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exam findings for cubital tunnel syndrome

**another condition where we pay attention to weakness as it may become permanent** can see intrinsic atrophy positive tinels at the elbow reproducing dysesthesias and or pain along the peripheral ulnar nerve distribution 2 point discrimination > 5 mm diminished intrinsic muscle strength

Secondary prevention happens after illness or serious risk factors have already been diagnosed. Examples?

-Routine screening: mammograms, colonoscopy

Assessing strength of muscles: Movement and full PROM, unable against gravity

Bone densitometry using DXA with t score below _________ is osteoporosis

2.5

Assessing strength of muscles: Full AROM, but not against resistance

Grade ____ AC separation: complete rupture of AC and CC ligaments :/

hemoglobin X ______- = Hct

curves with Cobb angles under _____ tend not to progress curves with Cobb angles of __ to ___ degrees at skeletal maturity progress of 1 degree per year

30; 50-75 (can be a problem later in adulthood)

Pelvis view to see hip joints nicely

AP pelvis

two thoracic views

AP, Lateral

if you suspect spinal stenosis, get these xrays:

AP, Lateral, Flexion, Extension views

Three lumbar views

AP, Lateral, Oblique (Can pick up the pars fracture)

ankle views

AP, Medial oblique (Mortise joint), Lateral

Foot Views

AP, Medial oblique, lateral

hip views (take individually)

AP, frog leg

what x-rays to get SCFE diagnosis

AP, frog-leg views of hip acute pain-crossed tibia

Knee views

AP, lateral (febella), tunnel (find osteochondritis dissecans), sunrise

elbow films

AP, medial oblique, lateral(must be 90 degrees), jones

Thumb Views

AP, oblique, lateral

Minimal radiography for a fx

AP/Lat, including joints above and below where indicated

standard cervical series

APOM (AP open mouth) APLC (AP lower cervical) LCN (Lateral cervical neutral)

APAP aka

Acetaminophen

Barely an NSAID-antipyretic and analgesic, but lacks anti-inflammatory activity. common cause of accidental overdose, avoid in severe liver disease

Acetaminophen (APAP)

AC ligament connects:

Acromion and Clavicle

Tx and monitoring of PAN

Aggresive tx of HTN treat underlying cause if needed (antivirals?) treat complications corticosteroids cytotoxic therapy ESR and CRP may be helpful to monitor during tx, monitor for infection if they are on corticosteroids, monitor for delayed appearance of neoplasms after tx

Tx for prepatellar bursitis (septic)

Aggressive: sterile aspiration, gram stains, cultures, sensitivities Gram stain + -> surgical bursectomy if skin is broken treat it as septic

Risk factors for osteoarthritis

Aging Gender-F Obesity Genetics Joint injury Anatomic factors (less cartilage) Occupation (those that use same joints continuously, for example athletes)

What med can you use to keep uric acid level low in gout?

Allopurinol

first line urate lowering therapy for gout, generally well tolerated. Must screen ppl of Chinese, Thai, and Korean descent for HLA B*5801 genetic variant-SJS warning. Must maintain hydration.

Allopurinol

Serum urate-lowering therapy should be initiated to prevent recurrences in persons with a history of gout and any one of the following: at least two flares per year (one per year in persons with chronic kidney disease stage 2 or greater), tophi, or a history of nephrolithiasis. Name of drug?

Allopurinol, continue 3-6 months after flare. Indefinite if 1 or more tophi present.

C-reactive protein (CRP)

An acute phase reactive protein, rise above normal limits earlier than ESR but returns to normal earlier than ESR (peaks early, faster return to normal)

What does a fat pad sign indicate?

An occult elbow fx

Sacral view

Angulated lumbrosacral spot view (take it if you think someone might have ankylosing spondylitis, stress fracture of sacrum)

poorly aligned ankle fx may lead to _________ down the line

Arthritis

Which nerve roots leave below the pedicle?

C-8, T- 1-12, L- 1-5

Tx for Osgood Schlatter

Conservative RICE, NSAIDs, cho pat straps 3-4 weeks off of sports

features of congenital scoliosis

Curve is typically a short c-shaped curve Other skeletal anomalies common(hemivertibrae, block vertibrae, bridging bars, fusion of ribs, etc--this may happen during bone segmentation) Often involved with congenital anomalies with GU system (kidneys form at same time as bones)

Salivary gland calculi (stone in salivary gland)-when they eat something, the gland swells up. If you suspect that, tell them to do what?

Eat something sour (dill pickle, lemon)-sometimes they salivate so much it will pop loose and be a treatment

If someone has lupus and gets tested for syphilis through a VDRL, what might happen? What test could you follow up with to make sure that syphilis is actually negative?

False positive RPR or T. pallidum test

Over 90% of cases of SLE occur in men. T or F

False, 90% of SLE occurs in women. It frequently starts during childbearing years.

The MIC number is important in determining what abx to use. T or F.

False, as long as it is susceptible that is good enough. Other factors when choosing which abx are more important

Usually, we want to always operate on a broken clavicle as they hardly heal on their own. T or F

False, clavicles should heal on their own if possible (unless its a distal clavicle fx)

In systemic JIA, the arthritis is usually the first presenting sx. T or F

False, it is hard to diagnose because arthritis may not present right away

PAN generally affects women more than men. T or F

False, mostly affects men

x-ray is non-ionizing radiation, meaning that it does not cause any harm to us. t or f

False, x-ray uses ionizing radiation, it is dangerous to us as there are high frequency photons that create free radicals in our body.

Recurrent attacks of inflammatory arthritis diet: alcohol, high fructose soft drinks, MC in MTP joint of great toe Crystals negative birefrigence tx?

Gout Tx: prednisone colchicine prophylatic: allopurinol

Hallmark of gout- joint aspirate says what? Uric acid will be _______ because the crystals are _____________.(this test is better for monitoring tx, not diagnosis) WBC will be close to normal

Gout: Needle-shaped negatively birefringent crystals Elevated; monosodium urate

Flip to see grading of AC separation

Grade 1-3 most common, what you will be tested on. use x-ray to determine grade (1 is usually tender with no deformity, 3 there is more separation noted)

Staphylococcus, streptococcus, and enterococcus are all

Gram + aerobes

Lincosamides(Clindamycin) what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

Gram +, anaerobes Bacteriostatic, inhibitors of protein synthesis Caution hepatic impairment Use when pt has PCN allergy PO, IV Widely into body tissues and fluids including bone, abscesses, CSF penetration is poor Cumulative dose dependent C. diff box warning, hepatotoxicity

Haemophilus influenzae, neisseria, moraxella, vibrio, and pseudomonas are all

Gram - aerobes

An incomplete fracture with angular deformity, seen in children. bending of bone

Greenstick

Pediatric population fractures

Greenstick (one side of bone only-bending) Buckle (force fx that doesnt break bone completely, makes a little bump in it)

WHO: Average number of years that a person can expect to live in "full health" by taking into account years lived less than full health

Health adjusted life expectancy

History questions for ddx of gout

History of trauma? History of obesity? Flares in past? What is your diet like? Alcohol, tobacco use?

H&P for a fx

History: Mechanism of injury and timing PE: Whole extremity, joints above AND below -Observe: swelling, eccyhmosis, deformity, skin integrity (lacerations, abrasions) -Palpate: tenderness, crepitus, and compartment tightness -Function: surrounding joints ROM Neurologic and Vascular status

Colles fx examination

History: usally FOOSH tenderness and swelling, deformity and impaired wrist ROM Check skin for breaks Check median nerve function (Palmar parethesias)

Provide support, flexibility, and resilience. most abundant cartilage. 60-70% water may become calcified-only cartilage with this capacity intercostals, wall of trachea and bronchii articular cartilage of bone epiphyseal plate fetal axial skeleton

Hyaline cartilage

Findings for a proximal humerus fx

I: dramatic eccyhmosis of entire upper arm/chest wall P: focal proximal upper arm pain and tenderness S: cant assess NV: Sensory motor: musculocutaneous, radial, median, ulnar M: ok to perform gentle motion of the elbow, wrist, and fingers--crepitance of shoulder w/ this exam

exam findings for a supracondylar humerus fx

I: significant swelling and guarding P: diffuse tenderness most exquisite at supracondylar regions Neuro: Check radial, median, ulnar sensorimotor

exam findings for midshaft humerus fx

I: upper arm swelling P: be gentle, tenderness is diffuse NV: Radial-> can you bring the wrist up, extend the fingers (if not, surgery immediate) Sensation over dorsal forearm and hand and wrist extensor / Extensor Pollicis Longus strength.

What to do with this type of inversion injury: Distal 5th metatarsal (dancer's) fracture

Immobilize in posterior mold splint, non-weight bearing, refer to ortho

A fracture that occurs when one bone hits or "impacts" an adjacent bone

Impaction

Types of ankle fx. What should we focus on?

Malleolar, bimalleolar (lateral and medial), trimalleolar (posterior, lateral, medial) Often will disrupt tib-fib ligament and disrupt mortise joint-would need to be restored perfectly->weightbearing. (exception: distal fibular fx)

Flexion deformity of toe DIP joint, bad fitting shoes (crammed into shoe), callus formation likely. tx?

Mallet toe, surgery

Tx for skier's/gamekeeper's thumb

Minor-Thumb spika RICE, PT, etc Major-Surgical repair

neuropathy of interdigital nerve, usually proximal to bifurcation usually supplying 2nd nd 3rd toes nonspecific inflammation of nerve and proliferative CT most common in middle aged women-high heels may be culprit

Morton's neuroma

Cardinal rules of what views to get for imaging

Must have two views at 90 degrees to eachother

Syndrome causes muscle paralysis Inability of NMJ to transmit enough signals from the nerve junction, ACh cannot attach to receptors at motor end plate. Antibodies attack ACh

Myasthenia gravis

is hormone therapy a recommened tx for osteoporosis

No (increased risk for breast cancer)

Tx for fibromyalgia

No cure Focus on symptomatic relief Start with lose dose Avoid narcotics and steroids Non-pharm: exercise, therapy, massage, sleep hygiene Med can be added for certain things like depression, sleep disturbances, pain (be careful)--small dose Tricyclics (amitryptiline) may be a good option especially if they have sleep disturbances

Malignancies associated with Sjogren's syndrome:

Non-hodgkins lymphoma Thyroid cancer

DMARDs are broken up into two categories

Nonbiologic (methotrexate, hydroxychloroquine, sulfasalazine) Biological (anakinra, canakinuman, tocilixumab) Choice depends on severity of dz, preference of route, side effects, pregnancy (NO methotrexate)

Antipyretic (decrease fever), analgesic (decrease pain), antinflammatory drugs that are hydrophobic weak acids. They inhibit COX-1 and/or COX-2 enzymes, are well absorbed orally, and are excreted via the kidney.

Nonsteroidal anti-inflammatory drugs (NSAIDs)

T score greater or equal to -1

Normal

Lab findings for OA

Normal Neg RF, Anti-CCP negative ESR and CRP: normal Leukocytosis absent

ESR results: normal and not normal

Normal is less than 20 mm per hour Always worry if its over 100 (or greater than 50 for non-rheum conditions)

Thin cartilage-bone rubbing together

Osteoarthritis

toe walking management

PT, casting, night splints, surgery

Cat bite-organism

Pasteurella multocida

Connective tissue sheath of skeletal muscle: fibrous CT surrounding fascicles (groups of muscle fibers)

Perimysium

Outer fibrous layer of bone, inner osteogenic layer. Osteoblasts, osteoclasts, osteogenic (stem), nerve fibers, blood vessels, secured to underlying bone by sharpeys fibers

Periosteum

Tendons that are evertors and pass posterior to lateral malleolus

Peroneals

Diagnositic criterea for OA

Persistant usage related joint pain Age greater than 45 Morning stiffness less than 30 min

lab findings for sjogrens syndrome

Positive SS-A (Ro) antibody Positive SS-B (La) antibody anti-ds DNA antibody Positive ANA Positive RF

Abx used for prevention of infection

Prophylactic

sx of polymyositis

Proximal limb weakness (hip, thigh, shoulder) gait slow and waddling Dysphagia Weakness of extensor neck muscles Respiratory impairment Cardiac involvement (30%): EKG changes, CHF- the heart is a muscle!

what type of scaphoid fx has poor healing, high non-union rate, therefore needs surgery?

Proximal pole

Pseudogout will look like what on the joint aspirate test? What are the crystals composed of?

Pseudogout: Rhomboid shaped positively birefringement crystals Calcium pyrophosphate

Puncture wounds of feet that cause nonhematogenous OM are often caused by ______. For this may reason you may need multiple antibiotics

Pseudomonas

Tx for OA (non-pharm)

Pt education Weight loss exercise, PT/OT walking aids, knee braces rest for only short periods/acute

Extensor mechanism of knee includes

Quadriceps tendon, patella, patellar tendon

Injury to ulnar collateral ligament of thumb "I fell on my hand and now I cant have a cup of coffee (weak pinch or poor grasp)" swelling or bruising over the thenar eminence instability of metacarpal joint of thumb

Skier's thumb/Gamekeeper's thumb

monobactams (aztrenoman) abx type, what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

beta-lactam Mostly gram -, resistant to narrow spectrum b-lactamases and metallo-b-lactamase Bactericidal, disrupt cell wall synthesis Not a lot of cross reactivity-if they have pcn allergy you are probably safe. CI: Cross reactivity with ceftazidime, check allergies IM, IV only Time dependent Hepatotoxicity

Carbapenems abx type, what type of bacteria, MOA, bactericidal or bacteriostatic, time or concentration dependent

beta-lactam reserved for serious infections, IV only bactericidal, disrupt cell wall synthesis time-dependent CNS toxicity (seizure) Derm reactions

common source of bacterial resistance breaks open b-lactam ring and deactivates drug

beta-lactamases

Penicillin allergy do not prescribe:

beta-lactate abx penicillins

muscles of the flexor compartment of the arm

biceps brachii, coracobrachialis, brachialis

how to describe the ddx for PAN

broad

if you have this disease you are predisposed to disc herniation

degenerative disc disease

Tx for fx

depends alignment and immobilization Urgent: displaced, open, angulated, nerve or vascular injury, impending compartment syndrome, risky fractures-immediate referral Stable, non-displaced: cast or splint and follow up referral

tendinitis on radial side of wrist- pick up baby

dequervain's tenosynovitis

sx of disc herniation?

dermatomal pain, numbness, weakness.

Parts of Scotty Dog

dog ear-SP neck-pars interarticularis eye-pedicle nose-transverse process front leg- inferior articular process back-lamina

movement superiorly

dorsiflexion

clavicle fx: usually arm turned inward and downward. Open fractures result from severe tenting and piercing of overlying skin-> what to do

emergent!

vertebra that are most tipped into the curve apex

end vertebra (E)

Delicate membrane on internal surface of bone, also contains clasts and blasts

endosteum

Escheria coli, klebsiella pneumoniae, salmonella, serratia, shigella are all

enterics

what is bursa

extension of synovial joint outside joint cavity-it can secrete fluid, can get inflamed causing bursitis

Boutenniere Deformity: what doth and what is it related to

extension or hyperextension at DIP, flexion at PIP; RA

common hand deformities in OA

heberden nodes-DIP joints bouchard nodes- PIP joints hold up index finger (DIP is head, PIP is body)

scoliosis can be.. (causes)

idiopathic, neuromuscular, congenital, syndromic

internal tibial torsion, as measured by the thigh-foot angle, is a cause of ___ in toddlers.

in-toeing

bony rotational problem of femur, tibia, or foot-common. usually normal and will resolve by itself.

in-toeing, out-toeing

''Radicular'' means

nerve

Other skeletal muscle relaxants: Diazepam-benzo, Tizanidine, Baclofen, Carisoprodol (Avoid)

typical question on a test: appropriate tx for scaphoid waist fx?

thumb spica cast

5th metatarsal (jones) fracture: transverse fx of base of 5th greater than 15 mm distal to proximal end (diaphyseal) less common, more severe

(pic on right is a pseudo-jones: styloid avulsion fx --more benign)

reducing GI risk of NSAIDs for patients

*Risk is dose and duration dependent Take with food Consider celecoxib Avoid indomethacin, diclofenac, ketorolac Use phrophylaxis with hx of ulcer (PPI, PGE analog)

Target serum uric acid levels during therapy are 5-6 mg/dl. xanthine oxidase inhibitors for gout: second line treatment:

-Allopurinol, Febuxostat -Probenicid

topical NSAIDs: example and use

-Diclofenac: Voltaren gel, Pennsaid solution, Flector patch -Effective for osteoarthritis, acute injury, no evidence for neuropathic pain. -low incidence of adverse effects

Methods of primary prevention to promote health (can be population or individual basis)

-Safe means of transportation -Sanitation -Eating healthy, good exercise,

criteria for screening:

-Significant effect on quality or length of life -Prevalence sufficiently high to justify costs -Acceptable methods of tx available -Asymptomatic period during which detection and tx significantly reduce morbidity and mortality -Sufficient sensitivity -Sufficient specificity -Acceptable to patients

opioids for chronic pain should only be used when:

-alternative therapies have not provided sufficient pain relief -Pain is adversely affecting function/quality of life -Potential benefits outweigh potential harm -Can only be continued when there is well-documented benefit after a trial of opioid therapy

how to diagnose impingement syndrome

-an arc of pain- from 90-120 degrees of abduction or forward flexion -Hawkins maneuver (arm at 90 degrees of forward flexion and have it rest on one of your arms--you can put the hand under their arm and on opp shoulder. Then do passive internal rotation) -impingement test/neer test (you stand behind them, stabilize the scapula with one hand and the other brings their arm up in passive forward flexion) -maintained rotator cuff strength (if arm down at side and elbow flexed at 90 degrees, they can still resist when you push on palm) full ROM

types of forefoot fx

-complete midshaft metatarsal fx, usually crush mechanism->RICE -phalanges

drug-drug interactions of NSAIDs

-increased serum concentrations of: Phenytoin, warfarin -Methotrexate: can decrease renal clearance, usually ok w/doses used for rheumatoid arthritis

growth plate aka

-physis

Assessing strength of muscles: No movement

CRP results-standard

0-8 mg/L

Assessing strength through movement/ROM: what are the 5 levels you can ascribe to the patient's injury?

0: No movement 1: Trace movement 2: Movement and full PROM, but unable against gravity 3: Full AROM, but not against resistance 4: Full ROM against gravity & resistance, but weak 5: Full ROM against gravity, full resistance

Assessing strength of muscles: Trace movement

Grade ____ AC separation: ligament is stretched, it is tender but no deformity.

two types of proximal femur fractures, describe complications

1. Femoral neck aka intracapsular hip fractures (high risk for avascular necrosis and nonunion)-need surgery 2. Intertrochanteric region fx (extracapsular hip fx), require more robust fixation, risk for implant failure

Manifestations of systemic JIA (4)

1. Fever (>101.3, high spiking fever that returns to normal, happens on a daily basis). *Lack of response to abx. 2. Rash Macular, salmon-pink. Axilla, around waist MC-tight clothing or heat makes it worse. Worse when febrile. Koebner phenomenon. 3. Arthiritis any joints, MC wrists, knees, ankles, hips 4. Systemic manifestations hepatospenomegaly lymphadenopathy pericarditis **uveitis is rare

diagnostic criteria for RA

1. Inflammatory arthritis of 3+ joints 2. Symptoms lasting at least 6 weeks 3. Elevated CRP or ESR ANA also positive in 1/3 of patients 4. + RF (may be 0 in 20% of pts) or anti-CCP

Clinical presentation of reactive arthritis

1. arthritis most common below the waist-knees/ankles 2. enthesitis inflammation of tendon heel pain/achilles 3. dactylitis sausage fingers 4. back pain 5. conjunctivitis 6. urethritis

Warnings for allopurinol

1. hypersensitivity reactions including SJS/TEN 2. check HLAB*5801 in patients of Chinese, Thai, Korean descent 3. hepatotoxicity 4. avoid with mercaptopurine/azathiprine

Scoliosis: Lateral curvature of the spine greater than ____ degrees

10 (anything less is a convexity)

If someone has a normal result on a DEXA scan, how long can you wait before you check it again

10-15 years

Female hemoglobin levels

12-15.5 g/dL

Male hemoglobin levels

13.5-17.5 g/dL

classification of ankle sprain: ligament stretching, local tenderness, minimal swelling

1st degree

Gout is characterized by painful joint inflammation, most commonly in the ____________, resulting from precipitation of monosodium urate crystals in a joint space.

1st metatarsalphalangeal (MTP) joint

Grade ____ AC separation: partial rupture of AC ligament

how many ATPs are needed for a cross bridge cycle?

2 (1 to attach, 1 to detach)

Peak incidence of oligoarticular JIA

2-3 years old, more common in females

New guideline for Vancomycin dosing: for known or suspected severe S. aureus infection, use 24 hours area under the curve to minimum inhibitory concentration ratio--abbreviated as:

24AUC:MIC Patient data is collected-trough and peak

when do we have peak bone mass?

25-35

classification of ankle sprain: severe stretching, partial tear abnormal stress tests

2nd degree

Ankle sprain with complete tear of ligament, cant bear weight

3rd degree (may need surgery)

Assessing strength of muscles: full ROM against resistance and gravity, but weak

polyarticular occurs with greater than _ joints. it is idiopathic or autoimmune

OM tx - chronic

4 weeks-24 months of IV/po abx can be managed as outpatient if not systemically ill good wound care, take pressure off wound manage comorbid conditions, especially DM

Fracture of the proximal femur needs ortho referral and surgery in ___ hrs due to high risk of thromboembolic events.

Assessing strength of muscles: full ROM against gravity, full resistance

oligioarticular involves less than ___ joints. can be idiopathic or autoimmune

Cervical: how many bones, how many nerves

7, 8 (C8 leaves below the pedicle)

What percent of motion happens at C1 and C2

overlap between actin and mysosin appears darker, this is known as the _______

A band

During muscle contraction which band does not change size

A band (I band and H zone shorten)

what is a medical home?

A place where you can go where multiple providers of different specialties can work together. This might be helpful for SLE crisis, systemic sclerosis for example

What is the Thompson test?

A positive test results when squeezing of the calf muscle plantarflexes the foot. This is normal. IF there is an achilles tendon rupture, nothing will happen.

Sprain: typical mechanism: fall onto lateral shoulder (football) ligamentous injury Affected joint is TTP pain, guarding, often deformity

AC Separation (check axillary nerve-sensation on deltoid)

Loss of articular cartilage resulting in: Pain at the AC joint with overhead or push pull movements (bench press) Tenderness at the AC most common Prominence at the AC joint Pain on crossed arm adduction (crossover test) Common in older age weight lifters

AC joint arthritis

A tear of the anterior cruciate ligament

ACL tear

lab findings for polyarticular JIA (no single diagnostic test

ANA (MC pos in younger children) ESR: mild elevations mild anemia RF pos if you older than 10 (10-20%)

lab findings for oligoarticular (no single diagnostic test

ANA and ESR might be pos/elevated CBC normal RF normal

Testing for systemic sclerosis

ANA- elevated in over 90% of patients but this is not specific test more specific testing-refer to rheum Test for complications

Most common age, gender, and presentation for structural scoliosis (idiopathic)

Adolescent (12-16) Females affected 4:1 Right thoracic convexity

Locations of red marrow, adults/infants

Adults: Trabecular cavities of heads of femur and humerus Diploë of flat bones Infants: Medullary cavities and all spaces in spongy bone (eventually replaced by triglycerides)

Mental checklist for opioids: ABCD PQRS

Alcohol Benzos Clearance and metabolism of drug Delirium, dementia and fall risk Psychiatric comorbidities Query the Prescription Monitoring Program Respiratory insufficiency and apnea Safe driving, work, storage, and disposal

Lordosis, kyphosis, scoliosis, deformity, spondylolisthesis, fracture alignment are related to what word of the TABCs of radiologic interpretation?

Alignment

Warning of tramadol

Also inhibits reuptake of 5-HT and norepi, caution with other serotenergic drugs. lowers seizure threshold.

Synergist of triceps brachii

Anconeus

Decreased hemoglobin aka

Anemia

Fx: Bones are not straight

Angulated fracture (2nd pic it has been reduced and casted)

tests for lupus

Anti nuclear antibody (ANA)-may be present in many diseases

really important test for RA-very specific

Anti-CCP antibody, 98% specific for RA

clinical presentation of oligoarticular JIA

Arthritis Usually asymmetrical MC in LARGE joints (knees, ankles, wrists, elbows) rarely in hips limping w/o pain walks funny in morning but then improves joint tender and swollen, NO erythema

clinical presentation of RA

Arthritis (morning stiffness, greater than 1 hour, symmetric joint swelling- MCP, PIP, IP (thumb), MTRP, elbows shoulders knees DIP usually spared insidious onset Extra-articular involvement (see image)

___________ joint pain has loss of active and passive ROM (range of motion), or "locking"

Articular

Not used for MSK pain- doesn't have a great analgesic or antinflammatory effect. mostly used in CV disease for prevention of clots

Aspirin (ASA)

Modifiable risk factors of osteoporosis

BMI Smoking Alcohol Calcium/vitamin D Vision-impaired may lead to fall Overall health Medications

ganglion cyst of the knee-joint fluid. what is it called and what is the tx

Baker's cyst tx the intra-articular pathology-meniscal tear, OA or cause of hemarthrosis (ACL, intra-articular fx, patellar dislocation)

One bone pieces overlaps another piece

Bayonetted fracture

Cephalosporins abx type, what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

Beta-lactam 5 different generations/spectrum different in each (as time goes on, better cell penetration, more focus on gram negative) No CI Bactericidal, disrupt cell wall synthesis PO, IM, IV Widely distributed, 3-5th generation has best CSF penetration Time dependent Renally eliminated Rash, diarrhea

Penicillins what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

Beta-lactam Mostly gram + (susceptible staph, strep) Bactericidal, disrupt cell wall synthesis Allergies are common Avoid intrathecal injection, sciatic nerve injection PO-preferred Widely distributed in around the body, low CSF penetration Time dependent Renally eliminated Rash, diarrhea

Better prognosis vs worse for SLE

Better: isoloated skin and MSK involvement, earlier diagnosis, milder disease, disease-specific tx and good medical care Worse: Renal and CNS disease, mortality currently result of medication side effect or CV events.

fusion of two or more vertebrae due to failure of segmentation of somites small vertebral bodies appear to be fused, anterior concavity important to recognize this is a congenital anomaly

Block vertebrae (note the vertebral bodies are slightly smaller, appear to be fused at the anterior aspect, creating an anterior concavity across all 3 segments)

what to monitor with chronic NSAIDs use

Blood pressure, CBC, BUN, Creatinine, AST

1 cause of genu varum. bilateral, worsens with walking. obesity. mechanical overload of tibia tx is bracing or surgery

Blount's disease

Cortex, medullary cavity, trabecular pattern, overall density are things you would look for related to what TABCs of radiological interpretation?

Bone

fewer X-rays pass through the _______, which leads to less exposure of the image. These show up light grey on x-ray.

Bone

Work up for OM-Labs

Bone aspiration (pus) and/or bone bx with gram stain and culture (culturing sinus tract or open wounds is not accurate) In acute WBC, ESR, CRP could be elevated, these are more helpful for tx monitoring

Microstructure of bone: Consists of ground substance in which numerous collagen fibers are embedded, proportions vary with age, location, and metabolic status

Bone matrix

The anterior compartment of the arm contains what muscles and whats the innervation

Brachialis, biceps brachii; musculocutaneous nerve

Tetracyclines (doxycyline) what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

Broad-spectrum, including intracellular pathogens Bacteriostatic, inhibits protein synthesis Only doxycycline can be used in peds-tooth discoloration PO-empty stomach, large glass of water, IV widely into body tissues and fluid, poor CSF penetration is poor Cumulative dose-dependent Photosensitivity, hepatotoxicity

subacute OM, localized cystic OM; pus and necrosis encapsulated in granulation tissue usally 2/2 staph aureus often these ppl need abx, bx to make sure this isnt a malignancy

Brodie abscess

compression injury of long bones, usually distal radius. what is it and MOI?

Buckle fracture, FOOSH tx: splint or short arm cast 3-4 weeks

Goals of tx for osteoporosis

Build up bone density, fall prevention, prevent secondary cause of bone loss, reduce morbidity and mortality

Flattened, fibrous sacs with synovial membrane that contain synovial fluid

Bursae

congenital spine defect: sagittal cleft in a vertebral body, etiology is unknown, most common in the thoracolumbar junction

Butterfly segment (clearly the other bodies adapted to this, there is upward curvature of the body below. thats how you tell its not trauma)

Crest syndrome (limited scleroderma)

C - calcinosis of the fingers R - Raynaud's E - Esophageal dysmotility S - Sclerodactyly T - Telangiectasia

What tests are positive for femoral acetabular impingement?

C-sign, Anterior impingement, posterior impingement

Which nerve roots leave above the pedicle?

C1-C7

What dermatomes of the upper extremity are good to know? what do they innervate?

C5 (deltoid), C6 (biceps, wrist extensors), c7 (triceps and wrist flexors), c8 (claw-lumbricals)

someone has numbness of thumb, what dermatome is probably affected

Tx for pes planus (tarsal coalition)

CAM boot 4-6 weeks PT- help with tight heel cords cast if nothing else works: surgery

Standard lab tests for SLE

CBC (is hematologic ok?), Serum creatinine and urinalysis with microscopy (kidneys) ESR and CRP (inflammation markers-often elevated) Complement levels (the additional tests the rheum specialists would do) Looking for other organ involvement-> LFTs Creatine kinase assay Spot protein/spot creatinine ratio

Monitoring-Parenteral abx tx

CBC weekly BMP weekly Serum inflammatory markers at beginning/end of parenteral therapy

Septic arthritis, what to order?

CBC, joint aspiration with culture (high WBC, low glucose, high protein), ESR, CRP, Procalcitonin (bacterial blood cultures) blood cultures, X-Ray (soft tissue swelling/effusion)

Which one tests muscle damage? Creatinine or Creatine kinase?

someone is started on statins and they have a lot of muscle issues what could you check to make sure the muscle isnt being damaged?

what lab do you order to get LFTs

CMP

NSAIDs CV effects

COX-1: vasoconstriction, platelet aggregation, thrombosis COX-2: vasodilation Bottom line: Upsets balance Increase risk of CV events (MI, stroke, death) even in healthy pts (rare). risks increases over time

Celecoxib is a selective NSAID, only inhibits ______.

COX-2 (less GI affects, CV risk controversial)

complex bony injuries; bone, muscle, fat tissues images

computer x-ray. cross sectional, takes an image all the way around them, good for looking at fine bony detail, thorax, liver, urinary tract, GI tract, head trauma

CT (computer tomography)

Bones that are difficult to visualize with xray, you can do a

CT scan

Most commonly fractured ankle bone mechanism: compression usually involved with other injuries-check everywhere especially spine.

Calcaneus

Flip to see a CT of pseudogout

Calcified tophy in knee joint to medial and lateral collateral ligaments and intracondyle notch, erosion at medial plataeu

When blood calcium is too high, what hormone will tell the osteoblasts to deposit Ca in bone

Calcitonin

High risk osteoporocis are recommended to have pharm intervention, including:

Calcium (limit 500-600 mg per dose) and vitamin D (essential for calcium absorption- 15 min of sun at least 2x a week) Biphosphonates: first line, prevent hip and vertebral fx decrease bone resorption

trabecular/medullary bone is same as

Cancellous/bone marrow

traumatic disruption of the quadriceps tendon-what cant they do?

Cant extend knee/straight leg raise usually requires surgery

Disc spaces and all joints, assess joint width, subchondral bone, symmetry with other side are related to what TABCS of radiological interpretation

Cartilage

specialized type of CT of the bone, does not have vessels or nerves. poor regenerative capacity. cells form isogenous groups

Cartilage (more degeneration)

A joint where bones are united by cartilage. No joint cavity What are the two types/their qualities?

Cartilaginous joints 1. Synchondroses (immovable) 2. Hyaline cartilage covers articulating surfaces and is fused to an intervening pad of fibrocartilage (amiphiarthrosis/partially movable)

Clinical presentation of polyarticular JIA

Children less than 10 Symmetric arthritis Indolent onset, starts with 1-2 joints, spreads rapidly knees, wrists, ankles, hips Older children/adolescents rapid onset in multiple joints fingers, wrists, elbows, hips

Complications of polyarticular

Children with early onset have low chance of spontaneous remission May cause destructive damage uveitis osteoporosis

what may happen after an ankle sprain (chronic condition)? What would be the tx for that?

Chronic lateral ankle instability (10-20% of sprains)-more likely to resprain, recurrent pain, talar tilt, laxity with inversion stress. refer to ortho Tx: ankle brace surgical ligamentous repair

development of deformity of the foot, feet are plantarflexed, heel is in varus, kidney bean shaped foot

Clubfoot

distal radius fx with dorsal angulation, often associated with an ulnar styloid process fx

Colles fracture

A fracture in which there are more than two fracture fragments

Comminuted

what is important to assess with a tibial plateau fracture

Common fibular nerve (peroneal nerve foot eversion, sensory at dorsum of foot, 1st webspace) DO NOT assess ROM

Rifampin what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

Commonly used synergystically with other agents to reduce development of resistance for gram + organisms, intracellular pathogens Bactericidal, inhibit RNA polymerase Caution in hepatic disease PO and IV-Best taken on empty stomach Concentration-dependent orange-discoloration of body fluids, flu-like symptos CYP P450 drug interactions

Relatively solid, found on external surface of bone, dense part of structure

Compact/cortical bone

occurs when blood flow is cut off and pressure builds in compartment between bone and fascia. Pain is most important symptom. Dx-device that measures pressure-not done in clinic.

Compartment syndrome

A type of impaction fx that occurs in the vertebrae, resulting in depression of the end plates.

Compression

Older adults are more susceptible to these types of fractures due to decreased bone health.

Compression, pathologic

Conditions and meds that increase risk for GI toxicity when taking NSAIDs

Conditions: Age, H. pylori infection, heavy alcohol consumption Meds that increase risk of GI bleed: glucocorticoids, antiplatelet agents, anticoagulants (warfarin, apixaban), SSRIs

type of synovial joint that is convex or concave movement of two articulating surfaces not dissociable example: knee, temporomandibular joint

Condylar

tx for patellofemoral pain syndrome

Conservative RICE NSAIDs PT activity modification consider bracing with a sports holiday

Tx for prepatellar bursitis (inflammatory)

Conservative: RICE, activity modification, time and monitoring do not aspirate (high rate of infection)

How would you diagnose SLE?

Constellation or clinical findings Elevated ANA titers (sensitive, not specific. refer to rheumatologist for additional testing)

Spiral groove of humerus: whats special

Contains the radial nerve and deep artery (profunda brachial artery)

an adjacent skin infection that may happen along with nonhematogenous OM

Contiguous infection

Flexing the shoulder is the same action as extending the arm.

Coo

For NSAIDs, why does cox-1 inhibition lead to adverse GI effects?

Cox-1 stimulates gastroprotective prostaglandins. When you inhibit it, there will be adverse GI effects. This is why selective cox-2 inhibitors (celoxib) were created.

test to assess autoimmune muscle condition? dermatomyositis, polymyositis, inclusion body myositis, polyarteritis nodosa

Creatinine kinase elevated: muscle damage

How to evaluate for AC joint arthritis

Crossover test-pain on crossed arm abduction x-ray most important

way to remember difference in action of dorsal and palmar interossei?

DAB (dorsal abduction) PAD (palmar abduction)

controlled substance prescribing tips

DEA. number, patients full name and DOB, MNPMP (prescription monitoring program)

low level ionizing radiation, measures bone mineral density. documents small changes in bone mass. can evaluate for osteoporosis (T score: -2.5 or lower is osteoporosis. spine and hip are most important)

DEXA (dual energy X-ray absorptiometry)

determines bone mineral density, usually in the hip or lumbar spine. radiation exposure

DEXA Scan

Tx for RA

DMARDs (methotrexate-may be indefinite) NSAIDs for pain-do not help with progression of dz Glucocorticoids (oral or injections) Consider surgical intervention if advanced

Diet recommendation for gout: do and donts

DO: vegetables and low fat or non fat dairy products, water, weight control, DONT: some purine rich foods (shellfish, organ meats, beef, lamb, pork-red meat) alcohol (esp beer) high fructose corn syrup beverages

immobility can lead to this hematologic MSK condition where there blood clots too fast

DVT (deep vein thrombosis)

Mechanism of quadriceps tendon rupture. What does it disrupt?

Deceleration injury (jumping from height) The extensor mechanism of the knee

patellar tendon tear MOI

Deceleration injury-jumping down from a height of 3ft or more abrupt stopping

Abx used when organism is known, uses narrowest spectrum agent to prevent abx resistance

Definitive

Exam findings for a distal biceps tendon rupture

Deformity of biceps, diffuse swelling and ecchymosis about the elbow and antecubital fossa Focal antecubital fossa pain and tenderness often cant assess strength due to discomfort high energy mechanism: get an X-ray

A type of impaction fx that occurs in the knee when the femoral condyle strikes the softer tibial plateau.

Depression

Name 3 potential derm manifestations of SLE. There are others if you want to try to name those too!

Derm sx of SLE: Malar rash (days-weeks, spares nasolabial folds) Photosensitivity Discoid lupus-chronic, sun exposed areas Other less common ones: urticaria, telangiectasias, purpura, bullous lesions, etc. Just know that there are other derm sx than malar rash!

patients at higher risk for chronic OM

Diabetic/PVD neuropathy, high blood sugar, poor tissue perfusion

Blood supply to long bones

Diaphysial, metaphysial, epiphysal arteries

Jones fx of 5th metatarsal involves the __ of the 5th metatarsal

Diaphysis; high incidence of non-union chance if it doesnt heal may need surgery

Skin findings for systemic sclerosis (scleroderma)

Digital ulcerations Digital pitting Tightness, swelling, thickening of digits Hyper/hypopigmentation Narrowed oral aperture Scaling of skin SC calcinosis

WHO: Sum or lost years of "healthy life," measures burden of disease across population

Disability adjusted life years (DALY)

Pain with straight leg raise. What are some ddx?

Disc herniation/back and spine pathology Osteoarthritis of the hip/hip pathology

Patellar dislocation

Dislocation of the patella laterally

bones are displaced from their normal joint alignment, out of their sockets, or out of their normal positions

Displaced fracture

Bone fragments shattered

Distracted fracture

should you assess ROM in femoral condyle fractures? how to examine this patient? What is there a risk of?

Do not assess ROM examine as it lies risk for NV injury-check deep, superficial peroneal and sural nerve function

if a drug is time dependent you probably have to do what

Dose multiple times per day

Name of test: Stabilize lower tibia with one hand, with other hand you pull forward with hand behind the heel

Drawer test

Clinical effects of opioids

Drowsiness, GI effects (nausea/vomiting/constipation), histamine release (morphine, flushing, pruritis, hypotension, euphoria, risk of dependence

Because someone with rheumatoid arthritis may have Sjogrens syndrome, what sx do you want to ask them about?

Dry mouth, dry eyes, swollen glands

When is the fetus most radiosensitive?

During the first few weeks of pregnancy

Two inflammatory markers we check, which increase in acute and chronic inflammatory states. Non-specific.

ESR and CRP

useful in monitoring disease activity for rheumatologic conditions

ESR and CRP

cartilage with elastic fibers located in: ear external auditory canal, eustachian tubes, epiglottis and larynx bridge of nose does not calcify

Elastic cartilage

etiology: overuse of extensor muscles of forearm Very TTP over the medial or lateral epicondyle

Elbow overuse: Tennis elbow (lateral epicondylitis) golfers elbow (medial epicondylitis)

Lab findings for polymyalgia rheumatica

Elevated ESR (above 40) Elevated CRP Normocytic/normochromic anemia common Serologic test negative (ANA, RF, CCP) Temporal bx if giant cell arteritis sx are present (tenderness in temple areas, jaw cramping, elevated sed rate, headache) Normal EMG Normal muscle bx

Abx used when organism is unknown, tx covers the most likely organisms causing the infection, may require multiple agents or broad-spectrum agents

Empiric

Connective tissue sheath of skeletal muscle: fine areolar CT surrounding each muscle fiber

Endomysium

With allergies, asthma, parasites, what might be elevated?

Eosinophils

Connective tissue sheath of skeletal muscle: dense regular CT surrounding entire muscle

Epimysium

SLE management

Exercise is important Stress management Sunscreen Team approach

Deep group of extensor muscles of forearm

Extensor indicis, extensor pollicus brevis, extensor pollicus longus, abductor pollicus longus, supinator, anconeus

evaluation of femur fx- what is their presentation? what cant they do? what imaging to get?

Externally rotated, Abducted, Limb shortened (if displaced) AP of pelvis Cross table lateral view unable to straight leg raise avoid frog-leg view

exam for dequervain's tenosynovitis

FINKELSTEINS

What populations in general tend to have higher inflammatory markers?

Females, older people, obesity, chronic disease

Skeletal muscle relaxant: Acts via CNS, reducing motor neuron activity. Approved for short term use only. Contraindications: Patients w/ seizure risk, glaucoma, arrhythmias/CHF/recent MI, avoid w/ tramadol. May cause sedation

Flexeril

flexor carpi ulnaris

Flexes and adducts wrist; ulnar nerve

If prepatellar bursitis is severe, ROM may be affected. What specifically would be limited?

Flexion

PE findings of meniscal tears. what are two special tests

Focal and medial or lateral joint line tenderness McMurray's Appley's

actions to assess nerves of lower extremity?

Foot eversion- peroneal Foot plantar flexion-sural

inflammation, fibrosis, and scarring of joint capsule-- does not involve rotator cuff. insidious onset- female 40-55 years old. Number 1 complaint is pain, stiffness. ROM limited more by stiffness than pain. Pain management and PT are key

Frozen shoulder (adhesive capsulitis)

GI, Kidney, Pulmonary, PV, Neuro and Cardiac Sx of systemic sclerosis---this can be a bad disease.

GI -dysphagia -esophageal reflux due to dysmotility -malabsorptive diarrhea -n/v -weight loss -xerostomia Kidney -Hypertension -Potential for sclerodermal renal crisis: renal failure PV -Telangiectasia Pulmonary -Crackles in lung bases -Dyspnea Cardiac -Conduction abnormalities -Cardiomyopathy -Pericarditis Neuro Peripheral neuropathy Trigeminal neuropathy bells palsy like (paralysis on one side)

Etiology of reactive arthritis

GU or GI infection (diarrhea, STI risk?) Chlamydia trachomatics Camplyobacter C. diff E. coli Salmonella

Lab findings for reactive arthritis

HLA-B27 common (30-50% pts pos) The following only if they have STI or GI concerns: Genital swab may reveal Chlamydia Stool culture: Salmonella, Shigella, Yersinia, Campylobactor, C. diff

ankylosing spondylitis: gene and classic finding

HLA-B27, bamboo spine

Stiffness of MTP joint of great toe, caused by arthritis, local trauma, gout, more common in men pain with walking tender MTP joint, pain with dorsiflexion what is it and tx?

Hallux rigidus curved-sole (rocker-sole shoe), NSAIDs, possible surgery-podiatry/ortho

Allopurinol: Screening for human leukocyte antigen-B*5801 genotype is recommended before initiating treatment in patients of __________

Han Chinese or Thai descent, regardless of kidney function, or in Koreans with chronic kidney disease stage 3 or greater.

Osteoporosis: what you could monitor

Height-old people might get shorter and have higher risk. greater than 1.5cm is significant

What ways is osteomyelitis spread?

Hematogenous (20%): bacteria in blood stream travek to bone nonhematogenous (80%): trauma, injection, surgery, nearby infection (cellulitis, abscess)

failure of ossification of half a vertebra triangular shaped vertebral body instead of a rectangle MC in thoracic spine may produce significant scoliosis

Hemi vertebra *extra one between L5 and S1

Secondary PAN may be related to what causes

Hep B, Hep C, Hairy cell leukemia (rule these out!)

tests for polymyalgia rheumatica

HgB: Decreased (Anemia) elevated ESR Elevated CRP negative ANA, RF, CCP

type of synovial joint that is flat, planar motion: in one plane; flexion, extension Example: Interphalangeal joints of hand and foot, elbow

Hinge

Eldery patients with hip pain (thigh pain, knee pain) should be treated as if they have a __________.

Hip fracture

adjunct to surgery and abx, enhanced bone and soft tissue healing, used in refractory chronic OM

Hyperbarics, increase oxygen to limbs

Growth plate fx: Salter-Harris classification

I (Same): X-ray negative II (Above): Metaphysis through epiphysis III (Lower) Physis through epiphysis IV (Through): Epiphysis, Physis, and Metaphysis V: compression of the Physis

Part where there is only actin filaments appears lighter, this is known as ___________

I band

How to treat felon

I&D(scalpel, irrigation), abx (amox/clav (Augmentin-cover oral flora) OR clindamycin OR cephalexin

Exam findings for distal biceps tendonitis

I: Normal P: focal antecubital fossa pain and tenderness S: Pain in elbow area with resisted supination

Tx for septic arthritis

IV abx followed by PO usually at least 4 weeks target staph, strep, MRSA, gram - IV vanco + 3rd gen cephalosporin cefepime if they have a lot of comorbidities or are immunosuppressed ortho and possible ID consult admission

OM tx- acute

IV antibiotics (usually for 1 week before transition to oral) ortho/podiatry/infectious disease consult admission aspiration, surgical drainage, wound care, amputation, immobilization manage diabetes if needed

Tx for septic bursitis

IV/po abx (vanc and/pr cefazolin; po cephalexin; clinda or doxy) ortho consult if extensive

CK can be elevated after a marathon, a muscle biopsy or even caused by medications like statins. Illness caused by medicine is called ___________.

Iatrogenic

first line NSAIDs

Ibuprofen (advil, motrin) Naproxen (Aleve) (go to- only dose once every 12 hours, may be safer for CV risk)

Inflammation of the ITB is what

Iliotibial band syndrome

Neutrophils may undergo morphologic change during disease. Presence of band means what?

Immature neutrophils; reflect left shift->active infection or severe anemia

Patient education for SLE

Importance of adherence to medications and follow-up appointments Seek medical attention of new sx including fever Increased risk of infection and CV disease Avoid exposure to sunlight and UV light Avoid other triggers Non-live vaccines during stable periods of disease Stop smoking Plan pregnancies

Determines probability of an individual being diagnosed with a disease in a given time period. The number of newly diagnosed cases of disease.

Incidence

This step in pain signaling involves transient vasodilation and increased vascular permeability. The release of chemical mediators such as histamine and 5-Ht result in throbbing, burning, or aching sensation.

Inflammation

What is prepatellar bursitis? types? MOI?

Inflammation of the bursa over the patella-MC May also present as septic prepatellar bursitis inspect the skin-is there anything that could make it infected? Housemaid's knee Kneeling excessively

Pes anserine bursitis hx and PE finding

Insidious onset of medial joint pain Often will point exactly to the Pes Anserine bursa medial aspect of the knee below the joint line Tenderness medial aspect of knee below the joint line

Findings of long head of biceps tendonitis:

Inspection: Normal (the pic is a rupture) Palpation: Focal anterior shoulder pain and tenderness radiating inferior to biceps muscle. Strength: Focal pain with resisted shoulder forward flexion and resisted elbow flexion and resisted forearm supination.

Clinical presentation of talus fx. What must you get to help in dx?

Intense pain, inability to bear weight, localized tenderness and swelling more to the front of the foot, may have loss of normal foot contour, may be misdiagnosed with talus fx, so they need Foot x-rays (ideal, ankle x-rays may also pick up on it)

The fracture line crosses the articular cartilage and enters the joint

Intra-articular

Name of test: Forcibly inverting ankle

Inversion stress test (significantly more movement + , significant disruption of lateral ligaments)

Tx for bite wounds

Irrigating and debriding Prophylaxis with Td, amox/clav (Augmentin) Rabies? Vaccine + immoglobulin exposure labs? XR to look for teeth

Make sure you ask this when someone is having joint pain in one joint

Is there pain in any other joints?

muscle contracts but without appreciable change in length (for example just holding something)

Isometric

What is the gold standard for diagnosing gout?

Joint aspirate

suspect a septic joint, GOUT, RA. what do you do

Joint aspirate diagnostic and therapeutic to evaluate synovial fluid Indications: painful, swollen joint. septic: huge WBC count (over 10,000)

Help with ddx for reactive arthritis?

Joint aspirate: No crystals or abnormal bacteria (septic arthritis gout)

tx for pseudogout

Joint aspiration, NSAIDs, intraarticular steroid injections can reduce symptoms to less than 10 days (allopurinol will not work)

MSK symptoms of SLE:

Joint pain MC-Arthalgia. May seem out of proportion to other sx. myalgia, arthritis of small joints Usually symmetrical, polyarticular Swan neck deformity increased incidence of avascular necrosis

criteria for JIA diagnosis

Joint pain, swelling, and inactivity stiffness Last at least 6 weeks Involves one or many joints Symptoms begin prior to 16 yo

MSK findings for systemic sclerosis

Joints, tendons, bones -Flexion contractures -Friction rub on tendon movement -Hand swelling -Joint stiffness -Polyarthalgias -Sclerodactyly (stiff appendages) Muscles -Proximal muscle weakness

flip to compare Jones and proximal 5th metatarsal avulsion fx. which is worse?

Jones worse

jones and psuedojones management

Jones: high incidence of malunion, ortho consult for operative, lengthy treatment PJ: extrarticular-walking cast or stiff shoe 2-3 weeks intraarticular: non-weightbearing cast 6-8 weeks with ortho f/u in 1 week

NSAIDs are excreted via the _____. So caution in this disease!

Kidney

most commonly involved organ with PAN

Kidney

Most patients with pseudogout have preexisting joint damage from other conditions like OA and RA. What joint is the most commonly affected?

Knee

common joint deformities in OA?

Knees: bony enlargements varus > valgus

rediculopathy common dermatomes lower extremity and what actions they do

L3 (flex hip), L4 (flex quad, straighten knee), L5 (toes to nose), S1 (push the gas) dermatomes

If someone can't squat think

Patellar reflex associated with what nerve?

Damage to this nerve-cannot heel walk

branches of lateral cord of brachial plexus

LML Lateral pectoral nerve Muscluocutaneous Lateral root of median nerve

Other lab findings in RA-CBC and X-ray

Lab Thrombocytosis Anemia CMP normal Serological studies or synovial fluid analysis if uncertain about diagnosis X-ray Joint erosions, displacement

most specific test for an ACL tear

Lachman

special tests for ACL

Lachman's (grab knee, slight flexion, thumb on tibial tubercle, thumb on quad tendon) Anterior/Posterior drawer test

Risk factors for osteoporosis

Lack of estrogen, calcium or vitamin D deficiency; petite body form; immobility; low levels of TSH; diabetes mellitus

The time following the initial radiation event before the first-detectable effect occurs.

Latent period

Vaglus is when the distal joint is more _________ than the proximal joint.

Lateral (vaLgus-Lateral)

Testing for lateral and medial epicondylitis (3 each)

Lateral epicondylitis: resisted wrist extension and forearm supination Arm extended, push long finger down Medial epicondylitis: resisted wrist flexion and forearm pronation Arm extended, push long finger up

Gold standard for skeletal maturation assessment

Left hand and wrist PA x-ray compared to the Greulich and Pyle atlas Risser index more common however (see image)

Presentation for a posterior dislocation of hip

Leg is shortened, hip is fixed in flexion, adduction, internal rotation, sciatic nerve palsies common (check sensation and distal palsies)

Basophils may be increased in what condition

Leukemia

Lab findings in systemic JIA

Leukocytosis Thrombocytosis Anemia low hgb and hct-often exacerbated by GI blood loss due to NSAIDs Elevated ESR and CRP (inflammation markers) ANA and RF negative Mild LFT elevations UA normal (hematuria or proteinuria should prompt alt dx)

complications of PAN

Limb edema is common infarction gangrene of fingers, toes ulceration extending into SC tissue

MC locations for hematogenous OM in children

Long bones-femur, tibia, humerus, fibula

Etiology: Use/overuse (overhead use, swimmers, tennis, etc.) Tendon becomes frayed/worn between lesser and greater tuberosity Anterior shoulder pain with resisted supination/forward flexion of the shoulder Sometimes it ruptures and there is a deformity. Tx: RICE, activity modification, NSAIDs, injection is an option.

Long head of biceps tendonitis (a rupture is also known as popeyes deformity)

Proteins interconnecting myosin filaments

M Line

Complete tear of the MCL or LCL, MOI? What should you also suspect?

MCL, LCL tear Blow to the lateral aspect of the knee often with foot planted (valgus stress to the knee) Always suspect an associated ACL tear (LCL-most common with ACL)

branches of medial cord of the brachial plexus

MMMMU Medial pectoral nerve Medial root of median nerve Medial cutaneous nerve of arm Medial cutaneous nerve of forearm Ulnar nerve

soft tissue detail imaging

MRI

go to for spine/ortho imaging, no ionizing radiation. uses magnets to line up atoms and flips them out of phase, shows good anatomical detail, fat is brightest signal

MRI (magnetic resonance imaging)

Work up for OM-Imaging

MRI test of choice x-ray (Cant fully rely on, may take weeks or months to appear) CT: more useful for chronic than acute less common Bone scan (sensitive but not specific) Ultrasound: subperiosteal fluid collection or abscess adjacent to bone

Common resistant pathogens

MRSA (multidrug resistant s aureus) Vancomycin-resistant enterococcus Pseudomonas Extended spectrum beta-lactamase producing e coli, klebsiella Carbapenemase producing E. coli, klebsiella

pelvic fx can be stable or unstable. Unstable may be associated with _____ loss. What to look for on x-ray for pelvic fx? What can you do to evaluate for pevlis fx?

Massive blood loss; Trace the main pelvic ring and two obturator foramina push on ASIS pt supine

Varus is when the distal joint is more _______ than the proximal joint.

Medial

With a supracondylar humerus fx, what are we worried about for risk of damage?

Median nerve, radial nerve, vascular compromise (5-17% supracondylar fx have: brachial artery injury or compartment syndrome)

lateral femoral cutaneous nerve syndrome aka

Meralgia paresthetica tx: remove cause, neuropathic pan med if needed

nagging forefoot pain over middle metatarsal heads, usually d/t faulty weight distribution

Metatarsalgia

Fx with radial nerve effected wrist drop, numb on back of hand Immediate surgery

Midshaft humerus fx

Difference in potential causes between monoarticular vs polyarticular pain

Mono: could be localized injury, monoarticular arthritis, or infection Poly: Could be inflammatory, immunologic, or neurologic disorder, or infection

Fx of proximal third of the ulna, dislocation of the proximal head of the radius

Monteggia fx

Allopurinol can be started during an acute gout flare if used with ____ and ____.

NSAID, colchinine

tx for polyarticular JIA

NSAIDs

Tx for reactive arthritis

NSAIDs Intra-articular glucocorticoid injections systemic glucocorticoids DMARDs Antibiotics if Chlamydia is present

Tx and screenings for oligoarticular JIA

NSAIDs Intra-articular glucocorticoids DMARDs rarely used Regular eye exams (more frequent if they have a pos ANA)

Tx for systemic JIA

NSAIDs (indomethacin good option, improvement should happen in 1-2 weeks) Oral glucocorticoids DMARDs (disease modifying antirheumatic drugs) Pediatric rheumtaology referral

what can you do with greater trochanteric bursitis

NSAIDs, activity modification, ice, injection of corticosteroid injections

management of stress fx

NSAIDs, restriction of activity, time

Should you test someone that got bit by a tick right away?

Nah, the IgM antibodies to B. burgdorferi take 1-2 weeks and IgG antibodies take 2-6 weeks

Tx for OA

Naproxen first line Topical (if there is only 1 joint involved) and oral NSAIDs (Cox-2 inhibitor) Duloxetine (multiple joints, if they cant be on NSAIDs) Topical capsaicin (if only 1 or 2 joins affected, the above failed) Intra-articular glucocorticoids injections Surgical: if failed conservative measures, hip or knee replacements

common adverse abx effects

Nausea, diarrhea, Rash: hypersensitivity, photosensitivity

Consists of motor neuron, motor end plate, synapse, synaptic cleft, synaptic vesicles, NTs (ACh)

Neuromuscular junction

Dx for Sjogrens

No single diagnostic test, clinical dx to rule other causes out. Salivary gland bx used to confirm suspected diagnosis (not fun) Drugs may be a cause of dryness (anticholinergics) so take a thorough hx

is sx of gout started recently, would the uric acid be elevated?

No, its not always high in a first attack

If someone has an acute illness and a tick bite or exposure in an endemic area (like MN), do you want to get a test?

No, just treat them (doxycycline)

OM that occurs through direct inoculation: happens when there is penetrating wounds, open fractures, invasive ortho procedures, pressure ulcers

Nonhematogenous OM

When you pick up a child typically under 4 by the arms you might pop the elbow out (radial head dislocation). They don't have pain, their

Nursemaid's elbow, reduce it by supinating wrist and extending arm, apply pressure over radial head

Other contraindications for NSAIDs: Kidney injury, eGFR < 30mL/min, cirrhosis/advanced liver disease, ASA-exacerbated respiratory disease, avoid in pregnancy (esp after 32 weeks)

A fracture with angulated fracture line

Oblique

Red flags to watch out for when evaluating a fx

Open fx-refer immediately to hospital Extreme swelling-suspect impending compartment syndrome

Opiate vs opioid vs narcotic

Opiate = in poppy (morphine, codeine) Opioid = includes opiates and similar drugs (we use this term the most) Narcotic = gov't definition: controlled substance

Drug that inhibits pain transmission neurons, causing analgesia best for continuous dull pain, higher doses can be used for acute, sharp pain Respiratory depression

Opioids

Treatment of acute gout should commence within 24 hours. What drugs are used for acute gout flares? What is the first line tx?

Oral corticosteroids, intravenous corticosteroids, NSAIDs, colchinine (CI renal or hepatic impairment; expensive) are equally effective, but NSAIDs are first-line treatment, particularily Indomethacin. Oral NSAIDs are given at maximal dosage and continued for 1-2 days after relief of sx. Single joint-corticosteroid injection

Biggest cause of hip pain

Osteoarthritis Others: rheumatoid arthritis, septic arthritis, fractures of proximal femur or pevlis, dislocation of the femoral head (hip dislocation)

Leptin has also shown to influence bone density, inhibiting _______ and doing what

Osteoblasts, softening the bone

stem cells in periosteum and endosteum that give rise to osteoblasts

Osteogenic cells

the structural unit of bone matrix, laid down in organized manner, laid down in lamellae tubules, haversian canal contains nerve, vein, artery

Osteon/haversian system

T score less than -1 but greater or equal to -2.5

Osteopenia

imaging for scoliosis

PA (Cobb angle, risser sign) and lateral spine films

Two chest views

PA, Lateral

Wrist Views

PA, Oblique, Lateral (scottie duck-no duck droppings, sign of triquetral fx), Scaphoid (distance between scaphoid and lunate important)

Tender erythematous nodules, palpable purpura, livedo reticularis, ulcers, bullous or vescicular eruptions, more frequent on lower extremities

PAN

determine areas that are metabollically active, can detect cancer, heart issues

PET Scan (spine infection-cancer looks exactly the same, have to pair this with other imagine)

Patient education for polymyositis

PT and OT can be helpful Monitor for steroid induced complications Most patients improve w therapy

What hormone regulates the blood Ca level that will stimulate the osteoclasts to degrade bone matrix to release Ca

PTH (parathyroid hormone)

clinical presentation of trochanteric bursitis

Pain and tenderness over greater trochanter, may radiate to knee or ankle or buttock, worse when first rising from sitting, night pain

Osgood Schlatter's disease presentation

Pain at the insertion of the patellar tendon on the tibial tubercle

clinical presentation of osteoarthritis

Pain exacerbated by activity, better with rest Morning stiffness Knees, hips, hands, spine Weight-bearing joints more prevalent in females

presentation of morton's neuroma, tx

Pain in the toes and dorsum of the foot May palpate small nodule in web space Initial tx: steroid/lidocaine tx Potential surgery

flip to see clinical presentation of ankle fx

Pain, swelling, bruising, inability to bear weight. Significant deformity if dislocation present as well

How do fx usually present?

Pain, swelling, decreased function stress-insidious onset, pain during weight bearing

Clinical presentation of ankle sprains, which are usually inversion mechanism

Pain, swelling, may or may not be able to bear weight, foot may be passively inverted (talar tilt), passive inversion related to increased pain

A CBC finding you may get for lupus

Pancytopenia (anemia, neutropenia and thrombocytopenia)

Terminal cisterine?

Part of sarcoplasmic reticulum where calcium is stored

Flip to see an x-ray of a quadriceps tendon rupture deformity--what will look off?

Patella sunken down

A fracture through bone weakened by tumor, metabolic bone disease, or osteoporosis

Pathogenic

collapsed medial arch-may be congenital or acquired from polio, RA, tendon rupture. can be flexible (MC, with weight bearing) or rigid. tx?

Pes planus (flat foot) arch support. if underlying condition may need surgical correction

MOA for patellar dislocation

Pivoting injury or valgus injury (patella valgus) on extended knee Can spontaneously reduce

usually an overuse injury (runners, standing occupations, also RA or gout) Pain over plantar surface Strain of fascial fibers, friction causes periositis of calcaneus

Plantar fasciitis tx: rest, NSAIDs, heel and arch support, if refractory: steroid injection

generalized pain, fever, weight loss painful nodules on legs necrotizing arteritis of medium or small arteries Involvement of renal and visceral arteries is characteristic ocasionally effects small arteries middle or older age adults, male predominance does not involve veins

Polyarteritis nodosa (PAN)

morning stiffness and pain typically lasts at least 30 minutes, shoulder, hips, and neck limited ROM in affected joints subjective weakness inflammatory rheumatic condition occurs in adults over 50 women more affected

Polymyalgia and rheumatica

Both ends of this muscle are insertion and origin, depends on how we move the joint

Popliteus muscle

Tx for gout flares

Potent NSAIDs: Naproxen (500 mg BID) Indomethacin (50 mg TID) Glucocorticoids: Oral-short burst 5 days, then follow up) Colchicine (use w/ NSAID/glucocorticoid intolerance; use within first 24 hours of a flare, lots of drug drug rxns)

When mycobacterium infect thoracic spine, this type of hematogenous OM is also known as

Pott's disease

CT scan contraindications

Pregnancy WT >450lbs allergy to contrast die kidney/liver disorder Huge radiation exposure

Likelihood of having disease, total number of cases in a population

Prevalence

two types of scoliosis

Primary (idiopathic-MC) Secondary (congenital abnormalities, neuromuscular disorders, tumors)

flip to see ulnar drift, what is it related to

risk factors for septic arthritis

RA, Lyme prosthetics

What to do when you see these things on a clavicle fracture/AC separation Midshaft or proximal: Overriding of greater than about 1.5 cm Displaced distal third clavicular fractures. AC separation with skin tenting or unsightly deformity. Polytrauma Floating Shoulder (Rare combination of clavicle and glenoid neck fracture).

REFER!

Tx options for elbow overuse

RICE Corticosteroid injections for short term relief new,wont be tested on:Nitroglycerin patches applied 1/4 daily

Management of talus fx

RICE ortho will usually make call on surgery

Management of ankle sprain

RICE for first 1-2 days immobilize with plastic or plaster splint Consider crutches if moderate or severe

Tx for Osgood Schlatter

RICE, NSAIDs, chopart strap

Tx pes anserine bursitis

RICE, activity modification, NSAIDs, Sports holiday 3-4 weeks

mechanism: fall on outstretched hand (FOOSH), direct blow focal tenderness on radial head

Radial head fracture

Reiter syndrome aka

Reactive arthritis

Pes planus rigid causes, what to do

Refer tarsal coalition (pain with activity, repeated strains, 8-12 years old) vertical talus iatrogenic/posttraumatic ant eater sign seen here

if you suspect RA, what to do

Refer to rheumatologist Pt education (be aware of functional limitations, psychosocial component), PT/OT

Colles' Fx management

Refer, URGENT reduction and immobilization stable: closed reduction and casting unstable: pinning

What is the number 1 cause of work related injuries

Related to lifting, pushing, holding, carrying, holding

Prognosis and complications of systemic JIA

Resolves completely in 40-50% of patients Complications: destructive damage severe growth retardation osteoporosis Macrophage activation syndrome (life threatening-widespread->bleeding, shock)

autoimmune, inflammatory disease chronic synovitis (synovial fluid)-bony erosion and damage to joint Can be systemic

Rheumatoid arthritis

suspect rheumatoid arthritis, what do you check?

Rheumatoid factor (more likely to see in active disease) May also be seen in Sjogren syndrome, lupus, even healthy individuals Way more specific test: Anti-CCP Antibody "positive" in RA

Organism that causes osteomyelitis

S. aureus

Nonhematogenous OM: common organism

S. aureus, frequently multiple organisms

If someone cant toe walk think what

achilles reflex is mediated by

rotator cuff muscles

SITS Supraspinatus Infraspinatus Teres Minor Subscapularis

Multiple myeloma (they have bone pain) test

SPEP UPEP Looking for gamma globulin CBC-Anemia ESR and CRP increased Hypercalcemia

Pts with sickle cell typically have osteomyelitis due to

Salmonella

Sickle cell think about

Salmonella

network of smooth endoplasmic reticulum surrounding each myofibril

Sarcoplasmic reticulum (blue)

common mechanism: FOOSH snuffbox tenderness: axial compression of thumb metacarpal, pronate the wrist and ulnar deviation 10-25% of them are missed on initial radiographs, come back in 10-14 day for repeats

Scaphoid fx

Why should you not miss a scaphoid fx? Why would this be easy to miss? What can you do about that?

Scaphoid fx have a very high rate of non-union (poor blood supply to scaphoid), but they may be occult on x-ray. Get an MRI to be sure.

Screening is an example of _________ prevention.

Secondary

A type of comminuted fracture in which a completely separate segment of bone is bordered by fracture lines

Segmental

Where can you test to make sure the axillary nerve isnt injured? (rare concern for an AC separation)

Sensation/strength of deltoid

A _______ test picks up the disease most of the time, may have false positives.

Sensitive

Step of pain signaling: Occurs with repeated stimulus and/or inflammation Increase in chemically gated and voltage gated ion channels Increases excitability of nociceptor terminals, lowers threshold for activation, especially true w/ visceral nerve fibers. Nerve injury-> burning, shooting, tingling pain

Sensitization

infectious arthritis, usually involves a single joint (can be multiple if they have RA, CT disorder, or spesis), can be hematogenous (MC) or nonhematogenous. Knee>hip>shoulder>ankle>wrist gonococcal (MC) vs nongonococcal worse

Septic arthritis

2 yo limping cant walk, pain with PROM of hip

Septic arthritis put abuse on ddx for kid who cant walk Test: ESR hip: do ultrasound-> effusion XR: hip and knee hip arthrocentesis blood cultures

prosthetic. R knee history of OA, diabetes, Knee is swollen w erythema, decreased and painful flexion. ddx? workup?

Septic arthritis-diabetes prosthetic-nongonococcal

PE findings, differentiating the septic arthritis and gout.

Septic arthritis: Range of motion pain, Toe would be hot, indurated, decreased glucose, elevated protein and WBC Gout: Excruciating pain even when touched gently, toe wouldn't be hot to touch, shiny purplish red, no induration negatively birefringent Imaging to rule out OA and trauma

Dry eyes, dry mouth, swollen glands chronic inflammatory autoimmune disorder characterized by lymphocytic infiltrates exocrine organs More often in women Can be a complication of rheumatoid arthritis, may be associated with scleroderma,SLE,polymyositis,HIV,HepC(immune deficiencies)

Sjogren's disease

What type of muscle is multinucleated

Skeletal

A snapping or popping sensation due to tendons around the hip moving over bony prominences

Snapping hip

Looking at organs, blood vessels, gas patterns, fat, calcifications, fluid levels relates to what TABCS or radiological interpretation

Soft tissues

A ________ test will confirm a diagnosis, may be some false negatives.

Specific

Antibiotic selection considerations

Spectrum Bacteriostatic (halting growth) vs bactericidal (killing organism) Allergies ROA Penetration Dose/Frequency Monitoring

type of synovial joint with convex surface in concave cavity movement:wide-ranging, flexion, extension, abduction, adduction, rotation, circumduction ex. shoulder, hip

Spheroidal (ball and socket)

fever, cant walk, low back pain, decreased anal tone. ddx? test?

Spinal epidural abscess-get MRI

patient with back pain who is leaning forward on a shopping cart pushing it for comfort should make you think about (there is more room for spinal cord and nerves when leaning forward). inflammed ligaments, CSF squeezed out. Think of this as pre-cauda equina, progression is slow. global weakness (not focal), numbing, difficulty walking, cannot stand upright, no hyperreflexia or clonus

Spinal stenosis

A multiplanar and complex fracture line

Spiral

someone comes to you saying they have pain or limited motion while in a cast.. what do you do?

Split the cast or remove and check under the splint

Soft part of bone

Spongy/cancellous/medullary bone

hematogenous osteomyelitis: MC organism

Staph aureus

Organism for felon

Staph, strep, oral flora

damage to bone exceeds the rate of repair, hard to detect (may need a bone scan or MRI). pain, repetitive traumatic activity, plain film might not show anything

Stress fracture

continuous low level stress over time, may not show up on x-ray. usually 2nd and 3rd MT's, which are relatively fixed. if you suspect, what to do?

Stress fx; rest and immobilize. bring back in 2-3 weeks-calcification may form. Tx: RICE

clinical tests to assess the stability of ankle ligaments (done at follow-up, not acutely)

Stress maneuvers drawer test inversion tests

A fracture in the normal bone that has been subjected to repeated or cyclical loads that in and of themselves are not sufficient to cause a fracture

Stress-Fatigue

A fracture in weakened bone that has been subjected to a load insufficient to fracture normal bone

Stress-Insufficiency

Discoid lupus (chronic conditon) are typically on what areas of body

Sun exposed areas

DMARDs action

Suppresses the body's overactive immune system RISK: sepsis Labs (CBC, BMP), screenings, imagine (chest x-ray) before May takes weeks to become effective

FOOSH, elbow pain, swelling, limited ROM. Fracture immediately proximal to the condyle of the distal humerus

Supracondylar humerus fx (common)

presentation of an achilles tendon rupture

Swelling of distal calf, palpable tendon defect, weak plantar flexion, may still be able to flex (can press down weak) Pos thompson test

Patellar fx PE

Swelling, abrasion possible, rarely open, possible depression at mid patella Palpation: anterior tenderness over the patella, possible depression at mid patella DO NOT assess ROM Cannot straight leg raise

Partially movable cartilaginous joint, bones united by fibrocartilage

Symphyses

Systemic sclerosis management/prognosis

Symptomatic and supportive Monitor every 3-6 months for end-organ and skin involvement, medications Ecocardiology and pulmonary tests yearly Prognosis: possible improvement but incurable. Worse if there is early organ manifestations

Cartilaginous joint where bones are united by hyaline cartilage, immovable.

Synchondroses

type of fibrous joint held together by ligament, immovable

Syndesmosis

Joints with maximum amt of movement, more likely to be arthritic, has joint cavity, articulating surfaces lined by hyaline cartilage, lined by synovial membrane that secretes synovial fluid, articulating bones kept in place with fibrous capsule

Synovial. ** most important for us to know

Subsets of juvenile idiopathic arthritis

Systemic JIA (10-20%) Oligoarticular JIA (50%) Polyarticular JIA (35%) Enthesitis related JIA Psoriatic JIA

chronic dz, diffuse fibrosis of skin and visceral organs and vascular abnormalities Stiff Raynauds phenomenon-chief complaint, skin thickening, "puffy hands" pruritis, GERD Most manifestations have vascular features Many organ systems may be involved Can range from mild disease, affecting the skin, to a systemic disease that can cause death in a few months More often in women

Systemic sclerosis (scleroderma) CREST is limited version

clinical presentation of PAN (most important-systemic, MSK, Skin, Renal)

Systemic sx fatigue, weight loss, weakness, fever, arthalgia/arthritis/myalgia Other organ involvement skin lesions (rash, purpura, nodules) hypertension renal insufficiency neurologic dysfunction-cerebral ischemia GI-abdominal pain esp after meals

fibromyalgia presents as pain that involves both sides of the body, above and below the waist. T or F

T (pain may be initially localized however)

invagination of sarcolemma, part of extracellular compartment. penetrates the cell's interior at each A band-I band junction, associated with paired terminal cisternae to form a triad

T Tubule

The number of standard deviations from the bone mineral density in healthy young white women

T-score

MRI image: fat is bright white

T1-weighted image

MRI image: Water is bright, myelographic effect

T2-weighted image

What should be included on an image interpretation?**

TABCS (technical quality, alignment, bone, cartilage, soft tissues) Description DDx Follow-up

worried about back pain in a TB endemic country (it can infect spine), what tests for a latent TB infection?

TB Gold (Active TB infection necessitates a bacterial culture)

compression fractures are usually treated with _____ brace or _____ (injecting bone cement into vertebral body)

TLSO; verterboplasty

physical exam findings for RA

TTP or with movement Swelling Decreased ROM "bogginess" Warmth and redness may be present Joint deformities

fx usually due to foot hyper-plantar flexion (pressing gas pedal). Top of bone may lose blood supply leading to avascular necrosis-must diagnose.

Talar fx

Abx for OM

Target S. aureus including MRSA and gram - Hematogenous/nonheme: vanc + 3/4 cephalosporin (ceftriaxone-gram - or cefepime-pseudomonas)

What are the TABCS of radiologic interpretation?

Technical quality of image Alignment Bone Cartilage space Soft tissue

Diagnostic criteria for fibromyalgia

Tenderness in soft-tissue anatomic locations Widespread pain in all quadrants (they will have pain at least 11 of these points)

PE findings for OA

Tenderness to palpation along the joint line Bony enlargements (osteophytes) typically no swelling, redness, warmth Decreased ROM Crepitus Joint deformities

infection of the synovial sheath, penetrating injury or spread from septic joint, soft tissue, infection or felon. Kanavel's signs may be present

Tenosynovitis

______ prevention focuses on helping people manage complicated, long-term health problems such as diabetes, heart disease, cancer and chronic MSK ain. Goals include preventing further physical deterioration

Tertiary

suspect DVT. what do you test for (if you have a low suspicion for a blood clot?)

Test for D-Dimer, which indicates thrombolysis If its positive, follow up for mores testing If its negative, there is likely NOT a clot

MC location for adult hematogenous OM. What are some common reasons for an infection?

Thoracolumbar spine IV drug users at risk, UTI, respiratory and skin infections

who are tom dick and harry? what are they responsible for?

Tibialis posterior, flexor digitorum, flexor hallicus. Plantarflexion of foot

useful for diagnosing causes of non-specific systemic symptoms after a tick bite. can pick up on: ehrlichiosis, anaplasmosis, babesiosis, maybe Lyme

Tick panel

two ways we look at antimicrobials and pharmacokinetics:

Time-dependent killing Concentration-dependent killing

Break=fracture Treatment principles: RICE first 48 hrs Pain med-tylenol, ibuprofen more often than NSAID Why dont we put fractures in a cast right away?

To prevent compartment syndrome and allow swelling, if injury is recent it may increase swelling.

why can achilles tendon rupture still plantar flex?

Tom, dick, harry tendons (Tibialis posterior, flexor digitorum, flexor hallicus)

An incomplete buckle fx of one cortex, usually from a compression injury (like FOOSH) often seen in children.

Torus

1st step of pain signaling: nociceptors activated by chemical mediators release an electrical signal

Transduction

A fracture that is perpendicular to the shaft of the bone

Transverse

Two types of regulatory proteins on the actin (thin) filament

Troponin (Ca attaches, actin changes its structure, exposing sites where myosin heads attach) Tropomyosin (detaches from the active sites so myosin can bind)

Test and Tx option for metacarpal fx

Tx: ulnar gutter or radial gutter splint for 1 week followed by buddy taping and progressive motion OR buddy taping and range of motion from the onset Examine these with finger flexion and extension. Check motion with fist closed Focal tenderness at fx site

Prognosis and complications for oligoarticular JIA

Typically resolves in 6 months Uveitis-eye inflammation, screen them with eye exams dont want vision loss

branches of posterior cord of the brachial plexus

ULTRA Upper subscapular Lower subscapular Thoracodorsal Radial Axillary

What should you do instead of saying medial or later forearm?

Ulnar aspect or radial aspect (thumb side) of forearm

joint deformities in RA

Ulnar drift Swan's neck Boutonniere deformity (can be hands or feet, feet less common) Subcutaneous rheumatoid nodules (common in wrists, elbows)

what we can use to look for effusion, what best pocket of fluid to go in, how to guide needle for arthrocentesis of joint

Ultrasound

Most common reason for uric acid level to be high in gout?

Underexcretion (overproduction 2nd most)

Types of Fluoroquinolones

Urinary (good for UTIs) Ciprofloxacin Levofloxacin Respiratory Levofloxacin Moxifloxacin New delafloxacin

Osteomylitis tx-Empiric therapy

Vancomycin PLUS a 3rd/4th generation cephalosporin

what is relationship between vitamin D and calcium

Vitamin D is required for calcium to be absorbed

Two haversian canals in the bone matrix are interconnected by

Volkmann's canal

A dreaded sequela of a missed vascular injury in a supracondylar humerus fx

Volkmann's ischemic contracture

Labs that support septic arthritis diagnsosis

WBC of joint aspirate over 10,000 blood culture lyme antibody

When the fibular is fx below syndesmosis, mortise is usually intact. Most distal fx-distal to the ligament. Treated conservatively--no surgery. What is tx?

Weber A; Pt needs a splint, non weight-bearing on crutches.

When the fibular fx at the level of the syndesmosis, often tearing the ligament. May disrupt the mortise. Tx?

Weber B (mortise joint here looks smooth and symmetric.) Needs 6 weeks of immobilization. Splint->Cast. + Crutches Will need surgery only if mortise is injured.

When the fibula fx above syndesmosis, always tearing ligament, disrupting mortise, always instable. tx?

Weber C, surgery ref

What are some questions you can ask to tease out the mechanism of injury for a patient with msk problem

What happened? How did it happen? Accidental or avoidable? When did it happen? What was the joint position when it happened? outstretched or rotated? How have symptoms changed or progressed? Other injuries? Other joints? Associated symptonms?

What is counted in a CBC

White blood cells -Granulocytes (Eosinophil, neutrophil, basophil) -Lymphocytes -Monocytes Red blood cells (RBCs) Platelets

White vs red muscle:

White: fast twitch type II, poorer blood supply susceptible to fatigue leg muscles (more cramps in this area) Red: slow twitch type 1 more myoglobin resistant to fatigue posture muscles

a bone grows and remodels in response to demands placed on it is (ie. my right hand bones are thicker and stronger)

Wolff's law

Polyarticular JIA most common in

Women, bimodal distribution of age of onset (peak sat 2-5 years old and 10-14 years old)

Ottawar ankle rules: Any tenderness on distal fibula or tibia, bony tenderness at base of 5th metatarsal, or inability to bear weight. Do what?

X-ray (ankle sprains not usually tender on the bones- tender just on the ligaments)

Tests for ankylosing spondylitis

X-rays, HLA-B 27

most calcaneus fx need ____

XR foot views, surgery

Maintenance therapy for gout- go to

Xanthine-oxidase inhibitors, prevents conversion of hypoxanthine to uric acid (gout is a urate crystal deposition disease)

can bacteriostatic drugs become bactericidal if there is an increased conc for susceptible organisms? can bactericidal become bacteriostatic for less susceptible organisms?

Yes

can you bruise muscle? bone?

Yes

Proteins interconnecting the actin filaments

Z disc

Similar to the T score but corrected for age and gender of the patient.

Z-score (used less)

Displacement of clavicle greater than one bone width, shortening greater than 1.5 cm, distal clavical fx always warrants

a referral. non union risk

flip to see a peds xray of elbow

a. olecranon b. humerus c. capitulum d. radial head

opening the fingers is an example of _________, while closing the fingers is an example of ______________. (anatomical movement)

abduction, adduction (midline of hand is the middle finger)

Consider that LBP is effected by knee problems, and knee pain is effected by foot problems. This is why you must always consider the joint _____ and joint ____ as there are many contributory factors effecting more than the joint of pain.

above, below

why surgery may be needed for OM

abx alone will not heal infected, necrotic bone

Tx for femoral acetabular impingement

acetaminophen, NSAIDS, activity modification, deep tissue massage potential surgery

usually due to forced dorsiflexion of ankle (initiating sprint, slipping on stair) may see with direct trauma, may be partial or complete MC in middle-aged men sudden pain, trouble walking, pt may hear a "snap" May still be able to flex Positive thompson test

achilles tendon rupture

arises from gastroc and soleus inserts on calcaenus. what is the action?

achilles tendon; plantarflexes foot

overuse of calf muscles, tenderness increased pain with dorsiflexion

achilles tendonitis, RICE, NSAIDs, immobilize chronic: maybe surgery

clinical presentation of flat fooot

aching feet with standing/walking shoes poor fitting medial border of foot almost touches ground when standing

two types of myofibril

actin (thin filament) myosin (thick)

tests for adolescent idiopathic scoliosis

adam's forward bend test, scoliometer

Another less specific and less sensitive test for muscle breakdown

adolase

Non-modifiable risk factors of osteoporosis

advanced age, caucasian or asian ethnicity, female gender, fam history or osteoporosis or atraumatic fx

intrinsic muscles of hand- nerve supply

all muscles supplied by ulnar nerve except thenar muscles and 1st, 2nd lumbricals which are supplied by median nerve adductor pollicis recieves dual nerve supply from ulnar and median nerves

Gentamicin, Tobramycin, Amikacin are all

aminoglycosides

what drugs should you avoid in someone with myasthenia gravis

aminoglycosides, fluoroquinolones

Bacteriodes, cutibacterium/propionobacterium, clostridium, clostridiodes, and peptostreptococcus are all

anaerobes

long bone is angled

angulation

"Bamboo spine" on x-ray, vertebral inflammation, fused spine, genetic (HLA-B27 20% chance if a first degree relative is affected), calcification of the spine ligaments

ankylosing spondylitis

3 ligaments that make up the lateral ankle

ant talo-fibular calcaneo-fibular post talo-fibular

features of patellofemoral pain syndrome

anterior knee pain at the onset of running, subsides during workout insidious onset Pain from the patellofemoral joint often in young active female-distance runners

majority of ankle sprains involve what ligament

anterior talo-fibular

overall profile of antimicrobial susceptibility testing, generally done for a facility, used to aid in antimicrobial selection, also used to track trends, emerging resistance patterns

antibiograms

ligament of elbow not developed until 2 years of age, common dislocation here in children

anular ligament

angulation toward back of hand or dorsum

apex dorsal

segment that has the greatest rotation or furthest deviation from the center of vertebral column

apex vertebra (A)

angulation toward palm (colle's), arrowhead

apex volar

adds shape to the bone

apophysis

secondary growth center in bone aka

apophysis- starts in boys at 16, girls at 14. Takes 2-3 years to fuse down at iliac crest. Fusion is an indication of complete skeletal growth.

osgood-schlatter, sinding-larsen-johansson, sever's disease are all

apophysitis

bone ends are touching

apposition

growth of cartilage: mature cartilage

appositional growth

what type of postnatal bone growth increases thickness and remodeling of all bones by osteoblasts and osteoclasts on bone surfaces

appositional growth

special test for patellofemoral pain syndrome-- most everything else is normal

apprehension test-patellar inhibition test (With the knee in extension, downward pressure just superior to the superior pole of the patella. Ask the patient to straight leg raise - + result is pain or guarding)

deep vein accompany an _______

artery

difference between arthritis and arthralgia?

arthritis: visible swelling, arthralgia: pain, cant see swelling

surgical fixation of joint

arthrodesis

joint replacement

arthroplasty

surgical procedure to open and explore a joint

arthrotomy

what type of cartilage covers bones at joints to protect them

articular cartilage (type of hyaline cartilage)

Aconeus: a weak synergist muscle

assists triceps in extending elbow, radial nerve

rare, pinches brachial plexus, can mimic carpal tunnel, cubital tunnel, radial palsy, or radiculopathy (so r/o those conditions) loss of radial pulse with raising arm over head

athoracic outlet syndrome

flip to see categories of penicillins

augmentin- amoxicillin/clavulanic acid should be under aminopenicillins

Systemic JIA is an __ disease

autoimmune//idiopathic

continuation of subclavian artery, three branches (gives rise to posterior circumflex humeral artery)

axillary artery

Surgical neck of humerus is important bc it is a site that is prone to fracture, it contains two structures:

axillary nerve posterior circumflex humeral vessels

exits axilla via quadrangular space, winds around surgical neck of humerus with the posterior circumflex humeral vessels, innervates deltoid, teres minor, skin over deltoid region and joint capsule of shoulder

axillary nerve (c5, c6)

CRP may rise above normal within 6 hours of an injury. It peaks at 48 hours. Very high levels are associated with _______

bacterial infections

kills organism, 99.9% reduction in viable bacteria density after 24 hours

bactericidal

When to use bactericidal vs bacteriostatic

bactericidal: high concentrations of organisms, CNS infections, neutropenic patients, infections in areas that are difficult to penetrate like bone bacteriostatic: potential for endotoxin surge slow growing bacteria

inhibits growth, keeps organism in a stationary phase of growth

bacteriostatic

fall prevention

balance training (try standing on one foot) muscle strengthening remove hazards in home fall reduction measures remove meds that may cause AMS

evaluation for hip dysplasia

barlow (infant supine, knees flexed to 90 degrees, hands on knees, legs out-> adduct in and push down-will feel hip dislocated) Ortolani (Out, In)-> knees adducted, reduce femoral head back into acetabulum

How to take biphosphonates correctly

be upright for 30min-1hr after you take it, take with full glass of water (make sure pt is competent enough to do this)

ganglion cyst test

big-mushy small-hard transillumination is diagnostic-flashlight on the bump that pops up when you put the index finger down

difference between osteoblasts and clasts?

blasts-build bone clasts-crush bone

Patellar fx MOI

blunt trauma to patella falling directly on the patella unable to ambulate

bone scan aka ___. what is it

bone scintigraphy (helpful to determine areas of metabolic activity in the body, tracers will collect in highly active areas, can see degeneration.. have to pair this with other imaging)

99% of the body's calcium is found in the ___

bones

Fracture of necessity surgery inherently unstable Referal

both bone forearm injury ((one on left-apex volar one on right-slight valgus))

microscopic fx in periosteum, usually in ulna or radius angulation over 20 degrees-refer

bowing fracture

formed by ventral rami of c5-c8 and T1, gives rise to nerves that innervate the upper limb

brachial plexus

Six superficial muscles of extensor forearm (except 1, 2, the rest take a common origin from lateral epicondyle of humerus)

brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis, extensor digitorum, extensor digiti minimi, extensor carpi ulnaris

what to do with 20-45 degrees of scoliosis

bracing consult

concentrations used for interpretation of susceptibility testing

breakpoint

fluoroquinolones what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

broad-spectrum, limited anaerobic activity. resistance is developing in many gram + organisms Bactericidal, inhibitor of dna gyrase avoid in pts with myasthenia gravis or genetic disorders involving blood vessel changes, or cardiac arrhythmia PO-chelation (dont wash it down with milk) IV Widely distributed into body tissues, urine, kidney, lung, etc Concentration-dependent, renally adjust Tendon rupture, aortic dissection, neuropathy, QTc prolongation Photosensitivty

how is cephalic vein formed, terminated

by lateral end of dorsal venous arch, axillary vein

how is basilic vein formed, terminated

by medial end of dorsal venous arch, brachial vein

presentation and MOI of meniscal tear

can be traumatic or atraumatic (degenerative) focal pain over joint line repetitive squatting, twisting, or compression weight bearing pivoting injury

flip to see a salter harris 3 fx

can result in posttraumatic arthritis casted 3-6 weeks x-ray 7 day after casting follow up at 6 and 12 month to reassess for growth arrest refer

PE findings for a quad tendon rupture Special test?

can't ambulate +/- deformity with a depression above patella diffuse swelling often a palpable step off or soft spot above patella low risk of NV injury ROM: patient cannot straight leg raise

pressure on median nerve-motor branch to thenar weakness (chronic-atrophy). numbness.

carpal tunnel syndrome

spinal surgical emergency: complete compression of spinal canal below L2. Saddle anesthesia. Blunted sensory and motor nerve function to legs, bowel, bladder. Back pain, urinary or bowel incontinence. Diminished patellar and achilles reflexes.

cauda equina syndrome

If someone has Salmonella (sickle cell) or psuedomonas, what abx to use?

cefepime

a single muscle fiber is synonymous with muscle____, skeletal muscle fibers can be up to 30 cm long!

cell

when a person comes in looking drunk/imbalanced and has neck pain, extremity weakness, it might be

cervical myelopathy

taken to see the cervical intervertebral foramen, also known as swimmers view

cervical obliques (this is normal-good sized spaces for intervertebral foramen)

downward TPS-> upward TPS->

cervical, thoracic

hematogenous osteomyelitis more common in

children

other manifestations of sjogren

chronic arthritis, interstitial nephritis, rheumatoid arthritis, vasculitis, vaginal dryness, pleuritis, pancreatitis

glycopeptides Main example, when its used, MOA

class vancomycin is in Not a b-lactam but often used in place of b-lactams if resistance is present MOA is similar-disrupts cell wall synthesis

pectoral (shoulder) girdle components

clavicle and scapula

what is the most commonly broken bone in body, was it poorly designed?

clavicle, no. its there to break to protect apex of lung and other vital structures. its like the bumper of a car

diagnosis of PAN

clinical diagnosis with compatible lab results dx should be confirmed by bx whenever possible angiography sometimes identifies microaneurysms

General principles of splinting: 1. remove _____ from fracture area 2. record pulse, ________, and neurological status at site of injury 3. Cover all wounds with a _______ 4. Immobilize joint ______ and ______ 5. Pad rigid splints to prevent local pressure 6. Support site of injury while splinting 7. Gently align areas of deformity if possible 8. When in doubt-splint!

clothing cap refill sterile dressing above, below

never inject steroids after arthrocentesis if fluid appears

cloudy/purulent

serum concentration is the most important parameter for effectiveness

concentration-dependent killing

dorsal dislocation of navicular bone over talus

congenital vertical talus

Triad of reactive arthritis

conjunctivitis urethritis arthritis Cant see cant pee cant climb a tree

alignments we look for in scoliosis

coronal and sagittal alignment

Enzyme of NSAID: Dominant source of prostanoid formation in housekeeping functions, gastric protection

cox-1

Enzyme of NSAID: Dominant source of prostanoid formation in inflammation; upregulated by cytokines, shear stress, growth factors, tumor promoters

cox-2

fracture of the proximal tibia metaphysis that may cause genu valgum

cozen fracture

elbow overuse carpal tunnel of the elbow, affects ulnar nerve etiology: insidious/over use/resting on elbow persistently

cubital tunnel syndrome

usually due to a crush injury pain/swelling/tenderness need foot x-ray

cuboid fx

ACL tear: history

deceleration injury- possibly with pivoting or hyperextension contact or non-contact giving out episode can be: very painful/non-ambulatory (suspect associated injury) can be: mildly painful/ambulatory (some continue playing) May or may not see joint effusion (palpate posteriorly)

supplies muscles of posterior compartment of forearm

deep branch of radial nerve

exam findings for a both bone forearm injury

deformity frequent, significant swelling NV injury is rare diffusely tender at fracture site check radial, median, and ulnar sensorymotor function, 2 point discrimination/cap refill -Allens test to see if artery is disrupted

patellar tendon tear PE findings

deformity of the patella "high riding patella" step off or soft spot on patella avoid ROM Cannot straight leg raise knee gives out-unable to ambulate patella has gone superiorily

What is the medial ligament called?

deltoid ligament

limited rotation on hip abduction, gait asymmetry-get an x-ray to rule out

developmental dysplasia of the hip

Advanced OA is one of the most common causes of ______ in adults, may have issues with falls and living alone.

disability

sciatica AKA

disc herniation

Phalanges fx what to do

dislocated-reduction conservative: buddy taping

usually surgery decision with ankle/foot fx depends on whether it is ___ or not. leave it up to ortho

displaced

bone is "translated", two bone ends are not touching

displacement

common antibiotic mechanisms

disrupt cell wall synthesis or decrease protein synthesis

Always check circulation and sensation ______ to the injury.

distal

what reflex is mediated by c6?

distal biceps tendon reflex

Etiology: overuse (weight lifters) Inflammation of the distal biceps tendon Pain in antecubital fossa Pain in the elbow area with resisted supination. Diffuse antecubital fossa tenderness. Tx: RICE, activity modification, NSAIDs, rare: sling (remind patients not to use it), surgical exploration (brings more blood supply to area)

distal biceps tendonitis

what type of clavicle fx doesn't heal well

distal clavicle fx--refer for surgery

what fx can develop acute carpal tunnel syndrome

distal radius fx

common, volar tilt is lost

distal radius fx (colles)

in a long bone, one end is growing faster, site of entry and angulation of arteries characteristically going away from the ___________

dominant growing epiphysis

how is the ankle unique in terms of anatomical movements

dorsiflexion and plantar flexion

tendons: extensors of ankle aka

dorsiflexors

What is the Cobb method?

draw lines on the VB of the extreme ends of curve, then perpendiculars from these and measure the angle

side effect of the muscle relaxant Flexeril

drowsiness

CI for colchicine

drug-drug interactions (CYP3A4 inhibitors-grape juice), hepatic or renal impairment

Common physical exam findings Sjogren syndrome: eye (slit lamp) and mouth, neck

dry eyes, decreased tear pool in lower conjunctiva, dilated conjunctival vessels, mucous threads filamentary keratosis dry mouth, decreases sublingual salivary pool, tongue may stick to tongue depressor, frequent caries recurrent swollen salivary glands, need to drink liquids to aid in following foods

inflammation of medial end of palmar aponeurosis can lead to what

dupuytren's syndrome

Epiphysis vs. Apophysis

e-secondary growth plate at end of long bone, adds length a-secondary growth plate that adds shape

what organism-fight bite. what is work up for fight bite

eikenella-use augmentin

flip to see movements of elbow

elbow movements

what age group do we need to be most concerned about NSAIDs?

elderly (risk of GI bleed, heptic issues)

6 diff nerves (subclavius, suprascapular, c5, c6, anterior and posterior division of upper trunk) form this

erb's point

Paralysis involving erb's point, weakness of elbow and flexion and shoulder abduction, policeman's tip hand

erb-duchenne paralysis

symptoms of acute OM

erythema, warmth, swelling, pain at site, reduced ROM, fever, sepsis (if patient comes in septic, look them all over!)

Peroneals function, what do they pass?

evertors of ankle, pass posterior to lateral malleolus

reative arthritis is seropositive t or f

false, RF and ANA are negative

risk factors for polymyositis

fam history of autoimmune disease (SLE, myositis) Vasculitis

infection of pulp space in finger is known as

felon

abscess of finger pad pulp, usually d/t biting nails, can spread from paronychia what could this lead to if its not treated?

felon osteomyelitis of phalanx

patient lying prone, rotate legs in-> external rotation of hip patient lying prone, rotate legs out-> internal rotation if IR is greater than ER, what is present?

femoral anteversion (cause of in-toeing)

fracture of both femoral condyles, moi?

femoral condyle fractures-almost always surgery many types High energy injury (fall from height)

MRI scan contraindications

ferro-magnetic objects allergy to contrast dye kidney/liver disorder obesity (above 350)

definitive dx for systemic JIA

fever present for 2 weeks arthritis for 6 weeks tenatve dx can be made however and therapy started

Dense collagenous bundles, extracellular matrix does not contain much water intervertebral discs, meniscus of knee joint, pubic symphysis cant calcify

fibrocartilage

fatigue, "i hurt all over" tender areas in soft tissues often accompanied by cognitive and mood disturbances over 90 percent female chronic widespread noninflammatory msk pain syndrome with multisystem manifestation higher perception of pain than average--central condition. morning particularly hard

fibromyalgia

lumbrical muscles

flex at the MCP joint extend PIP

flexor digitorum profundus

flexes distal interphalangeal joints; lateral: median nerve (anterior interosseous branch) medial part: ulnar nerve

flexor pollicus longus

flexes thumb, median nerve (ant interosseous branch)

how to determine if flat foot is flexible or rigid

flexible-good arch when they get up on tip toe rigid-painful, no arch on tip toe

flip to see swan neck deformity, what is it and what is it related to

flexion at DIP, hyperextension at PIP RA

flexor digitorum superficialis

flexion of proximal IP joint, median nerve

brachialis

flexor of elbow joint; major part: musculocutaneous nerve and radial nerve (small lateral part)

flexor carpi radialis

flexor of wrist, median nerve

Deep muscles of the flexor compartment

flexor pollicus longus, flexor digitorum profundus, pronator quadratus

deep fascia adjacent to carpal bone, tunnel contains digital flexor tendons and median nerve. structures passing superficially: palmaris longus, palmar cutaneous branch of median, ulnar, and radial nerve, ulnar nerve.

flexor retinaculum (implicated in carpal tunnel syndrome

what to do with flat feet

foot orthotics, PT for heel cord stretches

spondylolisthesis

forward slipping of one vertebra over another (note spinal stenosis also on this pic)

results from tendinitis involving rotator cuff

frozen shoulder

fat pad signs around the elbow, always think

fluid filled cyst arising from degeneration of joint capsule or tendon sheath. tx?

ganglion cyst. usually spontaneous. could aspirate, if recurred: surgery

polymyalgia rheumatica may be associated with what dangerous

giant cell (temporal) arteritis-need to catch right away

mechanism: fall with axial load and external rotation history: "i broke my arm" "i dislocated my shoulder" exam: deformity neurovascular: peripheral nerves: axillary, musculocutaneous (bicep strength-supination, sensation on radial border of arm), ulnar

glenohumeral dislocation

ligaments holding the ball and socket shoulder together

glenoid labrum, glenohumeral ligaments, coracohumeral ligament, transverse humeral ligament

vancomycin abx type, what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

glycopeptides only treats gram +, active against MRSA Bactericidal, disrupts cell wall synthesis Poor oral bioavailability, given IV, PO for C-diff only Widely distributed Cumulative dose-dependent killing AUC-guided-careful with renal Renally eliminated Red man syndrome, nephrotoxicity, ototoxicity (loss of hearing-discontinue immediately)

If patient has a lot of lifestyle modifications they need to make, what can you do to not overwhelm patient?

go over changes, get input from the patient. Ask where would you like to start? Schedule follow up to check in

Peg in Socket fibrous joint. Periodontal ligament holds tooth in socket. immovable

gomphosis

typical causes for septic arthritis

gonococcal (MC in 18-30- Neisseria gonorrhoeae) vs nongonococcal (worse- S. aureus)

migratory arthritis and tenosynovitis followed by pain and swelling settling into 1 or more joints. what is it and tx

gonococcal septic arthritis (MC in young adults) Tx: ceftriaxone PLUS chlamydia tx

the most common form of inflammatory arthritis among men, twice as common in Black men

gout

flip to see the Nash-moe method of vertebral rotation of v bodies

grade 3 significant

Aminoglycosides what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

gram - organisms, mycobacteria (not great for anerobes) bactericidal, inhibits protein synthesis only use when necessary d/t toxicities, avoid in myasthenia gravis PO (empty stomach, large glass of water) Widely into body tissues and fluids including bone, abscesses, poor CSF penetration. Concentration-dependent Nephrotoxicity, ototoxicity

bones bend but don't break-pediatric fx bc their bones are more cartilage

greenstick fracture

incomplete fracture on child-what to do

greenstick- refer, x-ray is repeated 1 week after casting

Pain from hip joint can present as

groin pain, anterior proximal thigh pain, knee pain

orthopedic intervention for genu varum/valgum

guided growth, osteotomy

Most common foot deformity great toe angles "inward" (valgus) Obvious deformity-bunion. red, swollen

hallux valgus tx: wide, padded shoes surgical: corrective osteotomy

side by side hammer and mallet toes. What joints are effected in each

hammer: PIP mallet: DIP

PIP joint fixed in flexion, DIP extended. Most commonly affects second toe. shoe pressure may produce callus. tx?

hammertoe, surgery

how is osteomyelitis spread to the bone?

hematogenous (bloodstream infection) nonhematogenous (localized)

How is rate of mortality for elderly pt with pan

high

bursa between calcaenus and achilles tendon another bursa outside of achilles tendon what if they are inflammed

hindfoot bursitis NSAIDs, proper fitting shoes

Big ones- ped fractures, hip dysplasia, scoliosis, SCFE (13-15 male, 11-13 female usually obese), Perfes (3-12 years old) any child with knee pain-look at their _________. if a child has a limp, ______

hips; refer them

type of surgery for grade 3 and 4 AC tears

hook plate (first lets the coracoclavicular ligaments heal, removed after about 6 months, letting AC heal)

flip to see how we evaluate hip x-rays for dislocation

how we determine the acetabular index

bones originate as _____ cartilage (a 2 year old kid will look like they don't have a lot of bones on x-ray, but they just haven't ossified yet)

hyaline

when to refer genu varum/valgum

if you suspect it is pathological

findings for cervical myelopathy

imbalance, hyper reflexes, clonus

Carbapenems: Impipenem Meropenem Ertapenem doripenem What spectrum do these have? What is the warning for doripenem?

imipenem: Moderate Meropenem: Moderate Ertapenem: narrowest, no pseudomonal activity doripenem: Most pseudomonal activity; dont use in ventilator associated pnemonia

Retic account is a measure of

immature red blood cells (high- body is sensing something wrong, will produce more RBCs)

fibrous joints are mostly synarthrotic, meaning they are ______ . what are the three types?

immovable sutures, syndesmoses, gomphoses

Tx for Polymyositis

immunosuppressants/corticosteroids: Prednisone (high dose-40-80g-cconsolidate doses and reduce slowly when enzyme levels are normal) If that doesnt work: Azathiopine or Methotrexate diet and exercise to avoid weight gain from steroids

pinching of supraspinatous tendon over the humeral head and below the acromion; narrow subacromial space can happen from overuse, predisposition, AC arthritis

impingement syndrome

Menopausal women have ______ osteoclastic activity and _______ osteoblastic activity.

increased, decreased

clinical presentation of osteonecrosis, what imaging?

indolent onset dull ache or throbbing pain in the groin/thigh, lateral hip pain with attempted straight leg raise AP of pelvis, frog-lateral view, MRI if needed

three subcategories of adolescent idiopathic scoliosis, which is more common in girls, usually family history

infantile, juvenile, adolescent

Abnormal WBCs indicate

infection or inflammation viral infections-> slight leukopenia, reactive lymphocytes larger Bacterial infections->leukocytosis with left shift Sepsis-high or low WBC meds can interfere: prednisone (increase), chemo (decrease)

complications of open fractures

infection, chronic osteomyelitis, soft tissue problems, chronic pain, limp, non-union, malunion

What types of medical factors may inhibit fx healing?

infection, nicotine use, meds (NSAIDs controversial, phenytoin, ciprofloxacin, corticosteroids, anticoagulants), malnutrition, diabetes, immobility, alcohol abuse, albumin deficiency

osteomyelitis pathogenesis

infectious agent binds to bone, phagocytes attempt to contain infection, releasing enzymes to kill infection and break down bone bacteria difficult to kill when adhered to bone pus pocket created dead bone separates from healthy bone to fragments (sequestra) elevated periosteum deposits new bone (involucrum) sinus tract may form

4 stages of legg-calve-perthes disease

inflammation (pain) fragmentation (mottled femoral head on xray, painless) re-ossification healed

cauda equina physical exam

inspection, palpation, percussion, ROM, reflexes (patellar/achilles seated), strength, rectal exam looking for tone, perianal strength exam_boyyyye how do u do that>??

PE findings: patellar dislocation

inspection: visible swelling relocated or dislocated palpation: tenderness medial side of patella, focal to this area palpate posteriorly for effusion Skip ROM Special: if its in question apprehension test : extend knee, gently push the patella laterally, again recreate the position of injury

Shoulder views

internal, external rotation (look at humeral head to see figure out which one, internal: ice cream sitting on cone-eating ice cream with arm turned in, external: icecream falling off cone-arm facing out), baby arm, scapular Y, acromioclavicular stress view

what type of postnatal bone growth helps in lengthening the bones

interstitial bone growth

growth of cartilage: immature cartilage

interstitial growth

Two types of ossification during development, what are they?

intramembranous ossification (membrane bone develops from fibrous membrane-flat bones-cervicles, cranial bones) endochondral ossification (this is the pic) (cartilage-endochondral bone forms by replacing hyaline cartilage, forms most of the rest of skeleton)

elevated periosteum deposits new bone

involucrum

Joint damage in RA is

irreversible- bony erosions can only be stopped progression wise untreated-joint destruction increased disability and decreased quality of life

generates force by changing muscle length

isotonic

Why is HCTZ (Hydrochlorothiazide) a risk for gout pts?

its a diuretic, which increases serum uric acid

collagenous structure that surrounds the joint like a sleeve; protects cartilage while allowing movement of joint

joint capsule

paralysis that causes a claw hand, effects lower trunk of brachial plexus

klumpke's paralysis

normal infant posture

kyphosis in the sitting position

Sulfamethoxazole-trimethoprim what type of bacteria, MOA, bactericidal or bacteriostatic, CI, time or concentration dependent

large spectrum, including MRSA bactericidal, inhibitor of folate synthesis don't use with sulfa allergy or pregnancy PO Widely distributed into tissues and CSF may cause SJS, hyperkalemia, blood dyscrasias

Looking at alignment of verterbral bodies in neck

lateral cervical flexion (this image is normal that it is a little but of forward motion at multiple levels)--important to assess the ADI region-make sure the spinal cord isnt smashed between odontoid process and C1 spinous process

_____ meniscus associated with ACL tear, but ______ meniscus more common over all

lateral; medial

flip to see AP view of the pelvis. Which one is dislocated, how can you tell?

left is posterior dislocated, cant see the lesser trochanter, looks like its adducted

avascular necrosis of the hip present with pain/limping more common in boys 3-12 years old

legg-calve-perthes disease

attach bone to bone

ligaments

what is the ligament connecting the femur and pelvis

ligamentum teres

important components of pt education related to health promotion & screening tests

limitations of screening, screening options, customize risk communication, risks and benefits, potential to help pts avoid preventable morbidity and early death, counsel about behavior and lifestyle

bones are classified by four shapes

long (humerus), short (tarsal), flat (scapula), irregular (sacrum)

typical management of greenstick fx

long arm splint and refer to ortho

features of neuromuscular scoliosis

long c-shaped curve may happen in cerebral palsy or other neuro conditions tend to be in thoracic spine, toward left convex

flip to see the achilles tendon rupture tx

longggg recovery

the leading cause of disability in the world, second most common reason to seek care in a primary care office

low back pain (LBP)

ankylosing spondylitis sx

low back pain, SI joint pain, stiffness. at least 30 minutes every morning to loosen up, weight loss/fatigue, costochondritis, endhesitis-achilles/plantar fascia, heart block)

Tx for polymyalgia rheumatica

low dose corticosteroids (Prednisone 10-20mg/day) most patients require at least 2 years calcium and vitamin D-prevent osteoporosis PT- ROM

pain over lower leg, tender. x-ray may not show anything (would need bone scan to see). pain with activity. tx?

lower leg stress fx try to rest (tibia 6-8 weeks; fibula: 4 weeks). NSAIDs.

Test for lymes

lyme antibody test + western blot to confirm

hx and PE of osgood schlatters

males more often often sports injury with insidious onset complaints of chronic focal pain at tibial tubercle maybe will have prominence of the tibial tubercle

Presentation of tibio-femoral dislocation. what is at risk

may complain of a cool foot or inability to move foot often an ortho emergency-get arteriogram and ortho involved Motor sensory: high association with peroneal or tibial nerve

aligment check for genu varum

measure intercondylar distance, anything above 6 cm is abnormal

how to check for genu valgum

measure the internalleolar distance, greater than 8 cm is abnormal

erythrocyte sedimentation rate (ESR). What is it and whats normal?

measures time it takes for erythrocytes to fall through plasma over a period of 1 hour normal: RBCs settle slowly from plasma inflammation: increased plasma proteins called acute phase reactants cause RBCs to aggregate and settle rapidly->increased ESR

all muscles of flexor compartment nerve are all supplied by median nerve, except

medial muscle of flexor carpi ulnaris, medial muscle of flexor digitorum profundus

Pectoralis major

medial rotation and adduction of shoulder, flexion of shoulder joint; medial and lateral pectoral nerve

How do the basilic and cephalic veins communicate?

median cubital vein (used for drawing blood)

anterior interosseous nerve is a branch of the

median nerve

nerve formed by both medial and lateral cord, lies medial to brachial artery, enters forearm between two heads of pronator teres, enters palm deep to flexor retinaculum

median nerve

thenar muscles are innervated by

median nerve

a tear in the medial or lateral meniscus

meniscal tear (lateral is most commonly associated with an ACL tear, medial is the most common)

common injuries that go with ACL tears

meniscal tears are common with ACL tears PCL tears are often associated with ACL tears

fibrocartilage structure between articular cartilage that provides stability and cushion. Adherent to the synovial membrane.

meniscus

medial deviation of the forefoot, heel is neutral

metatarsus adductus (also evaluate hip [developmental dysplasia] and necK)

if a bone like clavicle is broken in half, you could call it a ________ fx

midshaft

drug concentration required to inhibit growth

minimum inhibitory concentration (MIC)

Step of pain: adaptive processes through which pain impulses may be enhanced (central sensitization) or diminished either centrally or in periphery

modulation

When a muscle fiber is excited, the AP is carried to t tubule, causing an integral protein to detach from sarcoplasmic reticulum, causing Ca to be secreted out. This leads to ______

muscle contraction (the blue is the sarcoplasmic reticulum, the inverted box is the T tubule)

testing the sensorimotor function for musculocutaneous, median, and ulnar nerv

musculocutaneous m: biceps, s: radial aspect of forearm radial s: back of hand, m: wrist extensors median s: thumb index long radial half of ring finger, m: thenar muscles ulnar s: ulnar side of hand m: intrinsics abduction)

derived from lateral cord, below the elbow it pierces the deep fascia and continues as lateral cutaneous nerve of the forearm

musculocutaneous nerve

What can happen in PAN when there is narrowing or occlusion of coronary arteires

myocardial infarction

densely packed, rodlike elements of skeletal muscles, why it is striated

myofibrils

tx for ACL

need MRI and surgery (wont heal on own, bathed in joint fluid which inhibits healing)

Management of Legg-Calve-Perthes

non weight-bearing refer may need PT

tx for patellar fx nondisplaced vs displaced

non-displaced conservative- knee immobilizer displaced (MC) surgery

___________ joint pain has loss of active but not passive range of motion and tenderness. no deformity

nonarticular

Integrity of bone has been disrupted, but the pieces have not been displaced at all

nondisplaced fracture

potential complications of scaphoid fx

nonunion, avascular necrosis. ANY suspected scaphoid fx is treated like one until proven otherwise

tests for carpal tunnel syndrome

normal inspection-possible thenar atrophy and dry skin over median nerve distribution if late Phalen's maneuver and Tinel's test test abductor pollicus longus 2 point discrimination

partial dislocation of radial head in kids, caused by parents grabbing child by the wrist

nursemaid's elbow

what is OLD ACIDS of describing pediatric x-rays (after you describe the age, gender, type of view, MOI)

o (open or closed) l (location) d (degree-complete or incomplete) a (articular) c (comminuted) i (intrinsic bone quality) d (displacement) s (soft tissue injury)

curves 10-25 degrees: curve 25-40 degrees: Curve over 45 degrees:

observation TSLO brace surgery

What to do with scoliosis of 20 degrees or under

observation and conservative management

Be aware of sulfa allergies and celoxib

Opioid pearls: start with immediate release formulation, combine analgesics from different drug classes: targets different pain pathways, synergistic effect allows for lower doses, decreases opioid dependence Prescribe other essentials: Bowel meds, naloxone

Sometimes you may miss a fx. On day 10-16 of bone healing, you can see calcification on x-ray. So if its not getting better in 10-14 days, have patient come back and get another x-ray. if we miss a fracture it will show up (calcium deposits)!

Tx options for herniated disc include: oral steroids epidural steroid injection cervical or lumbar disectomy surgery

causes of internal rotation you should refer to ped ortho: club foot, skew foot, cerebal palsy, and developmental dysplasia

children until age 2 should be checked for developmental dysplasia of the hip at every well child visit

deep elbow flexion test-numb fingers is good for ulnar nerve ulnar nerve abducts fingers (intrinsics)

for CBC w/differential we want to look at the absolute numbers. not percentages.

for fx in kids, closed reduction and casting usually sufficient. non union is rare. be aware of growth plates

growth plate fx may result in premature growth cessation and deformity. Growth problem in types 3,4,5. All types require reduction if significantly displaced, splinting, non-weightbearing status, and orthopedic referral

growth plate is weakest part of bone, especially in hypertrophic zone. periosteum protects the bone.

intermedulary rod through cancellous bone favored over traction

keep in mind: inflamed meninges increase drug penetration eye-use topicals pericadium-transporters biofilms-common in prosthetics-are negatively charged, they bind with positively charged anx and prevent them reaching target

out-toeing causes to refer to ped ortho: external tibial torsion, slipped capital femoral epiphysis, legg-calve-perthes

pars defect have minor trauma and pain, it goes away. Back pain from minor injury. often happens in young athletes

polymyositis most common in women mid-40s

etiology: trauma, slip on ice is common fat pad signs cant extend the elbow treated surgically

olecranon fx

Which end of the muscle is immovable, which is movable?

origin, insertion

intraarticular knee fractures always go to

ortho, usually needs surgery

degenerative joint disease AKa

osteoarthritis

what is the most common form of arthritis

osteoarthritis

osteocytes are matured _____

osteoblasts

cells that break down / reabsorb bone matrix

osteoclasts

inflammation of bone due to infection can be acute vs chronic

osteomyelitis, note bone demineralization on xr

Flip to see some rare pathological fx that could occur when taking biphosphonates

osteonecrosis of the jaw could also happen

Results from death of varying amounts of bone in the femoral head from traumatic disruption of vascular supply, potentially from steroids or other causes. They may develop local osteopenia/osteoporosis. Loses trabeculae, may lead to femoral collapse.

osteonecrosis/avascular necrosis (here you can see sclerosis of bone, head is basically gone/misshapen, subluxed femur)

T score less than -2.5

osteoporosis

low bone density-imbalance between bone resorption and bone formation predominantly over age 60, mostly women (50% post menopausal women get osteoporosis fx) greater risk of mortality after a fx

osteoporosis

number 1 risk factor for compression fractures

osteoporosis

bones are cut and re-oriented, often used in the correction in malunion of fractures

osteotomy

what can make respiratory depression worse when taking opioids

other depressants, sleep, age (infants/older adults), disease (COPD, cardiopulmonary, renal), similar effect in all agents at equianalgesic doses)

clinical presentation of Hip Impingement aka Femoral Acetabular Impingement (FAI)

pain over greater trochanter with associated hip abductor weakness positive C sign (where pt points to the pain)

characterized by chronic thickening of the tendon of the supraspinatus and its impingement against the coraco-acromial arch

painful arc syndrome

deep fascia, central thick part of fascia in palm, triangular in shape, (attached to middle phalanx, inflammation of medial end leads to contracture-dupuytren's contracture)

palmar aponeurosis

This superficial hand muscle improves the grip by steading the skin on the ulnar side, lies across the hypothenar eminence

palmaris brevis

what muscle in the forearm is not always present in people

palmaris longus

c2 is the only cervical verterbrae to have a ______ (can fracture)

pars

what is subluxation

partial dislocation of a joint

A sesamoid bone (a bone formed after birth in a tendon where it passes over a joint) example is..

patella

Adam's test

patient stands in front of you, feet shoulder width apart, hands together, bend forward at waist, arms hanging down

holds hips in flexion and abduction, treatment for developmental dysplasia of the hip

pavlik harness

Muscles of the pectoral region

pectoralis major, pectoralis minor (deep to major), subclavius (inferior to clavicle), serratus anterior

things to look at thoracic AP view

pedicles, TPs, every rib

Flip to see other lab tests to support the RA diagnosis

people can get gout and RA!

flip to see arthrocentesis results

people that have Gout can also have septic arthritis

Thick heavy fibrous envelope of all bones

periosteum

inflammation of tendons passing posterior to lateral malleolus

peroneal tendonitis (tx: RICE, possibly immobilize, possible steroid injection)

flat feet aka ___. often family history

pes planus

what is the end of a long bone in a child that is formed from one or more secondary ossification centers?

physis

Chronic Plantar Fasciitis

plantar fibroma soft insoles, padding cortisone injections surgical

hemoglobin is decreased in

polymyalgia rheumatica

idiopathic polymyositis, idiopathic dermatomyosytis, SLE or Systemic sclerosis associated polymyositis/dermatomyositis myositis associated with malignancy or HIV these are all types of

polymyositis

systemic ct disease characterized by inflammatory and degenerative changes in proximal muscles, sometimes skin rash

polymyositis

clubfoot treatment over 4-6 weeks

ponseti technique (series of casts to bring the foot into the neutral position)

Joint aspiration findings between pseudogout and septic arthritis

positively birefringement rhomboid crystals septic arthritis: pus, high WBC, low glucose, high protein

inflammation of post tibial tendon (a plantar flexor of foot) passes posterior to medical malleolus tx?

posterior tibial tendonitis Rest, NSAIDs, immobilize steroid?

hip dislocation: pain, cant walk what direction is it usually in? what nerve might be affected?

posterior; sciatic

biceps brachii

powerful supinator of forearm, flexor of elbow joint, musculocutaneous nerve

if someone has CI for NSAIDs or elderly/GI problems, you can use ____ for gout

prednisone

septic bursitis--need to differentiate between septic arthritis. It is usually less serious than septic arthritis. MC areas? sx? dx?

prepatellar and olecranon pain, tenderness, erythema, swelling, warmth of bursa bursa aspiration (dont go right into the redness)

pronator quadratus

principle pronator, median nerve (interosseous branch)

a more severe symptom to. look out for with herniated disc

profound weakness (this may become permanent)

Pronator teres

pronator of forearm, weak flexor of elbow joint; median nerve

superficial muscles in flexor compartment of forearm, all origin of medial epicondyle (5)

pronator teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, flexor digitorum superficialis

serratus anterior

protracts scapula; long thoracic nerve

Pectoralis minor

protracts scapula; medial and lateral pectoral nerve

by far, the most common metatarsal fx. often occurs with lateral ankle sprain- forcibly evert ankle (peroneal brevis can pull the bone off). Avulsion fx

proximal 5th metatarsal (make sure to palpate base of 5th metatarsal!) tx: usually conservative, immobilize, crutches--likely to heal aka psuedojones!

Fx of the humerus in the proximal third (close to surgical neck) Predisposition: Osteroporosis Tx: immobilize with sling PT: pendulums

proximal humerus fracture

how to divide up long bones

proximal, middle, distal third

Deposition of calcium pyrophosphate crystals

pseudogout

spaces between palmar skin and distal phalanges, tight compartments called fibrous septa

pulp space

Be worried about pseudomonas with

puncture wounds of feet IV drug users, immunosuppressed

when ultrasounding a patients hand what should you do

put it in a water bath-pink tray. eliminate scattering

space is important because axillary nerve and posterior circumflex humeral vessels exit from here

quadrangular space

flip to see normal radius x-rays and what to look for

radial inclination should be 30 degrees wrist joint slight tilt toward palm

branch of posterior cord of brachial plexus exits axilla traversing through lower triangular space divides into two branches: superficial (courses anteriorly along with radial artery, supplies skin of lateral dorsum of hand) and deep (runs posterior to forearm, supplies all muscles in posterior compartment of forearm)

radial nerve

sciatica is an umbrella term for all the

radiculopathies

On an X-ray image, things that are more dense will have more ____________ while less dense will be more _______________.

radiopacities (white) radiolucent (dark)

arthritis following an infection *microorganisms cannot be cultured from joints, seronegative (RF and ANA neg) Affects males more, age 20-40

reactive arthritis

in-toeing/out-toeing management

reassurance and observation; refer if it is activity limiting, pain, limping

back pain, leg pain, leg numbness and/or incontinence always warrants a _________

rectal exam (r/o cauda equina-looking for tone)

tx for patellar dislocation

reduce (put it back into extension) knee immobilizer with patellar cutout

growth mostly occurs in the physis, but it is the weakest point. more likely a growth plate fracture than a sprain. what are the classifications?

refer all of them to ped ortho-risk of growth arrest

what to do with SCFE?

refer, non-weightbearing, may need pinning in situ (surgery)

what to do with skeletally immature patients at risk for scoliosis. When to consider surgery?

repeat AP x-rats every 4-6months. A change of over 5 degrees, resulting in a curve magnitude of 20 degrees warrants a spinal surgeon

Presentation of septic arthritis

resistance or significant pain with passive ROM swelling, fever, joint warmth, joint effusion, TTP, pain with weight bearing, fever, sepsis

fibrous bands that hold ankle tendons in place

retinacula

cause of genu varum/valgum (later onset around 4), disease of bone mineralization. may be due to poor diet or vitamin D absorption Tx: medications (see endocrinology), surgical correction

rickets (low bone density)

when to refer pes planus

rigid flat foot, painful flat foot

what finger receives nerve supply from all 3 nerves (median, ulnar, radial)

ring finger

why do you want to reduce the hip right away?

risk of sciatic nerve issues

Presentation: Weakness more so than pain, functional deficits of ADLs, poor ROM in some Examination: no atrophy, minimal tenderness if any, severe:cant hold arm up or reach overhead, may or may not involve trauma, focused strength of supra, infra, spinatous and subscapularis (empty can test-push down they will still be strong) Drop arm (cant hold weight of arm)-> Virtually diagnostic when positive.

rotator cuff tear

organisms involved in tenosynovitis tx (empiric/bite/gonococcal)

s. aureus, strep, gonococcus, oral bacteria (eikenella if human, pasteurella if cat) empiric tx: vanc + 3rd gen cephalosporin pain control splint ortho consult for likely i&d bite wound: ampicillin/sulbactam (unasyn) gonococcal: ceftriaxone and doxy for chalmydia

if a child has tenderness near a growth plate, always suspect

salter-harris fx

what is the key to the Cobb method

same endpoints should be used when comparing curves over time 2-7 degrees difference is considered measurement error

unit of muscle fiber for contraction

sarcomere

tendons that attach to the pes anserine - hamstrings

sartorius gracilis semitendonosis NOT semimembranosis (semi-not a memberanosis)

anatomic snuff box tenderness or diffuse tenderness and guarding with ASB tenderness = ________ until proven otherwise. what to do?

scaphoid fx (MRI, thumb spica, reeval n 1 week or bone scan if cannot do MRI)

anatomic snuffbox tenderness is bascially diagnostic for what

scaphoid waist fx

all rotator cuff muscles attach to the

scapula

when looking for shoulder dislocations, sometimes the AP view is not diagnostic. What other x-rays should you order?

scpaular Y or axillary

right elbow pain and forearm swelling. pos for gon and chlamydia

septic arthritis, septic bursitis arthocentesis: few WBCs gonococcal septic arthritis

dead bone separates from healthy bone to fragments

sequestra

chronic OM features

sequestra usually present sinus tract presence is pathognomonic-may drain pus flare-ups wounds/ulcers overlying bone that does not heal

inflammation of sesamoid bones repetitive force, high feels tx?

sesamoidits

common cause of heel pain, overuse injury, running and jumping sports. self-limited, will stop after growing stops

sever's disease (tx activity modification, NSAIDs, ice, heel cups, CAM boot)

hip fx presentation, what x-rays to get

severe pain in thigh, obvious deformity, unable to move or bear weight hip, knee, and pelvis (AP lateral of femur) x-rays (joint above and below)

buckle fx in kid/distal radius torus fx. what is the treatment?

short arm cast

what to do with a torus fx

short arm cast 2-3 weeks, complications rare. usually little swelling or tenderness, very common

scaphoid fx tx

short-arm thumb spica splint (6-8 weeks) + ortho referral follow up 1 week

bone is displaced and translated longitudinally

shortening/overriding

flip to see shoulder joint movements

shoulder movements

apophysitis of distal pole of patella, jumper's knee, more often males. what is it and tx

sinding-larsen-johannson syndrome' RICE, NSAIDs, activity modification

the tract of infection between bone and skin

sinus tract

What type of muscle is voluntary?

skeletal

What types of muscles are striated

skeletal and cardiac

1 cause of genu varum: long bones are thinner

skeletal dysplasia

Used as adjunctive therapy for muscle spasms, back/neck pain, limit use to 2 weeks, do not work directly on muscles, relief is most likely d/t sedation, avoid in older adults, esp in combo with benzos as it is sedating!

skeletal muscle relaxants

Creatine kinase: CK-MM mostly found in ______ muscle, while CK-MB mostly found in _______ muscle

skeletal; cardiac

the superficial veins typically supply the ____

skin

Tx for radial head fx

sling for 7-10 days ROM exercises as early as day 2 (elbows are terrible about stiffness)

Management of non-displaced, not severly displaced clavicle fx

sling, gentle ROM exercises

anterior and superior displacement of femoral neck, usually after puberty, fracture of femoral neck. obese adolescent, male dull aching, knee pain looks like ice cream falling off of a cone

slipped capital femoral epiphysis (SCFE)

Pain can be described in many ways by patients. what are some examples

soreness, aching, shooting pain, dull, referred pain, numbness

ESR stays elevated longer than CRP Can also be elevated in: anemia, renal disease, obesity.. so it is non-_____

specific

infection spread from vertebral bodies to end plate, pus pocket pushes out on spinal cord, producing neuro deficits and radicular usually back pain. How to diagnose?

spinal epidural abscess need MRI to diagnose

if someone has growth plate tenderness, always

splint it and send to ped ortho

a test to check for disc herniation where you do extension and rotation of neck, will cause numbing of dermatome

spurling's maneuver

compression fracture on AP xray looks like

squished owl face

choosing an abx agent: tips

start with beta-lactam if possible use agent with narrowest spectrum possible patients recent hx of antimicrobial use use facilities antibiogram to avoid agents with growing resistance

subclavius

steadies the clavicle, nerve to subclavius

injury of a muscle or tendon

strain

a bursa located deep to acromion process of scapula, comes in constant tension with supraspinatus muscle

subacromial bursa

bursa under elbow that can be inflammed with friction and be very tender

subcutaenous olecranon bursa

supplies skin on lateral dorsum of hand

superficial branch of radial nerve

fracture above elbow/condyles

supracondylar fracture (does not disrupt triangle)

most common pediatric elbow fx, mechanism, what is the risk? what to check?

supracondylar fx, FOOSH, high risk of NV compromise (check brachial artery, cap refill, check bones above and below elbow including clavicle), watch for compartment syndrome) refer

Apex posterior angulation (radius should normally point to condyle) Have to be perfectly reduced to heal (refer to specialized ortho surgeons) Gunstock deformity: cant extend

supracondylar humerus fx

fat pad signs (which are bleeding) on xray in which fxs?

supracondylar humerus fx radial head fx olecranon fx

gunstock deformity can come from what fx

supracondylar humerus fx--- refer

tx for osteonecrosis

surgery

what to do with 45 degrees of scoliosis

surgical consult

flip to see clinical presentation of stress fractures of the femoral neck (hip). in a young patient it is considered a

surgical emergency--potential for osteonecrosis

uses abx in serially diluted solid agar that contains a culture of the test microorganism to determine MIC and resistance to drug

susceptibility testing

type of fibrous joint only found in the skull, held together with very short interconnecting fibers, bone edges interlock

suture

gout sx

swelling near and beyond affected joint pain redness or shiny skin loss of appetite mild fever or chills

Radial head fracture exam findings

swelling, bruising, careful examination of the skin tenderness over the radial head-focal neuro: sensorimotor to radial, median, and ulnar nerve low risk of nerve injury

exam findings for olecranon fx

swelling, bruising, palpable indentation at the olecranon. don't assess the strength neuro: sensorimotor to radial, median, and ulnar nerve

exam findings for a distal radius fx

swelling, often deformity diffuse tenderness about the wrist check radial, median, ulnar nerve sensorimotor, including 2 point discrimination. median nerve is most at risk can develop acute carpal tunnel syndrome>hematoma into carpal tunnel the bruising in this pic might come overnight

allows you to see cervical thoracic vertebrae region (if you cant find C7)

swimmers view

how are joints classified with movement?

synarthrosis (no movement), amphiarthrosis (slightly moveable), diarthrosis (freely moveable), synovial (freely moveable, enclosed by joint capsule and lined with synovial membrane)

thick viscous fluid inside joint capsules

synovial fluid

Gout is typically diagnosed clinically based on the rapid development of monoarticular arthritis marked by swelling and redness usually involving the first metatarsophalangeal joint. In equivocal cases, what can be used for dx?

synovial fluid analysis collected from joint or tophus

work up for septic arthritis

synovial fluid analysis with culture (athrocentesis-Pus usually happens) high WBCs->infection often greater than 100k if nongonococcal glucose less than 40 (bacteria eat it up) lactate >10 gram stain with bacteria 50% of time WBC, CRP, ESR, Procalcitonin (tells us about bacterial infection) Blood cultures (pos over 50% nongonooccal and 20% gono) XR- soft tissue swelling/effusion

Still's disease aka

systemic juvenile rheumatoid arthritis

a chronic autoimmune multisystem inflammatory disease, relapsing and remitting course, affect any organ system. but most often: skin (CT), joints, kidneys, blood cells, nervous system. sx: triad of fever, joint pain, and rash. fatigue may be most bothersome Other manifestations: pulmonary, MSK, GI, Derm, Cardiac, Renal, Heme, Psych, Neuro management depends on type of organ involvement

systemic lupus erythematous

bacteria can thrive in our joints, they aren't protected by our immune system. t or f

entrapment of posterior tibial nerve by flexor retinaculum due to inflammation Pain on sole of foot repetitive activity RA, pregnancy, acute trauma: fx, dislocation, soft tissue swelling

tarsal tunnel syndrome Rest, NSAIDs, immobilization (ankle splint), possible surgery

Lactate dehydrogenase (LDH)

tells us if there is acute or chronic tissue damage investigate variety of diseases involving heart, liver, muscle, kidney, lung, blood monitor changes in tumor burden after chemotherapy disorders of muscle breakdown (dermatomyocitis, polymylocitis, PAN) innaccurate is blood sample is hemolyzed (potassium is also like this, remember?)

Sx to look out for to differentiate polymyalgia rheumatica and giant cell arteritis. What to do if they have the sx of GCA?

tenderness in temple arteries, jaw cramping, elevated sed rate, headache, high fever, lack of response to prednisone, visual loss, high sed rate Immediate: Temporal artery bx

PE for MCL, LCL tears

tenderness over the MCL or LCL Valgus stress testing (knee in slight flexion) Varus stress testing (knee in slight flexion) Lachman: test for ACL integrity Anterior/posterior drawer test (for ACL, PCL integrity)

attach muscle to bone

tendon

elongated bursa that wrap completely around a tendon

tendon sheath

what is injured in a sprain? strain

tendon, muscle or tendon

rotator cuff is the ______ of the SITS muscles (supraspinatus, infraspinatus, subscapularis muscles, teres minor)

tendons

tear of radial collateral ligament causing elbow issue

tennis elbow

inflammation of tenosynovium

tenosynovitis

What are Kanavel's signs?

tenosynovitis - sausage digit (swelled, firm) - digit held in slight flexion - tenderness over flexor tendon sheath - pain with passive extension - flexed posture of finger

the sheath surrounding a tendon

tenosynovium

good test for motor median nerve

testing the abductor pollicis longus; turn palm up, thumb toward push toward index

When someone has congenital scoliosis, monitor what

the progression

subgroups of hand muscles

thenar (flexor pollicis brevis--does not flex the IP joint, abductor pollicis brevis, opponens pollicis-deepest) hypothenar (flexor digiti minimi, abductor digiti minimi, opponens digiti minimi, palmaris brevis-v superficial, SC muscle) midpalmar (adductor pollicis, lumbrical muscles, palmar interossei-deepest muscle in hand, dorsal interossei)

Distal pole scaphoid fractures, which have good blood supply, low non-union rate. what tx?

thumb spica cast

fracture of the proximal tibia is known as

tibial plateau fracture (intra-articular injury)

super rare- dislocation of the knee tibia posterior. what is it and what are the risks?

tibio-femoral dislocation high risk for popliteal artery disruption high risk for peroneal nerve or tibial nerve disruption multiple ligament disruptions

maintains integrity of the mortise joint

tibofibular ligament

what ligament joins the distal tibia-fibula? What is its function

tibofibular ligament maintains integrity of mortisse joint

time above MIC is the most important parameter for effectiveness

time-dependent killing

common in kids 9months-3 years old non-displaced spiral fracture tibial shaft slide with a parent patient will not bear weight on affected leg

toddler's fracture long leg cast

Plantar flexors that pass posterior to medial malleolus aka

tom, dick, and harry tendons

subcutaneous nodules comprised of monosodium urate crystals in a matrix of lipids, protein, and mucopolysaccharides

tophi

tx for femur fracture

traction splint-temporary

Step of pain: Electrical signal moves from site of injury to spinal cord and brain

transmission

Risk factors for osteonecrosis?

trauma, corticosteroids, alcohol, sickle cell anemia

space is important because it has radial nerve and deep artery of arm

triangular interval (lower triangular space)

The posterior compartment of the arm contains what muscle and what is the innervation

triceps brachii, radial nerve

C7 mediates what reflex?

triceps reflex

the Y- shaped epiphyseal plate at the junction of the ischium, ilium, and pubis in the immature skeleton

triradiate cartilage

inflammation and hypertrophy of the greater trochanteric bursa

trochanteric bursitis (beneath IT band

two sets of lymph nodes related to upper extremity

trochlear nodes (by elbow-basilic vein/radial side drains here) and axillary nodes (radial side-drains here)

toe walking is usually idiopathic. t or f

true

neurofibroma, astrocytoma, osteoid osteoma (benign-low back pain in child-aspirin helps) are all ______ that could cause scoliosis

tumors

What is the weber classification of ankle fx?

typically classified at medial end--worry about the syndesmosis

because NSAIDs have GI toxicity, avoid using in someone with an active _________

ulcer

what artery divides into superficial palmar arch and deep palmar arch (a little bit, it is mainly formed by radial artery)

ulnar artery

branch of medial cord, descends down and pierces medial intermuscular septum. hit it--funny bone. accompanied by ulnar artery, enters palm superficial to flexor retinaculum

ulnar nerve

Imaging for developmental dysplasia of the hip

ultrasound of hip x-rays- AP/Frog (children 6mo or older)

space is important because it has circumflex scapular vessels and branches of subscapular vessels

upper triangular space

joint aspiration is gold standard, but not usually done in primary care. usually you could follow up and check ___ levels

uric acid

Lab findings for PAN

urine may show protein or RBC casts CK may be elevated

What testing for tenosynovitis

usually clinical but can get XR, US

intervention for femoral condyle fx

usually surgical, want to prevent osteoarthritis

knock knee

valgus

flip to see risk factors for OM. What are the ones for peds?

varicella, strep, recent URI, animal handling

genu varum vs genu valgum, ages?

varum-6months valgus 2-4 years, slowly going to normal at age 8.

like riding a horse- applies to knee, opposite of valgus

varus

inflammatory disease of the blood vessels destruction of blood vessel walls subsequent thrombosis ischemia bleeding possible aneurysm

vasculitis

MC locations for hematogenous OM in adults

vertebrae, sternoclavicular, pelvic

another term for the palmar aspect of the hand and forearm (btw, the other side is dorsal)

volar

coracobrachialis

weak flexor of shoulder; musculocutaneous nerve

palmaris longus

weak flexor of wrist, median nerve

diagnostic tests for polymyositis

weakness (isolate and test muscle groups) CK (can monitor activity) Lactic dehydrogenase (LDH) Abnormal electromyogram Findings on muscle bx labs/tests to rule out differentials

scoliosis progression: compress on concave side of curve, compression on convex side of curve. the segments will become ___ shaped

wedge

Imaging for OA

weight bearing x-ray look for joint space narrowing, sclerosis, osteophytes

4 W's of documenting an injury

where, when, who (witnesses, other people involved), what (mechanism of injury)

RA most common in

white ppl, female more often

if you suspect scoliosis, refer!

will do

a lesion of long thoracic nerve, paralyzing serratus antertior

winged scapula

children w OM have joint effusion 60-70% of time

wow

radial nerve injury, can happen with fracture of humerus in the region of spinal groove, cant extend wrist

wrist drop

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