Muscularskelectal system

Gonococcal arthritis

Gonococcal arthritis is noted for migratory arthralgias. Common joints affected include the knees, wrists, ankle and elbows. Nearly 40-70% of patients with disseminated gonorrhea have a rash, which can take many different forms. Broad-spectrum cephalosporins (of which ceftriaxone is the most common) is the appropriate treatment.

Muscle: attach to bone by tendons

Ligament: attach bone to bone (joint)

Mechenical back pain (대부분 경우)

adult pt nonspecific low back pain -dull , may persist for several days to weeks -악화 완화 -어떤 움직임으로 악화 (bending, lifting) -*no neuro sign*

slipped capital femoral epiphysis 비만!!

anterior thigh pain and limping for 1 day The most common demographic for SCFE is overweight/obese males ages 10-15. Patients present with a limp and often difficult-to-localize pain in the knee or thigh. Appropriate management is to make patients non-weight-bearing to prevent progression and to refer for surgical fixation. Up to 50% of cases can be bilateral, so contralateral imaging is recommended

Which of the following tests is considered to be the LEAST helpful in diagnosing ACL tear of the knee? A. Lachman test B. Pivot-shift test C. MRI of knee D. Anterior drawer test

d

루퍼스. SLE

-multisystem자가면역 -woman (9:1) -AA, Hispanic 많다 *피부, 신장, 심장, 혈관 *maculopapular butterfly shaped rash on the middle face (malar rash) -nonpruritic thick scaly red rashes on sun-exposed area(discoid rash) -UA: *positive for 단백뇨* ※치료 -류마티스전문가 refer -sun피하기 -skin cover, high SPF sunblock (UVA, UVB) -sunprotect cloth -nonfluorescent light bulb쓰기

Plantar fascilitis (족저근막염) : stone bruise 책>아침에 몇걸음 worse , continues worse with prlonged work

-plantar (foot) fascia 감염 -acute or recurrent pain on bottom of feet : walk으로 악화 -Microtears in plantar fascia due to tightness of 아킬레스건 -overuse때문에 -stone bruise 로 불린다 -severe pain on heel of food upon getting up from bed in morning -Pain may get better later in the day ※risk -비만 -당뇨 -aorobic운동 -flat feet -오래서있기 ※치료 -stretching 운동 of foot (아킬레스건 & 족저근막염 stretch) -ice to sore area 3 to 4번/day -밤에 orthotic foot appliance for a few weeks -NSAIDS & topical NSAIDS -스트레칭,마사지 of food : golf ball 을 roll -Wt. loss(if overweignt) -맨발로 걷지말기 -wear 스니커즈 *x-ray: r/o fx, heel spurs, complicated cases -refer to podiatrist

말판증후군

-유전질환 (autosomal dominant) -connective tissue -fibrillin 단백질 돌연변이 -눈, 골격근, connective tissue -심혈관질환 -fx of disorder *class -tall and thin -longer than normal arm and leg -hands longer and very flexible : bend thumb across palm, hyperextend finger -scoliosis : common -sternum deformity (pectus excavatum or funnel chest) -sternum stick out (pectus carinatum or pigeon chest) -lens displacement ※danger 합병증: arotic dilation/dissection ※geneticist 에 refer

-decreased ROM -Some mild swelling no deformity -no pain except at medial joint line -extension is limited to +10 degree He has a negative Lachman's test. X-rays ordered in the office are normal locked knee emergency

A. Knee extension is normally between 0 and -10 degrees. The patient's injury is characterized by lack of full extension (locked knee), pain over the medial joint line, and effusion. This is concerning for a "bucket-handle" meniscal tear. This is a relative surgical emergency and should be addressed within a few days. "Locking" may occur in meniscal tears as a result of the torn flap, the "bucket-handle," impinging between the articular surfaces.

plantar fasciitis

extremely common cause of pain in the sole of the foot common in ballet dancers tenderness along the plantar fascia without deformity or mass that is worsened with dorsiflexion of the toes especially noticed when the patient starts walking or running Initial treatment is NSAIDS and temporary cessation of aggravating activity. -rays are not needed to diagnose this condition. ex>mild diffuse tenderness along the arch and heel of each foot

concussion

headache, nausea, photophobia, phonophobia, and dizziness. Loss of consciousness happens infrequently and is not required for diagnosis of concussion. (B) Concussion is a clinical diagnosis, and a head CT is not required. If there is concern for worsening symptoms or signs of intracranial pressure, CT should be considered.

골다공증 잦은 골절 SITE

hip, forearm, humerus, spine, and pelvis. 오답>Fracture of the lower leg is not clearly associated with osteoporosis.

Apley's sign. torn cartridge. (torn meniscus.) Explanation: Apley's sign, locking of the knee or the sounds of clicks and pain, may indicate a loose body, such as torn cartilage. This test is done to indicate torn cartridge. It is performed to detect a torn meniscus.

prone position with the knee flexed to 90 degrees. The tibia is firmly opposed to the femur by exerting downward pressure on the foot. The leg is rotated externally and internally. If locking of the knee occurs, this is accurately called a positive:

골다공증

r/o fx -스테로이드 (만성) 사용 체크

night pain, fever, sweating, wt. loss

r/o metastatic ca (hx of ca 체크)

knee pain-ACL TEAR x-rays of the knee to assess for possible bone damage? 필요한경우

x-rays of the knee to assess for possible bone damage? A. 55세이상 B. Isolated tenderness of patella C. Tenderness at fibula (종아리) D. Inability to flex knee to 90°

Pectoral muscle tear.

young male. sudden onset of chest pain after tackling an opposing player. no dyspena, no hx of any problem He has an easily seen and palpable defect in the muscle belly of his chest inferior to his clavicle

Chondromalacia Patella (patellofemoral syndrome) 슬개연골연화증

-cartilage (behind the patella)의 damage (kneecap) -보통 overuse injury 때문에 -inflammation->knee pain -young athlete ※치료 -cold pack x 1~2일 -RICE -NSAIDS fOR PAIN -PT for quadricep muscle to stabilize affected knee

Meniscus tears occur when the knee is twisted while flexed with the foot planted on the ground.

-typically no trauma involved and no immediate pain following the injury. (trauma는 케바케인듯)-연령에 따라 - joint-line tenderness, difficulty squatting, joint effusion, and loss of smooth motion of the knee. -Meniscus tears are diagnosed by the McMurray test -there is effusion

Ankylosing spondylitis (관절굳음) -pain : 운동으로 좋아지지만, rest로는 안좋아짐 -3rodnjfdltkd!! 만성pain

-점진적 seronetative (혈청검사음성) 관절염 -95%: HLA-B27 positive -만성 염증성 spine -bony *ankylosis* (관절굳음) -남>여 , puberty to 40yr *classic: stiffness -most of spine (up to thoracic-cervical) -thoracic back pain -upper thoracic spine -general sxs: low grade fever, fatigue -joint pain도 keep awake -chest pain and respiration (costochondritis) -some: midbuttock pain (sciatica) *PE -lumar spine: lateral flexion loss (early finding) -markedly decreased ROM -Respiratory excursion down to less than 2.5 -some: lordosis, hyerkypohsis -Spinal radiography: classic bamboo spine ※합병증 -anterior uvetitis -caudu equia syndrome -raiculopathy -aortitis -spinal stenosis ※Lab -CRP and ESR : 상승 ※치료 -류마티스전문의 refer -NSAIDS (first line: dramatic response) -DMARS, biologics, spinal fusion: severe case -Sulfasalazine -methotrexate -Enbrel

MCL injury

24-year-old female was water-skiing and fell has severe knee pain and feels like her knee is unstable, especially when moving her leg laterally -no joint effusion, and her Lachman test is negative. -Hip flexion, knee flexion, and knee extension all show normal strength. : MCL is extra-articular, an isolated injury to this ligament does not cause a joint effusion. Patients will often complain of feelings of instability. pain with valgus stress and laxity with valgus load

Salter-Harris classification system-fx 단계

1. TYPE 1: breaks across the physis 2 TYPE2: physis and metaphysis : 두개는 close reduction요함 3. TYPE 3: Physis and epiphysis + intraarticular regions 4. TYPE 4: extension of the fracture through the metaphysis, physis, and epiphysis of the bone.

LBP 치료`

1. proper back machanic 교육 -무거운 lifting and prolonged sitting 피하기 -bedrest피하기!!! 2. Meds -Acetaminophen 325mg to 650 -NSAIDS -Naproxen 3. X-ray: 첨에는 필요 x (hx of spinal trauma, suspect spinal fx or presence of Red flags) 4. MRI of lumbar sine -for neuro deficit (possible Caudu Equina) Suspect ca metastases 5. No blood work/lab needed: unless infection/ bone mets (CBC, sed rate, CRP) 6. 심한 근육 spasm: muscle relaxant or dizaepam (Valium) <Muscle spasm> -Metaxalone (Skelaxin) 800 mg qid prn (diziness, drowsiness, avoid etho, avoid sedating drug)

developmental dysplasia of the hip

6개월이하: Pavlik harness 6개월 이상: Closed reduction with hip spica cast Open reduction is not usually indicated in these cases. Infants up to age 6 months are usually treated with a Pavlik harness

rect answer: (C) Subluxation of radial head.

A little girl fell while holding hands with an adult. Afterwards, she holds her arm in a pronated position and refuses to use her hand or elbow. She is taken to the ER, where the pediatrician is able to reduce the injury manually. What is the most likely diagnosis

X-ray indication after ankle sprain

A. Tenderness of medial malleolus B. Tenderness of lateral malleolus Tenderness of 5th metatarsal E. navicular bone 오답>C. Tenderness of cuboid bone

sternoclavicular dislocation

Anterior이 90%임 posteriror은 vascular or nerve에 영향 (inferior, superior은 업슴)

osteochondritis dissecans 이단성골연골염(osteochondritis dissecans)" 연골에 염증이 생겨 본체로부터 떨어져 나간 것 정도로 이해하시면

Bone or cartilage fragment with diminished blood supply from trauma or vascular insult. Explanation: An osteochondritis dissecans lesion is an area of aseptic necrosis that occurs most commonly in adolescents but can occur in older populations. It often has spontaneous healing, and likely many more people have this condition with self-resolution than is known. Conservative management is ->rest from activity to avoid repetitive microtrauma to the area. Surgical management is sometimes necessary if the bony fragment is thought to be unstable, as determined by MRI.

응급상황

Cauda equina syndrome -점진적 loss of bladder (가끔씩 bowel function) -urinary retention or incontinence -progressive numbness of pelvic area -in saddle-pattern (saddle anesthesia) -*bilateral* sciatica(밑으로전이) & progressive weekness of legs -Refer to ED

A 15-year-old competitive swimmer presents with pain in the right shoulder aggravated by movement. Physical exam is significant for tenderness on palpation and muscle weakness in the affected arm. Physeal fractures and apophysitis have been ruled out. What is the most likely diagnosis?

Correct answer: (A) Rotator cuff tendonopathy. Explanation: Rotator cuff tendinopathy is an overuse injury commonly found in swimmers. Therapy includes ice, anti-inflammatories, activity modification, and physical therapy

A 3-month-old boy with (weight = 3.6kg, length 57cm) has the following anthropometric measures: weight-for-age z-score = -2.50 height-for-age z-score = -1.55 weight-for-height z-score = -2.11 In addition, assessment via the Waterlow classification shows that he is suffering from moderate-acute malnutrition and mild-chronic malnutrition. His RDA for protein is 2.2g/kg/d, and his ideal weight for length is 4.8kg. Which of the following is his estimated protein requirement for catch-up growth?

Correct answer: (B) 3g/kg/d. Explanation: He should consume 3g/kg/d for catch-up growth. To calculate protein requirement for catch-up growth, use the following formula: {(RDA protein for age) x (ideal wt for ht (kg))}/Actual weight (kg)

An 83-year-old man presents with a complaint of left knee pain with intermittent swelling that lasts a few days and then self-resolves. He denies any recent trauma. He has a past medical history of knee arthroscopy (knee scope) when he was 50 along with removal of a part of the meniscus. Otherwise, he only has well-controlled hypertension. On exam, he has a small joint effusion with no erythema and mild pain to palpation along his medial joint line. There is no erythema or streaking. What is the most appropriate step in management of his problem?

Correct answer: (B) Obtain standing bilateral x-rays. Explanation: Standing bilateral x-ray allows evaluation of the amount of joint space a patient has.

A 15-year-old athlete develops an episode of burning pain, weakness, and numbness of his right arm that resolves in 15 minutes. He does not recall a specific trauma to the arm. His left arm is asymptomatic, and he reports no symptoms in his lower extremities. There is no evidence of cervical spine injury or limited range of motion in the neck or arms. What is the most likely diagnosis?

Correct answer: (A) Brachial plexopathy.

What are the three most common types of fractures in children?

Correct answer: (A) Metaphyseal, epiphyseal, apophyseal. Explanation: Children are different from adults in that they have an metaphysis and a physis which is also known as the growth plate. This is the area of bone where it lengthens. Salter-Harris fractures are epiphyseal-metaphyseal fractures. Children also have apophyses in

What is a frequent cause of exercise-induced patellar pain and swelling at the tibial tubercle in pre-adolescent girls and early adolescent boys ?

Correct answer: (A) Osgood-Schlatter disease. Explanation: Osgood-Schlatter disease refers to a microfracture at the ossification center near the tibial tubercle, where the patellar tendon inserts.

A 23-year-old male football player presents with severe pain after an acute injury to his right leg. On exam, he is unable to bear weight on the right side, and his right leg is significantly shorter than the left. The right leg is rotated internally at the hip at rest. Which of the following injuries is likely present?

Correct answer: (A) Posterior hip dislocation. Explanation: About 90% of hip dislocations are posterior in which the affected limb is shortened and internally rotated. Posterior dislocations with an associated fracture are categorized by the Thompson and Epstein classification system. (B) In an anterior dislocation, the limb will not be shortened as significantly and will be externally rotated.

Which of the following is NOT true regarding ACL injuries?

Correct answer: (D) Early ACL reconstruction prevents osteoarthritis associated with ACL ruptures. Explanation: Anterior cruciate ligament rupture, whether treated surgically or not, is associated with an increase in osteoarthritis. (A) Studies have shown a 1.4 to 9.5 times increased risk of ACL tear in women. (B) An avulsion (분열) of the ligament from the tibia or a "Segond" fracture (antero-lateral capsular avulsion) at the lateral margin of the tibial plateau is indicative of an ACL rupture on imaging. (C) ACL injuries caused by contact require a fixed lower leg (i.e. planted) and torque with enough force to cause a tear. Contact injuries account for only about 30% of ACL injuries. The remaining 70% of ACL tears are non-contact injuries occurring primarily during deceleration of the lower extremity, with the quadriceps maximally contracted and the knee at or near full extension

A 16-year-old basketball player with PMH of hernia surgery suffered an inverted ankle sprain 20 hours ago when playing basketball. He states that during the middle of a playoff game, he went up for an offensive rebound and landed on an opponent's foot. He rolled his ankle over his opponent's foot and felt extreme pain and tenderness immediately. He was taken home to ice and wrap the ankle. Earlier this morning, his ankle became swollen, and he had tremendous difficulty walking on it. Following the injury, the patient is able to bear weight but states that he cannot walk more than a few steps because the pain is too severe. He denies any tenderness at the malleoli or metatarsals. He does not complain of any numbness or tingling. The patient's temperature = 97.8°F, HR = 80, RR = 16, and BP = 110/70. Physical exam reveals swelling over the entire ankle region and pain upon inversion, eversion, and plantar and dorsiflexion. There are no deformities or crepitus. What is the next step in management?

Correct answer: (D) Conservative management (RICE, NSAIDs, walking boot). Explanation: This athlete has suffered a typical grade 2 ankle sprain involving an incomplete tear of a ligament. Patients have moderate pain, swelling, and tenderness. There is mild to moderate joint instability on exam with some restriction of range of motion and loss of function Weight bearing and ambulation are painful. Because the patient is not tender to palpation at any of the key locations in the Ottawa ankle criteria, he does not require any x-ray series. There is no apparent structural damage; his ankle injury is standard and requires rest, ice, compression, and elevation. NSAIDs to calm the pain are also helpful, and a walking boot should be administered to help the patient walk. (A) A foot x-ray series is required if there is any tenderness at the base of the 5th metatarsal or the navicular bone. (B) An ankle x-ray series is required if there is tenderness to palpation at the medial or lateral malleoli. (C) There is modest evidence supporting the use of cryotherapy in treating ankle injuries. Ice or cold packs should be applied directly to the injury to achieve a numbing effect, and the area should be checked periodically to avoid frostbite. Most studies have used a protocol of 20 minutes every 2 hours. However, in our patient, conservative treatment is the more useful therapy, given his constellation of symptoms and lack of any apparent structural damage.

A high school student plays tennis and basketball most days. He presents with his mother complaining of a ball-like mass behind his right knee. He is in otherwise good health and denies any acute trauma. Examination reveals normal vital signs. The patient has a soft, smooth mass that is tender to palpation, located behind the knee. There is no overlying redness or warmth. Which of the following is indicated? Correct answer: (B) RICE.

Explanation: The patient in this case has a presentation consistent with a Baker's cyst. A Baker's cyst, or popliteal cyst, is a type of bursitis that results in swelling and inflammation behind the knee from joint damage, usually over a long period of time. The bursa, a protective synovial sac in the posterior portion of the knee joint, can rupture, which may result in increased inflammation and may resemble cellulitis over the surround area, including the posterior calf. First line treatment is RICE: rest, ice, compression, and elevation, with NSAIDs as needed. If the bursa is large, draining with an 18-gauge syringe can relieve discomfort. The synovial fluid should be a clear golden color. If the fluid is cloudy or bloody, order a C&S to rule out a septic joint infection. MRI is only indicated if the diagnosis is uncertain.

RA 중증도 사정

How long does it take for your joints to loosen up after you get up in the morning?" Correct answer: (C) "How long does it take for your joints to loosen up after you get up in the morning?"

iliotibial band syndrome Ober's test knee pain. , 방학때 운동쉬었다. 새로운동시작-> feels her knee pain after 2 miles, and it worsen as she keeps running. (no swelling, no clicking, locking, or instability in the area. ) On examination, her knee appears normal. She has mild discomfort over the lateral epicondyle of the femur. Her range of motion and ligament testing are normal. You find a positive Ober's test.

Prescribe a home exercise program for iliotibial band stretching and hip/core strengthening. - The patient has iliotibial band syndrome. She most likely sustained some deconditioning during her full semester without running.

Sprain

Protecting and elevating the knee from further injury, use of ice intermittently for 48 hours. Explanation: PRICE: Protect, rest, ice, compress and elevate is the acronym used for minor musculoskeletal injuries. Elevation will help decrease swelling to the knee. Application of ice will also minimize tissue swelling if done in the first 48 hours . (B) Heat is not recommended in the first 48 hours of an acute musculoskeletal injury.

Pulmonary contusion. Explanation: A pulmonary contusion is caused as a result of blunt trauma, such as in a motor vehicle accident or in sports like football. The history and the hemoptysis narrow down the differential.

football player chest pain and dyspnea after a hard tackle during a game. hemoptysis. No rales are heard on exam but he intermittently wheezes. Plain film reveals an infiltrate in the left lower lobe. D-dimer is negative.

. Clavicle fracture

involves pain on palpation and typically deformity of the clavicle.

발 뒤꿈치 통증(Sever's apophysitis) / #종골골단염(Calcaneal Apophysitis)

Sever's disease is apophysitis of the calcaneal apophysis, essentially Osgood-Schlatter's of the foot. It is common in growing youth since bones tend to grow faster than tendons, causing irritation to the apophysis and pain. Management is rest from activity, stretching, and anti-inflammatories. Pain often resolves once growth has ceased. (- activity modification. )

lateral epicondylitis (tennis elbow).

Tennis elbow is characterized by -gradual onset of pain on the outside of the elbow, sometimes radiating to the forearm. -The pain is increased with twisting or grasping movements, such as shaking hands or opening a jar. Tendon pain over the lateral epicondyle, like other episodes of tendinitis, can be treated conservatively at first. It is the result of microscopic tears of a tendon, which cause inflammation and pain. Tendinitis is usually due to repetitive microtrauma, overuse, or strain. RICE is a mnemonic that refers to initial treatment of tendinitis: Rest. Ice: cold is preferable to heat during the first 48 hours after an injury. An ice pack can be applied for 20 minutes per hour several times a day. Compress the joint as needed, using an Ace bandage. Elevate the affected joint to decrease swelling. NSAIDs, including naproxen BID or ibuprofen QID, are useful for treatment of pain and swelling.

When compressing the suprapatellar pouch back against the femur you feel fluid entering the spaces. (C) Balloon sign.

The balloon sign -occurs in instances when considerable fluid is in the suprapatellar pouch; -ballottement of the patella is possible. -The balloon and the bulge test can test for an effusion in the knee joint -however the maneuvers for each of these is different. -The balloon test is performed when the patient is lying in supine with the leg extended. -Pressure is applied on the proximal side of the knee in an effort to squeeze the fluid out of the suprapatellar pouch. -The fluid can be moved under the patella while maintaining the pressure on the suprapatellar pouch.

The nurse practitioner understands that chronic synovitis with pannus formation is the basic pathophysiologic finding in clients with:

The chronic inflammatory disorder of RA is associated with synovial hypertrophy from chronic synovitis and pannus formation that results in progressive destruction of cartilage.

Pulmonary barotrauma is caused when a SCUBA diver holds his or her breath during the ascent to the surface.

The compressed gas expands during the ascent. Symptoms will typically begin immediately upon ascent.

in-toeing

This often is caused by increased flexibility in hip internal rotation (femoral anteversion). In-toeing is a common complaint seen in outpatient clinics. Most often, it is due to an increased amount of flexibility in the hip. This is naturally corrected as the child ages and ligaments become less flexible. Tibial torsion and metatarsal adductus should be examined because a certain level of severity may need intervention. (B) In-toeing does not require referral in most cases. Bracing is neither recommended nor helpful. (C) Internal tibial torsion is responsible for in-toeing in toddlers. (D) In-toeing does not correlate to delayed walking. Toe-walking from spasticity in cerebral palsy can cause a delay

류마티스관절염 Joint stiffness lasts longer than OA.

골관절염 Symptoms are exacerbated by activity and relieved by rest.

Orthopedic injury (RICE)

*1. R: Rest* *2. Ice* -1~2일 -첫 2일: cold pack or cold water immersion (for 15 to 20 분) : until swelling감소 *3. compression* -early to decrease swelling. Splint prn *4. Elevation* -at level or above heart ※치료 -타이레놀 -Ibuprofen -Naproxen ※Joint friendly 운동 1) isometric exercise (등척성-길이변화x): spare joints, build muscle에 도움됨 (resistant bands) 2) Aerobic 운동 (수영,walking, bicycle) 3) Flexibility: strech, ROM shoulder, calf stretch ※Imge test 1)Radiography(x-ray): bone fx show 2) CT SCAN: detail view of bone/joint 3) MRI: soft tissue (cartilage, tendon, joint) 4) EMG: nerve function evaluation

LBP

*대부분 overstretching or straining of muscle, tender, and/or fascia of the lower back pain -(mechanical back pian) -will resolve within 4~6주 ※다른원인 -lumbar/sacral disc herniation -spinal stenosis -fx (골다공증, trauma) -cancer 전이 -뼈감염

Sinding-Larsen-Johansson lesion. (무릎)

- a pediatric version of "jumper's knee - the proximal end of the patellar tendon as *it inserts into the inferior pole of the patella.* - occur in adolescents during the growth spurt - high level of physical activity, especially in sports involving running and jumping such as basketball, football, or gymnastics - Pain is usually aggravated by exercise. No radiographs are necessary in the absence of trauma. - Management requires activity modification. Pain should be the main guide for the limitation of activity

ankylosing spondylitis,

- bamboo spine. - HLA-B27 antigen positivity 와 관련 - upper thoracic spine의 loss of ROM - may have costochondritis and will sometimes complain of chest pain with inspiration. - Uveitis, which is swelling of the uvea of the eye, is associated with AS. Pericarditis is associated with rheumatoid arthritis."

Proximal humerus stress injury (Little Leaguer's shoulder is rest) -point tenderness over the shoulder physis -rest때 나아짐

- injury to the growth plate of the proximal humerus as a result of repetitive microtrauma found in young pitchers who throw a lot of breaking balls - present with arm and shoulder pain when throwing the ball that increases in intensity over time. - pain is worsened in the late cocking or deceleration phases of throwing and resolves with rest. - Patients complain of point tenderness over the shoulder physis and pain reproduced when throwing - The best therapy for Little Leaguer's shoulder is rest case> tenderness, probably due to microtrauma on the physis from long periods of pitching a breaking ball

Prepatellar bursitis. = carpet layer" knee

- persistent irritation of the prepatellar - no joint effusion afebrile, no streaking on exam - overtly swollen knee that is red and tender - lack of joint effusion -tx: avoid further irritation with knee pads or resting from the occupation. if there is septic busa: 항생제 (but no aspiration)

Colles fx 책> Fracture of the distal radius (with or without ulnar fracture) of the forearm along with dorsal displacement of wrist. History of falling forward with outstretched hand (as in navicular fracture). This fracture is also known as the "dinner fork" fracture due to the appearance of arm and wrist after the fracture. The most common type of wrist fracture.

-Distal radius fx -with radius tilting upward *Radius: 가장흔하게 fx of wrist bone -Refer to ED ※depends on type of fx displaced or unstable fxs surgery (screw/plate)

Golfer's elbow (medial epicondylitis-상과염 -Funny bone

-Golfer/baseball picher -aching pain over medial elbow(몸쪽) -tender to palpation over inner aspect of elbow ※Risk -golf -라켓 스포츠 -야구 -볼링 -wt.lifting ※합병증 -ulnar nerve neuropathy/palsy

Sciatica-밑으로 방사통: disc!!!

-L4~L5의 impingement -sciatica pain (a type of radiculopathy) -sharp burning pain (located midline through buttocks) -radiate to posterior thigh to top of foot -weakness of affected leg and foot <원인> -bulging disc -inflamed joint -muscle <Straight leg raising test> -lumboscaral nerve root irritation (prolapsed dis) -SLR positive

Slipped capital femoral epiphysis disease vs Leggs-Calves-Perthes

-SCF: painful condition, but Leggs-Calves-Perthes disease can present as painless limping. - Usually, SCFE is found in children older than 10, and LCP is typically seen in children under 10. - SCFE requires surgical fixation, and LCP often involves initially conservative management through watchful waiting with surgical treatment for residual disease.

Ruptured bake's cyst (Bursitis)

-baker's cyst:type of bursitis -located behind of knee (popliteal fossa) -phsical active pt : complain ball like mass (one knee 뒤에) -soft and smooth -pressure pain cause or asymtomatic -if rupture: cause imflammatory reaction : cellulitis 같은 ※labs -clinical presentation and history 로 dx -MRI: 진단이 uncertain시 ※치료 -RICE -NSAIDS PRN -Large bursa: drained with syringe (paindlTdmaus) (cloudy하면: septic joint infectino 의심)

Meniscus test (of knee)

-cartilaginous lining (between certain joint) -tears in meniscus : trauma or overuse *classic* -locking of knee -unable to fully extend affected knee -may limp -knee pain difficult walk or bend -some : joint line pain -decreased ROM *Best MRI Orthopedics refer

OA

-early morning joint stiffness with inactivity -류마티스에 비해서 duration of joint stiffness가 짧다 -overuse of joint로 pain 악화 -RA에 비해 전신증상x

Pes anserine bursitis (무릎!!) ex>비만->back pain->back problems could have led to gait changes and hip muscle weakness, which may be the source of her knee pain. -무릎 관절 과사용 -무릎 4-5cm밑에 통증?

-knee pain -no trauma -no effusion -tender to touch -ligament are intact *치료: treatment may be only topical anti-inflammatories. In addition, the treatment should involve therapy that improves gait and hip strength, since often the etiology involves abnormal forces on the knee because of pelvic weakness

Carpal tunnel

-median nerve compression -swollen carpal tunnel wrist (repetitive motion, 갑상선저하, 임신) -gradual onset of paresthesia(numbness, tingling, burning) on thumb, index finger, middle finger, half of ring finger -nocturnal awakening, : having to shake hand for relif (*Flick sign*) *Late sign: atrophy of tiner eminence ※Plan -일관련: modify, 반복적 손/wrist use 피하기 -night splint(wrist 부동) -NSAIDS -OT referral (2주후-차도없으면 )

Medial tibia stress syndrome(Shin splint) Medial tibial stress fx

-runners common(female high incident) -runner and flat feet -overuse: microtears inflammaiton of muscle, tendon, bone on tibia *class -runner: 최근 frequncy,distance상승 -최근 recent onset of pain on inner edge of tibia -pain: sharp/stabbing or dull/throbbing -during and after 운동에 악화 -sore spot on shin anterior aspect -focal area of tender -만질때 tender -some: stress fx on tibia ※plan -활동과 rest stop -RICE -cold pack x 20min on shin -NSAIDs prn -pain사라지면, 2주기다리기 before resume 운동 -stretch before운동 -start lower 강도 -supportive sneakers wear (Cusion shoes) *fx suspect (avoid exercise) -image test: bone scan, MRI (X-RAY does not show stress fx) -orthopedic specialist refer

Morton's neuroma

-scarring of common digital nerve (ganglion) -inflammation of digital nerve of foot (3~4 metatarsals사이에) -chronic pressure때문에 -하이힐, tight fitting shoes, 비만, flat feet, dancer, runner -pebble 같은 mass (조약돌) -pain in interspace area (가장 common: space between 2nd and 3rd toe-metatarsals) ※치료 -NSAIDS prn -하이힐 , 타이트하게 맞는 신발 피하기 -forefoot pad (앞발) -well padded shoes -Podiatrist -seroid injection of nerve/ganglion

Pneumomediastinum. On exam, she appears anxious and has palpable swelling in her neck. A crunching sound is heard over the precordium during the cardiac exam. What is the most likely diagnosis?

-scuba divers or with trauma in sporting events. -Free air in the mediastinum can be observed on x-ray. -Crepitus, , is often found on physical exam, as well as Hamman's sign (rales over the precordium). *Treatment is supportive care while air resorbs. If there any diagnostic question, CT is the imaging of choice.

*DeQuervain's tenosynovitis/tendonitis (건막염)*

-tendon sheath overuse -entrapment of thumb tendons -wrist pain over thumb side -pain with grasping -pain radiate from thumb, wrist, to forearm ※PE -tenderness/swellling over thumb tendon/wrist ※치료 -wrist splint 24hr x 4 to 6 주 -NSAIDS for pain ※test: Finkelstein test -주먹쥐고 밑으로

Gout

-uric acid crystal (monosodium urate) deposition -on joint/tendon -inflammatory반응 cause *class -중년 to old 남성 -acute 악화 of gout -심한 painful podagral and severe joint (ankle, knee, wrist,,etc) -최근 알콜 섭취 -해물, steak meal -serum uric acid level : 상승 ※PE -MTP joint (*Metatarsophalangeal*) of great toe -red, hot, sowllen -very painful (limping) -과거 비슷 hx (same site) -술, meat, seafood, 이뇨제 -진단: 요산>7 and clinical finding -tophi: small white nodule filled with urate (ears and joint) -podagra: classic red, swollen, painful toe of goat (통풍결절) *<관리>* *1. acute phase* -goal: pain relief -if already on allopurinol: dose continue and pain relief med add -tx ASAP (onset 12hr 내에) -lab: serum uric acid, sed rate/CRP 1) NSAIDS 2) 저용량 Colchicine (짧은기간) (GI증상, 설사, n/v) 3) 1-2L/day of water *치료안되면: joint destruction, 신장 damage *2. Maintainance med* (acute attack 4-6주후에 -acute때는 allopurionl (Zyloprim)시작말기 : CBC체크하기(골수에 영향) -Probenecid (uricosuric drug); urine으로 요산 배출 -콜키신 쓸수도 있음 (항 anti inflammatory) *<합병증>* -joint destruction

Rotator cuff tendititis =shoulder impingement =*supraspinatus* tendinitis (Rotate cuff중하나)

-young athelets (swimmer, tennis,야구) -middle aged *Supraspnatus tendonitis -supraspinatus tndon 염증 ※증상 -gradual (acute ) of pain -overhead movement of arm *Pain on front of shoulder and radiate to side of arm -Lifting/reaching: cause pain -night pain with limitation of shoulder ROM -Sharp pain when lying on affected shoulder during sleep ※Tx -NSAIDS -refer for PT -excessive pverhead activity during acute pahse 피하기 ※※gold standard of test; MRI

골관절염 / Degenrative joint ds -unilateral or bilateral -cartilage covering articular surface of joint become damaged <책도 읽기!!>

-가장 흔한 joint ds세계적으로 -affect weight bearing joint (knee, hip), & hand -may: extensive 연골 loss with joint destruction *risk factor -나이(늙은이) -overuse joint -positive family hx ※class older adult to eldery painful knee or hip with morning stiff (30분 이하로) -cold 날씨, 날씨변화, 영향받은 joint의 prolonged or overuse ※PE -joint crepitus -joint 변형 -synovitis (활액막염) -swelling ※Heberdens node (dip) Bouchard (PIP) ※치료 -Analgesics first: 타이레놀, aspirin -NSIAD prn *alternative: glucosamine, chondroitin, capsaicin cream ※관리 -rest or restrict use -wt bearing on affected joint -analgesics PRN (Tylenol) -if inflammation: NSAIDS prn -high risk stomach ulcer: COX-2 inhibitor: celecoxib (celebrex) daily -glucosteroid 관절내 if severe

Fibromyalgia

-만성 -last more than 3m -generalized 근골격 pain -fatigue, cognitive impair, sleep distruption, -psych sxs (불안, 우울) -cause is UK ※미국 류마티스 학회 기준 -Tender point 최소 11/19 -widespread pain -pain usually bilateral

Tennis elbow (lateral peicondylitis) 상과염 -바깥쪽

-반복적 overuse of forearm muscle (flexors, extensors) ※Risk -tennis player -manual labor (페인터, screwdriver) ※classic -gradual pain -outside elbow -sometimes: forearm으로 방사 -twisting or grasping movement에 의해 악화 (shaking hand, opening jar, lifting) ※treatment -RICE -NSAIDS -tennis elbow strap prn -refectory: cortisone steroid주사, cast

Impending rupture AAA

-심한 abd and low back pain in elderly male smoker

Navicular/Scaphoid bone fx (wrist pain) 책> Wrist pain on palpation of the anatomic snuffbox. Pain on axial loading of the thumb. History of falling forward with outstretched hand (hyperextension of the wrist) to break the fall. Initial x-ray of the wrist may be normal, but a repeat x-ray in 2 weeks will show the scaphoid fracture (due to callus bone formation). High risk of avascular necrosis and nonunion. Splint wrist (thumb spica splint) and refer to a hand surgeon.

-앞쪽으로 넘어질때 손앞으로 stretch해서 넘어짐 (hyperextension of wrist) -wrist pain : below thumb area *(anatomic snuffbox)* ※증상* -wrist pain (below thumb area) -difficulty gripping objects -tenderness to palpate of anatomic snuffbox *Casting name: thumb spical cast ※치료※ -Splint in anatomic position : 1) non-displaced fx-thumb spica cast 2) displaced: surgery (open reduction with screw) -Refer hand specialist ※risk※ -avascular necrosis -early DJD (Degenerative joint ds) OA of wrist -만성 통증 ※MRI: most sensitive test for dx of fx <24hr ※Bone scan: at 72hr에 ds ※CT scan: less sensitive to diagnosis occult fx

류마티스 관절염 : bilateral, symmetric !!!(골관절염보다 더 많은 곳에) pain and stiff : not relieved by rest -commonly report 조기 아침 stiff/pain(최소 *1시간*), warm, tender, swolen fingers in DIP/PIP joints (also called 소세지 joint) *systematic 자가면역 ds -여자가 만음 (e.g.middle aged) -multplp joint의 감염: goal->joint damage막는것 *chronic ds의 높은 risk -grave ds -pernicious anemia

-전신 자가면역 ds (women>men) -multiple joint -만성 multi-organ ds -악화/완화 1) Swan neck deformity -DIP joint flexion, PIP hyperextension 2) Boutonniere deforminty -DIP hypertension, PIP flexion 3) Bouchard's node 4)chronic ds->rheumatoid nodule ※classic -adult to middle aged woman -new onset of swelling, painful, stiff joint -특히 on hand and wrist -joint stiff when awaken -stiff can last for hours -pain is worse in moring -*pain and stiff : not relieved by rest* -fatigue, 미열, myalgia, general body ache, normocytic anemia -multiple joint: swollen, red, hot on both side -inflamed joint: tender to palpate (sausage joint) -류마티스 nodules (means chronic ds)

<Shoulder impingement> -tendons of the rotator cuff become irritated and inflamed as they pass through the subacromial space. - pain, weakness, and decreased range of motion in the shoulder. -Pain is often exacerbated by shoulder movement, especially when lifting the arm over the head. -Onset of the pain may be acute or chronic, and it can be accompanied by a grinding sensation during shoulder movement. -Typically, pain in impingement is not related to temperatures, *worsens in the evening*, and *improves with lidocaine injection.*

<Rotator cuff tendinitis> - the swelling of the rotator cuff tendons from repetitive activities associated with overuse of the arm and shoulder, especially in physical activities such as volleyball or baseball. - Symptoms involve shoulder weakness - difficulty lifting the arm over the head. - In addition, there may be pain and swelling in the front of the shoulder, - *a clicking sound* when the arm is raised, and stiffness. *Resting the shoulder and icing it along with ibuprofen treatment should improve the symptoms.

Meniscus tears occur when the knee is twisted while flexed with the foot planted on the ground.

A 24-year-old female tennis player complains of knee pain upon presentation to the orthopedic clinic. During one of her games a month ago, she quickly changed direction to return a served ball from her opponent. She felt an uncomfortable painful twisting motion as she reached for the ball. After the incident, she was able to put weight on her knee and felt fine walking. However, recently she has felt increasing amounts of knee pain when walking, joint-line tenderness, and increasing difficulty putting weight on her knee. The patient's temperature = 98.3°F, HR = 70, RR = 16, and BP = 120/80. Her BMI is 24. McMurray test is performed in which the patient feels pain in the knee when it is flexed completely and the examiner provides a valgus stress. Which of the following is the next step in management?

Ganglion cyst

A 38-year-old tennis player with a PMH of HTN complains of pain in her wrist. The pain is located along the dorsal radial side of the wrist and has been occurring for several months. She feels a reduced sensation along the radial side of her hand with accompanying numbness and tingling. In addition, she also feels an occasional temperature change in her hand that she describes as a "cool feeling." She does not know exactly when the pain and discomfort started and cannot recall any traumatic or inciting event. The patient's temperature = 98.3°F, HR = 80, RR = 16, and BP = 130/90. Physical exam reveals a subcutaneous, mobile wrist mass that is non-tender to palpation and transilluminates with lighting. Patient has trouble gripping objects. What is the most likely diagnosis?

A nurse practitioner in a family practice clinic is evaluating a patient with an ankle injury. The patient is an otherwise healthy 20-year-old male who hurt his ankle during a soccer game. He is able to bear weight and ambulate. Which of the following is indicated? Correct answer: (C) RICE. Explanation: Ankle injuries are common. The Ottawa ankle rules are used to determine whether or not a patient needs radiographs of the injured ankle.

A grade I sprain, which is mild and characterized by slight stretching and minimal damage to the ligamentous fibers, can be treated with rest, ice, elevation, and compression. These patients will be able to bear weight and ambulate. A Grade II sprain refers to partial tearing of the ligament, characterized by the presence of moderate swelling and pain, ecchymosis, and joint tenderness to palpation. Patients will complain of pain with ambulation and weight-bearing. There will be mild to moderate instability of the joint. For these paints, you should consider X-ray studies and referral to an orthopedic physician. Complete rupture of the ligaments of the ankle characterizes a Grade III sprain. These sprains should be referred to the ED. Patients may have a fracture. They will be unable to bear weight immediately after the injury, with inability to ambulate at least 4 steps. Tenderness is present over the posterior edge of the lateral or medial malleolus. There may also be severe pain with bruising and swelling.

A 52-year-old male present for pain and swelling in the anterior knee. This condition started 2 days ago while he was helping a friend install new wood floors. He had no specific injury that he can recall. On examination, you notice significant swelling over the anterior knee with tenderness but no erythema or warmth. His range of motion is normal, but he feels pain at the end of flexion. His ligaments are intact. On films, you notice some soft-tissue swelling and some mild to moderate osteoarthritis. What is the most likely diagnosis?

Correct answer: (D) Prepatellar bursitis. Local tenderness to palpation is a hallmark of the condition. Pain with joint range of motion is atypical except for discomfort at extreme flexion, which compresses the inflamed bursa Management of aseptic prepatellar bursitis typically consists of rest, compression, nonsteroidal anti-inflammatory drugs (NSAIDs), and possibly a local corticosteroid injection.

An 11-year-old boy was tackled while playing football and landed on his shoulder. He immediately complained of upper chest pain and dyspnea. On exam, he has mild neck-vein engorgement and a swollen sternoclavicular joint. What is his most likely diagnosis? Correct answer: (A) Posterior sternoclavicular joint dislocation.

Explanation: Posterior sternoclavicular joint dislocations are rarer than anterior sternoclavicular dislocations but are a life-threatening emergency when they do occur. Open or closed reduction should occur as soon as possible while the patient is monitored and under controlled conditions in the presence of a cardiothoracic surgeon. with posterior SC dislocation may also complain of difficulty breathing, dysphagia, or upper extremity paresthesias.

Gymnast's wrist is associated with which of the following conditions?

Explanation: Gymnast's wrist refers to injury to the *distal radial physis*, occurring as a result of repetitive stresses due to weight bearing on the upper extremities.

Treatment for gouty arthritis during an acute attack is: Correct answer: (C) Naproxen (Naprosyn).

Explanation: NSAIDs are first line for gouty attacks. During an attack, symptom management is the goal of treatment. (A) Aspirin is not recommended as first line treatment for Gout. (B) Probenecid helps to increase the body's excretion of uric acid. It is used for chronic gout to prevent attacks, but not during an attack. (D) Allopurinol is first line for chronic gout and prevention of gouty attacks; however, it is not used to treat gouty attack and it is unclear whether or not it can make attacks worse. Allopurinol can be started four to six weeks after an attack.

Correct answer: (B) RICE.

Explanation: RICE Rest - avoid use of injured part. Ice - 20 minutes with ice and 10 minutes off. Compression - compress and support joint to decrease swelling and support affected area. Elevation - avoid bearing weight and keep elevated to decrease swelling. These are very important in the first 48 hours after an injury

On valgus stress, you suspect a grade 3 (complete) MCL tear. The rest of your examination is negative. He is anxious to know what the next step is because he is on a soccer team and they have an upcoming season. What is the appropriate treatment ? Correct answer: (A) Refer to physical therapy for rehabilitation.

Explanation: The treatment of MCL injuries involves a conservative rehabilitation program. Patient with grade 3 MCL injuries that have been treated conservatively have been shown to return to sport as well as those treated surgically. A hinged knee brace provides support and protection to the injured MCL during the rehabilitation process.

Patients with sternoclavicular (SC) injury usually have anterior chest and shoulder pain that is worsened by arm movement.

If posterior displacement of the medial clavicle or clavicular fracture injures the recurrent laryngeal nerve, hoarseness may also be present. Displacement may be difficult to appreciate.

Metatarsalgia.

Metatarsalgia is simply pain on metatarsal heads that results in tenderness over the ball of the foot and sometimes the toes. Patients who run a lot or who wear tight-fitting shoes often complain of these symptoms, which are worsened by running and improve with rest and relaxation. - presents with an arched foot and excess pronation of the foot. -PLAN: Conservative therapy (rest, ice, NSAIDs). and this self-limited condition can be treated with conservative management. 오답: Arch support and orthotics of foot,X-RAY, MRI

Which condition affects young athletes with posterior heel pain and an antalgic limp, especially with activity? 발 뒤꿈치 통증(Sever's apophysitis) / #종골골단염(Calcaneal Apophysitis)

This condition is due to overuse and repetitive microtrauma from a pull on the calcaneal apophysis by the Achilles tendon. This process resolves when the apophysis fuses to the main body of the calcaneus—by age 9 in girls and 11 in boys. Athletes who wear soccer-type, cleated, hard-soled shoes are at greater risk because the shoes have 4 cleats at the heel and 9 at the sole. This syndrome is characterized by pain in the posterior aspect of the heel, especially after sports activities in prepubertal children. Lack of adequate ankle dorsiflexion in a running or jumping athlete is always causative. There is a high incidence of overpronation, but pronation/eversion is likely to be compensation for lack of true dorsiflexion.

A 42-year-old male who plays basketball on the weekends has medial knee pain after landing after a rebound and pivoting (로테이션?)sideways to pass. He felt a "pop" and experienced swelling a few minutes later. He has pain with walking. He denies any instability but does feel like it is "catching" with knee flexion. On exam, he has a joint effusion, his Lachman's is negative, and he has no pain with patellar mobility. What is his most likely injury?

This is most likely a meniscal injury, based on demographics and history. While meniscus pathology can occur in younger populations, it is more likely to be the result of a traumatic injury in the younger population than a rotation of the knee. Patients can complain of "locking" or "catching" with knee movement, as sometimes cartilage fragments act like doorstops in the knee joints, preventing normal range of motion. Meniscal injuries most often cause a joint effusion and may cause pain along the joint line. (A) Anterior cruciate ligament (ACL) injury can occur with twisting motions and may cause a knee effusion. With lack of complaint of instability and a negative Lachman's, a meniscal injury is more likely.

A 15-year-old teenager with no PMH presents with shoulder pain that has occurred for several years. He states that he has been playing baseball since he was 10 and that the shoulder pain has increased gradually over time. He denies any trauma, but he does state that after he pitches, he feels a sensation of coldness in his hand along with tingling and burning of the arm and forearm. The pain has been there for many years but has worsened since he started playing baseball, and it is not relieved with NSAIDs. The pain is not related to temperature or time of day. The patient's temperature = 98°F, HR = 70, RR = 14, and BP = 110/75. Physical exam shows decreased coloring of the hands and difficulty in moving the shoulder in any direction. There is no pinpoint tenderness identified. Which of the following is the initial diagnostic test used to evaluate his condition?

Thoracic outlet syndrome occurs when there is compression at the superior thoracic outlet resulting from excess pressure placed on a neurovascular bundle between the scalene muscles. Because the nerves of the upper limb and/or vessels pass through the outlet, all of them can be affected. Typically, the syndrome is caused by congenital abnormalities such as cervical rib or prolonged transverse process, or by trauma or repetitive strain. Patients present with sharp, burning pain of the upper arm, forearm, and/or fingers. Decreased coloring of the hands and coldness are commonly found as well as tingling. Our patient's shoulder, arm, and hand pain probably began with a congenital anomaly at birth that has worsened with repetitive trauma from baseball. The tingling, burning pain in his arms and fingers along with discoloration confirm the diagnosis of thoracic outlet syndrome. In this syndrome, ultrasound (US) is the best diagnostic method, especially in venous or arterial thoracic outlet syndrome when the patient presents with discoloration of the hands. US is a highly sensitive and inexpensive test, especially when used to evaluate vaso-occlusion.

___ A 58-year-old male presents for right knee effusion. He denies any trauma or injury but has had some knee pain in the past. He woke-up with a swollen knee and pain this morning. He has no fever or chills. On examination, in addition to the 3+ effusion, he has generalized tenderness and minimal range of motion (20°). You perform an arthrocentesis and obtain the following findings: Color = Yellow Clarity = Transparent Viscosity = High WBC per mmᶾ = 1,500 PMNs = 20%

What is the most likely diagnosis? Correct answer: (D) Osteoarthritis. Explanation: The patient has a non-traumatic knee effusion. Therefore, infection or inflammatory causes should be ruled out. He has no fever, but fever is not always present in septic arthritis. Synovial fluid findings in osteoarthritis usually suggest a minimally inflammatory or noninflammatory process with a white blood cell count <2000/mm3. Crystals are absent when examined using compensated polarized light microscopy. The patient's synovial fluid analysis is more consistent with effusion related to osteoarthritis. Films may be helpful by showing some joint space narrowing, subchondral bony sclerosis and/or cysts as well as osteophytes. Inflammatory causes like rheumatoid arthritis, lupus arthritis, or gout usually present with opaque synovial fluid, high proteins, WBC between 2,000 and 50,000 and PMNs >50%. (Polymorphonuclear leukocytes)am stain and culture are negative.

Osgood-Schlatter disease anterior knee pain that is often found in adolescents. As they grow, their bones lengthen faster than their tendons, which can lead to apophysitis of the tibial tubercle. Management is rest from activity, stretching, and anti-inflammatories. Pain often resolves once growth has ceased. Occasionally, surgery is required if the apophysis becomes avulsed. 14-year-old female basketball player presents with anterior knee pain that is exacerbated by jumping. She denies any specific injury. There is no effusion, joint-line tenderness, or instability. She has tenderness to palpation over the tibial tubercle. What is the most likely diagnosis, and what is the appropriate management?

is a common pathology in growing children, as tendons often have greater strain placed on them during bone growth. Pain is the result of irritation of the apophysis of the tibial tubercle. * On physical exam, there is tenderness at the insertion of the patellar tendon. It is not a cause of joint effusions.

Acromioclavicular sprain *초기 diagnostic: An AP radiograph of both shoulders can be used to classify the injury.

tearing of the acromioclavicular and/or coracoclavicular ligament caused by : a strong, direct blow to the front or top of the shoulder from trauma or by a fall on an outstretched hand. - initially,generalized shoulder tenderness and swelling over time, specific tenderness at the acromioclavicular joint that is worse in the evening and a stiff and sore shoulder when awakening Popping of the AC joint may occur as well.. *초기 diagnostic: An AP radiograph of both shoulders can be used to classify the injury.

Patellar sub-luxation

teenager girl giving way episode of knee mild effusion

scaphoid fx

tenderness with palpation over the anatomic snuffbox 치료: thumb spica splint

류마티스

※LAB -positive rheumatoid factor -RF(75%) -ANA (Posi in some pts) -normocytic anemia -sedi rate/C-reactive protein is elavated -cbc: mild microcytic or normocytic 빈혈 common ※Image test _radiograph (x-ray) of hand, wrist, feet -x-ray: bony erosion, joint space narrow, sublaxation (or dislocation) *수술: joint replacement ※합병증 -uvetits (안과전문의) -vasculitis, scleritis, pericarditis, -악성: lymphoma -실명올수있으니: 잦은 눈검사 요함 -joint 파괴 ※치료 1.NSAIDS OR aspirin joint pain PRN 2. 전신oral dose스테로이드 스테로이드 주사: synovial space 3. DMARDS 1) Methotrexate or sulfasalazine, cyclosporine 2) Hydroxycholorquinolone (Plaquinil): antimalarial agent-->처방전 눈검사!! 3) Prednisone daily (전신 스테로이드) *if poor responce to DMARDS-> 4. TNF (tumor necrosis factor) inhibitor (never 처방-> 감염 sign시: sorethroat,fever..etc) -Adalimubab (HumIra) -Etanercept (Enbrel) -Infliximab (Remicade) : check PPD and CBC before 치료 심한 합병증-->감염, lymphoma

ACL, MCL, PCL

은 trauma가 선행 급성으로 pain