MSP Test 2
What are some common signs and symptoms of an ACL injury?
pain feeling or hearing an audible "pop" Instability and giving way edema loss of knee motion inability to continue playing sports Severe swelling and hemarthrosis within 1-2 hours post injury
Osteogenesis imperfecta (brittle bone disease): Definition: _____ Etiology:_____ OI has the most impact on which type of collagen fibers? Signs and symptoms: _____ Treatment (2 parts):
rare congenital disorder of collagen synthesis affecting bones and connective tissue Inherited Type I Occasional fractures, growth retardation, long bone and spinal deformities 1. No cure for this disease, but orthopedic management (fracture prevention, treatment, and fracture complication care) is important 2. Strengthening (from no resistance to light resistance) to reduce muscle atrophy and bone loss, positioning, and standing activities are recommended
What are the characteristics and indications for the use of CT?
- X-ray based technology - Multiple plane and 3-D images available - Gray scale same as x-ray interpretation - Creates much better differentiation of soft tissue densities - Accurately measures bone density - Trauma - Fracture detection and evaluation - Spine alignment - Tumor staging
What are the six functions of the meniscus?
- facilitate joint gliding - secondary joint stabilizer - prevent hyperextension - protect joint margins - distribute stress over knee - (3x greater contact area) - absorb shock - compressive loading function
Swelling for an ACL injury will occur ______ hours post-injury while swelling for a meniscal injury will occur ____ hours post-injury.
1-2 4-6
What are the four signs and symptoms of IT band syndrome?
1. pain localized to the lateral knee over the lateral femoral epicondyle or Gerdy's tubercle 2. runners typically start running pain-free with symptoms reproduced at predictable time or distance 3. may be painful during walking or stair negotiation in severe cases 4. may present with crepitation, snapping, or mild pitting edema over affected area
Scoliosis: Definition: Lateral curvature of the spine >____ degrees Severe scoliosis can impact ____ function Common signs and symptoms: What type of Cobb angle and Risser grade combination would result in a higher progressing risk? How much curve (degrees) would often require surgery regardless of Risser grade? For neuromuscular scoliosis, convex towards the stronger or weaker side?
10 Pulmonary Pain anywhere along the spinal column and adjacent regions. Pain is not generally caused by spinal curves, but instead by curvature of spine placing abnormal forces on other areas of the body. Curve 20-29 degrees and Risser 0-1 29-40 and >40 Weaker side
Ankle sprains: 3 grades of ligament sprain. Anterior drawer test is a common test to classify ankle sprains. The test will be positive in which grade(s)? Most common ligaments injured? The ATFL restrains_____ when the TCJ is in PF. Prevalence: more in younger or older individuals? Which sport has more injury prevalence? Etiology, mechanism of injury
2 and 3 ATFL and calcaneal fibular Inversion Younger people, basketball Rapid inversion of ankle with some PF
At what knee flexion angle does the IT band slide over the lateral femoral condyle during knee flexion?
30 degrees
What are the 5 P's and 3 A's of compartment syndrome? What other symptom can occur?
5 P's: pain, parasthesias, pulselessness, pallor, paralysis 3 A's: Anxiety, agitation, analgesia increase Diffuse pain on passive extension or flexion
What is the etiology and mechanism of injury for full and partial MCL injuries?
A blow to the outside of the knee Full tear: Direct valgus blow to the knee Partial tear: Noncontact, such as decelerating, cutting, or pivoting
Posterior tibialis tendinopathy: a. Definition: _____ b. Etiology, mechanism of injury Etiology: _______ Mechanism of injury:______ c. Signs/symptoms: _____ d. Clinical pearls: the patient may exhibit the "too many toes sign" with a severely pronated foot. An individual with posterior tibialis tendinopathy may have progressive collapses of the medial longitudinal arch, abducted foot, or excessive pronation. When observing from the rear, a clinician would be able to see more toes from this patient than from a healthy subject. e. Clinical pearls: posterior tibialis contribute to the first 15º of plantar flexion. Patients with posterior tibialis weakness may weaken their single-leg heel raise capability.
A range of conditions from tendinitis to rupture; it is a common cause of foot dysfunction and pain tendon thickening, irregular tendon structure, synovial sheath effusion, fibroblast hypercellularity, and neovascularization over-use, age-related degeneration, and tendon rupture following degeneration Med. ankle pain and swelling, pain in med. Plantar arch, and collapse of the med. long. arch
Lumbar spine x-ray letters A-E mean:
A: Alignment B: Vertebral bodies C: Central canal and posterior element D: Degenerative changes E: Everything else around the spinal region
Knee injuries acute hemarthrosis: The most and second commonly injured structure? Injuries of the above 2 structures often occur side by side
ACL or meniscal tear
What are two events that can cause hemarthrosis?
ACL tear and patellar dislocation
What is the unhappy triad of knee injuries?
ACL tear, MCL and medial meniscus injury
Prevalence of achilles tendinopathy: More in ___, _____ individuals. Why them? Prevalence compared to subjects with patellofemoral pain: Age and gender difference?
Active, older adults Decreased blood flow, collagen fibers and thickness, decreased GAG, decreased crosslinking, decreased tensile strength and linear stiffness Achilles tendinopathy: Older male athletes Patellofemoral pain syndrome: Female adolescents and young adults
What is the difference between acute/traumatic and chronic/degenerative meniscal injury mechanisms?
Acute: Sudden twisting motion or rapid direction change Chronic: Age-related and may result from repetitive activities over time
Management of GH dislocations: Traumatic: depends on the _____ Young patient: ______ 16 y.o. or older "active" individuals, recurrent injuries: _____ Old "sedentary" individuals: ______ Atraumatic: Often _____ instability presented Discourage voluntary dislocation Surgery or no surgery?
Age Reduction and mobilization Surgical intervention Reduction and immobilization Multi-directional Voluntary No surgery (rotator cuff muscle strengthening instead)
What does the x-ray letter A mean and what are some examples?
Alignment: Pay attention to continuity along the posterior border of the vertebral bodies to spot any potential protrusion to the spinal cord Examples: scoliosis, kyphosis, lordosis, spondylolisthesis (slippage of one spinal segment in relationship to its adjacent segment)
What are CT scans?
An advancement in x-ray based imaging technology
_____ injuries are the most common athletic injury
Ankle
What are the signs and symptoms of synovial plica syndrome? How does the common pain location compare to PFP? What is the rehab consideration ?
Anterior or anteromedial knee pain, intermittent or episodic pain, clicking PFP is directly on the patella, medial plica is more medial and lower Consider surgery if conservative treatment for 3-6 months fails
What are some prevention measures for DVT?
Anti-coagulants, compression leggings, mobilization
Tibial spine fracture: Common etiology: ____ What ligament is attached to the tibial spine?
Bicycle accident ACL
What tissue appears darker and what appears lighter with CT scans?
Bone is white, with cortical bone white and cancellous bone light gray. Soft tissue will appear darker as they are less radiographically dense than bone
How do CT scans differ from x-rays? Radiation comparisons?
CT offers more info because it allows multiple plane views and 3-D images where a bone can be studied from infinite angles. Greater contrast makes otherwise undetectable pathologies visible CT is more radiation
What does the x-ray letter C mean and what are some examples?
Central canal and posterior element Central canal defect example: central canal stenosis Posterior element defect examples: Pars defect (pars interarticularis defect/fracture), pedicle lesion: - Scotty dog sign/fracture: Spondylolysis/Pars interarticularis of lumbar spine has a defect or break (neck of dog) - Which view can best identify pars defect: Lumbar oblique projection
Metatarsal stress fracture: Also called march fracture, fatigue fracture b. Definition: _____ c. Etiology, mechanism of injury Etiology: _____ Mech of injury: ______ d. Signs/symptoms: ____
Closed incomplete fractures through the cortex and into the trabecular bone matrix in the shaft of a metatarsal bone Caused by repetitive stress and overload to the forefoot and metatarsal bones Abnormal loading pattern of the foot during walking/running (tightness of calf muscles, short 1st metatarsal, excessive femoral anteversion, and imbalances in muscle force Insidious onset of midfoot/forefoot pain, stress pain/aching after training, and tenderness to palpation at fracture site
What is the most common reason for an orthopedic lawsuit?
Compartment syndrome
What is the PCL function?
Controls posterior tibia translation, knee hyperextension, and tibia IR
What is the definition, mechanism of injury, symptoms, and treatment of the "acute" compartment syndrome?
D: A condition in which increased pressure within a limited space compromises the circulation and function of the tissues within that space MOI: Acute: Blunt trauma, crush injuries, fractures, tight cast, prolonged limb compression Symptoms: Pain that doesn't improve with medication, severe pain and loss of voluntary movement, aggravated by walking, running, and tight clothing Treatment: Fasciotomy
What is the definition, mechanism of injury, signs and symptoms of DVT and PE?
D: Partial or complete occlusion of a vein by a thrombus with secondary inflammatory reaction in the wall of the small deep vein MOI: Physical immobility, trauma, surgery S/S: Swelling, tightness, ache, pain with possible redness. Signs are often absent. Aggravated by walking or calf exercises.
Components of pronation and supination and their movement axis?
DF and PF are around a M-L axis Eversion and inversion are around an AP axis Abd and Add are around a vertical axis Pronation: eversion, abduction, dorsiflexion (oblique axis) Supination: inversion, adduction, plantarflexion (oblique axis)
Healthy ligaments and tendons will be ______ (_____ signal intensity) in both T1 and T2 weighted MRI scans
Dark Low signal intensity
What does the x-ray letter D mean and what are some examples?
Degenerative changes Examples: Disc space narrowing, osteophytosis (bone spurs)
What is the common injury mechanism and treatment for a Monteggia lesion?
Direct blow to the ulna or fall Closed reduction, immobilize in a reduced position
What are some examples of direct and indirect forces that can cause fractures?
Direct: Direct blow, crush, penetrating Indirect: Traction, angulation, rotational, vertical compression
What are the 3 classifications of fracture?
Displaced vs non-displaced Stable vs unstable Open/compound vs closed
Knee area fracture: Growth about the knee (70% of lower extremity length): therefore leg length discrepancy is a common complication for knee area fracture · Distal femur or proximal tibia has more bone growth potential? 3 common complications: ____, _____, _____
Distal femur · Growth arrest · Angular deformity · Leg length discrepancy
Distal Patella Apophysitis (Sinding-Larsen-Johansson Syndrome): Definition (different from Osgood-Schlatter!!!): _____ Injury mechanism: _______ Signs and symptoms: _____ Prognosis and common management: ______
Distal patella apophysitis Repetitive microtrauma because of sports that include running and jumping Pain localized to anterior knee, limping, mild swelling Rest, crutches, NSAIDs, adequate stretching
What is the most commonly fractured bone in children?
Distal radius
What is the etiology and common treatment option for the "chronic" compartment syndrome?
E: Repetitive heavy use of the muscles, such as being a runner T: Conservatively with rest, NSAIDs, elevation of the limb, compression, proper footwear. CCS can develop into ACS if not treated
Anterior (anterolateral) ankle impingement: a. Definition: _____ b. Prevalence: _____ c. Etiology, mechanism of injury: _____ d. Signs/symptoms: ______
Entrapment of soft tissue (capsule or synovium) or bone in the ant. lat. gutter of the ankle, primarily w/ dorsiflexion more common in athletic/dancer population and those with chronic ankle instability Result of ankle sprain or repetitive micro trauma (esp. forced DF in ballet and soccer) Vague to sharp pain, catching, and locking in the ant. lat. ankle or feeling of the ankle giving way
Tarsal tunnel syndrome: a. Definition: ____ b. Etiology, mechanism of injury Etiology: _____ Mechanism of action: ____ c. Signs/symptoms: _____
Entrapment of the tibial nerve as it passes through the tarsal tunnel post. to the med. malleolus trauma, foot deformities, and space-occupying lesions 50% idiopathic, can result from ankle injury or repetitive stress associated with excessive pronation Sensory disturbances in med. ankle and plantar part of foot, atrophy of muscles innervated by tibial nerve, and abnormality in med and lat plantar nerves (these branch from the tibial nerve)
What does the x-ray letter E mean and what are some examples?
Everything else (around the spine region) Examples: renal stones, gallstones, cancer
Scheuermann's disease: Definition: _____ Etiology: _____ Common management: _____
Excessive thoracic kyphosis (Cobb angle >45° with wedging of 5° or more) of at least 3 adjacent apical vertebrae and vertebral end plate irregularities Unknown Orthotic treatment, or if patient is skeletally immature a Milwaukee brace
Medial tibial stress syndrome (MTSS)/shin splints: a. Definition. Does MTSS include exertional compartmental syndrome and tibial stress fracture? _____ b. Prevalence: more common in what kind of athletes? c. Mechanisms of injury: ____ d. Common signs and symptoms
Exercise-induced leg pain; it excludes exertional compartmental syndrome and tibial stress fracture Runners, even more so in military recruits Overload, esp. from running and jumping activities Pain in mid. to distal tibia, pain at the beginning of activity (esp. when beginning a new type of strenuous activity), and pain when starting a bout of activity (symptoms could increase to the point of constant pain during activity)
Extrinsic and intrinsic risk factors for achilles tendinopathy i. What are they? Extrinsic vs. intrinsic?
Extrinsic = overuse and toxicity d/t drug/med use Intrinsic = Age, male, decreased vascularization, systemic diseases, previous injury i. Restricted DF and excessive calcaneal pronation can be an intrinsic risk factor.
What are the gender differences for ACL injuries and what could be a possible contributor to these differences?
Females are more likely to sustain an ACL injury than males Greater knee valgus motion during landing
What 4 things can cause in-toeing?
Femoral anteversion Femoral torsion Tibial torsion Metatarsus adductus
LCL injury occurs most commonly at which attachment?
Fibular
What is the definition of a Monteggia lesion? Also know that it is a commonly missed diagnosis (especially for radial head dislocation) which can lead to very poor outcomes.
Fracture of the proximal third of the ulna with dislocation of the proximal head of the radius, along with tear of forearm IM
What are signs and symptoms of PFP?
Generalized knee pain, swelling, crepitus, pain increases with prolonged or repeated activity or activities that involve increased quad muscle force
What is the grading system of ACL injuries? What is the difference between grade I and grade II in terms of weight bearing?
Grade I: Microscopic tears in the ligament, does not significantly affect knee joint's ability to support body weight Grade II: Ligament partially tears, mild to moderate instability during weight bearing Grade III: Ligament is completely torn or separated from insertion into bone, significant knee instability
What is the impact of Q angle on PFJ stress? What is the impact of increased hip internal rotation on PFP? Prolonged immobilization in ___ can worsen the symptoms (______ sign)
Greater Q angle increases PFJ stress Leads to patellar mal-tracking and decreased PFJ contact area Knee flexion, movie-goers sign
What is the impact of mass and velocity on traumatic fractures?
Greater mass and velocity means greater impact on the body
Blount disease Definition: _____ Treatment: bracing first (which type?) before osteotomy
Growth disorder of the tibia that causes the lower leg to angle inward, resembling a bowleg KAFO
Slipped Capital Femoral Epiphysis (S.C.F.E.) Definition: ______ Injury mechanism/etiology: _______ Signs and symptoms: 1. _______ pain 2. Decrease hip ROM in what directions? Prognosis and common management: Increased slip severity places patient at higher risk for ____ and _____. Surgical stabilization using central percutaneous pin fixation with one or more cannulated screws.
Growth plate of the proximal femoral physis is weak and becomes displaced from its normal position Unknown, but genetic, hormonal, and mechanical factors play an important role 1. Hip, groin, thigh, or knee (referred pain) pain 2. IR and abduction AN and chondrolysis
Salter-Harris fractures are most common in what type of bone? What are the 3 most common injury mechanisms?
Growth plates Trauma, overuse, and birth injuries
How is rehabilitation for IT band syndrome addressed?
Hard to effectively stretch the ITB because muscles will be stretched instead Address impairments of strength and ROM (hip abductors) Address movement impairments (minimize hip adduction, varus thrust, pelvic drop)
Glenohumeral dislocations: - ______ risk of recurrent dislocation - Dislocation directions: ____ (most common), ______, _____ - Instability direction: · Traumatic: ______ · Atraumatic: _____
High Anterior, posterior, inferior Traumatic: Often one direction Atraumatic: Often multiple directions
Ankle syndesmotic sprains are also called _____. What is this sprain?
High ankle sprains Sprain of the ligaments between the tibia and fibula (esp the thickening of the distal part of the interosseous membrane)
Femoral shaft fracture: Injury mechanism: ______ · Clinical pearls: if the infant is less than a year old and cannot stand and walk, femoral shaft fracture could be the result of other reasons such as child abuse. 3 treatment goals? ______ as a potential closed conservative treatment 4 complications of the closed treatment for femur fractures?
High energy impact (such as being hit by a car) Restore length, alignment, rotation Spica cast Foot drop, skin loss, compartment syndrome, and malrotation/shortening
Proximal humerus fractures: Birth fractures: · Which type: Salter ____ · _____remodeling potential · Common management: _____
I Great Immobilization
What kind of combined loading state will make ACL more vulnerable?
IR, varus/valgus such as during landing, stopping, or planting to change directions
Legg-Calve-Perthes disease (Perthes's disease): Definition: ________ Injury mechanism/etiology: _____ Signs and symptoms: _______ Prognosis and common management:
Idiopathic osteonecrosis of the capital femoral epiphysis of the femoral head Unexplained interruption of the blood supply to the capital femoral epiphysis Limp, pain in groin, knee or hip, pain with weight-bearing activities (running or jumping), short stature Maintenance of range of motion and containment of the femoral head. Proximal femoral varus derotation osteotomy between 6-10 years. Older and unsatisfactory results. Self-limiting and complete healing generally occurs within 3-4 years
What is the definition of a Galeazzi lesion in adults and children? What is the mechanism of injury? What can this cause?
In adults: radial shaft fracture with dislocation of the distal radioulnar joint (distal radioulnar joint injury) In children: radial shaft fracture with the separation of the distal ulnar epiphysis Due to a fall on an outreached arm or a direct blow to the forearm High incidence for growth arrest in children with the separation of distal ulnar epiphysis
What is the MOI for high ankle sprain?
In an open-chain condition, forceful ankle dorsiflexion with foot external rotation may cause the injury. In a closed-chain condition (eg, cutting), forceful ankle dorsiflexion with tibia internal rotation (relative foot external rotation) can also cause the injury.
Achilles tendon rupture: a. Most common site?
In sports injuries it is the mid-substance tear; for others, insertional tears are more common
What are common signs and symptoms of Salter-Harris fractures?
Inability to bear weight on involved extremity Impaired function and decreased ROM in affected extremity Localized joint pain Swelling near the affected joint with focal tenderness over the physis
What is the mechanism of injury for IT band syndrome?
Increased strain rate on affected LE, excessive hip adduction and IR, ipsilateral trunk lean in females, reduced hip abduction strength
MTSS: a. Etiology? Current thought? b. Differential diagnosis: Compartment syndrome (CS) i. Etiology for acute vs. chronic CS Acute - trauma related (closed fracture, contusion, intense ex., snake bite Chronic - exercise induced (s/s include tightness, numbness, weakness, foot drop, aching/burning/cramping pain, and possible swelling/bulging) ii. Symptoms for the acute traumatic compartment syndrome. 4Ps?
Induced by repetitive tibial bending forces at the narrowest cross-section of the tibia; d/t this, tibia deposits new bone leading to a chronic hyper-metabolic state within the bone; onset of pain is after day 5 of new activity and can take 8 wks to heal 1. Pain 2. Pallor 3. Pulselessness 4. Paralysis
Congenital dislocation of the hip (CDH)/ developmental dysplasia of the hip (DDH) Why is it better to be called developmental dysplasia of the hip? Prevalence: unilateral (____ common) or bilateral More common in what gender? Major hip ROM limitations? Infants and babies would not feel pain or show ADL deficits at early stages Common management: Newborn: _____ 6-18 months: _______
Is a developmental process occurring dynamically in utero and during the first year of life; this condition is not necessarily present at birth as the word congenital implies More common More in girls than in boys Loss of abduction Splinting in abduction (Pavlik harness) Closed reduction (traction), open reduction
An increase or decrease in the following biomechanical risk factors causes an increase in ACL tear risk? Kinematics: ____ hip and knee flexion ("stiff landing") ____ knee valgus ____ hip internal rotation Kinetics: ____ knee valgus moments ____ knee extensor moments ____ hip extensor moments Muscle Activation Patterns: ____ quadriceps activity ____ gluteus maximus activity
Kinematics: ↓ hip and knee flexion ("stiff landing") ↑ knee valgus ↑ hip internal rotation Kinetics: ↑ knee valgus moments ↑ knee extensor moments ↓ hip extensor moments Muscle Activation Patterns: ↑quadriceps activity ↓gluteus maximus activity
An ____ injury is the least common in all knee ligament injuries.
LCL
What are common signs and symptoms of an ankle sprain?
Lat. ankle pain, bruising/swelling, loss of ROM, weakness, instability, loss of wt bearing ability
Anatomically, how does the lateral meniscus differentiate from the medial meniscus?
Lateral: Circle shaped, more mobile Medial: C shaped, less mobile
What changes occur following a lateral ankle sprain?
Lig. laxity, synovial inflammation, impaired proprioception, altered neuromuscular control, and strength deficits in eversion and inversion
What could be contributing factors for a limping child? What pathology is most common, and would prompt an immediate referral (red flag) to a physician/surgeon?
Limb length, foot: splinter or injury, knee: infection, arthritis, or tumor, hip: septic arthritis, dislocation, subluxation, coxa vara Joint infection/sepsis - Untreated joint infection can damage articular cartilage - Joint infection could be originated from pulmonary, urinary tract, ear, and skin infections
Ilizarov apparatus: What is it? Indications: 1. _____ 2. _____
Limb lengthening external fixator Bone lengthening for leg length discrepancy Fracture management (function as an external fixator)
Which tissues appear darker in x-rays and which tissues appear whiter?
Low density tissues appear darker (lungs, adipose tissue, osteoporotic bone) High density tissues appear whiter (thick cortical bone, orthopedic hardware, tendon)
What is the most frequently injured ligament of the knee? Which attachment is more common to be injured?
MCL Femoral attachment
What is MRI? What are the advantages and disadvantages of MRI?
Magnetic resonance imaging: Magnetic field in combination with a radio wave transmitter and receiver to produce images A: Good contrast in water density tissues, excellent MS and neuro anatomic detail D: High cost, not for measuring bone tissue, extended time length
What are 4 pediatric forearm fracture complications? Which is most common?
Malunion, refracture, compartment syndrome, synostosis (fusion) Malunion Clinical pearls: severe unexplained pain with passive range of motion (such as moving the fingers and wrist passively) is a common sign for the compartment syndrome
What are examples of mechanical vs functional instability in ankles?
Mechanical Instability- excessive joint play Functional Instability- instability present but appear to have normal mechanical restraints. Theorized to have deficits in sensorimotor &/or neuromuscular systems
What causes achilles tendinopathy pain?
Mechanical factors (discontinuity of collagen fibers), neovascularization, neoinnervation, biochemical issues (increased NTs, etc.)
Is it more common for the medial or lateral meniscus to get injured? Why?
Medial meniscus is more commonly injured because of its attachment to the joint capsule, making it less mobile than the lateral meniscus
Distal radius fractures: Which part of the radius is most vulnerable? Which type of Salter-Harris fracture? Common injury mechanism? Common management for non-displaced and displaced fracture? (Immobilization or surgery?) Be on the lookout for ____fracture
Metaphysis Type II Falls Non-displaced: Below elbow immobilization Displaced: Immobilization Scaphoid
Pediatric clavicle fractures: - Often occurs at ____ - Healing capacity is _____ (non-union is extremely rare) - Common management: often no treatment is needed, even with a displaced fracture (with a sling to provide stabilization at times) - Complications are _____
Mid-shaft Very good Uncommon
What are the signs and symptoms of a PCL injury? Is it common to hear an audible pop at injury? Is swelling often severe?
Mild knee pain, moderate swelling, instability and giving away Not common to hear an audible pop at injury Swelling is not often severe
What are signs and symptoms of an LCL injury? Bruising in the lateral knee is often present. Why?
Mild to moderate knee pain, pop in the knee, lateral joint line pain LCL is an extraarticular structure Swelling builds up slowly over several days
What are the signs and symptoms of MCL injury?
Mild-to-moderate knee pain, tearing in the knee, bruising in the medial knee, swelling building up slowly over a couple of days
What are the functions of the foot and ankle (at heel strike and toe-off)? Windlass effect?
Mobile adapter and rigid lever (Windlass - toe extension, tightens plantar aponeurosis)
What impact does knee valgus angle have on ACL injury rates?
More valgus means higher risk for ACL injury
Signs and symptoms of achilles tendinopathy: Most common injury site? Why? Second most common site? What movement/movements would often cause pain? For a partial lesion, what testing maneuver would most likely to elicit pain?
Most common = mid portion of tendon, 2-6 cm prox to insertion (region of poorest vascularization) 2nd most common = insertion of Achilles tendon Stretch and contraction are most likely to cause pain selective tissue tension testing Cyriax System
What is the etiology, prevalence (gender, sports), and injury mechanism for PFP?
Multifactorial, but repetitive overuse activities play a large role More prevalent in runners, females, and young physically active females No specific mechanism of injury, typically a combination of multiple factors
Do ACL injuries occur more commonly in contact or non-contact sports?
Non-contact
Patellar dislocations: Etiology/mechanism of injury: ____ Epidemiology: · Initial dislocation often occurs in _____ ______ years of age · High recurrence rate (up to 44%) Common dislocation direction: _____ Signs and symptoms: Contributing factors? Treatment:
Non-contact, lower extremity IR and knee valgus stress on a fixed distal extremity Girls 10-17 years of age Lateral Anterior knee pain and swelling, complaints of knee giving way Young, active, female, increased Q angle, genu valgum, excessive foot pronation Surgical treatment
What is the impact of hip muscle strength on ACL injuries?
Non-injured athletes had stronger hip abductors and ERs than injured athletes
Cerebral palsy: Etiology: _____ Classification: ____, ____, or _____ Tight _____ is a common MS problem. 1. Tendon lengthening (Z-plasty) 2. Use AFO brace to correct Botox for spasticity? 1. Mechanism: _____ 2. Results? Mixed 3. Duration for Botox effect? Must be repeated every ______
Nonprogressive insult of the central nervous system during the perinatal period Diplegic/periplegic, hemiplegic, quadriplegic Achilles tendon blocks the transmission of nerve impulses to the muscle, reducing spasticity 3-6 months
What is fat embolism syndrome? What are common symptoms?
Occurs when embolic fat macroglobules pass into the small vessels of the lung and other sites, producing endothelial damage and resulting respiratory failure, cerebral dysfunction, and petechial rashes It is not due to fat blocking arteries Common symptoms: Anxiety, tachypnea, confusion Often occurs suddenly, 1-3 days after a fracture or joint replacement surgery (eg, THA, TKA), when long bone is involved (femur) or when engaging activities with additional oxygen demand (eg, stand up from bed or walking after periods of bedridden)
Signs and symptoms of plantar fasciopathy: Most and second most common location for pain (under the "anatomical lesion" slide)? e. 24 hour symptom pattern and acute-chronic symptom pattern: _____
Origin of fascia on the med. calcaneal tubercle Mid-portion of central band before 5 slips Pain is most obvious with the first few steps of the day, gets better after warming up, then feels worse at the end of the day; after 4 wks, pain may be present even at rest
Kienböck's disease: Definition: _______ Etiology: ______ Contributing factors: _______ Injury mechanism: _____ Signs and symptoms: _______
Osteonecrosis of the lunate carpal bone Unknown; possibly from repetitive microtrauma, decreased vascular supply, and ulnar variance Male 20-40 who engages in manual labor or recreational activities that load the wrist. Extrinsic factors: Repetitive microtrauma, ulnar variance (ulna shorter than radius causing lunate to absorb more wrist force). Intrinsic factor: Limited vascular supply to the lunate Repetitive microtrauma Pain in the wrist, swelling, difficulty gripping objects, limited wrist motion
Which injury location (outer third or inner third of the meniscus) has a better healing potential?
Outer third because it is more heavily vascularized
What are common signs and symptoms of patellar tendinopathy?
Pain during or after activity, insidious onset of symptoms, aggravated by running, jumping, or going up and down stairs
What is the definition of PFP? It is also called the ____ knee.
Pain located behind or around the patella that is readily reproduced with activities that require quadriceps contraction Runner's
What is the injury mechanism for a PCL injury? Is it more common at the femoral or tibial attachment?
Passive external forces applied at the knee such as anterior aspect of flexed knee striking a dashboard Tibial attachment
What is the common pain and swelling location of patellar tendinopathy? Swelling is more evident in ____ injuries (tendinitis), less evident in _____ injuries (tendinosis)
Patellar tendon, most often at the proximal insertion at the inferior pole of the patella Acute Chronic
How is OA defined?
Pathology associated with inflammation in the joints of the body that most commonly affects the TFJ and PFJ. "Wear and tear" on the joints leading to the breakdown and subsequent impaired biomechanical behavior of articular cartilage.
Plantar fasciopathy: i. Definition: _____ ii. Differential diagnosis: _____ b. Etiology: _____ c. Risk factors: ______- d. Signs/symptoms
Pathology in plantar fascia (usually at prox. insertion at med. tubercle of calcaneus) consider the muscles/tendons in the area (FDB, abd hallucis, QP), peripheral nerves (post. tibial nerve branches), S2 radiculopathy, fat pad, joints (STJ), and bone spurs (would have to be a massive bone spur) more common in females and people age 40-60; it is an overload injury and free nerve endings in the fascia may generate some of the pain obesity and pronation (best evidence); limited DF and MTP ext., time wt bearing during work, running, and heel spurs (these have less evidence)
Shock: What fracture location that is more likely to cause heavy blood loss?
Pelvis > Femur > Humerus/tibia
What do those terminologies mean: pes cavus, pes planus, claw toes, hammer toes, mallet toes, hallus valgus (bunion), bunionette (Tailor's bunion)
Pes Cavus - Midtarsal supination Pes Planus - midtarsal pronation Claw toe - MT extension, DIP and PIP flexion Hammer toe - MT extension, PIP flexion Mallet toe - DIP flexion Hallus valgus (bunion) - valgus mvmt at PIP joint of hallux Bunionette - valgus 5th metatarsal PIP
Does DVT occur more in younger or older patients? What is the time of occurrence? How does this compare to fat embolism syndrome?
Prevalence is highest in people older than 40 Up to 2 weeks post-operatively (vs 1-3 days for FES)
Tibial tubercle fracture: Location? Mechanism? Often during what sport? Common age?
Primary insertion of patellar tendon into secondary ossification center of proximal tibia Jumping or landing, quadriceps resisted contraction, basketball 10-15 years
What are the three functions of the ACL?
Primary restraint to anterior tibial translation Secondary restraint to varus/valgus rotation Secondary restraint to internal tibial rotation
Achilles tendinopathy: The major factor of tendinopathy and its progression/continuum: _____ Adaptation syndrome: what are the 3 phases? Continuum of tendinopathy: what are the 3 outcomes? Extrinsic vs. intrinsic risk factors?
Reactive -> tendon disrepair -> degenerative (load drives the location on the continuum) Depletion, replenishing, and super-compensation Tendon overload, too much loading with not enough rest Extrinsic - overuse, drug induced (toxicity) Intrinsic - Increased risk with age, being male, decreased vascularization, systemic diseases, and previous injury
What is the mechanism of injury for OA?
Reduced knee flexion, decreased shock absorption, increased rate of TFJ loading leads to TF OA
What is the etiology, prevalence, and injury mechanism for patellar tendinopathy? It is also known as ____.
Results from overuse activity, such as basketball, volleyball or track and field More common in aging athletes between 30 and 50 Repetitive jumping and running or eccentric loading of tendon Jumper's knee
For the pediatric fractures, correcting the _____ deformity (such as a mal-union) is more important than correcting _______ deformity and fragment displacement
Rotational Angular
What type of athletes/activities would have higher IT band syndrome prevalence? Why?
Runners and cyclists, common in activities involving repeated knee flexion and extension
What are the signs and symptoms of OA? What is the 24 hour symptom pattern?
S/s: deep, diffuse (non-specific) knee pain, knee stiffening with inactivity, crepitus with knee motion, joint deformity (valgus or varus) 24-hour pattern: Stiff in morning, better after a warm shower and taking medication, can worsen with excessive movement, stiffens again in the evening, deep achiness in the knee at night described as throbbing
For fracture fragments/ends, new fractures tend to have ______ edges, while old fractures tend to have _______ edges.
Sharp Rounded
What are 5 complications from fractures?
Shock (Inadequate tissue perfusion due to inadequate flow or oxygenation), fat embolism (pneuomonitis due to marrow fat expulsion and breakdown), DVT/PE, gangrene, compartment syndrome
The pain location for the acute patellar tendinopathy injury is similar to which MS pathology in pediatrics?
Sinding-Larsen-Johansson
What are 4 impacts of soft tissue integrity on fracture healing?
Skin and muscle for stability, blood supply, coverage, sensation
What is the vulnerable knee range of motion for ACL injury?
Small knee flexion angles 0-20/30 degrees
What are the five goals of fracture management?
Stability, alignment, length, precise joint preservation with stable fixation, apposition
What are the 5 factors in fracture healing?
Stability, apposition, vascularity (impacted by smoking), humoral factors (hormones), nutrition Vascularity is often considered the most important factor
What makes a fracture less stable?
Strong muscle pulls, near a joint, no fixation, larger displacement, being an oblique and/or comminution fracture, lesser soft tissue support
What is the source of pain with OA?
Subchondral bone because the articular cartilage is aneural
There is no special test for PFP. Clinicians use exclusionary diagnosis for PFP. What type of radiograph can provide good information about patellar alignment?
Sunrise view (tangential /axial) 15 degree angle
Which tissues appear darker or lighter in a T1 or T2 weighted image?
T1: Fat appears white T2: Water appears white
What is the rehabilitation consideration for MCL injuries?
The MCL is well vascularized so surgery is rarely required for MCL sprains solely without other associated injuries.
Why would an x-ray study be repeated 7-10 days after an injury?
The ideal time frame to catch the hard callus can vary. The most comprehensive range would be from 7-21 days
What is the most common fracture that causes the compartment syndrome?
Tibial shaft fracture
Patients often avoid which part of the gait cycle? Why?
Toe-off, places tendon on greatest stretch Clinical pearls: at the early stage of tendinopathy, pain occurs at the beginning of the exercise/activity but would gradually decrease. At the later (more severe) stage, pain may increase with exercise or persist throughout the exercise.
For the shoulder joint, having the _____ view would be beneficial to diagnose GHJ dislocation
Transcapular y-view
Osgood-Schlatter Disease: Definition: ____ Injury mechanism: ______ More common in athletes than non-athletes Prevalence: during their ______ Signs and symptoms: _____ Prognosis: symptoms usually resolved spontaneously within _____ Common management (conservative or surgical?)
Traumatic partial separation of the tibial tuberosity epiphysis Repetitive micro-trauma (especially from jumping, playing basketball) Growth spurt Pain with active knee extension, swelling 1 year (self-limiting) Conservative
What are the 4 types of fracture?
Traumatic, stress, pathologic, peri-prosthetic
What are the 5 different types of Salter-Harris fractures?
Type 1: Separation of epiphysis from metaphysis Type 2: Fracture line runs along physis through metaphysis, but the epiphysis is not involved; bony fragment of metaphysis is formed; the most common type of S-H fracture Type 3: Vertical fracture line from epiphysis through physis, parallel to physis to periphery Type 4: Vertical fracture line from epiphysis, through physis and metaphysis and enters the joint; may be displaced bone fragment Type 5: Crushing of physis from severe compression force; generally very rare
What type of collagen fibers is articular cartilage?
Type II
Salter-Harris Fractures: Which type is the most common in general? Which type is the most common type at birth? Most common in what type of lifestyle?
Type II Type I Active kids
Proximal tibial physeal fracture: Which Salter type is the most common? 4 complications: ___, ___, ___ and ____
Type II · Angular deformity · Malunion · Physeal bar · Leg length discrepancy
What is the etiology, prevalence, and injury mechanism for synovial plica syndrome?
Unclear etiology Common overuse syndrome that appears more commonly with repetitive stress activities No specific mechanism has been indicated, but repetitive stress, blunt trauma, or injury secondary to other knee pathologies are a possibility
What is the etiology and mechanism of injury for LCL injuries?
Varus load to the knee with the foot plantar flexed and knee in extension A sudden twist at the tibiofemoral or tibiofibular joints
What does the x-ray letter B mean and what are some examples?
Vertebral bodies Examples: Compression fractures, Schmorl's nodes (protrusions of IVD cartilage through the vertebral body endplate and into the adjacent vertebra of the aging spine)
What are signs/symptoms of a high ankle sprain? What are passive supporting structures of the syndesmotic articulation?
Weight bearing could be painful in this condition (not much pain during WB for ATFL injury). Ant. + post. tibiofibular lig., distal interosseous lig., and inf. transv. tibiofibular lig. No active/dynamic support such as muscles
When should T2 images be utilized instead of T1 images?
When identifying pathology: Edema, tumors or hematoma formation are all fluid based
What is the definition and location of synovial plica syndrome?
When the extension of the synovial capsule of the knee becomes irritated or inflamed One finger medial to the medial border of the patella
When fluid-sensitive sequences (T2) are better utilized?
When viewing trauma, joint effusions, bone edema, joint fluid, and bone or soft tissue tumors
____ and _____ are not good early stage imaging tools for stress fracture. ____ is better, but expensive.
X-ray and CT MRI
Expensive: rule of tens ( _____ in $10s, ____ in $100s, ____ in $1000s)
X-ray, CT scan, MRI
Proximal tibial metaphyseal fractures: Common age of patients? Injury mechanism? ____ deformity can result from medial tibial overgrowth
Young patients less than 6 years old Low-energy valgus force across the knee Valgus
Distal femoral physeal fractures: Common injury mechanism: ____ Most common type: Salter _____ Check neurologic and vascular status Premature growth arrest is most common in which age group? Distal femur physeal bar may occur (A physeal bar or partial premature physeal arrest is a result of injury or infection to an unfused physis. It consists of a bony bridge crossing the growth plate that results in growth disturbance and/or deformity.)
direct blow I or II are common (Salter II is the most common) 2-11 years old
Supracondylar humerus fractures: Common injury mechanism: _____ Signs and symptoms: ______ Proper re-alignment of body fragment is very important: · No _______ · Minimal ______ · Some ______ OK Often use _______ pins (vs. _______ pins) to avoid ulnar nerve injury
fall on out-stretched arm pink, pulseless extremity (ulnar and radial pulses) No varus/valgus Minimal rotation Some translation ok Lateral entry vs medial entry
Pediatric forearm fracture-radial and ulnar shafts: Common injury mechanism: ______ Goals of treatment? Regain full _____ Restore _______ For ADL's need _____ degrees supination, _____ degrees pronation Correcting the _____ deformity is crucial for closed reduction methods
falls on an outstretched arm forearm rotation alignment and clinical appearance 50, 50 Rotational
What are the 3 classifications of scoliosis? Most common type? Typically convex to the right or left in the thoracic region?
idiopathic, congenital, neuromuscular idiopathic right
Sever's Disease (Calcaneal Apophysitis): Definition: ______ Injury mechanism: ______ Signs and symptoms: _____ Prognosis and common management: _____
inflammation of the calcaneal apophysis repeated "microtrauma" at the site of the attachment of the Achilles tendon to the apophysis of the heel Heel pain worse with activity, wearing shoes is painful, calf stretches produce heel pain Self-limited, reduce repetitive trauma, stretching, Advil or Aleve
