ORTHO PREIST EXAM 1

patellofemoral syndrome

- general term describing pain or discomfort in the anterior knee -often termed chondromalacia patella which refers to softening of the articular cartilage of the patella

Hallux Rigidus/Limitus

-Degenerative arthritic changes of the 1st MTP

ATFL Sprain

1. Laxity during Accessory Mobility 2. Tenderness c palpation 3. Special Test -Look for EFFUSION. It attaches into the joint capsule (calcaneofib injured with DF and inversion, PTFL injured with SEVER abduction Anterior tibfib l. - DF and tibial ER on plated foot -Talus driven up between tibia and fibula

Erythrocytes: Tell me about them...

1. Most abundant cell in the body 2. Responsible for tissue oxygenation (O2 carried by hemoglobin) 3. Biconcavity and reversible deformity #Elastagirl!!! 4. 120-day life cycle No nucleus, no replication, no protein synthesis, etc. Just does its job. (explanation of limited lifespan.) Men have more RBC than women. Varies on where you live.

CRPS symptoms

1. allodynia 2. hyperalgia 3. hyperpathia 4. edema 5. bluish/red shiny skin 6. abnormal sweating or hair growth 7. contractures 8. muscle spasms 9. decreased strength 10. low tolerance for activity

DMARDs (disease modifying anti-rheumatic drugs)

A classification of medications that modify rheumatic disease, instead of just treating symptoms

strain

A condition resulting from damaging a muscle or tendon

Boutonniere deformity

A tear of the extensor tendon of the PIP joint, at the middle of the finger, and the DIP joint that controls the fingertip. extension of dip

sprain

An injury in which the ligaments holding bones together are stretched too far and tear. months to a year to heal.

Ottawa Ankle Rules

Ankle film if: -Bone tenderness at lateral malleolus -Bone tenderness at medial malleolus -Inability to to walk/ bear weight 4 steps after injury and in ER Foot films if: -Bone tenderness at base of 5th metatarsal -Bone tenderness at navicular bone -Inability to to walk 4 steps after injury and in ER

Angle of declination (torsion angle)

Axis of femoral head & neck and transverse axis of the femoral condyles intersect at the long axis of the femoral shaft

Diagnostic Imaging and Labs

Diagnostic Imaging and Labs •Laboratory studies showed normal rheumatoid factor and anti-cyclic citrullinated peptide (anti-CCP) levels, and a normal white blood cell count. •Hand radiography was ordered

Strain grades 3 grades of severity

Gr I - minor tearing along musculotendinous unit Gr II - partial tearing along unit with more swelling and tenderness Gr III - complete tear with possible avulsion

Enthesitis

Group of conditions characterized by inflammation, fibrosis, and calcification around tendons, ligaments, and muscle insertions.

Monoarthritis

Inflammation affecting a single joint

Brevity is the soul of wit

Intelligent speech and writing should aim at using few words

O'Donahue's triad

MCL ACL MM

Polyarticular arthritis

More than 5 joints are involved. Distribution will be symmetrical with knees, ankles, elbows, wrists, hands. 50% have rheumatoid fever

fluffy calcifcation

Myocytis ossificans

PA radiograph of the left hand of a 42-year-old woman with advanced rheumatoid arthritis (RA).

Note the ulnar translocation of the carpus (black arrow); the pencil shape of the ulna (white arrow); the dislocation of the metacarpophalangeal joints of the index and middle fingers (black arrowheads); the destruction of the interphalangeal joint of the thumb and the proximal interphalangeal joints of the long, ring, and little fingers (gray arrows); and the arthritic changes in the distal interphalangeal joints (gray arrowheads

joint space narrowing, thick subchondral bone

OA

CRPS treatment

PT: Transcutaneous electrical nerve stimulation, progressive weight bearing, tactile desensitization, massage, and contrast bath therapy. May not tolerate touch - begin with AROM. Avoid passive manipulation and ROM of shoulder because heightens the response.

Thompson's Test/ Simmond's Test

Patient prone with feet hanging off table, doctor flexes knee to 90 degrees and squeezes calf. Positive sign is no plantar flexion of the foot indicating achilles tendon rupture

OA LOVES THE DIP

RA SPARES THE DIP

baker cyst (popliteal cyst)

Related rheumatology - and can mimic DVT

Enthesis

Site where ligaments, tendons, and the joint capsule are inserted into bone

Davis Law of Soft Tissue

Soft tissue models along the lines of stress "Davis likes strong tendons"

Spondylolysis and Spondylolisthesis

Spondylolysis and Spondylolisthesis • Spondylolysis refers to the lytic line that crosses the pars interarticularis, known as a pars defect. • The etiology of the pars defect is currently believed to be the result of a stress fracture. • As a result, the involved vertebra may slip forward on the vertebra immediately inferior to it. • This forward slippage is called spondylolysthesis. Spondylolysis and Spondylolisthesis • A person may have a spondylolysis without having spondylolisthesis, and a person may have spondylolisthesis without having a spondylolysis. • For example, spondylolysthesis may occur with an intact pars interarticularis in patients with degenerative arthritis. • The vertebra most commonly involved in spondylolysis and spondylolysthesis is the L5 vertebra. • The second most common is L4.

Spondylolysis and Spondylolisthesis

Spondylolysis and Spondylolisthesis • The degree of forward slippage is measured clinically by the relationship of the superior vertebra to the inferior vertebra. • A widely adopted method of grading the severity of spondylolisthesis is the Meyerding classification. • It divides the superior endplate of the vertebra below into 4 quarters. • The grade depends on the location of the posteroinferior corner of the vertebra above: • Grade I: 0-25% • Grade II: 26-50% • Grade III: 51-75% • Grade IV: 76-100%

The Baker cyst is the most common benign synovial

The Baker cyst is the most common benign synovial cyst in the knee.

Genu Varum and Genu Valgum

The femur is placed diagonally within the thigh, whereas the tibia is almost vertical within the leg, creating an angle, the Q-angle, at the knee between the long axes of the bones. The Q-angle is assessed by drawing a line from the ASIS to the middle of the patella and extrapolating a second (vertical) line through the middle of the patella and tibial tuberosity. The Q-angle is typically greater in adult females, owing to their wider pelves. A medial angulation of the leg in relation to the thigh, in which the femur is abnormally vertical and the Q-angle is small, is a deformity called genu varum (bowleg) that causes unequal weight distribution. Excess pressure is placed on the medial aspect of the knee joint, which results in arthrosis (destruction of knee cartilage). A lateral angulation of the leg in relation to the thigh (exaggeration of knee angle) is genu valgum (knock-knee). Consequently, in genu valgum, excess stress is placed on the lateral structures of the knee. The patella, normally pulled laterally by the tendon of the vastus lateralis, is pulled even farther laterally when the leg is extended in the presence of genu varum so that its articulation with the femur is abnormal.

Grade depends on

The grade depends on the location of the posteroinferior corner of the vertebra above: • Grade I: 0-25% • Grade II: 26-50% • Grade III: 51-75% • Grade IV: 76-100%

glenohumeral joint

The synovial ball-and-socket joint of the shoulder

•Heberden nodes (bony swellings in the distal interphalangeal joints) along with a deviated distal finger are a classic finding in osteoarthritis; digital nodes at the proximal interphalangeal joints (Bouchard nodes) often occur in patients with osteoarthritis, but were not present in this patient.

This patient has a variant form of the condition known as erosive osteoarthritis that is common in postmenopausal women. The radiograph of her hands shows subchondral sclerosis and the "gull wing deformity" in the distal interphalangeal joint of the left middle finger (Figure 3). The gull wing deformity is indicative of this variant form.

osteophytes/oa

a bony outgrowth associated with the degeneration of cartilage at joints.

heel spur

a calcium deposit in the plantar fascia nears its attachment to the calcaneus bone that can be one of the causes of plantar fasciitis

ACL

anterior cruciate ligament of the knee

baker cyst (popliteal cyst)

can occur with a knee effusion, and develops in the popliteal bursa located at the posteromedial aspect of the knee joint

CRPS

complex regional pain syndrome

O'Donahue's manuver

differentiate

glenohumeral joint

dislocation

Enthesopathies

disorders of peripheral ligamentous or muscular attachments

ligaments need to be rehabed

do not forget to rehab the damaged ligaments

DLR

dont look right

oligo

few or small

Swan neck deformity (flexed DIP, extended PIP, flexed MCP)

flexion of dip

Ligaments

heal with the accordance of the stress you out on them

ligament heal slowly

hold bone to bone

•"Swan neck" or "Boutonniere" deformities may develop in chronic

in chronic cases and are suggestive of RA but not pathognomonic because these deformities can occur for several different reasons (trauma, laceration of tendons, etc).

Myocitis Ossificans

inflammatory process in area of fracture; leads to bony particles being laid down in the muscle

compartment syndrome

involves the compression of nerves and blood vessels due to swelling within the enclosed space created by the fascia that separates groups of muscles

Musclotendinous junction( sprain)

less blood is more risk for traumatic injury

MCL

medial collateral ligament (elbow, knee)

Clinical Prediction Rules(guidelines)

modification of parallel testing -> combination of history, physical exam, lab tests (positive and negatives) gives stronger prediction

ATFL (anterior talofibular ligament)

most common ankle injury inversion

treat the patient

not the radiograghic image

intermittent

occurring at irregular intervals; not continuous or steady

Myocytis ossificans

ossificationm of muscle following severs or contusion

OA

osteoarthritis

5 p of compartment syndrome

pain pallor pulselessness paresthesias pressure

Compartment Syndrome S/S

pain; swelling; ecchymosis; firm and tight skin over anterior shin; weakness of foot dorsiflexion and/or extension of big toe (foot drop); parathesia of web between 1st and 2nd toe over the foot's entire dorsal region; decreased dorsalis pedias pulse

Diapedesis

passage of blood cells (especially white blood cells) through intact capillary walls and into the surrounding tissue

Pes Planus

pronate foot inward, foot pad flat foot

Anti-citrullinated protein antibodies (ACPA)

rheumatoid arthritis

RA

rheumatoid arthritis

sesamoid bones

round bones found near joints e.g., the patella

a/c joint

separtion

Lateralization

specialization of the two cerebral hemispheres for particular operations

Joint mobilization and manipulation

technique used when a patient's dysfunction is result of joint stiffness or hypomobility; applies specific passive movement to a joint, either oscillatory (rapid, repeated movement) or sustained

Diapedesis

the passage of blood cells through the intact walls of the capillaries, typically accompanying inflammation.

patellofemoral joint

the point where the kneecap and femur are connected in the trochlear groove

RA•Joints are boggy, warm, and tender .

to palpation as in osteoarthritis, but lack erythema and rarely involve the distal interphalangeal joint.

EXAM CONTENT

upper extremity principals and cervical and thoracic spine and rhum powerpoints

Achilles Tendon Rupture

usually one to two inches above tendinous insertion on calcaneous, greatest btwn 30-50 yrs of age, typically be unable to stand on their toes and tend to exhibit a positive Thompson test

ww2/water

white water on 2 (imaging)

severity of injury

will guide treatment

•Based on the patient's history, physical examination, and radiographic findings, which one of the following is the most likely diagnosis?

•A. Gouty arthritis. •B. Osteoarthritis. •C. Psoriatic arthritis. •D. Rheumatoid arthritis.

RA

•Definition and Etiology •Rheumatoid arthritis (RA) is a systemic autoimmune disorder characterized by acute and chronic inflammation in the synovium, causing proliferative and erosive joint changes. •The etiology is unknown, but it is theorized that an unknown agent activates an immune response in synovial tissue. •Genetic predisposition, hormonal changes, infectious agents, and immunologic cytokines all have been postulated to trigger the abnormal immune response seen in RA.

rheumatoid arthritis (RA)

•Elevated titers of RF (high sensitivity) and anti-cyclic citrullinated peptide antibodies AKA anti-CCP (high specificity), as well as erosive margins and joint-space narrowing on radiography, also help to differentiate rheumatoid arthritis from osteoarthritis. •A "swan neck" deformity is present in chronic cases.

treatment

•First-line treatments: acetaminophen, topical therapies, exercise, tai chi, knee taping, physical therapy (PT was not beneficial for hip OA in a well-designed trial). •Acetaminophen is less effective than NSAIDs for OA, but given its safety, a trial at an adequate dosage is appropriate. •Second-line treatments: NSAIDs. •Third-line treatments: tramadol or duloxetine (Cymbalta). •Fourth-line treatments: carefully supervised opiates (50 mg of hydrocodone or 30 mg of oxycodone per day or less), joint replacement in patients with moderate to severe pain and moderate to severe radiographic evidence of osteoarthritis.

Case: Painless Nodules in the Fingers

•History and Physical Examination •A 61-year-old woman presented with a history of chronic pain and stiffness in multiple joints. She had morning stiffness in her hands, hips, and knees that gradually improved with activity. She did not report any foot pain or stiffness, fever, or rash. •On examination, she had swelling around the distal interphalangeal joints in multiple fingers with relative sparing of the proximal and metacarpophalangeal joints (Figure 1). The joints were not warm or tender to palpation.

medial compartment

•Medial compartment cartilage loss is much more common.

•Patellofemoral disease

•Medial compartment cartilage loss is much more common. •Patellofemoral disease also is common, and joint crepitus often can be felt when palpating the patella while taking the knee through range of motion.

RA Patients present with

•Patients present with symmetric stiffness in multiple joints, most often occurring in the morning, that lasts at least 45 minutes before subsiding.

•RA is the most common autoimmune rheumatic disorder Sjogren's Syndrome is second most common

•Patients present with symmetric stiffness in multiple joints, most often occurring in the morning, that lasts at least 45 minutes before subsiding.

Physical Examination

•Physical Examination •In the knee, genu varum (bowleg) or genu valgum (knock-knee) can result from loss of articular cartilage in the medial (genu varum) or lateral (genu valgum) knee compartment.

RA

•RA affects women more often than men (3:1 ratio). •The prevalence increases with age, with peak onset in the late 40s and early 50s. •RA is typically symmetric and most often involves the joints of the hands, wrist, knees, feet, and ankles (Figure 1).

popliteal bursa

•The popliteal bursa communicates with the knee joint between the interval of the gastrocnemius and semimembranosus muscles. •Other than producing a sensation of fullness and occasionally pain, most popliteal cysts are relatively asymptomatic. •The Baker cyst is the most common benign synovial cyst in the knee.

•Treatment eoa

•Treatment •Acupuncture is at best minimally effective for OA of the knee or hip. •Oral glucosamine with or without chondroitin does not appear to be effective in well-designed trials. •Arthroscopic meniscectomy with or without debridement is no more effective than sham procedures or exercise for knee OA, according to a systematic review of nine studies (it is also ineffective for patients with degenerative meniscal tears). •Corticosteroid injections improve function and provide short-term pain relief, but do not improve overall quality of life, according to systematic reviews (a recent large randomized trial found no benefit and greater cartilage loss in patients receiving corticosteroid injections).

Common sites of OA in the foot are the first metatarsophalangeal joint (hallux valgus and rigidus), the subtalar joints, and the articulations between the talus, calcaneus, and navicular bones.

•Valgus vs. Varus: The terms valgus and varus refer to angulation (or bowing) within the shaft of a bone or at a joint. It is determined by the distal part being more medial or lateral than it should be. Whenever the distal part is more lateral, it is called valgus. Whenever the distal part is more medial, it is called varus. •Mnemonic: The L of "lateral" is also in valgus, but not in varus. The direction of the distal part is key: distal (more) lateral means valgus and distal (more) medial means varus.