canal and spinal nerve roots, related to either bony stenosis or a large herniated disc. Lordosis, kyphosis, scoliosis: • Kyphotic curves refer to the outward curve of the thoracic spine (at the level of the ribs). • Lordotic curves refer to the inward curve of the lumbar spine (just above the buttocks). • Scoliotic curving is a sideways curvature of the spine and is always abnormal. A small degree of both kyphotic and lordotic curvature is normal. Too much kyphotic curving causes round shoulders or hunched shoulders (Scheuermann's disease). Too much lordotic curving is called swayback (lordosis). Lordosis tends to make the buttocks appear more prominent. Piriformis syndrome: thought to be a condition in which the piriformis muscle compresses or irritates the sciatic nerve. The piriformis muscle is a narrow muscle located in the buttocks. There is debate among the medical community whether this is a discrete condition since it lacks objective diagnostic evidence and therefore cannot be reliably assessed.

8. use the fracture identification practice tool format to describe the findings in these x-ray films

Transverse fractures of the middle radius and ulna. The ulnar fracture is open and anteriorly displaced with medial angulation ?? Thirteen-year-old girl with open forearm fracture. Top Panels: AP and lateral x-rays; note extrusion of ulna on lateral view. Bottom Panels: After irrigation and debridement and flexible nail internal fixation; note the Penrose drain in the ulnar wound.

what are the 4 common plain radiographic views for identifying wrist fractures? - which 2 are usually obtained first? - which should be next if fractured suspected but not seen on first two? - which view is specific to the anatomical snuff box?

Wrist : - AP, lateral - Oblique: fracture suspected but AP and lateral negative (provides view of scaphoid-trapezoid-trapezium articulation) - Scaphoid: scaphoid fracture suspected; MOI is FOOSH

what is the Surgical treatment of acute paronychia?

- Surgical drainage is indicated for patients with acute paronychia who present late and have an abscess cavity - appropriate drainage procedure: (Left) Pre-operative appearance (Center) Elevation and excision of lateral third of nail (Right) Incision of perionychial fold with blade directed away from te nail bed and matrix

SUBACROMIAL SPACE LIDOCAINE INJECTION: - when is it used? - who should perform it? - How do you perform a Subacromial bursa injection?

- *a PCP procedure used to alleviate pain and to distinguish between rotator cuff tendinopathy and tear. Examination with adequate analgesia following injection provides a more accurate assessment of muscle strength. Patients with tendinopathy exhibit normal strength with pain relief; those with a large tear have persistent weakness. - lateral or posterior approach can be used to inject subacromial bursa; lateral approach shown here is safer to perform, since injection into rotator cuff tendons is nearly impossible with this technique - patient is to be sitting up, with hands placed in lap; patient is asked to relax shoulder and neck muscles - Traction applied to flexed elbow may be necessary to open subacromial space - lateral edge of acromion is located and midpoint marked - point of entry is 1-1.5 in (~2.5-4 cm) below marked midpoint - angle of entry should parallel patient's own acromial angle (averaging 50-65°). - depth will vary according to patient's weight and muscle development (1.5 in [~4 cm] in an asthenic patient and up to 3.5 inches [~9 cm] in an obese patient over 30% ideal body weight) - Ethyl chloride is sprayed on skin - Local anesthetic is placed in deltoid muscle (1 mL) and deep deltoid fascia (0.5 mL); needle is advanced through subcutaneous tissue and deltoid muscle until subtle resistance of deep deltoid fascia is encountered; If firm or hard tissue resistance is encountered (deltoid tendon or periosteum, often painful), then needle is withdrawn 0.5 in (~1.5 cm) and angle is redirected 5-10° either ↑or↓. A "giving way" or "popping" sensation is often appreciated when subacromial bursa is entered. - Following 1-2 mL of anesthesia and leaving needle in position, patient strength is tested again. If pain is reduced by 50% and strength of abduction and external rotation are 75-80% of unaffected side, then 1 mL of depo-medrol (80 mg/mL) is injected. - Note, never inject under moderate to high pressure. If high injection pressure is encountered, first try rotating syringe 180°. If tension is still high and patient obviously anxious, ask patient to take a deep breath and try to relax shoulder muscles. If tension remains high, reposition the needle by 0.25 inch (~0.5 cm) increments or by altering angle of entry by 5-10°. - subacromial bursa will accept only 2-3 mL of total volume before rupturing

Morton's Neuroma: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

- Symptoms of a Morton's neuroma include hyperesthesia of the toes, numbness and tingling, and aching and burning in the distal forefoot. - Pain radiates forward from the metatarsal heads to the third and fourth toes. - It is aggravated by walking on hard surfaces and wearing tight or high-heeled shoes. - Physical examination reveals tenderness in the plantar aspect of the distal foot over the third and fourth metatarsals; compressing the forefoot reproduces the symptoms (squeeze test) Tx: - cortisone injection - surgery

- how do you perform the Lidocaine injection test for shoulder? - who performs it? - what is it used to detect?

- *a PCP procedure used to alleviate pain and to distinguish between rotator cuff tendinopathy and tear. Examination with adequate analgesia following injection provides a more accurate assessment of muscle strength. Patients with tendinopathy exhibit normal strength with pain relief; those with a large tear have persistent weakness. - lidocaine injection test is used to exclude intrinsic glenohumeral joint pathology; eg, rotator cuff tear, frozen shoulder. - To ↑space for needle insertion, clinician may need to apply downward traction to elbow. - point of entry is 1-1.5 inches (2.5-4 cm) below midpoint of acromion - angle of entry parallels acromion. - A 1.5 inch (4 cm), 22-gauge needle is inserted to a depth of 1-1.5 inches (2.5-cm) and 1 mL of lidocaine is injected into -deltoid and 1-2 mL into subacromial bursa.

a) Describe the foot and ankle examination, including special tests.

- 20% of MSK problems affect foot and ankle; most can be handled by PCP - PMH: DM, PVD, neuropathies, OA Foot & Ankle PE: - gait: examine from front and back, look for foot drop, flat foot, equinous deformity - examine symmetry while standing from posterior and lateral angles, look for "too many toes sign" (posterior tibial tendon deficiency) - unilateral (common) or bilateral pain (systemic or spinal pathology) - *x-rays: standing, weight bearing* Special Tests: - Talar tilt: lateral ankle ligament instability - Anterior drawer: lateral ankle ligament instability - Squeeze test: for foot neuroma - Motor and sensory test for neuropathies - strength against resistance for n. fxn deficit

hip fracture risks (4)

- 25% die w/i 1 year Hip Fracture Etiology: - most common fracture in elderly - incidence doubles past age 50; F>M - **¼ pts w/ a hip fracture die w/i 1 yr after fracture - ½ of pts w/ hip fracture never return to previous level of ambulation and independence - 95% caused by falling, most often sideways Hip + Proximal Femur Fracture Etiology: - intra-capsular (femoral neck): usu assoc w/ high risk for non-union secondary to AVN - extra-capsular: intertrochanteric or above lesser trochanter: requires stronger fixation, has better chance of healing

What is the correct way to describe a fracture using: ANGULATION & ROTATION? - malalignment: do you describe the movement of the proximal or distal fragment of the fractured bone?

- A fracture is either angulated or displaced if it results in loss of normal anatomic alignment - ANGULATION refers to motion relative to long axis of bone; when describing angulation, the *angle or direction that the distal bone fragment makes with proximal bone should be stated* - medial angulation can be termed 'varus' and lateral angulation can be termed 'valgus' - direction of angulation can also be communicated by identifying orientation of fracture apex; in other words, fracture fragments will form a V shape, and the apex is the point of the V; direction of the apex is used to describe the fracture → e.g. a tibia-fibula fracture where foot is and distal portion are angled laterally is called both valgus angulation and apex medial angulation - ROTATION of long bone fracture may be internal or external

What is the correct way to describe a fracture using DISPLACEMENT? - malalignment: do you describe the movement of the proximal or distal fragment of the fractured bone?

- A fracture is either angulated or displaced if it results in loss of normal anatomic alignment - DISPLACEMENT describes movement when two ends of a fracture move away from each other in an anterior-posterior plane or a medial-lateral plane; *abnormal position of distal fracture fragment relative to proximal bone* → e.g. displaced/loss of alignment, angulated, rotation, bayonetted/shortened, ∆length: special cases of displacement occur when fracture ends are crushed together ("IMPACTED") or pulled apart ("DISTRACTED")

50. interpret this film ID: 42 y/o male - what is the most likely Dx?

- A lateral radiograph of the knee (A) shows superior dislocation of the patella (arrowhead) and soft tissue swelling below the patella (arrow). A T2 weighted magnetic resonance image in sagittal projection (B) shows rupture of the patella tendon (between arrows). There is fluid accumulation at the site of the tear (arrowhead). - Dx: Patellar tendon rupture with superior patellar dislocation

what are the steps in the procedure for Injection at the mid-trochanteric process?

- A local anesthetic block placed below the gluteus medius tendon at the periosteum of the trochanteric process can confirm the presence of trochanteric bursitis. The patient is placed in the lateral decubitus position with the affected side up and the knees flexed to 90 degrees. The superior, posterior, and anterior edges of the trochanteric process are palpated and marked. The point of entry is directly over the center point of the trochanter, approximately 4 cm (1.5 in) below the superior trochanter. Alternatively, the point of entry is at the crown of the trochanter viewed tangentially. Topical anesthetic (eg, ethyl chloride) is applied to the skin. Local anesthetic is injected at the gluteus medius tissue plane (1 mL) and at the periosteum of the femur (0.5 to 1 mL). A 4 cm (1.5 in), 22-gauge or 22-gauge spinal needle is inserted perpendicular to the skin; the depth is 4 to 7.5 cm (1.5 to 3 in) to the femur. The needle is held lightly and advanced through the low resistance of the subcutaneous fat to the firm, rubbery resistance of the gluteus medius tissue plane. Following anesthesia at this level, the needle is advanced with firm pressure approximately 1.3 cm (0.5 in) farther to the periosteum of the femur. The patient will usually experience sharp pain as the needle touches the periosteum. Injection at this deeper level requires firm pressure. The needle should be rotated 180 degrees or withdrawn slightly if excessive pressure is encountered. If the trochanter tenderness is significantly relieved with anesthetic injection, 1 mL of triamcinolone acetonide 40 mg/mL can be injected through the same needle.

2. use the fracture identification practice tool format to describe the findings in this these AP and lateral plain x-ray films

- A spiral fracture of the distal diaphysis of the tibia. The fracture shows no displacement or angulation. - Anteroposterior (left) and lateral (right) views of a patient with spiral fracture (arrow) of the tibia. Note that the anteroposterior view alone would most likely have been considered normal.

what is the name of the distal radius fracture where the volar rim of the radius is displaced?

- Barton's fracture dislocation of wrist: The patient is a 40-year-old man who presented with wrist pain following a fall on an outstretched hand, and found to have a Barton's fracture/dislocation. Image A is an AP radiograph of the right wrist demonstrating an intraarticular fracture of the distal radius (arrow). Image B is a lateral radiograph demonstrating an intraarticular radial fracture with dorsally-displaced radial bone fragments (arrow) and dorsal dislocation of the carpal bones with respect to the radius (arrowhead), consistent with a Barton's fracture/dislocation.

- what is COMPARTMENT SYNDROME? - what are common causes? - S/Sx: - Dx: - Tx:

- COMPARTMENT SYNDROME: muscle groups of human limbs are divided into sections, or compartments, formed by strong, unyielding fascial membranes; acute compartment syndrome occurs when fascial structures prevent adequate expansion of tissue volume to compensate for ↑fluid → ↑pressure w/i compartment compromises circulation and fxn of tissues w/i that space; surgical emergency b/c cellular anoxia leads to distal ischemia - Commonly follows major trauma such as: GSW, crush injuries, long bone fx, dislocations, bites, pediatric distal humerus fx, 3°/deep partial-thickness burns; - S/Sx: 5 Ps -- Pain way out of proportion; early sign due to ↑P -- Pallor -- Paralysis -- Paresthesias -- Pulselessness - Dx: intra-compartment press ≥30 mmHg; or 20 mmHg diastolic BP discrepancy btw extremities - Tx: fasciotomy

40. interpret the findings from this x-ray image - Dx:

- Chauffeur's/ Hutchinson's radiocarpal fracture: This anteroposterior plain x-ray of the right hand shows an intra-articular fracture through the radial styloid process (arrow) with minimal displacement.

What is the name for the distal radius fracture isolated to the radial styloid process?

- Chauffeur's/ Hutchinson's radiocarpal fracture: This anteroposterior plain x-ray of the right hand shows an intra-articular fracture through the radial styloid process (arrow) with minimal displacement.

SHOULDER EXAM - describe how to perform the following: DROP ARM TEST/ JOBE/ EMPTY CAN: - what is it used to find? - how is it performed? - how are the results interpreted?

- Drop arm test to assess *supraspinatus function* - assesses ability of patient to lower his or her arms from a fully abducted position - A positive test occurs when patient is unable to lower affected arm with same smooth coordinated motion as unaffected arm

- what are the 3 common plain radiographic views for identifying elbow fractures? - how should the radial head be aligned w/ the capitellum of the humerus? - what is the area most susceptible to fracture? and how does it appear on x-ray?

- Elbow views: AP, lateral, oblique - Note normal small anterior fat pad (black arrow), and normal alignment - radiocapitellar line (white line) extends from midshaft of proximal radius and bisects capitellum; Dislocation or displaced fracture of radial head or capitellum will disrupt this alignment - anterior humoral line (black line) extends along anterior of humerus and should cross middle of capitellum; A supracondylar fracture can disrupt this alignment - supracondylar area that looks like half of an hour glass is most susceptible to fracture

- what is etiology of CAUDA EQUINA SYNDROME? - Clinical presentation: - Tx:

- Etiology: central herniated nucleus pulposus (HNP) or fracture - S/Sx: -- acute or gradual in onset -- pain and weakness -- saddle parasthesias: early finding; check sphincter tone w/ rectal exam -- paralysis -- bowel/bladder dysfxn: overflow bladder incontinence, loss of bowel control -- bilateral LE neuro deficit: absence or ↓DTRs - Tx: emergent MRI → emergent surgical decompression - Image: cauda equina is a bundle of nerves that spread out from bottom of spinal cord; Cauda equina syndrome happens when some of the nerves in the cauda equina get squeezed or damaged.

how do you perform the FINKELSTEIN test - what is a positive test and what does it indicate?

- Finkelstein test for de Quervain tendinopathy - examiner gently rotates patient's wrist ulnarly (arrow) while patient's fingers are folded over thumb

what test is used to detect DeQuervain Tenosynovitis?

- Finkelstein test for de Quervain tendinopathy - examiner gently rotates patient's wrist ulnarly (arrow) while patient's fingers are folded over thumb

de Quervain tendinopathy presentation

- Finkelstein test for de Quervain tendinopathy - examiner gently rotates patient's wrist ulnarly (arrow) while patient's fingers are folded over thumb - entrapment tendonitis or tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius

- Foot deformities that cause hindfoot pain (4)

- HAGLUND: prominent superior process of calcaneus w/ common atrophy of achilles tendon at insertion point into calcaneus w/ achilles bursitis - POSTERIOR TIBIAL TENDON DYSFUNCTION: too many toes sign; tear in post tib tendon, peroneus is taking over and pronating - symptomatic PES PLANUS (FLATFOOT): hyperpronation and tight heel cord; check for bunions - Talus Osteochondral defect

- how do you perform the FABERE test (PATRICK TEST, "FIGURE of FOUR" test)? - how can it be used for examining a child with hip pain?

- Image: FABERE test (Patrick test or "figure of four" test) consists of Flexion of hip and knee, with ABduction and External Rotation at hip, so that ankle of one leg is on top of opposite knee (a figure four configuration). Force is applied downwards on bent knee and opposite hip, causing Extension at sacroiliac joint ipsilateral to bent leg.

CC: patient presents w/ R. hip pain X-ray: bony areas in R. pelvic girdle w/ low density, seems like lytic lesions - what is the next imaging technique to order, and why?

- Imaging: order a CT b/c looking for bony destruction - if unexplained from CT → order MRI to look for soft tissue → find a tumor → biopsy → order bone scan to see extent of bone involvement *most common lytic bone lesions are mets - Metastatic bone disease: conventional isotope bone scan using technetium 99m MDP demonstrates multiple sites of abnormally increased skeletal uptake

- how do you perform the TINEL TEST? - what does it assess? - what constitutes a positive sign?

- In a patient with carpal tunnel syndrome, tapping over a compressed nerve at wrist reproduces pain and paresthesia, proximal or distal to site of compression; this should recreate the pain that wakes them up at night - Tinel test for median nerve injury at carpal tunnel - if tingle goes away, like it does for most people, it is not (+)!

- how do you perform the PHALEN MANEUVER? - what does it assess?

- In patients with nerve compression in the carpal tunnel, acute wrist flexion maintained for 60 seconds reproduces symptoms

17. interpret the findings from these x-ray images

- Type II AC injuries represent a complete tear of the AC ligaments and partial injury of the CC ligaments. In this radiograph of a type II injury, note the subtle difference in AC joint position (arrow), and slight increase in CC distance. The patient was nontender over the right CC ligaments, suggesting that only the AC ligaments are significantly injured.

- what is a nonunion fracture? - what are the intrinsic and extrinsic risks factors for developing nonunion fractures? - what 3 methods can be used to correct a nonunion fracture?

- NONUNION: absence of radiographic evidenc of progression of callus formation over a 3-5 mo period; - intrinsic risks: regions of bone involved have a threatened or tenuous blood supply; *no healing w/o blood supply → e.g. fractures of femoral neck, scaphoid, talus, odontoid - extrinsic risks: smoking, indolent infxn, inadequate immobilization (*bones do not like to move when healing), malnutrition, NSAID use - correction: surgical, electrical stimulation, ultrasound

TRACTION-COUNTERTRACTION for REDUCTION of ANTERIOR shoulder dislocation: - how is it performed? - when is it used?

- Note how the clinician on the left has the sheet wrapped around him, allowing him to use his body weight to create traction. Some clinicians employ gentle external rotation to the affected arm while providing traction. - needed for acute dislocation - Rx: propofal "milk of agnesia"

- what is the mechanism of injury for Nursemaid's elbow? - what is the name of the bones involved and appropriate term for the type of injury?

- Nursemaid's elbow usually happens when someone pulls hard on a child's arm by the hand, wrist, or forearm when the child isn't expecting it. This might happen, for instance, when a child is about to fall (as shown in A). When the arm is pulled in this way, tissue moves between 2 of the bones of the elbow joint, called the radius and the humerus (as shown in B). - Dx: radial head dislocation

for each of the following common CCs regarding the hand and wrist, build a DDx or etiologic source: - Pain: - Instability: - Stiffness: - Swelling: - Weakness: - Numbness: - Masses:

- Pain: - Instability: - Stiffness: OA; trigger finger; carpal tunnel syndrome - Swelling: synovitis; tendinitis - Weakness: secondary to pain or chronic entrapment; - Numbness: nerve entrapment; neuropathy; trauma - Masses: ganglionic cyst; giant cell tumors; Dupuytren's nodules; RA / OA Bouchards Heberden nodules; carpal boss deformity

POSTERIOR shoulder dislocation REDUCTION: - how is it performed? - when is it used?

- Posterior shoulder dislocation reduction: underlying approach to the traction-countertraction technique demonstrated in this photograph is similar to that employed in the reduction of anterior dislocations. The notable difference is positioning. Note that the patient is upright and the clinician providing traction is standing in front of the patient.

how do the Forces exerted on the elbow during throwing lead to elbow dislocation?

- Powerful repetitive distractive forces (double arrow) and compressive forces (dashed arrows) during overhead throwing are responsible for many baseball-related injuries to the elbow.

20. interpret the findings from these x-ray images - what is your Dx?

- Radiographs of both clavicles (A) reveal superior displacement of left clavicle with marked widening of acromioclavicular (AC) distance (arrowhead) and coracoclavicular (CC) distance (arrow); - AC distance is more than twice distance when compared to contralateral normal side. Dislocation of sternoclavicular joint (dashed arrow) is also noted. - Image B focuses on widening of CC distance (arrow) and approximately 2.2 cm widening of CC distance (arrowhead). Dx: These findings are consistent with a Type V acromioclavicular injury

- what are the names for the pathologic findings in this image? - what condition does this represent?

- Rheumatoid arthritis hand deformities: Boutonniere deformity and Z-deformity of the thumb - A woman with longstanding rheumatoid arthritis has soft tissue swelling and subluxation of the metacarpophalangeal joints. The right thumb shows hyperextension of the interphalangeal joint (a Z deformity). Both ring fingers have boutonniere deformities with flexion of the proximal and hyperextension of the distal interphalangeal joints.

SHOULDER IMAGING: - what are the 3 common plain radiographic views for identifying shoulder fractures? - what is in the shoulder "trauma series"? - what is included in the "instability views"? - which views are included in the "impingement studies"? - when should CT, MRI, or arthrograms be ordered?

- Shoulder: AP, scapular Y, axillary, Zanca view - Trauma: AP, scapular "Y", axillary* (most important for shoulder instability) - Instability: - Impingement studies: - CT, MRI, arthrogram: most cases should be ordered by specialist

STIMSON technique for REDUCTION of (CHRONIC) shoulder dislocation: - how is it performed? - when is it used?

- Stimson technique for reduction of shoulder dislocation: patient is placed prone on stretcher with affected shoulder hanging off edge. Weights (10-15 lbs) are fastened to wrist to provide gentle, constant traction. - works w/ chronic reduction

SHOULDER EXAM: SULCUS SIGN: - what is it used to find? - how is it performed? - how are the results interpreted?

- Sulcus sign: this maneuver is used to assess glenohumoral instability* - patient is asked to relax shoulder; One hand is placed at the acromion and one hand is placed near antecubital fossa; Downward pressure is applied to arm to open subacromial space; examiner assesses looseness of shoulder and discomfort caused by maneuver - sulcus sign is positive when humeral head (X) is readily displaced by 2 cm or more inferiorly (arrow); ↑humoral movement in anterior and posterior directions demonstrates multidirectional instability

- identify the rotator cuff muscles - which one is the most commonly injured?

- Supraspinatus, Infraspinatus, Teres minor, Subscapularis - Subscapularis inserts on the lesser tuberosity. The remaining muscles insert at the greater tuberosity - *supraspinatus is most commonly injured

define the following orientations/ extensions of fracture lines: - transverse: - oblique: - spiral: - comminuted: - segmental: - intra-articular: - torus: - greenstick - compound: - simple:

- TRANSVERSE: fracture that is perpendicular to shaft of bone - OBLIQUE: an angulated fracture line - SPIRAL: a multiplanar and complex fracture line - COMMINUTED: a fracture in which there is >2 fragments - SEGMENTAL: when two fracture lines divide bone into ≥3 large pieces - INTRA-ARTICULAR: fracture line crosses articular cartilage and enters joint - TORUS: incomplete buckle fracture of one cortex, often seen in children - GREENSTICK: incomplete fracture w/ angular deformity, seen in children - COMPOUND = OPEN + DISPLACED, ANGULATED, bayonetted, DISTRACTED, - SIMPLE ↔ 2 fragments, NONDISPLACED

which nerve is compressed in each of the following syndromes? Tarsal Tunnel Carpal Tunnel Cubital Tunnel

- Tarsal Tunnel: posterior tibial n - Carpal Tunnel: median n. - Cubital Tunnel: ulnar n.

How is the PATRICK/ FABERE test performed? - for what is it used to assess?

- The FABERE test (PATRICK test or "figure of four" test) consists of Flexion of the hip and knee, with ABduction and External Rotation at the hip, so that the ankle of one leg is on top of the opposite knee (a figure four configuration). Force is applied downwards on the bent knee and the opposite hip, causing Extension at the sacroiliac joint ipsilateral to the bent leg. - A number of conditions can produce a positive test, which is marked primarily by reproducible pain with passive external hip rotation; Ankylosing Spondylitis

describe how to assess MOTOR function of the MEDIAN NERVE

- The OK sign evaluates anterior interosseous branch of median nerve by testing strength of flexor pollicis longus and flexor digitorum profundus; patient is asked to make OK sign and then maintain it against resistance

- identify the Lisfranc joint - what two parts of the foot does it connect?

- The foot has 28 bones, including 14 phalanges, seven tarsal bones (talus, calcaneus, cuboid, navicular, and three cuneiforms), five metatarsals, and two sesamoids. - The hindfoot connects to the midfoot at the midtarsal (Chopart) joint. - The midfoot connects to the forefoot at the Lisfranc joint.

what is the procedure for Injection for flexor tenosynovitis (trigger finger)?

- The hand is placed flat with the palm up and the fingers outstretched. The proximal volar crease of the finger or the distal volar crease over the metacarpophalangeal (MP) joint of the thumb is identified. The point of entry for the finger is just proximal to the first volar crease in the midline. The point of entry for the thumb is at the distal volar crease in the midline. Ethyl chloride is sprayed on the skin for anesthesia. A 5/8 inch 25 gauge needle is inserted to a depth of 1/4 to 3/8 inch for trigger finger and 1/8 to 1/4 inch for trigger thumb. The needle is advanced down to the firm resistance of the flexor tendon, a rubbery sensation. The needle is held flush against the tendon, utilizing just the weight of the syringe. Without advancing the needle, 1/2 mL of lidocaine is injected for an anesthetic block for diagnostic purposes. For therapeutic injection, 1/4 mL of methylprednisolone (80 mg/mL) is injected in addition to lidocaine.

what is the mechanism of injury of a Lateral condyle elbow fracture?

- The most common mechanism of injury is believed to occur when the elbow is forced into varus (bottom left), which, along with the extensor muscles and lateral collateral ligaments, applies an avulsion force to the lateral condyle. When the fracture line extends to the trochlear notch (bottom right), the elbow becomes unstable.

Dancer's Fracture

- The oblique view of this radiograph demonstrates a nonunion of a fifth metatarsal avulsion fracture (white arrow). Note the widened fracture line and sclerosis of the fractured edges.

how should you Palpate the plantar fascia?

- The toes are grasped and dorsiflexed with one hand, while the other hand palpates the plantar aspect of the foot, particularly the bands compressing the plantar fascia.

10. interpret the findings from this x-ray image - from what view was this image taken?

- This axillary radiograph of the shoulder shows a normal relationship of the humeral head to the glenoid (short black arrow), acromion (short white arrow) and the coracoid process (white arrow). This view is valuable in assessing for shoulder dislocation.

41. interpret the findings from this x-ray image - Dx:

- This fracture of the neck of the fifth metacarpal is nondisplaced and minimally angulated. A faint radiolucent fracture line can be seen (arrow). - Dx: Metacarpal neck fracture with minimal angulation; Boxer's Fx

21. interpret the findings from this x-ray image - what is your Dx?

- This radiograph shows a nondisplaced, one-part fracture (arrows) at the surgical neck of the proximal humerus.

what is ULTRASOUND imaging and how is it used in orthopedics?

- Ultrasonography (US), sometimes referred to as ultrasound imaging or sonography, is an imaging modality that utilizes reflected pulses of high-frequency (ultrasonic) sound waves. - *Musculoskeletal US can be used to assess soft tissues, cartilage, bone surfaces*, and fluid-containing structures and is becoming more widely available for diagnostic and therapeutic use in outpatient settings. - US can be used clinically for assessing and monitoring inflammatory arthritis, for imaging tendons and bursae, and for guiding aspiration and/or injection of joints or soft tissues. - Among possible advantages of US are avoidance of radiation exposure and of inconvenience associated with use of fluoroscopy for procedures involving otherwise difficult-to-enter joints and other spaces. - Limitations of US include poor soft tissue penetration of sound waves and their complete reflection by bone, resulting in limited acoustic windows for imaging joint pathology

31. interpret the findings from these x-ray images ID: 14 y/o boy CC: skateboarding accident Dx: ?

- Very unstable complete midshaft forearm fracture in a 14-year-old child. This fracture required open reduction and internal fixation in the operating Room. Both bones are 100 percent displaced dorsally and 50 percent displaced laterally. There is no intact periosteum. Dx: "both bones" fracture: Unstable midshaft forearm fracture

- How do you perform the TINEL'S SIGN? - what does it assess? - what constitutes a positive test?

- With elbow flexed at 90° and arm externally rotated, medial epicondyle and olecranon process are identified. - With firm pressure, groove between two bony prominences is tapped repeatedly with tip of finger. - sign for ulnar neuropathy - A positive tinel's sign should reproduce lancinating pain or numbness felt in fourth and fifth fingers; response should be distinctly different from opposite side

how do you perform a "Tennis elbow" injection?

- With the elbow flexed and pronated, the needle is inserted at the most tender area on the anterolateral aspect of the external condyle of the humerus. A combination of glucocorticoid and local anesthetic is injected in several areas.

what is a DEXA scan and how is it used in orthopedics?

- allows quantification of bone mineral density (BMD); Denser and thicker tissue contains more electrons and allows fewer photons to pass through to detector - CLINICAL APPLICATIONS OF DXA — Dual-energy x-ray absorptiometry (DXA) is used to diagnose osteoporosis or low bone mineral density (BMD), estimate the future risk of fracture, and monitor changes in BMD over time. - Radiation exposure to the patient is very small, usually of a similar magnitude to daily background radiation - DXA measures bone mineral content (BMC, in grams) and bone area (BA, in square centimeters), then calculates "areal" BMD in g/cm2 by dividing BMC by BA; T-score, the value used for diagnosis of osteoporosis, is calculated by subtracting mean BMD of a young-adult reference population from patient's BMD and dividing by standard deviation (SD) of young-adult population. Z-score, used to compare the patient's BMD to a population of peers, is calculated by subtracting mean BMD of an age-, ethnicity-, and sex-matched reference population from patient's BMD and dividing by SD of reference population; mean BMD and SD of the reference populations used for these calculations is a critical variable in the determination of T-scores and Z-scores

- identify the Location of the wrist anatomic snuffbox - what are the landmarks to identifying it? - how should it be examined? - what does tenderness in this region indicate?

- anatomic snuffbox is located proximal to base of thumb between extensor pollicis longus tendon medially and extensor pollicis brevis and abductor pollicis longus tendons laterally. - A good method for evaluating the body of the scaphoid is to gently bring patient's wrist into ulnar deviation and slight volar flexion then palpate anatomic snuffbox. The snuffbox lies between the extensor - A fracture of the scaphoid waist often manifests as tenderness in this region

- when and how should a neurovascular assessment be performed?

- as part of PE, dx assessment - before and after every procedure, always! - before and after reductions

Scaphoid fractures

- common - presentation: pain in anatomical snuff box - MOI: fall on outstretched hand - sequela: avascular necrosis

What is a Colles fracture?

- distal radius fracture w/ dorsal (apex palmar) angulation - Image: Fracture of the base of the ulnar styloid (anteroposterior radiograph) Extraarticular (Colles) distal radial fracture in frontal projection associated with a fracture of the base of the ulnar styloid which indicates disruption of the trianglar fibrocartilage complex (curved arrow).

identify the 3 distinct articulations of the Elbow joint :

- elbow is a complex hinge joint composed of three separate articulations: ulnohumeral (large purple circle), radiohumeral (small purple circle), and radioulnar (red circle) - radiohumeral and ulnohumeral articulations combine to provide hinge movement (purple arrows) and supination and pronation of forearm is facilitated by pivoting at radioulnar articulation (red arrows)

35. identify the finding in this image - what is the most likely Dx/etiology?

- four classic Kanavel signs including: fusiform swelling of whole finger, partially flexed posture of finger, tenderness limited to course of flexor tendon sheath, and disproportionate pain on passive extension of finger - Dx: infectious flexor tenosynovitis

which bone is fractured and which bone is dislocated in a: Galeazzi fracture-dislocation?

- fracture of distal third of radius - dislocation of ulna/ radioulnar joint

- how is gait assessed? - what is an ANTALGIC GAIT?

- gait cycle has four phases: Heel-strike to foot-flat (contact), foot-flat to heel-off (mid-stance), heel-off to toe-off (propulsion), and toe-off to heel-strike (swing). - When examining the child's gait, the examiner should pay particular attention to the following features: - With an antalgic gait, the stance phase is shorter on the affected side. - Circumduction (circular movement of the limb during swing phase) suggests an ankle or foot problem. - Downward pelvic tilt during the swing phase (Trendelenburg gait) suggests hip pathology (eg, developmental dysplasia of the hip, slipped capital femoral epiphysis). - Toe-to-heel sequence (toe-walking gait, as opposed to the normal heel-to-toe pattern) may indicate a neurologic problem, cerebral palsy, or idiopathic heel cord tightness. - Lack of full knee extension in the stance phase implies knee pathology or possible limb length discrepancy. - Elevation of the arm sometimes accompanies hemiplegia.

how are CT scans used for bone fractures?

- generates a 3-D images of the inside anatomy from a large series of 2-D x-ray images taken around a single axis of rotation - CT is extremely useful in detecting radiographically occult fractures of acetabulum, cervical spine, wrist, and foot; It is helpful in evaluating cortical destruction by metastatic lesions that may predispose to pathologic fracture; Ossific or calcific densities within a joint can be seen - CT imaging also has benefits for certain indications compared with magnetic resonance imaging (MRI). As an example, soft tissue calcifications and bony abnormalities are better characterized with CT, Osteoid osteomas are usually better demonstrated on CT. - CT exam requires less time and tends to be less alarming to claustrophobic patients - presence of metallic implants or pacemakers and the use of life-support equipment (eg, ventilators) do not preclude use of CT, whereas some of these devices are contraindications to MRI - it helps to identify the total bone damage and possible reconstruction strategies

- identify the Anatomy of the growth plate (physis) - identify the site where physeal fractures usually occur and why it is susceptible

- germinal zone of physis borders epiphysis - epiphyseal cartilage cells grow toward metaphysis and form columns of cells → columns degenerate → undergo hypertrophy → calcify at metaphysis to form new bone - hypertrophic zone (shaded red) is usual site of physeal fractures

b) Describe the Salter-Harris classification of physeal fractures

- growth plate is shown in green - mnemonic refers to fracture line and its relationship to growth plate - metaphysis is bone above growth plate, and epiphysis is bone below - Type I fractures disrupt the physis - Type II fractures involve a break from growth plate up into metaphysis, with periosteum usually remaining intact - Type III fractures are intraarticular fractures through epiphysis that extend across physis - Type IV fractures cross epiphysis, physis, and metaphysis - Type V fractures are compression injuries to physis

how do you perform an injection for de Quervain tenosynovitis?

- hand is placed in a neutral position and turned on the side with radial side up. - radial styloid and first and second dorsal compartments are identified and marked. - injection site is between two tendons of abductor pollicis longus (APL) and extensor pollicis brevis (EPB), in first dorsal wrist compartment. - best way to identify landmarks is by getting patient to extend and abduct thumb. - Prep insertion site with iodine disinfectant or a chlorhexidine scrub. - Using an aseptic technique, ethyl chloride is applied to skin for anesthesia. - Load syringe with one-fourth to one-half mL of methylprednisolone (80 mg/mL) with 1 to 2 mL of lidocaine 1%. - needle should be aligned parallel to tendons of APL and EPB, while aiming proximally towards radial styloid (enter about 3/8 inch distal to tip of radial styloid). A 5/8-inch, 25 gauge needle is inserted at a 45° angle to depth of 3/8 to 1/2 inch, flush against periosteum of radial styloid. - Insert needle between the two tendons (do not inject into the tendon); There should be no resistance to injection flow. Moderate pressure to injection, a poorly distensible sac, or both may indicate chronic stenosis of tendons.

what is the mechanism of injury for many fractures of wrist and forearm?

- image: A fall onto an outstretched hand (FOOSH) is a common mechanism for many fractures of wrist and forearm, including scaphoid, distal radius, and radial head. Such falls can also strain or rupture interosseous membrane

how is Elbow arthrocentesis performed for either aspiration or injection?

- landmarks for injection or aspiration of elbow joint are radial head, lateral epicondyle, and tip of olecranon. - A needle inserted into center of triangle penetrates only anconeus muscle and capsule before entering joint - patient is supine with elbow flexed to 90° and hand tucked under buttock - triangle is made with points at lateral epicondyle, radial head, and olecranon process - needle is inserted in center of triangle, perpendicular to skin and parallel to the radial head, 0.75-1 inch (about 2-2.5 cm) deep.

how is the two incision leg fasciotomy performed?

- medial and lateral incisions are depicted. Arrows represent the subcutaneous flaps that will be developed to gain access to the respective compartments. The four compartments to be decompressed are outlined in color. The approximate location for the fascial incision for each compartment is represented by a black line.

what are the characteristics of the shoulder that make it prone to injury?

- most mobile joint - head & cup like hip but more shallow and mobile - most frequently dislocated joint in adults - a weight bearing joint? - frequent source of complaints - site of most overuse-related injuries

when is a BONE SCAN indicated in orthopedics?

- nuclear medicine study where a technetium-99m (Tc-99m)-labeled diphosphonate compound is injected intravenously; compound is adsorbed onto surface of hydroxyapatite crystals → *↑bone uptake of tracer mostly reflects ↑bone turnover or remodeling in response to underlying processes (eg, infection, neoplasms, trauma, arthritis, etc)*; - In acute phase of infection or inflammation, ↑tracer uptake is also due to ↑blood flow, while contribution of blood flow to bone uptake in chronic conditions is substantially less - highly sensitive technique for detection of large variety of bone, joint, and periarticular disorders, including fracture, infection, tumor, arthritis, and metabolic bone disease; thus, a negative study effectively excludes most bone and joint abnormalities - A finding of "increased tracer uptake" on a bone scan is nonspecific, although recognition of characteristic patterns of uptake and/or locations of involvement typical of different disease processes may provide more specific diagnostic information. - Bone scan can also be useful for documenting presence of arthritis and for assessing extent and distribution of disease *sternum on bone scan has ↑uptake due to metabolism of contrast, prob not "hot"

if your patient presents w/ a locking knee that they cannot straighten, how should you treat it in clinic today?

- numb knee - w/ 10 cc syringe inject joint w/??? → straighten out before they leave

identify the Major branches of the ulnar nerve at the wrist

- numbers 1-4 relate to main sites of clinical syndrome associated with injury to the nerve: 1. Main trunk of the nerve proximal to or within Guyon's canal. 2. Deep motor branch proximal to the branches supplying the hypothenar muscles. 3. Deep motor branch distal to the hypothenar muscles. 4. Superficial branch (mainly sensory).

d) Demonstrate an understanding of orthopaedic emergencies.

- open fracture: final Tx: I&D surgery as soon as possible; used to be 4-6hr window to OR but now longer w/ abx - Compartment Syndrome: Tx: fasciotomy - Cauda Equina Syndrome: Tx: emergent MRI → emergent surgical decompression - Floating Shoulder scapula fractures: need emergent arteriogram and CT - Hand Flexor tendon injury??? - Hip Dislocation: reduce ASAP to ↓risk of osteonecrosis - Knee Dislocation: ortho and vasc surgery emergency involving mulstiple injuries; STAT angiogram - Septic Joint

which bones are prone to AVN?

- scaphoid - talus - distal humerus - pelvis-femur

how is a single incision fasciotomy of the lower leg performed?

- single-incision technique uses a generous lateral leg incision 1 cm anterior to the fibula. Extensive flaps expose the anterior and lateral compartments. Longitudinal fascial incisions are made in anterior and lateral compartment fascia, taking care to avoid injury to the common, superficial and deep (fibular) peroneal nerves near the fibular head. The lateral flap is extended posteriorly to expose the superficial posterior compartment. Once the gastrocnemius is identified, its fascia is incised longitudinally. The deep posterior compartment is accessed in the plane between the lateral and superficial posterior compartment which exposes the posterior margin of the fibula. The soleus is dissected from the posterior aspect of the fibula beginning distally. During the peri-fibular dissection, the fibular (peroneal) vessels are retracted posteriorly to avoid injury.

- in general, how does stiffness & pain w/ rest and stiffness & pain w/ activity help differentiate inflammatory from degenerative disease? - which 2 are the classic examples of each category

- stiffness & pain w/ rest, or when you wake up is indicative of an inflammatory dz; e.g. RA - stiffness & pain w/ activity, worsening as the day goes on, is indicative of degenerative dz; e.g. OA

when is the Thumb spica splint used?

- thumb spica splint provides excellent immobilization for the thumb. It is often used for carpometacarpal osteoarthritis, de Quervain's tenosynovitis, ulnar collateral ligament injury (gamekeeper's or skier's thumb), and fractures of the scaphoid, trapezium, and first metacarpal.

23. use the fracture identification practice tool format to describe the findings in this x-ray film

A) Diaphyseal humeral shaft fracture in 12-year-old boy treated in coaptation splint. B) Union at 2 months with mild varus angulation.

how do you perform a Manipulative supracondylar closed reduction?

A) Traction is applied with the elbow in extension and the forearm in supination. The assistant stabilizes the proximal fragment. After traction has been applied and the length regained, the fracture is hyperextended to obtain apposition of the fragments. B) With traction being maintained, the varus or valgus angulation along with the rotation of the distal fragment is corrected.

An 85-year-old farmer presents for evaluation of bilateral hand pain and stiffness. He states his hands have been bothering him for years and that he manages the pain with acetaminophen and topical analgesics. He has noticed some "lumps" that developed over the last few months. His bilateral radiographs are shown below. Which of the following is the most likely diagnosis? Rheumatoid arthritis Osteoarthritis Gouty arthritis Pseudogout

Answer: The correct answer is C. The "lumps" this patient describes are most likely tophi, which develop in chronic tophaceous gout. They can predispose the patient to gouty arthritis. This stage of gout usually begins after approximately 10 years of gout. The first attack often involves a sudden onset of painful arthritis, usually in the first MTP joint, but also may occur in the ankle, knee, finger, wrist, or elbow. Chronic gouty arthritis (which this patient likely has) is notable for tophaceous deposits, deformity of the joint, constant pain, and swelling. Tophi typically appear in imaging studies once calcified. The other conditions do not present with the tophi noted in the question.

Radiographs of an elderly woman's hand obtained to "assess morning stiffness" shows polyarticular erosive changes to the metacarpophalangeal and proximal interphalangeal joints with joint space narrowing, sparing the distal interphalangeal joints (not shown). There is periarticular soft-tissue inflammation around the affected joints, with a "swan neck" deformity with hyperextension of proximal interphalangeal joint and flexion of the distal interphalangeal joint. Which of the following is the most likely diagnosis? Osteoarthritis Gout Infectious arthritis Rheumatoid arthritis

Answer: The correct answer is D. Patients with rheumatoid arthritis (RA) typically present with MCP and proximal IP joint involvement, inflammatory erosive soft warm tender joint swelling, and morning stiffness. A patient with osteoarthritis (OA) presents with distal IP joint involvement, hard bony joint swelling, joints that stiffen with use, and joint-space narrowing from bone remodeling.

A 40-year-old male presents with multiple joint complaints. He states that he feels like he is "80 years old". In the morning, he feels stiff all over for 20-30 minutes. He has not noticed any joint swelling. The joints that bother him the most are his shoulders, knees, hips, wrists, and metacarpophalangeal joints. Initial workup includes negative rheumatoid factor (RF), Cyclic Citrullinated Peptide antibody (CCP-Ab), and antinuclear antibody (ANA). Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and complete blood count (CBC) are within normal limits. On examination, you note Heberden's and Bouchard's nodes, and his knees show hypertrophic changes. There is no evidence of synovitis in the upper or lower extremity joints. Non weight-bearing and weight-bearing radiographs of one knee are compared below. Which of the following is the most likely diagnosis? Gout Rheumatoid arthritis Ankylosing spondylitis Osteoarthritis

Answer: The correct answer is D. This patient has accelerated osteoarthritis (OA). Calcium pyrophosphate dehydrate deposition (CPPD) crystal deposition causes an acceleration of joint/cartilage destruction, causing accelerated OA. Ankylosing spondylitis typically presents in the spine. Rheumatoid arthritis would have a positive rheumatoid factor (IgM antibodies), as well as large numbers of lymphocytes in the synovial tissue.

11. interpret the findings from this x-ray image - from what view was this image taken?

Anterior shoulder dislocation on the AP radiograph: In this AP x-ray the humoral head clearly lies outside the glenoid and below the coracoid process.

3. what special maneuver is being performed in this image? - what is being assessed?

Cross-arm test for acromioclavicular joint pain. The arm is extended to 90 degrees, then adducted across the chest.

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Forearm Fractures: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - **Moteggia's fracture dislocation: fractured proximal ulna, dislocated radius - **Galeazzi's fracture dislocation: fractured distal radius, dislocated ulna/radioulnar joint - Nightstick fracture: isolated fractures of ulna, typically mid-diaphysis, usually resulting from a direct blow; looks like breaking the blow from a cop's night stick - "Both bones" fracture: v. difficult reduction; use propofol

SHOULDER EXAM - describe how to perform the following: APPREHENSION, RELOCATION TESTS: - what are they used to find? - how are they performed? - how are the results interpreted?

Dx: Anterior Instability of shoulder joint: Pt supine, arm abducted to 90° at edge of exam table, then external rotation until facial expression of "apprehension." - These tests work in combination and are most easily performed with patient supine; To perform apprehension test, patient is asked to place symptomatic arm in throwing position (shoulder abducted and externally rotated) - Next, clinician braces posterior shoulder with one hand while using other hand to push back on wrist with steady pressure, thereby increasing abduction and external rotation of shoulder (as if clinician is attempting to dislocate shoulder anteriorly) - Any sensation of impending dislocation at any time on part of patient constitutes a positive test - relocation test is begun at end of apprehension test and is performed by simply reversing forces being exerted by examiner. Forced abduction and external rotation are stopped, and clinician moves hand that was bracing posterior shoulder to anterior shoulder; examiner then pushes humerus posteriorly (as if he or she was attempting to relocate the shoulder)' resolution of either pain or sensation of impending dislocation on part of patient represents a positive test. - systematic review reported that positive apprehension, relocation, and release tests are "diagnostic of anterior instability," based primarily upon results of three high quality trials; authors emphasized that using apprehension as marker for a positive test, rather than pain, substantially improved test performance.

SHOULDER EXAM - describe how to perform the following: LOAD and SHIFT: - what is it used to find? - how is it performed? - how are the results interpreted?

Dx: instability of shoulder joint; Load and shift test: measures anterior and posterior glenohumeral laxity; - test is positive if there is significant translocation of humeral head anteriorly or posteriorly in glenoid fossa when applying a force in respective direction - standard load and shift test is performed by applying an axial load to glenohumeral joint (ie, pressing humeral head into glenoid) and then attempting to translocate humeral head anteriorly and then posteriorly; acromion is held in a fixed position with clinician's opposite hand while maneuver is performed. - modified version of shift and load test is performed with patient supine and their shoulder abducted 90°; examiner applies an axial load by pressing humeral head into glenoid, and then attempts to translocate humeral head; performing test with patient supine allows scapula to be stabilized by examining table, thereby making it easier to sublux humeral head → modified test may be easier to perform if patient is larger or more muscular than examiner - Translocation is scored as follows: Grade 1 is translation of 0 to 1 cm; Grade 2 is translation of 1 to 2 cm, or to glenoid rim; Grade 3 is subluxation beyond edge of glenoid rim; Grade 4 is a complete dislocation. - test should be performed on both shoulders to compare affected and normal sides - While a positive load and shift test suggests instability, apprehension, relocation, and anterior release tests are better predictors of arthroscopically evident instability

Scheuermann kyphosis

Epidemiology : prevalence of Scheuermann kyphosis ranges from 4-8%; more common among boys than girls; Tall boys are at increased risk for severe disease. Clinical features: typically occurs in early adolescence and affects the thoracic or thoracolumbar spine. It may be associated with spondylolysis, and rarely, myelopathy. Pain generally is subacute without a clear episode of precipitating trauma. The pain is worse after activity and at the end of the day and improves with rest. It tends to improve with skeletal maturity. However, long-term follow-up suggests an increased prevalence of back pain in adulthood . Patients with Scheuermann kyphosis have a rigid kyphosis with a relatively sharp angulation when the child bends over, best viewed from the side of the patient. The curvature does not flatten with forward bending, extension, or lying supine (in contrast to the curvature of poor posture) . There may be a compensatory increase in lumbar lordosis and tightening of the hamstrings manifest by limited passive straight leg raising and forward bending. The physical examination is neither sensitive nor specific for Scheuermann kyphosis. *Schmorl's nodes, representing herniation of the nucleus pulposus into the adjacent end plate;

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Common shoulder fractures: SCAPULA: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - S/Sx: - "floating shoulder": any fracture through body, or extending into glenoid fossa, or a comminuted fracture associated w/ clavicle fracture; v. unstable - associated injuries in 80-90% of pts: pneumothorax, pulmonary contusion, shoulder dislocation (A or P); brachial plexus injury; axillary artery injury; Tx: - non-displaced fractures usually treated conservatively - floating shoulders: orthopedic emergency; requires emergent arteriogram and CT to check for: pulmonary injuries (pneumothorax, pulmonary contusion); shoulder dislocations; brachial plexus injuries and axillary artery injury;

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Menisci injuries - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - Develops over years and presents in older adults typically without inciting trauma S/Sx: - not bleeding b/c not well profused, can make it down slope - Symptoms often mild but may complain of baseline discomfort - Pain with pivoting or knee twisting - Knee may catch or lock - Joint line tenderness - Knee motion may not be smooth and range may be limited - Provocative tests (eg, Thesaly, McMurray) usually positive - Pain increases with deep squat - US may show calcifications, fraying of peripheral meniscus, and cysts in regions of swelling - MRI: oreo cookie sign of synovial fluid in center of meniscus Tx: - image: One important factor for determining appropriate management of a meniscal tear is type of tear; most common types are shown above. Degenerative tears, which develop gradually from aging and cumulative effects of years of trauma, are managed differently than acute meniscal injuries. - surgical: shave off what can, try to preserve

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Dislocation of the hip - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - Dislocation of hip: bony components of a joint no longer are in contact w/ each other - possible sequela of early OA and osteonecrosis, secondary to cartilage damage of femoral head and acetabulum S/Sx: - neurovascular assessment before & after reduction Tx: - orthopedic emergency: need to reduce ASAP to ↓risk of osteonecrosis - neurovascular assessment before & after reduction

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Ankle sprains and instability - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - F>M due to shoes - peroneal tendon dysfxn: pops out onto lat. malleolus, hurts - talus OCD lesion - subtalar joint OA - tarsal tunnel syndrome - High ankle sprain: syndesmosis ligament (intraosseous membrane) - deltoid ligament sprain: S/Sx: - bruising, can't bear weight, swelling, (+)instability tests → get x-ray - image: Inside the ankle are tough bands of tissue called ligaments, which hold the different bones together. When a person sprains his or her ankle joint, it turns too far in a particular direction and one or more of those ligaments stretch too far or even tear Tx: - RICE - ankle brace - crutches - PT - peroneal tendon dysfxn: surgical relocation and fixation

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Radial Head Fractures: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - FOOSH injury S/Sx: - usually non-displaced - X-ray: Nondisplaced fracture of the radial fracture (Mason Type I) Tx: - splint/sling w/ early motions - may require cortison/anesthetic injection for pain relief and mobilization - refer to ortho if >30% comminuted fracture

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Patellar-femoral pain syndrome - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - History of overuse, often involving running - PFPS accounts for >70% of outpatient visits for knee pain S/Sx: - Diffuse, anterior peri-patellar pain - Knee may feel "unstable" - Pain increases with squatting, prolonged sitting, running (especially downhill), climbing or descending stairs - Patellar undersurface may be tender (medial or lateral) - Weak terminal knee extension and VMO atrophy common - Weak hip flexion, abduction, & external rotation common - Hamstring tightness common - Patellofemoral compression test may be positive - Normal knee motion - Effusion rare - Structural intra-articular damage must be ruled out if recurrent effusions or unusual findings (eg, abnormal knee motion or laxity detected) present - image: Bilateral sunrise x-rays of patellofemoral joint are obtained to confirm subluxation, early cartilagenous injury, or patellofemoral arthritis; position of patella should be centered in femoral groove; thicknesses of medial and lateral cartilage should be equal. With advancing wear and tear, lateral cartilage thins, subchondral bone thickens, and, in rare cases, osteochondritis dessicans occurs. Tx: - band over tendon

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Metatarsal Fractures: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - Tuberosity avulsion ("Dancer's fx): brevis attachment - Acute diaphyseal fracture ("Jones fracture") - Stress fracture of the diaphysis - Torg type 1 (early) - Torg type 2 (delayed union) - Torg type 3 (nonunion) - *Lisfranc: commonly missed; f/u in 1 wk after swelling goes done, use MRI to see soft tissue S/Sx: - Schematic representation of fracture zones for proximal fifth metatarsal fractures - stress fx symptomatic before evidence on x-ray → do bone scan Tx: - avulsion: non-surgical, heals well w/ short-leg cast non-weight-bearing (SLC-NWB); 3 mo - Jones: surgical - Stress: ORIF w/ bone-graft, compression screw

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Olecranon bursitis - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - acute or chronic - secondary to trauma, or infxn; 20% have septic cause - secondary to inflammation, Gout, or RA Labs: aspirate for definitive etiology - purple top tube: CBC, ESR, CRP, gram stain, culture & sensitivity, crystals Tx: - NSAIDs - Abx: oral or IV - elbow pad and/or splint: avoid splinting in hyperflexion - surgical resection

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 5. Human bites: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - bites older than 24 hrs are usually infected - bugs: Group A strep, S. aureus, Eikenella corrodens - chronic infxn → osteomyelitis, possible amputation S/Sx: - examine hand and wound w/ hand open and w/ fingers in full flexion (position of injury) Tx: - wash, wash, wash, irrigation, debridement, IV abx → do not close b/d need to let pus out, maybe delayed closure - image: Human bite injuries require hospital admission, antibiotics, debridement in OR and delayed primary wound closure. A wide exposure of the wound is required and joint should be opened and inspected, even if joint capsule appears intact. As shown in photograph, exposure of metacarpophalangeal joint is required to demonstrate true extent of injury.

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Olecranon Fractures: - Etiology: - Tx:

Etiology: - common after a FOOSH injury and posterior dislocations Tx: - displaced: ORIF - splint: 45° of flexion - f/u x-rays: 1, 2, 4 wks post injury b/c becomes chronically unstable b/c triceps pulling on it

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. ULNAR NERVE COMPRESSION / CUBITAL TUNNEL SYNDROME: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - common site of compression is at the medial epicondyle groove - occurs most often btw ages 30-60 y/o S/Sx: - aching pain, numbness and tingling in small finger (SF) and ring finger (RF); late findings of intrinsic muscle weakness and hypothenar compartment atrophy - Tinel test at elbow is performed by firm percussion over ulnar nerve in ulnar groove and a bit further distally over cubital tunnel → if results in paresthesia or pain in ulnar-innervated regions of hand, particularly fourth and fifth digits = Tinel's sign(+) Dx: - needle electromyography EMG/NCV tests w/ ↓velocity of 30% or more - typical findings for a motor nerve conduction study of ulnar-innervated hypothenar muscles with conduction block and slowing across elbow; smaller response on affected side is with stimulation above elbow and reflects conduction block. In this case, other two responses with stimulation at wrist and below elbow are normal and inset sensory response to 5th digit is normal. Tx: - activity modification, night splint, keep elbow from flexing to 90° - NSAIDs - surgical decompression, possible nerve transposition: free the nerve, release it from fascia

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Common shoulder fractures: CLAVICLE: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - common; accounts for ~5% of fractures in ED - neonates →children: v. common; generally heal well - adults: greater force needed to fracture, heals at slower rate, higher risk of potential complications, e.g. malunion, non-union S/Sx: - visible lump - pain w/ carrying back-pack Tx: - children: sling or figure 8 strap 3-4 wk - adults: sling or figure 8 strap 4-6 wk - surgery if segmental - diagram depicts mechanisms typically involved in displacement of a clavicle fracture, which is caused by upward pull of sternocleidomastoid muscle and downward pull of the weight of the arm.

Understand the signs, symptoms, diagnosis and treatment of the following conditions: Triangular Fibrocartilage Complex Tear: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - commonly assoc. w/ avulsion of ulnar styloid, scaphoid fracture, and distal radius fracture - TFCC prone to injury due to axial and shear forces applied as carpi rotate over radius and ulna S/Sx/: - pain w/ ulnar deviation Imaging: - MRI following arthrography shows a tear in triangular fibrocartilage complex (TFCC) of right wrist; T1 fat suppressed sequence (A) confirms presence of tear (white arrow) with leakage of contrast into distal radioulnar joint (yellow arrow head). Similar findings are seen in the STIR sequence (B). Tx: - scope, clean out debris

Tarsal Tunnel Syndrome: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - compression squeezing on Posterior Tibial N - The tarsal tunnel syndrome is caused by entrapment of the posterior tibial nerve beneath the flexor retinaculum on the medial side of the ankle. Entrapment may also include the two branches, the medial and lateral plantar nerves. S/Sx: - numbness, tingling, burning

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Osteoarthritis and basic recommendations for total hip arthroplasty - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - degenerative dz S/Sx: - restricted ROM, antalgic gait, inguinal pain and stiffness (w/ activity) → ↓ambulation and independence - Internal and external rotation are measured to assess integrity of hip joint, measure rotation, and evaluate pain and stiffness.; examiner places one hand at ankle and one hand at knee; lower leg is rotated laterally to test internal rotation, and medially to test external rotation; patient is instructed to avoid rolling ;buttocks during ;maneuver. Internal and external rotation can be reduced by the loss of articular cartilage and outgrowth of acetabular osteophytes associated with osteoarthritis and pain and muscle spasms of acute synovitis. Patients with severe osteoarthritis, acute synovitis, and septic arthritis may have as little as 5-10° of rotation Tx: - meds, cortisone injections - activity modifications, use of assistive devices (cane, walker) - total hip arthroplasty (THA): for pts w/ persistent pain after failure of conservative therapy - poor candidate: morbid obesity (BMI ≥33%); poorly controlled DM; unstable comorbidities

Cellulitis: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - diffuse skin and soft tissue involvement - trauma, ulceration, lymphedema - primarily a clinical Dx - beware of septic joint or deep space infxn overlying cellulitis S/Sx: - r/o septic joint: if can palpate joint + if can ↑pressure w/o pain + full ROM - image: warm, tender area of erythema that is well demarcated and progresses over time; skin surrounding area of erythema may be edematous; photograph shows forearm cellulitis that developed following repair of lacerations Tx: - early: oral abx → if no resolution in 24-48 hrs → IV abx w/ 1st gen cephalosporin or vancomycin if in hospital - immobilization/ splint - elevation

Felon

Etiology: - digital pad infxn; closed poorly compliant compartment; most likely S. aureus - complications: necrosis, osteomyelitis, flexor tenosynovitis - image: fingertip pulp contains compartments of eccrine sweat glands and fat globules separated by fibrous septae. An abscess within these compartments is a felon S/Sx: - intense throbbing pain Tx: - I&D, irrigation; locations of neurovascular bundles are shown; these areas should be avoided when incision and drainage are performed - f/u to monitor for complications: necrosis, osteomyelitis, flexor tenosynovitis

Felon: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - digital pad infxn; closed poorly compliant compartment; most likely S. aureus - complications: necrosis, osteomyelitis, flexor tenosynovitis - image: fingertip pulp contains compartments of eccrine sweat glands and fat globules separated by fibrous septae. An abscess within these compartments is a felon S/Sx: - intense throbbing pain Tx: - I&D, irrigation; locations of neurovascular bundles are shown; these areas should be avoided when incision and drainage are performed - f/u to monitor for complications: necrosis, osteomyelitis, flexor tenosynovitis

Patella Dislocation: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - direct blow to proximal portion of patella of a flexed knee S/Sx: - image: Intraarticular patellar dislocations occur following a direct blow to proximal portion of patella of a flexed knee sufficient to avulse deep fibers of guadriceps tendon and permit horizontal rotation of superior portion of patella into knee joint. Tx: - reduce by putting leg in full extension

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Carpal Tunnel Syndrome - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - entrapment of median n. at wrist; - most common compression neuropathy - most common in middle-aged or pregnant women - overuse, DM, thyroid dz, RA, pregnancy S/Sx/Dx: - Tinel's Test: - Phalen: - EMG/NCT: - A. Diagram-rated classic carpal tunnel syndrome (CTS) for both hands; nerve conduction tests confirmed bilateral CTS. - B. Diagram-rated probable because of palmar symptoms; nerve conduction tests revealed right CTS. C. Diagram rated unlikely; nerve conduction tests indicated left ulnar nerve entrapment. Tx: - surgical release

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: Shoulder Osteoarthritis (OA): - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - gradual, progressive, mechanical breakdown of articular cartilage and other joint tissue incl bone and joint capsule - risk factors: age, genetics, sex, weight, joint infxn, hx of dislocation, previous injury, occupations such as construction and overhead sports S/Sx: - as articular surface wears, friction w/i joint↑ → progressive loss of normal load-bearing surfaces → pain and disability - tear drop osteophyte seen on x-ray - image: Plain film radiography demonstrates joint space narrowing and osteophyte formation (arrow) consistent with osteoarthritis.

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Throchanteric bursitis - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - inflammation and hypertrophy of greater trochanter bursa w/ direct trauma or sometimes no apparent reason S/Sx: - pain and tenderness over GT area that could radiate to knee, but not foot - pain worse when first rising from sitting Tx: - NSAIDs, local cortisone injections - activity modifications, short term use of a walking cane - PT: long term - image: In patients with bursitis, corticosteroid-local anesthetic injections can be made into the trochanteric bursa

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 5. Animal bites: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - most common dogs > cats > rodents - 30-50% cat bites become infected - organisms: Staph, Strep, Pasturella multocida Tx: - meticulous wound irrigation + wet/oil mesh dressing b/c tendon does not like to get dry - exploration and delayed wound closure - Rx: prophylactic tx: augmentin/ amox or if pen allergy cipro + clindamycin - image: shows sloughing of eschar and healing by secondary intention several weeks after a recluse spider bite

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 6. Distal Radius Fractures: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - most common fracture in adults - fractures of distal radius >15% of all fractures in ED - type depends on MOI: - Colles: dorsal angulation - Smith: volar/palmar angulation - Barton: intra-articular fracture dislocation of volar rim of radius w/ displaced volar fragment taking carpus with - Chauffeur's/Hutchinson's: isolated fracture of radial styloid process; sometimes injury to scapholunate ligament; often part of comminutive intraarticular fracture - die-punch: depression fracture of lunate fossa of distal radius from transverse load through lunate; In healthy young patients, distal radius fractures often occur after violent injuries directly to bone or by a compression load driving the scaphoid or lunate into the distal radius, producing a "die-punch" fracture; Such high-energy fractures are more likely to be comminuted and intraarticular, and to occur in association with other significant injuries Tx: - closed reduction w/ hematoma block or conscious sedation → splint/casting or - ORIF

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 6. Scaphoid Fractures: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - most common fracture of a carpal bone - 20% in proximal pole, 60% middle, 20% distal - high incidence of non-union and osteonecrosis: b/c 80% of bone has articular cartilage and blood supply is commonly interrupted w/ injury S/Sx: - pain in snuffbox Imaging: - often do not show at first x-ray - lateral view of left wrist (A, magnified in B) reveals a fracture through scaphoid (arrow). A small fragment has been displaced from fracture line. Tx: - if pain in snuffbox ± x-ray evidence → splint → f/u 2 wks to re-xpray - casting needed for 8-12 wks

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: Elbow Dislocations: - Etiology: - S/Sx: - Imaging: - Tx: - Sequelae:

Etiology: - most common joint to dislocate during childhood - second to shoulder and finger dislocations in adults - common after a FOOSH S/Sx/Imaging: >80% are posterior dislocations w/ residual stiffness + rupture of ulnar collateral ligament; *common baseball player injury - neurovascular complications after dislocation in 5% cases; neurapraxia usu involving ulnar or median nn. → most deficits are short-termed - X-ray: A) AP: radial head is superimposed behind distal humerus; ↑cubitus valgus; medial epicondyle has not been avulsed. B) Lateral showing proximal radius and ulna are displaced posteriorly to distal humerus Tx: - closed reduction ASAP; w/ sedation; w/ or w/o joint aspiration and intra-articular anesthetic injection (lateral approach) → reduction maneuver w/ steady traction w/ elbow flexed to 45° and avoid post reduction splinting at >100° flexion - surgery if unable to reduce, usually b/c loose bodies and/or extensive swelling - PT and early motion starting 5-7 d post-reduction → 3-4 wks Sequelae: flexion contractures, hetertrophic ossification, post-traumatic arthritis, myositis ossification if hematoma not worked out in PT

Dupuytren's

Etiology: - nodular thickening and contraction of palmar fascia - dominant genetic component involving northern European descent - common in men >50y - assoc factors: DM, epilepsy, COPD, alcoholism, smoking, trauma S/Sx: - When people have Dupuytren's contracture, tissue under skin in palm of hand gets thick. Over time, this makes fingers (usually ring and little fingers) stiff and keeps them from straightening all the way.

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Dupuytren's Disease - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - nodular thickening and contraction of palmar fascia - dominant genetic component involving northern European descent - common in men >50y - assoc factors: DM, epilepsy, COPD, alcoholism, smoking, trauma S/Sx: - When people have Dupuytren's contracture, tissue under skin in palm of hand gets thick. Over time, this makes fingers (usually ring and little fingers) stiff and keeps them from straightening all the way. Tx: - injections if just a cord - surgical release but not recommended until flexion contracture ≥30°; 2 hr surger - splint in "pink" position b/c arteries are too short for full extension

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Flexor/extensor tendons injuries: Trigger Finger - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - nodule of flexor tendon entrapment at A1 pulley S/Sx: - can feel nodule; v. painful, v. inflammed - Mechanical triggering with flexor tenosynovitis (trigger finger): hands are placed in palms-up position and patient is asked to actively flex and extend fingers. Alternatively, if active triggering is not present, examiner places her fingers on proximal interphalangeal (PIP) joint as finger is actively flexed and extended, noting presence of loss of smooth motion or a clicking sensation Tx: - cortisone injection of tendon sheath and/or - surgical release: cut open pulley, nodule stays → pulley grows back longer

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Patellar tendons rupture - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - patellar is both a tendon and a ligament S/Sx: - Image: This lateral radiograph of knee demonstrates a high position of patella (PATELLA ALTA) (arrow) secondary to a torn patellar tendon. A small fragment of inferior aspect of patella (patellar avulsion fracture) is also noted (arrowhead). Tx: - lots of sutures and hareware

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: Rupture of Biceps Tendon: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - rupture of proximal long head of biceps is most common S/Sx: - proximal tear: muscle belly retracts distally → Popeye deformity; lose ~20% strength (b/c still have brachioradialis) - distal tear: muscle belly rides up proximally; weakness in supination Tx: - proximal tear: usually non-surgical other than for cosmetic reasons - distal tear: surgical tx depending on comorbidities - image: patient shows classic "Popeye" deformity associated with biceps tendon rupture. Note gap between contracted biceps muscle and deltoid

Understand the signs, symptoms, diagnosis and treatment of the following conditions: Hip Avascular Necrosis: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - secondary to trauma, stress fractures, chronic steroid us (RA, COPD, organ transplant) S/Sx: - Radiograph of pelvis and hips of a 41-year-old man who has received a cardiac transplant and who is on corticosteroids. There is stage III (moderately late) avascular necrosis of both femoral heads manifested by increased density within each femoral head but no collapse (arrows). The increased density reflects marrow infarcts with calcification.

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Quadriceps tendon rupture - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - steroid or EtOH abuse - sickle cell train, dz S/Sx: - ask about steroids use, EtOH abuse - image: Lateral radiograph of the knee demonstrates low position of patella (PATELLA BAJA) (arrow) secondary to chronic tear of quadriceps tendon. A small suprapatellar effusion is also noted (arrowhead).

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. Distal Humerus Fractures: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - supracondylar: - transcondylar: - intercondylar: - lateral/medial condyles: - radial head fracture: S/Sx/Imaging: - AP and lateral x-rays: look for (+)fat pad sign; look for displacement of "hourglass" lines → Type II extension supracondylar humeral fracture (left elbow). Lateral radiograph. Note the positive fat pad sign (arrows) and how the anterior humeral line does not intersect with the capitellar epiphysis (black vertical line). A, ulna; B, humerus; C, capitellar epiphysis; D, radial head. Tx: - open reduction and internal fixation (ORIF) - percutaneous wire fixation Sequelae: - residual pain, stiffness, deformity, mal-union/nonunion, AVN, compartment syndrome, ulnar neuropathy

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 2. DeQuervain Tenosynovitis - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - swelling or stenosis of abductor pollicus longus and extensor pollicus brevis tendon sheaths S/Sx/Dx: - Finkelstein test: for tendonopathy - x-rays: - image: entrapment tendonitis or tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons at the styloid process of the radius Tx: - thumb spica splint - Rx: NSAIDs, cortison injection - surgical release rarely needed

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Achilles tendon rupture - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - tear usu 5-7 cm proximal to insertion into calcaneus S/Sx: - difficulty bearing weight - step off deformity palpable on plantar surface of foot - Thompson test is performed with the patient's feet hanging over the edge of the examining table. When the examiner squeezes the calf muscle, on the uninjured side there is normal plantar flexion of the foot; on the side with a complete Achilles tendon rupture, there is no plantar flexion. It is important to note that in patients with significant but incomplete rupture of the tendon, the patient may still demonstrate a normal Thompson test as well as substantial strength. Tx: - surgery

SEPTIC ARTHRITIS: - Etiology: - Clinical Presentation:

Etiology: - "septic arthritis" usually refers to bacterial arthritis or fungal arthritis, but bacterial joint infections are most common CLINICAL FEATURES: - Bacterial arthritis classically presents with acute onset (two to five days) of fever and joint pain, swelling, and limited range of motion - bacterial arthritis usually occurs in a single joint, most commonly of lower extremity; Infections of knee, hip, and ankle consistently account for at least 80% of cases, with hip and knee most commonly affected - Swelling in the region of the thigh or buttock - Holding leg flexed with slight abduction and external rotation - Irritability on passive movement of hip (eg, during diaper change) - older children and adolescents usually also have fever and constitutional symptoms (malaise, poor appetite, irritability, tachycardia) within first few days of infection - *Pain with active or passive movement is a *cardinal feature, but findings related to involved joint may be subtle - children may present with limp or refusal to walk or bear weight; pain may be referred to adjacent structures; patients with bacterial arthritis of hip may complain of knee pain; those with bacterial arthritis of sacroiliac joint may have symptoms that mimic appendicitis, pelvic neoplasm, or urinary tract infection

PSEUDOGOUT - calcium pyrophosphate dihydrate (CPPD) crystal deposition diseases: - Etiology: - Clinical Presentation: -- how do differentiate clinically btw gout and pseudogout - Dx:

Etiology: - *Pseudogout accurately describes acute attacks of C*PPD crystal-induced synovitis, which clinically resemble urate gout Clinical Presentation: - characterized by self-limited attacks of arthritis involving only 1+ extremity joints; attacks resemble those of urate gout both in typical accompanying signs of severe acute inflammation and in occasional occurrence of cluster attacks - Trauma, surgery, or severe medical illness frequently provoke acute attacks in both of these crystal-induced arthritides - Despite similarities, joints most commonly involved in an acute episode differ between gout and pseudogout; **knee is affected in over 50% of all acute attacks of pseudogout, whereas first metatarsophalangeal joint is more frequently involved in gout Dx: demonstration of CPPD crystals in tissue or synovial fluid and/or upon radiographic evidence of disease - image: Plain radiograph shows chondrocalcinosis of knee in a patient with hemochromatosis. There is calcification within cartilage in tibiofemoral joint space (arrows).

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Common shoulder fractures: PROXIMAL HUMERUS - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: - 5% of shoulder fx - usually older patients w/ osteopenic osteoporotic, fragile bones; - usually occurs from a ground-level fall S/Sx/Imaging: - 85% non-displaced - Neer classification of proximal humerus fractures, based on four parts: 1. humeral head, articular surface 2. greater tubercle 3. lesser tubercle 4. diaphysis, shaft Tx: - non-displaced: sling + gentle ROM exercises by 7-10 d (if stable) - displaced: operative intervention - greater tubercle avulsion: open reduction w/ screws

Knee Dislocation: - Etiology: - S/Sx: - Imaging: - Dx: - Tx:

Etiology: *not patella* - popliteal artery and nerve S/Sx: - assess popliteal a. when do neurovascular assessment - image: lateral radiograph shows an anterior knee dislocation with bicruciate ligament injury. Note how alignment of patella and femur are no longer parallel and close proximity of femur and tibia. Tx: - STAT angiogram - ortho and vascular surgery emergency; multiple injuries

GOUTY ARTHRITIS: - etiology: - clinical presentation: - Dx:

Etiology: GoUt (monosodium Urate crystal deposition disease) is characterized biochemically by extracellular fluid urate saturation Clinical Presentation: - Recurrent attacks of acute inflammatory arthritis - A chronic arthropathy - Accumulation of urate crystals in form of tophaceous deposits - PODAGRA: great toe erythema, swelling w/ severe pain even to light touch; 80% of initial attacks involve a single joint, most often at base of the great toe (first metatarsophalangeal joint, known as podagra) or the knee Dx: - arthrocentesis: testing of synovial or bursal fluid should include cell counts and differential white count, Gram stain and culture, and examination of crystals under polarizing light microscopy - diagnosis of acute gout is most secure when supported by visualization of intracellular urate crystals in a sample of fluid aspirated from an affected joint (or bursa) - image: Plain radiograph of foot demonstrating features consistent with gout. There is soft tissue swelling and extensive erosions involving the first metatarsophalangeal joint, as well as calcifications within a tophus.

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 1. Medial and lateral epicondylitis - Etiology: - S/Sx: - Tx:

Etiology: represents a chronic tendinosis, rather than an acute inflammatory process, involving disorganized tissue and neovessels; described as angiofibroblastic tendinosis; few inflammatory cells are found in these lesions → MEDIAL=GOLFER'S ELBOW: caused by overuse of muscles of forearm leading to inflammation and pain around joint → LATERAL=TENNIS ELBOW: inflammation or tearing of tendens of extensor muscles of forearm; these muscles are used for turning and twisting motions of hand S/Sx/Dx: - MEDIAL epicondylitis (GOLFER'S elbow) is diagnosed clinically by the following findings: - Localized tenderness over the medial epicondyle and proximal wrist flexor muscle mass (the ulnar nerve/ulnar groove and medial collateral ligament should not be tender) - Pain with resisted wrist flexion with elbow in full extension - Pain with passive terminal wrist extension with elbow in full extension - LATERAL epicondylitis (TENNIS elbow) is diagnosed clinically by the following findings: - Localized tenderness over lateral epicondyle and proximal wrist extensor muscle mass - Pain with resisted wrist extension with elbow in full extension - Pain with passive terminal wrist flexion with elbow in full extension Tx: - behavior: stop what makes it worse; RICE - Rx: NSAIDs, cortisone injection - topical: creams, ice, heat, massage, elbow strap - OT

How is internal rotation of the hips performed on children?

Evaluation of internal rotation of the hips is performed with the child in the prone position and with the knees flexed; the ankles and feet are then rotated away from the body to compare the amount of internal rotation in the symptomatic versus the asymptomatic hip. The pelvis must be kept flat on the examining table; otherwise, asymmetry of internal rotation may not be appreciated.

what are the most common SPINE pathologies for men and women? Females: Males:

F: - ↑kyphosis - ↑risk compression fx due to osteoporosis - metastases to spine from breast CA M: - ↑risk for ankylosing spondylitis - ↑risk for multiple myeloma of spine - metastases to spine from prostate & lung CA

Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Femur Fractures: Femoral Neck - Etiology: - S/Sx: - Imaging: - Dx:

Femoral Neck Fractures: - disrupts blood supply to head of femur: lateral ascending cervical arteries provide blood supply to majority of femoral head. Foveal vessels may supply a varying area directly adjacent to insertion of ligamentum. There is little to no direct contribution to head from anterior vessels - Garden classification scheme is based upon radiographic appearance and is used specifically for femoral neck fractures: ●Type 1 is a stable impaction fracture in valgus ●Type 2 is a complete nondisplaced fracture ●Type 3 involves varus displacement of femoral head ●Type 4 involves complete loss of continuity between fragments

what is the typical Mechanism of a clenched fist injury?

Fight bite injuries to the hand usually occur with the fist in a clenched position. When the fist makes contact with a victim's mouth, the teeth can easily penetrate the skin and extensor tendon that are stretched tightly over the metacarpal head, thus injuring the underlying bone and joint.

Classification of acute Cervical spinal injuries: Mechanisms of spinal injury: Stability Flexion: Flexion- rotation: Extension: Vertical Compression:

Flexion: - Anterior wedge fx: Stable - *Flexion teardrop fx*: Extremely unstable, anterior cord syndrome - Clay shoveler's fx: Stable - Subluxation: Potentially unstable - Bilateral facet dislocation: Always unstable - Atlanto-occipital dislocation: Unstable - Anterior atlantoaxial dislocation ± fx: Unstable - *Odontoid fx with lateral displacement*: Unstable - Fx of transverse process: Stable Flexion-rotation: - Unilateral facet dislocation: Stable - Rotary atlantoaxial dislocation: Unstable Extension: - Posterior neural arch fx (C1): Unstable - *Hangman's fx (C2), traumatic spondylolisthesis (TS)*, extreme hyperextension: Unstable - Extension teardrop fx: Usually stable in flexion; unstable in extension - Posterior atlantoaxial dislocation ± fx: Unstable Vertical compression: - Burst fx of vertebral body: Stable - *Jefferson burst fx (C1)*: Extremely unstable - Isolated fxs of articular pillar and vertebral body: Stable

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 3. Fractures of the cervical, thoracic and lumbar spine

Fractures of the cervical, thoracic and lumbar spine:

SHOULDER EXAM: - HPI: - Shoulder Pain DDx:

HPI: - occupation: - hand dominance: - Sx and duration of pain: - Sx of instability: popping out is sign of chronic instability - aggravating positions/movements: - prior Tx: meds, therapy, surgery - voluntary or involuntary dislocation: how many? when was last? DDx: Extrinsic causes of shoulder pain (referred): - Neurologic: Cervical nerve root compression (C5, C6); Supraspinatus nerve compression; Brachial plexus lesions; Herpes zoster; Spinal cord lesion; Cervical spine disease - Abdominal: Hepatobiliary disease; Diaphragmatic irritation (eg, splenic injury, ruptured ectopic pregnancy, perforated viscus) - Cardiovascular: Myocardial ischemia; Axillary vein thrombosis; Thoracic outlet syndrome - Thoracic: Upper lobe pneumonia; Apical lung tumor; Pulmonary embolus

a) Describe the hand and wrist examination, including special tests.

Hand & Wrist PE: - Pain: - Instability: - Stiffness: - Swelling: - Weakness: - Numbness: - Masses: - Infection: Special Tests: - Finkelstein Test: (+) indicates tenosynovitis of first dorsal compartment = de Quervain tenosynovitis - Allen Test: compression of radial & ulnar aa. and assessment of refill - Phalen's maneuver: hold for 60s to see if numbness or tingling of median n. indicative of carpal tunnel syndrome - Tinel's sign: tapping median n. for parasthesias

Pedicle fracture of C2 (axis)

Hangman fracture (also known as traumatic spondylolisthesis of axis) is a fracture which involves the *pars interarticularis of C2 on both sides, and is a result of hyperextension and distraction. Clinical presentation: Post-traumatic neck pain after hyperextension high velocity injury is the most common presentation. Neurological impairment is seen only in 25% of patients. Pathology: This is known as a judicial lesion as these are the forces delivered by a noose, which, contrary to most ill-informed depictions, was placed with the knot towards the side of the neck, next to the angle of the mandible/mastoid process. This fracture is virtually never seen in suicidal hanging. Indeed it was not even seen in many of those who were judicially hanged; asphyxiation being the usual mode of death. Major trauma in hyperextension, such as a high speed motor vehicle accident, is in fact the most common association - especially in fatal cases.

a) Describe the hip and thigh examination, including special tests

Hip & Thigh PE: - gait: e.g. lateral shift of body c/w intra-articular hip pathology (OA, AVN) - use of cane, walker, wheelchair - location of pain: - anterior thigh: lat. cutaneous n. syndrome - lateral hip: greater trochanter bursitis/ snapping hip syndrome - inguinal: OA, AVN - medial thigh: femur fx Special Tests: - internal and external rotation - Faber test/ figure 4

SEPTIC ARTHRITIS: - Labs: - Dx:

Labs: - Complete blood count (CBC) with differential - Erythrocyte sedimentation rate (ESR) and/or C-reactive protein (CRP) - Blood culture - Synovial fluid analysis (white blood cell [WBC] count and differential, Gram stain, culture, and susceptibility testing) Dx: - Isolation or identification of a bacterial pathogen from synovial fluid (by culture or other diagnostic technique) confirms diagnosis of bacterial arthritis - WBC >50-100L, gram stain, cultures, crystals

Cervical spine injury: H&P:

MOI: high energy, height, MVA Sx: severe neck pain, instability, "floating head" Clear C-spine in trauma: x-rays incl. view of C7-T1, odontoid view Tx: immobilization, halo + IV steroids if suspicion of spinal cord injury

44. interpret the findings from this x-ray image - Dx:

Mallet finger with fracture: This lateral radiograph shows an avulsion fracture at the proximal portion of the distal phalanx in a patient with a mallet finger injury.

Nonorganic signs or Waddell's signs

Nonorganic signs or Waddell's signs: In patients with chronic pain, psychological distress may amplify low back symptoms, and may be associated with anatomically "inappropriate" physical signs. The most reproducible of these signs are: - superficial tenderness, - distracted straight leg raising (ie, discrepancy between seated and supine straight leg raising tests), - the observation of patient overreaction during the physical examination, also known as *Waddell's signs * Other Waddell's signs suggestive of symptom enhancement include: - nondermatomal distribution of sensory loss, - sudden giving way or jerky movements with motor examination, - inconsistency in observed spontaneous activity (dressing, getting off table) and formal motor testing, - pain elicited by axial loading (pressing down on top of head, or rotating the body at hips or shoulders). Presence of multiple Waddell's signs may suggest a behavioral component to a patient's pain. However, systematic reviews have not found an association between Waddell's signs and psychological distress, or claims for disability compensation or litigation

This 54-year-old patient presented with a gradual onset of numbness and tingling of the middle fingers of the right hand. Symptoms waxed and waned over a period of several months. The triceps reflex and muscle strength were normal. what do you expect to see on the oblique cervical film?

Oblique views are primarily used to determine the role of foraminal encroachment. This 54-year-old patient presented with a gradual onset of numbness and tingling of the middle fingers of the right hand. Symptoms waxed and waned over a period of several months. The triceps reflex and muscle strength were normal. The oblique film demonstrates C6-7 foraminal encroachment.

46. what is the arrow pointing to in this film?

Osteonecrosis (avascular necrosis) of right femoral head: Plain film radiograph of the pelvis demonstrates collapse of the right femoral head (arrow) from osteonecrosis (avascular necrosis).

14. interpret the findings from this x-ray image - from what view was this image taken?

Posterior shoulder dislocation and fracture: This axillary view demonstrates the dislocation more clearly, along with an avulsion of the lesser tuberosity (white arrow).

Burst (Jefferson) fracture of C1

The Jefferson fracture of C1 is highly unstable and occurs when a *vertical compression force is transmitted through the occipital condyles to the lateral masses of the atlas. *bilateral fx of anterior and posterior arches of C1

LACHMAN TEST: - how is it performed? - what does it assess?

The Lachman test is performed by placing the knee in 30 degrees of flexion and then stabilizing the distal femur with one hand while pulling the proximal tibia anteriorly with the other hand, thereby attempting to produce anterior translation of the tibia. An intact ACL limits anterior translation and provides a distinct endpoint. Lack of a distinct endpoint suggests ACL injury. - w/ big pt. use blanket under thigh

Zanca view of shoulder

The Zanca view (AP with a 10 to 15 degree cephalic tilt) of the involved shoulder highlights the AC joint, which is projected above the scapula

- what test may help determine severity of hip irritation and aid in distinguishing between transient synovitis and septic arthritis?

The modified log-roll test may help determine the severity of hip irritation and aid in distinguishing between transient synovitis of the hip and septic arthritis. The diagnosis of transient synovitis is more likely if an arc of 30 degrees or more of hip rotation is possible without pain.

b) Understand the signs, symptoms, diagnosis and treatment of the following conditions: 4. Acromio-clavicular injuries - Tx:

Tx: Types I-III - ice, rest, NSAIDs (if not CIs) - 2-4 wks in sling + symptomatic Rx Tx: Types III-VI - Type III: controversial surgery vs. conservative Rx → late sequela of AC joint degenerative joint dz (DJD) as common complication of surgical fixation - Types IV-VI: orthopedic evaluation; emergent referral if neurovascular compromise exists - image: drawing depicts a type three acromioclavicular (AC) joint injury; Both AC ligament and coracoclavicular ligament are completely disrupted; clavicle is displaced superiorly with such injuries.