Indications for splinting

FracturesSprainsJoint infectionsTenosynovitisAcute arthritis/goutLacerations over jointPuncture wounds and animal bitesPain control

Long Arm Posterior Splint

- Elbow and forearm injuries- Distal humerus fx- Both bones forearm fx- Unstable proximal radius/ulna fx

Doesnt completely eliminate supination/pronation - either add anterior splint or use double sugar-tong if complex or unstable distal forearm fx

Double sugar tong

Elbow and forearm fx -prox/mid/distal radius and ulnar fx

Better for most distal forearm and elbow fx - limits supination/pronation and flexion/extension - Soft tissue hand/wrist injuries - sprain, carpal tunnel night splints- Most wrist fx, 2nd-5th metacarpals- Some add dorsal splint for increased stability- Not used for distal radius or ulnar fx - can still supinate or pronate

Forearm sugar tong - Distal radius or ulnar fx- Prevents supination/pronation and immobilizes elbow

Radial and Ulnar gutter Fractures, phalangeal and metacarpal and soft tissue injuries of the little and ring fingers

Thumb spica

Scaphoid fx - seen or suspected (check snuffbox tenderness)- Lunate fx- All thumb fx- De Quervain tenosynovitis

Finger splints

Sprains - dynamic splinting

Dorsal/volar splints - phalangeal fractures, gutters better for proximal fractures

Jones compression dressing - Short term immobilization of soft tissue and ligamentous injuries to knee or calf- Pain relief- Allow slight flexion and extension, can add

posterior knee splint to further immobilize knee

Posterior ankle splint

- Distal tibia/fibula fx- Reduced dislocations- Severe sprains- Tarsal/metatarsal fx

Use coaptation splint to posterior splint - eliminates inversion/eversion especially useful for unstable fractures and sprains

Stirrup splint Similar to posterior splint, less inversion/eversion and plantar flexion, great for ankle sprains

Complications for casting

BURNS - thermal injury as plaster dries, increased number of layers, extra fast drying, poor padding - increase risk

ISCHEMIA

PRESSURE SORES

INFECTION Why do you do ophtalmologic examination when suspect child abuse

Shaken baby syndrome or retinal hemorrhages

Skeletal survey includes :

Skull - frontal and lateralSpine - frontal and lateralChestExtremitiesAdditional views as needed

Multiple rib fractures healing on xray is pathognomonic for _

CHILD ABUSE - ESPECIALLY POSTERIOR PART

Bruises - abuse vs accidental

ABUSE - on padded areas, pattern injuries, many lesions

ACCIDENTAL - on poorly padded areas, non-specific patterns, few lesions

Differential diagnosis for bruises

CHILD ABUSEBleeding disordersMongolian spotsHenlich-Shonlein purpuraCupping, coining

Which lesion is virtually pathognomonic for child abuse

Metaphyseal fracture - results from tearing and shearing forces

Most vulnerable part of bone in infant

Distal metaphysis (no chondrocytes - makes it weaker then physis, fewer organized cells and less calcification makes it weaker then proximal

metaphysis or any other part of the bone) what is central to radiologic diagnosis of abuse

RIB FRACTURES - posterior rib fractures are highly suggestive of abuse

Which parts of ribs are most commonly fractured in abuse

Head and neck - only in abuse and MVA

High specifity injuries suggesting abuse

- Classic metaphyseal lesions- Rib fractures - head+ neck, posterior- Scapular fractures- Spinous process fractures- Sternal fractures

Compartment syndrome definition

Elevation of interstitial pressure in closed fascial compartment that results in microvascular compromise

Tissue threshold to ischemia - muscle _ , nerve _

Muscle 4 hoursNerve 8 hours

Causes of compartment syndrome

Fractures of long bonesCRUSH INJURIESBurnsPneumatic tourniquetteHigh injury trauma/blunt traumaIschemia/reperfusionPenetrating injuries (snake spider bites)Chronic overuse

Which compartment is most commonly involved in compartment syndrome in lower extremity

Anterior compartment (stronger fascia, lower compliance, less subcutaneous fat for shock absorption)

6 P's of compartment syndrome

Pain (out of proportion)ParesthesiasPulselessnessPassive movement painPallorParalysis

You should consider diagnosis of compartment if pressure within compartment is equal to or exceeds _

30 mm Hg

Treatment of compartment syndrome

FasciotomyDebridement of necrotic muscleJelonet dressingIV heparin

Most common symptoms of PE

DyspneaPleuritic chest painCoughHemoptysis

Signs of PE

TachypneaRalesTachycardia4th heart soundAccentuated pulmonic compound of 2nd heart soundCirculatory collapse

In PE EKG will often show Sinus tachycardiaT wave and ST segment changes - S1Q3T3

What does chest x ray show in patient with PE

Non specific changes (12% normal)

- Hamptons hump - wedge shaped formation in lower part of the lung from occlusion of the vessel

Westmark sign - changes distal to occlusion of pulmonary artery

Also atelectasis, small pleural effusion, infiltrate, elevated hemidiaphragm

Which tests are don to diagnose PE

- PULMONARY ANGIOGRAPHY - gold standard- CT- Ventilation-perfusion scanning- D dimer

In diagnosis of PE 2 algorithms are used -

- Clinical suspicion + ventilation-perfusion scanning- Clinical suspicion + CT scan/D-dimer

Wells criteria assess Likelihood of patient having PE

What has become a modality of choice for diagnosis PE

CT SCAN (pulmonary angiography is a gold standard but it is less available and more invasive)

Mortality rate for patients with PE

30% w/out treatment

2-8% with prompt intervention

65-90% of PE arise from _ DVT in lower extremities

Virchow triad Vascular intimal injuryHypercoagulabilityVenous stasis

Risk factors for PE SURGERY- Immobilization- Stroke- Smoking- History of DVT- Malignancy- Chronic heart diseases- Fractures

- Oral contraceptives What should be INR in patients on Coumadin

2-3

SYmptoms for flexor tenosynovitis

- Pain with passive stretching- FUsiform swelling (sausage fingers)- Erythema- Intact sensation

Normal extension of the hip is _

20-30 degrees

Normal flexion of the hip is 135 degrees

Normal abduction of the hip is _

45-50 degrees

Normal adduction of the hip is _

20-30 degrees

What is a weight bearing portion of the hip ( would decrease in OA)

Superior portion of acetabulum

Causes of hip pain

Hip fractureHip dislocationsOAOsteonecrosisIliotibial band tendonitisIntraarticular pathologyTrochanteric bursitisPediatric causes - unique to children - growth plate problems, infectionsInguinal hernia

Intraarticular pathology

Labral tearsOssified loose bodies Synovitis (pigmented villonodular)Septic arthritis - pediatric patients and post joint replacement

Question AnswerSide

3

How would typical patient with septic arthritis present

- Pain in anterior aspect of the hip- Pseudoparalysis - patients are not paralyzed but it is very painful so they are trying to limit use of the extremity- Fever- Possible trauma history - if patient is bacteremic even small trauma can cause septic arthritis- Patient is usually 4 years old with no underlying illnesses

What is a common positioning of the hip in

Hip is in: external rotation, abduction and mild flexion - in this position capsule holds most fluid -

patients with septic arthritis and why

most comfortable position

Which blood tests should you do in patient with septic arthritis

CBCCRPESR

CRP and ESR are both acute phase reactants, CRP is more acut and ESR is more chronic - both used to evaluate progress in patients with septic arthritis

Blood cultures in patients with septic arthritis are always positive - T/F

FALSE - 40-50% are positive

If you see x ray changes in patients with septic arthritis what does it mean

Long standing infection

Is ultrasound useful as diagnostic tool in patients with septic arthritis

It looks for echogenecity - very sensitive for effusion but not infection, effusion can be normal (synovial fluid) or can be infectious (pus)

What procedure is used to determine organism in septic arthritis

Large bore needle aspiration - if you think joint is infected but nothing is coming out, inject sterile saline solution to give volume and suck it back out and bacteria will follow the fluid, dont inject anything bactericidal - will kill causative organism before determination

Describe WBC levels in patients with septic arthritis

Over 50000 and 90% PMN

Glucose levels in synovial fluid of patients with septic arthritis are _

40 mg/dL less then serum levels (also do blood glucose levels to compare)

How do you confirm diagnosis in patients with septic arthritis

Gram stain - can confirm diagnosis in 50% of cases

Cultures - positive in 50-80% of patients

How do you treat septic arthritis of the hip

Early diagnosis is very important. Also get cultures of synovial fluid as soon as possible to determine appropriate antibiotic, and do hip arthrotomy to drain surgically.

In high risk low birth weight neonates causative organisms of septic arthritis of the hip are _

S. aureus followed by group B strep

In kids 3 months- 3 years H.influenza type B, followed by Staph and Strep,

old causative organisms of septic arthritis of the hip _

declined drastically with H. flu vaccine

In kids older then 3 years old causative organisms for septic arthritis of the hip are_

S aureus (50%) , strep (25%)

What are the possible causes of Legg-Perthes-Calve disease

- Clotting factors/blood viscosity- Endocrine abnormalities (thyroid disorders, higher T3/T4 levels)

Usual age of presentation for LCP disease/sex

4-10 years old boys (often small for age)

WHat is common presentation of child with LCP disease

Limping (antalgic gait)- can present for weeks or months, usually no pain but if it does exist its mild and affects knee

What motions are limited in child with LCP disease

Internal rotation and abduction, internal rotation is best tested in extension

Which test is positive for LCP disease

Trendelenburg test - test for gluteus medius strength, opposite side drops

Pain is referred from hip to suprapatellar region - what nerve is involved

Femoral

Pain is referred from hip to medial thigh - what nerve is involved

Obturator

Pain is referred from hip to buttock - what nerve is involved

Sciatic nerve

What is a recommended treatment and goals for management of LCP disease

- Relief of weight bearing - Bedrest, traction, spica, slings, frames- Present goals- maintenance of hip motion and containment of involved femoral head from bases for treatment, inital goals are to restore mobility and to reduce pain- Operative and non-operative containment - if femoral head is not covered completely by acetabulum can do pelvic osteotomy and manipulate to get full coverage

What is prognosis for patients with LCP disease

Majority of patients will do well in 5th decade, 50% of untreated patients will develop arthritis by age of 55

How do patients with OA of the hip usually present

Groin, buttock, and or thigh and knee pain

Conservative measures for treatment of OA of hip

Activities modificationNSAIDSWeight controlTylenolInjectionsAssistive devices

2 types of hip fractures Intracapsular Extracapsular

Hip fracture patients typically present with what deformity

Limb is shortened and externally rotated

Hip fractures cause pain where

Usually groin pain , can also have thigh or knee pain - may not be weight bearing, both passive and active motion cause pain

Which imaging tests do you order when you suspect hip fracture

AP pelvisAP hipShoot through lateral of hipMRIBone scan

4 types of intracapsular hip fractures

CapitalSubcapitalTranscervicalBasicervical

2 types of extracapsular fractures

IntertrochantericSubtrochanteric

Anterior hip dislocations occur as result of _

Abduction and external rotation forces

If hip is flexed at the time of injury anterior hip dislocation is _

Anterior and inferior

If hip is extended at the time of injury anterior hip dislocation is _

Anterior pubic

Posterior dislocations of the hip occur when _

Longitudinal force is applied in line with femur and acting on adducted hip

Which posterior dislocation is worse when hip is more abducted or adducted

When hip abducted - worse dislocation, more adducted - cleaner dislocation

How do posterior dislocations present

Will be flexed at the hip, adducted and internally rotated

How do anterior dislocations present

Externally rotated with various degrees of flexion and abduction

How do you treat hip dislocations

- Emergent reduction- Closed reduction is attempted first unless there is

associated hip or femoral neck fracture (ipsilateral)- Complete paralysis should be obtained prior to attempt reduction

Which tests do you order when child presents with limping

ESRCBCMetabolic profile

Which anatomical cause of cervical region can result in limping

Cervical instability C1-C2

Joint diseases of hip that can cause limping

- Septic arthritis (toddler-adult)- Dislocated hip- Developmental dysplasia of hip- LCP disease (AVN of femoral head)- Slipped capital femoral epiphysis- Benign tumors - fibrous dysplasia, unicameral bone cyst- Stress fracture of the hip- Snapping hip - iliotibial band

Joint diseases of knee that cause limping

- Osteochondritis dissecans - AVN of femoral condyle- Tumor - benign or malignant

What can cause leg length discrepancy

- Growth arrest (infection, fracture, burn, JRA)- Fracture (physeal fracture)- Septic joint- Knee trauma - fracture, ligamentous injury- RA- Discoid meniscus (congenital abnormality of lateral meniscus - prone to tearing)- Osgood Schlatter- Patellar instability (can shear off femoral condyle)- Pathologic fractures- Brodies abscess (infection)

Which fractures of the knee are more common in little children vs older children

Little children - avulsion fracture, older children - ACL tear

What is Kohler disease AVN of navicular bone

What is Sever disease Apophysitis of tendo-achilles insertion

Which problems in feet can cause limping

- Clubfoot- Tarsal coalition- Tight shoes- Foreign body

Neurologic causes of limping

Cerebral palsy (diplegia, hemiplegia)Spinal cord pathologyTumors

In acute hematogenous osteomyeilitis infection begins where

Metaphyseal venous sinusoids

Describe cellulitic phase of acute hematogenous osteomyelitis

Infection begins in metaphysis and as it spreads metaphyseal vessels thrombose and prohibit inflow of WBC which must slowly migrate there from medullary cavity- Pus has not been produced yet- At this age antibiotics alone can be sufficient

Subperiosteal stage of acute hematogenous osteomyelitis

Once pus forms, to lessen interosteal pressure it will exit through porous metaphyseal cortex - this elevates periosteum and forms subperiosteal abscess

How do you diagnose acute hematogenous osteomyelitis

- Half of patients have history of recent or concurrent infection- May refuse to move limb- Tenderness over involved bone- Decreased range of motion over adjacent joints- Swelling, erythema and warmth over bone later

In acute hematogenous osteomyelitis ESR and CRP are _ EXCEPT in _

WBC are _

ELEVATED (90%)

EXCEPT sickle cell anemia patients, kids on steroid medications, and neonates

ELEVATED

Organisms causing acute osteomyelitis in neonates

S aureusGroup B strepGram negative coliforms

Organisms causing acute osteomyelitis in infants and children

S aureus

Organisms causing acute osteomyelitis in patients with sickle cell anemia

Salmonella

Organisms causing acute osteomyelitis in adolescents

S. aureus, gonorrhea

In acute osteomyelitis blood cultures are ALWAYS positive - T/F

FALSE - in 40-50%

Are there any x ray changes in acute osteomyelitis

Little change except soft tissue swelling for 7-10 days

How is definitive diagnosis of acute osteomyelitis made

By bone and subperiosteal aspiration

Antibiotics for treatment of acute hematogenous osteomyelitis in neonates

Oxacillin with cefotaxime or gentamicin

Antibiotics for treatment of acute hematogenous osteomyelitis in infants and children

Oxacillin or Cefazolin

Clindamycin or vancomycin if allergic to penicillin or cephalosporins

In neonates why does infection spread fast to joint

Why not in older kids?

Metaphyseal vessels communicate with epiphyseal in cartilaginous precursor of ossific nucleus permitting a route to spread to joints

As child matures epiphysis develops separate blood supply and there is no longer communication with metaphyseal vessels

Which areas are intraarticular in neonates and why is this important

Metaphysis of hip, proximal humerus, proximal radius and distal lateral tibia are intraarticular - provide tracks under the capsule into joint

How does infection affect growth plate in neonates

Thrombosis of vessels can cause ischemia of growth plate and infection can cause subsequent lysis of growth plate - complete ischemia and lysis of physis before ossification can lead to necrosis and reabsorption of femoral neck and head

Why do neonates get infections by microorganisms typically not seen in older children

Immune system is immature making inflammatory response compromised

Why is detection of osteomyelitis in neonates is often delayed

Minimal symptoms - malaise, failure to gain weight, no fever, ESR and WBC can be normal

Long term complications of osteomyelitis in neonates

Osteonecrosis of epiphyses, joint dislocation and premature physeal arrest

SUBACUTE HEMATOGENOUS OSTEOMYELITIS

Pain _

Fever _

Loss of function _

Prior antibiotic therapy _

Elevated WBC count _

Blood cultures _

Pain MILD

Fever FEW PATIENTS

Loss of function MINIMAL

Prior antibiotic therapy OFTEN (30-40%)

Elevated WBC count FEW

Elevated ESR MAJORITY

Blood cultures FEW POSITIVE

+ bone cultures _

initial radiographs _

Site _

+ Bone cultures POSITIVE IN 60%

Initial radiographs FREQUENTLY ABNORMAL

Site ANY LOCATION (CAN CROSS PHYSIS)

Assesment of open fractures in children should include _

ABC'sPatient diseaseSize of woundDegree of contaminationCrush (myoglobinuria)Bone lossVascular and nerve injuryDegree of periosteal slipping

If wound is contaminated with soil or barnyard , which organisms should you suspect

Tetanus

Clostridium (gas gangrene) If wound is contaminated in fresh water ponds which organisms should you suspect

Pseudomonas aeruginosa

Aeromonas hydrophilia

Which pathogenic contaminates of the wound are hospital acquired

MRSA

Pseudomonas aeruginosa Which pathogenic contaminates of wound can be received from patient to patient

HIV

Hepatitis If patients presents with open wound (fracture) and is not immunized up to date which immunizations should be given

Tetanus for clean or minor wounds and tetanus + immunoglobulin for under immunized

What is a treatment plan for open fractures in pediatric patients

Assess and documentSplint fractureGive antibioticsDebridement within 5-6 hours if at all possibleDo not close initiallyRepeat debridement as needed

What is the most important prognostic factor in kids with septic arthritis for outcome and prevention of growth anomalies

Duration of symptoms prior to treatment - requires urgent treatment, delay can cause destruction of articular cartilage

Signs and symptoms of septic arthritis in kids

Fever (38-40 C)PainEffusion and joint warmthLoss of motion

TendernessIn infants - limited spontaneous motion and assymmetric posture of extremity

In septic arthritis in kids WBC are _

Elevated in 30-60% of patients with left shift in 60% of those with elevated count

Which blood test in kids with septic arthritis is more sensitive then others

ESR - higher in patients with septic arthritis then in patients with osteomyelitis

What is differential diagnosis of septic arthritis in kids

JRAHemarthrosis CellulitisOsteomyelitisHenoch-Shonlein purpuraRheumatic feverSlipped capital femoral epiphysisLyme diseaseSickle cell crisisTransient synovitis (hip)Crystalline arthropathies (rare in children)LCP disease

What would x rays show in septic arthritis

Soft tissue swelling, adjacent bone destruction, joint narrowing (late)

When assessing for septic arthritis of hip in kid what other things should you consider

AppendicitisPsoas abscessPelvic osteomyelitis

Aspiration of effusion in septic arthritis will show fluid that is _

Cloudy

Most joint with early treatment in septic arthritis respond well to _

Aspiration and antibiotics

In septic arthritis of the hip there is risk of _ so its best treated with _

AVNSurgical drainage

When should surgery be considered in kids with septic arthritis

If aspiration fails once or twice

When should antibiotic therapy be started in septic arthritis patients

After you have all cultures - including joint aspirationsInfants and young children also need LP to look for meningitis

In neonates antibiotics used for treatment of septic arthritis are _

Oxacillin + cefotaxime or gentamicin

In child younger then 4 years old antibiotics used for treatment of septic arthritis are _

Oxacillin + cefotaxime or cefuroxime

In child over 4 years old antibiotic used for treatment of septic arthritis is _

OXACILLIN

In immunocompromised kids antibiotics used for treatment of septic arthritis are -

Oxacillin + ceftriaxone

Initial treatments of nail puncture wounds are _

Tetanys prophylaxisExcision of devascularized skin flapsIrrigation of puncture tract

Should antibiotic coverage for gram positive organisms be given in kids with nail puncture wounds

Only if there is evidence of cellulitis or soft tissue infection

Possible complications of nail puncture wounds

Cellulitis OsteochondritisOsteomyelitisSoft tissue abscessPyarthrosis

(Psedomonas osteomyelitis-osteochondritis 0.6-1.8 %)

Which organism is found in 93% of all nail pucture wounds osteomyelitis

Pseudomonas aeruginosa

Pseudomonas species have propensity for which part of the foot

Cartilaginous structures

What is a treatment for pseudomonas osteochondritis

Surgery to careful exploration for foreign bodies, debridement of dead tissue and extensive lavage7 day treatment of parenteral antibiotics

Question AnswerSide

3

What are the main steps in treating any infection

- Identify organism- Arrest tissue destructions (antibiotics or surgery if antibiotics cannot reach site)- Use surgery to prevent long term complications (AVN) or chronic joint changes

Adolescent idiopathic scoliosis definition

Structural lateral curvature of the spine occuring at or near onset of puberty for which no cause could be determined

Factors well known to predict curve progression

Lesser maturity and larger curve magnitude

Which curves tend to progress more

Over 50 degrees with more rotation

Which patients with scoliosis are at increased risk of cor pulmonale

High angle thoracic curves of more then 100 degrees

In patients with scoliosis (nonsmokers) significant FVC limitations start to occur _

after 100-120 degrees curve

Which x ray view is taken in patients with scoliosis

Standing x ray of spine - requires special grid for entire spine on one gridIf patient has structural leg length discrepancy put block under short limb until iliac crests are at level

What are you looking for on xrays in patients with scoliosis

Interpedicular wideningCongenital abnormallitiesRib pencillingSkeletal maturity

Typical idiopathic curves in scoliosis

Left lumbar and right thoracic

Juvenile idiopathic scoliosis presents with high incidence of _

Neuroaxis abnormalities

Which imaging test needs to be ordered in patients with juvenile idiopathic scoliosis

MRI - over 10 degrees deviation indicates progression

Diastemotomyelia

Boney or fibrous defect that splits spinal cord, as child grows and spine elongates traction occurs on the cord - can cause neuromuscular scoliosis

Diplomyelia Split cord - can cause neuromuscular scoliosis

Tethered cord Traction on end of cord - thickened filum terminale, lipoma

Myelomeningocele Neural tube defect - can cause neuromuscular scoliosis

Hydrosyrinx Expansion of spinal cord with CSF, scoliosis improves and sometimes resolves when hydrosyrinx is treated

Lower motor neuron diseases that can cause neuromuscular scoliosis

PolioSMADysautonomia

Myopathic causes of neuromuscular scoliosis

Muscular dystrophiesArthrogryposis

Patient with congenital scoliosis should also be evaluated for _

Heart problemsGU - need renal evaluationSpinal cordKlippel feil syndrome

Congenital scoliosis treatment - Bracing - only for compensatory curves- Hemiepiphyseodesis (under 7 years old)- Fusion - fuse early

Which infection is responsible for torticollis

Retropharyngeal abscess - erodes alar ligaments that connect C1 and C2 and you get cervical instability - need fusion

Congenital muscular torticollis Head side bent and rotated - contracted SCM, packaging defect

What else do you need to check in kids with congenital muscular torticollis

HIPS

What is Klippel Feil syndrome Congenital cervical spine fusions

Possible etiology of Klippel Feil syndrome

Homox gene

Problems associated with Klippel Feil

Sprengel'sDeafnessGU anomalies - get renal ultrasoundSynkinesis (mirror movements)Pulmonary problemsCongenital heart diseaseSpinal cordOther congenital problems (syringomyelia, neuroschisis, etc)

Sprengel deformity

Check shoulder height - retract shouldersScapula starts forming along cervical vertebrae, migrates distally with the limb, fibrous tether, shortening of the muscle

Which orthopedic problems are common in patients with Down Syndrome

Ligamentous laxityC1-C2 instabilityOccipital cervical instability

Which diseases are associated with cervical kyphosis

Diastrophic dysplasiaLarson syndrome - multiple joint dislocations, foot deformities, etx

Spondylolysis and spondylolisthesis in kids

Defect of posterior elements with fracture or slippage, not always painful

Treatments for spondylolysis and spondylolisthesis in kids

Activity limitationsBracing if recentSurgery if recalcitrant symptoms

Scheuermann disease (definition, common site, x ray findings)

Inflammation of growth plates of vertebral bodies- increased thoracic kyphosisIn thoracolumbar kyphosis + pain, in lumbar no deformity + painX rays- Cobb angle >45 degrees, wedging of 5 consecutive vertebrae

Discitis Inflammatory lesion of interverebral disc, narrowing disk space, self limiting inflammation, disc space infections (S.

aureus)

Differential diagnosis for back pain in children

Trauma - compression fx, physeal fxVertebral infection - S.aureus, TBMuscle spasmPsoas abscessTumor

Diagnosis of DDH includes _

Typical neonatal hip dislocationHip instabilityLate presentation hip dislocationTeratologic hip dislocation Acetabular dysplasia

Which DDH is hardest to identify

Bilateral

DDH is more prevalent in _ girls

Etiology of DDH

Remains uncertainPossible causes:Position in utero - very importantHereditaryPostnatal positioningIntrinsic dysplasia vs ligamentous laxity

Periods at risk for DDH

Impossible before 12th week of gestationMuscles are formed by 18 weeksLast 4 weeks from positioningEarly postnatal period

What is most common position in utero that causes DDH

Single breech + genu recurvatum (butt first + hyperextended knees)

What are risk factors for packaging defects

WomenLarge babiesFirst pregnancy

Effect of post natal positioning on DDH

Increased with swaddlingMore frequent during winter and springHip can dislocate with forced positioning

Which tests should be included in newborn exam to test for DDH

OrtolaniBarlow

What is necessary requirement for correct performance of Barlow and Ortolani tests

Baby need to be completely relaxed (this includes crying)

How do you diagnose DDH in older child

- Limited abduction- Galeazzi sign - looks at femoral lengths- Leg length discrepancy- Asymmetric skin folds- Increased lumbar lordosis - muscles of hip are contracted and pulling which increases lordosis in order to stay straight

X ray findings in patients with DDH

Acetabular dysplasiaShallow acetabulumAbsent ossific nucleusFemoral head displaced laterally

Pavlik harness is treatment for _ Hip instability

Treatment of DDH in older children

- Reduce hip- Avoid AVN by excessive pressure- Casting and surgery depend on age

Do children with DDH need regular follow up

X rays until child is walking - then once a year, recheck in adolescence for late subluxation

Which pediatric hip condition is an orthopedic emergency

Slipped Capital Femoral Epiphysis

Question AnswerSide

3

What is common age group for SCFE 12-15 year old

Patient with SCFE commonly presents with _ pain

KNEE

Risk factors for SCFE

OverweightEndocrinopathies - especially hypothyroidismDelayed skeletal maturation

Triad of symptoms for SCFE Knee painLimpingExternal rotation of the extremity

Untreated SCFE leads to _ Progressive slippage and early arthritis - onset of OA directly depends on degree of slippage

Which treatment is reliable in patients with SCFE

Early treatment with screw fixation (EARLY DIAGNOSIS IMPORTANT !!!!!!!)

If the slip in SCFE becomes unstable what complication is likely

AVN

In patients with _ due to ligamentous laxity and collagen problems slipped capital femoral epiphysis can persist even after treatment

DOWN SYNDROME

Age group for children with LCP disease

3-9

In LCP disease pain is at _ hip

When LCP disease is bilateral you need to consider _

Hypothyroidism or skeletal dysplasia

LCP disease = AVN of femoral head

Which processes occur in bone in LCP disease

Collapse and fragmentation

Children with LCP disease aged 6-9 statistically benefit from _

Surgery to redirect femoral head into acetabulum

Best outcome of treatment in LCP disease occurs in children

Younger then 6 at time of onset

Which treatments are used to preserve motion and reduce symptoms in LCP disease

Bracing, casting, traction and bed rest

What are consequences of leg length discrepancy

Increased energy expenditure of gaitFunctional scoliosis (insignificant)Pelvic obliquity causing increased center-edge angle of hip of long leg

Neurologically intact children with leg length discrepancy will compensate by _

toe walking

Which conditions should you beware of when diagnosing leg length discrepancy

Wilms tumorHemihypertrophy (look at size of hands and face)

Name things that can cause functional leg length discrepancy

Flexion contractures of hip or kneeAbduction or adduction contractures of hipPelvic torsion

Treatment of leg length discrepancy of 0-2 cm

No treatment necessary

Treatment of leg length discrepancy of 2-6 cm

Shoe lift, epiphysiodesis, shortening or leg lengthening

Treatment of leg length discrepancy of 6-20 cm

Lengthening (possible combined with other procedures)

Treatment of leg length discrepancy of over 20 cm

Prosthetic lifting

Which imaging test is used to assess leg length discrepancy

Scanogram - x ray with ruler to measure lenght of long bones

When adolescent patient presents with knee pain what are the things you should be concerned about

HIP PATHOLOGY - especially slipped capital femoral epiphysisPhyseal fracturesTumors - night pain is very concerning

Patellofemoral syndrome is also called _

patellar chondromalacia

Patellofemoral syndrome is most common in _

Adolescent girls

In patellofemoral syndrome pain is localized to _

anterior knee

In patellofemoral syndrome patient experiences locking and feeling of

FALSE - no locking and giving way

knee giving way - T/F In patients with patellofemoral syndrome pain gets worse with _

Stairs, walking hills and weather changes

Which test is positive in patellofemoral syndrome

Patellar grinding test

In patellofemoral syndrome you need to strengthen _ and stretch _ (muscles)

Strengthen quadsStretch hamstrings

Which exercises are best in patients with patellofemoral syndrome

Exercises with knee in nearly full extension - shallow squats, terminal extension weights, bike riding with seat fairly high

What are recommendations for patients with patellofemoral syndrome

Avoid deep knee bends and stairsDecrease force across patellaNSAIDS for symptoms

Osgood Schlatters disease is a childhood equivalent of _

Patellar tendonitis

Describe Osgood Schlatters disease

In growing adolescents proximal tibial apophysis is weak and susceptible to overuse injuries - microfractures with elevation of tubercle and bursitis

Treatments for Osgood Schlatters

-Decrease activity during periods of severe pain- Severe pain improves with rest- Ice knees after vigorous activity- Hamstring stretching- NSAIDS periodically

Patients with Osgood Schlatters have slight predisposition toward

Tibial tubercle fractures

Why can small avulsions occur in Osgood Schlatters

Quadriceps pulls on tibial apophysis

Osgood Schlatters is most common in _

11-14 year old boys

Triad of symptoms for diagnosis of patellar subluxation

Hurts anteriorlyGives wayPositive apprehension test

Osteochondritis dessicans is AVN of _

Medial femoral condyle

Osteochondritis dessicans can lead to _

Osteochondral fracturesChondral flaps Chondral separationLoose joint bodies

Common cause for meniscal surgery in children

Discoid lateral meniscus

With discoid lateral meniscus patients experiences

Snapping in lateral aspect of knee and occassional blocking of extension

Children are more likely to have _ then ligamentous injuries

Physeal injuries

When patient presents with bowed legs always keep in mind _

Dwarfism and metabolic disorders

Tibia vara is also called _ Treatment - Diagnosis -

Blounts diseaseTreatment - surgery and bracingDiagnosis - x rays

Difference between tibia vara and physiological genu varum

Genu varum is normal, tibia vara only gets worse and leads to early DJD

Question AnswerSide

3Patient present with pain out of proportion to injury and pain on passive stretch, it is a surgical emergency - what is the diagnosis

COMPARTMENT SYNDROME

If child isnt walking independently by 24 months what do you need to do

Refer for evaluation of significant developmental delay to orthopedic surgeon or neurologist

Child should be able to do reciprocal crawling by what age?

6-9 months

If primitive reflexes persist in child what can it indicate

Cerebral palsy

Hand grasp reflex tests _ Extuinguishes by_

Tone of upper extremity flexors2-4 months

Plantar grasp reflex - describeExtuinguishes by _ If persists indicate _

Tonic flexion and adduction of toes when stroked on bottom of footExtuinguishes by end of 1st yearIf persists - developmental delay, birth injury

In Moro reflex baby _ when startled Extends all 4 extremities

Persistence of Moro reflex after 6 months indicates _

Cerebral palsy

Moro reflex is decreased or absent in _ Floppy baby syndrome

Asymetry of Moro reflex indicates _ Peripheral nerve injury or cerebral palsy

Stepping reflex in baby should disappear by _

1-2 months

Placing reaction (baby lift foot and steps when brought to edge) persists until _ and its absence indicates _

12 monthsBrain damage

In crossed extension reflex pressure is applied to _ and opposite leg _ and toes _

Inguinal area

Flexes, adducts, extends

Fan Crossed extension reflex should disappear by _ and if it persists it indicates _

1 month

partial spinal lesion In asymmetric tonic neck reflex, baby is lying on the side and head is rotated to the side , arm and leg on chin side should _ , and on occiput side should _

Extend

Flex

Asymmetric tonic neck reflex should persist until _ and if it persists after that indicates _

4-6 months

Cerebral palsy - contributes to neuromuscular scoliosis in those kids

Which reflex appears at 6 months and persists throughout life and its absence indicates brain damage

Parachute reaction - when held at stomach extends arms as if to break fall (diminished response indicates hypertonicity in upper extremities)

In plain films in kids _ and _ is not visible

Non ossified bone and cartilage

Characteristics of toddlers gait

- Wide base- Little arm swing- Short stride length- Higher center of gravity- Little ground clearance- Mild foot drop

Center of gravity in gait of adult is _ Anterior to S2

Requirements of gait

Stability in stanceClearance in swing phaseAppropriate swing phase repositioningAdequate step lengthConservation of energy

Toeing out during walking can indicate _

External hip rotationExternal tibial torsionCalcaneovalgusVertical talusPes planus

Toeing in during walking can indicate

- Internal femoral torsion- Internal tibia toria- Metatarsus adductus- Equinovarus deformities

Multiple epiphyseal dysplasia presents with progressive _ deformity, DJD, pain

VALGUS

and altered mechanical axis

Differential diagnosis for valgus

- Post traumatic/post infection partial growth arrest- Salter II fracture of proximal tibia- fibular hemimela- Genu recurvatum- Physiological genu valgum in adolescents

Achondroplasia causes varus/valgus deformity

VARUS

Differential diagnosis for varus

- Blounts disease- Skeletal dysplasia- Fibrocartilaginous dysplasia- Fibrous cortical tether of distal femur- Rickets- Post traumatic/post infection partial growth arrest- Combination of external femoral rotation and internal tibial torsion- Tibial bowing

In positive Trendelenburg test which muscle is weak

Gluteus medius

What happens to knee when patient has weak quadriceps femoris

It locks

During walking patient is unable to push off with toes which results in calcaneus gait and tibia shifts posteriorly over talus in last portion of stance phase - which muscle is weak in this patient

Gastrocnemius - soleus

Patient has steppage gait to clear foot through swing phase, patients externally rotates foot and lifts foot higher - which muscles are weak

Dorsiflexors of the foot

Patients weightbearing is shortened during stance on affected side to relieve or lessen pain - this gait is called _

Antalgic

Most common form of polydactyly Small nubbin on lateral border of foot (postaxial), may have a nail

What treatment is indicated in polydactyly

Surgical to ensure comfortable foot wear

Syndactyly is caused by _ Failure of programmed cell death

Syndactyly usually occurs _ where Between 3d and 4th toes - skin only, partial webbing

Surgical intervention is medically necessary in syndactyly

no, cosmetic - shoe fit generally not a problem

4 types of syndactyly

Complete - webbing entire length of digitIncomplete - webbing partial length of digitSimple - soft tissue unionComplex - boney union

In metatarus varus (adductus) medial border of the foot curves _

Inward

With any packaging defect you should also check _

hips

Etiology of clubfoot deformity

IdiopathicPackaging defectArthrogryposisMyelodisplasiaHereditary

With clubfoot deformity you also check _ and _

Hips for dysplasia or instabilitySpine for sacral cleft, dimples and hairy patches

Signs of clubfoot

- Adductus of forefoot- Varus of hindfoot- Posterior and medial creases- Supination of mid and forefoot- Empty heel pad

Vertical talus is also known as _ Rockerbottom foot - rigid foot, cannot plantarflex, can palpate head of talus on plantar foot

Cleft foot is caused by _ Central failure of formation

Goal of treatment of cleft foot is _ Comfortable shoe wear

Flat foot is called Pes planus

Which arch is flattened in pes planus - what else is abnormal

LongitudinalHindfoot valgusSubluxation of talonavicular joint

Which type of pes planus is painful and should be refered to orthopedic surgeon

Rigid

3 types of tarsal coalitions Syndostosis - bone coalitionSynchondrosis - cartilage coalitionSyndesmosis - fibrous coalition

Question AnswerSide

3Increased height of longitudinal arch is called _

Cavus/cavovarus

X rays are high/low energy HIGH - only gamma rays are higher

X rays are measured in _ Roentgens

Radiopacity is dependent on 3 factors - what are they

Atomic numberPhysical densityThickness

With any packaging defect you should also check _

hips

Etiology of clubfoot deformity

IdiopathicPackaging defectArthrogryposisMyelodisplasiaHereditary

With clubfoot deformity you also check _ and _

Hips for dysplasia or instabilitySpine for sacral cleft, dimples and hairy patches

Signs of clubfoot

- Adductus of forefoot- Varus of hindfoot- Posterior and medial creases- Supination of mid and forefoot- Empty heel pad

Vertical talus is also known as _ Rockerbottom foot - rigid foot, cannot plantarflex, can palpate head of talus on plantar foot

Cleft foot is caused by _ Central failure of formation

Goal of treatment of cleft foot is _ Comfortable shoe wear

Flat foot is called Pes planus

Which arch is flattened in pes planus - what else is abnormal

LongitudinalHindfoot valgusSubluxation of talonavicular joint

Which type of pes planus is painful and should be refered to orthopedic surgeon

Rigid

3 types of tarsal coalitions Syndostosis - bone coalitionSynchondrosis - cartilage coalitionSyndesmosis - fibrous coalition

Increased height of longitudinal arch is called _

Cavus/cavovarus

X rays are high/low energy HIGH - only gamma rays are higher

X rays are measured in _ Roentgens

Radiopacity is dependent on 3 factors - what are they

Atomic numberPhysical densityThickness

Higher atomic number more/less radiopaque?

More radiopaque

Air less dense so it appears _ Black - radioluscent

Fluid and soft tissue is more dense so it appears _

Grey/radiopaque

Thicker substance is more/less radiopque

More radiopaque

When two tissues/objects overlap, how do they appear on film

Additive - appear more white

Which tissues have same radiopacity Soft tissue and fluid

Fat is more lucent then _ but more opaque then _

Bone/soft tissue

Gas Most radioluscent material visible on film

GAS

Most opaque shadow seen on radiographs

Metal

In x ray machine there is electrode pair - cathode and anode, cathode is _ , anode is _

Cathode - heated elementAnode - tungsten plate or beam

How x ray works - free electrons from _ collide with _ - knocking an electron out of _ . A _ fills gap releasing energy as x ray photon.

Heated cathodeTungsten atomLower orbitHigher orbit electron

95% of electron energy is deposited as _ , 5 % generates _

Heat on anode

x rays

1 gray equals _ 100 rads

How do you protect from radiation Reduce time of exposureIncrease distance from radiation sourceProvide radiation shielding

Where should you view radiographs Darkened quiet room with at least two viewing boxes and good illuminator

You always need two orthogonal projections when viewing x rays - T/F

TRUE

Radiographic views are named according to _

Direction primary beam enters and leaves tissues and body part being examined

Digital radiography uses _ photostimulable phosphor plate and image reader-writer

Computed tomography is _ rotated around patient

Fanned x ray beam

Compute tomography uses _ to Mathematical measurements of

display as image transmissions at various angles

How does ultrasound work Sound waves are sent through patient and returning echo is recorded as image

Resolution of images in ultrasound depends on _

Wavelength and frequency of waves

Low frequency ultrasound has _ wavelength, _ resolution, _ depth of penetration

Longer

Less

Greater

High frequency ultrasound has _ wavelength, _ image detail and superior for _

shorter

greater

orthopedic views of ligaments and tendons

What is the origin of signal used in generation of MRI images

Proton (hydrogen nucleus)

What is the feature exploited in detecting NMR signal in MRI

Magnetic moment (spin) of H nucleus when placed in strong external magnetic field

In MRI response of excited proton is measured when _

Second (RF) signal is applied to small slice of scan

T1 MRI image measures energy released as _

Proton exposed to RF signal realigns to magnetic orientation

T2 MRI image measures energy transmitted by _

Wobbling effect of protons that have been exposed to RF signal (they are out of phase and release energy as they become in phase)

Every tissue has same T1 and T2 property on MRI - T/F

FALSE - every tissue has unique T1 and T2 property (can have same T1 but different T2, or same T2 but different T1)

Normal and strained muscle have same appearance on _ , but different on _ (T1, T2)

Same T1

Different T2

Question AnswerSide

3

Fat and muscle have same appearance on _, but different on _ (T1, T2)

Same T2

Different T1 When radioisotope localizes in skeleton, _ is measured and recorded

Gamma radiation

First isotope used clinically for bone scannin Strontium 85

Which isotope has shorter half life then Strontium 85 but poor soft tissue clearance

Strontium 87

Which isotope has short half life (excreted in urine after 4 hours) and binds to _ in bone

Technetium - binds to Ca in bone

Which isotope used to tag WBC's Indium

Which isotope impregnates into Ca hydroxyapatite crystals uptake in neutrophils and bacteria

Gallium 67

Which isotope doesnt require in vivo use IgG labeled

Factors affecting uptake of isotopes

Bone turn over rateBlood flow to areaTraumaTime isotope is in system

Example of metabolic imaging is _ PET scan

PET scan is best to use for detection of _ Soft tissue neoplasms or osseous metastases

What is the name of tracer used in PET scans 2-deoxy-2-fluoro-D-glucose

What does PET scan measure Glucose utilization by tissue

PET scans can be combined with _ for precise imaging

CT scans

DEXA scan stands for _ Dual energy x ray absorption

DEXA scan measures absorption of _ and compares to _

2 beams of radiation into hip and spine

standard

DEXA scan calculates _ and uses them to identify if patient has _

T scores

Osteopenia or osteoporosis If you need cross sectional capability which imaging modality would you choose

CT scan

For early detection of fracture or infection and degree of involvement, imaging modality that you would choose would be _

Bone scan

For identification of bone contusions, articular cartilages, relationships of neurovascular structures to other anatomy which imaging modality would you choose

MRI

For identification of fluid filled tissue and vascular supply imaging modality of choice is _

Ultrasound

What is the best therapy of ankle sprain PT with emphasis on proprioceptive training

How do you diagnose Achilles tendon rupture

Local tenderness/swellingPalpable defectMRI/ultrasoundInability to plantar flex foot

Thompson test detects _ Achilles tendon rupture

Describe Thompson test

When you squeeze calf - foot will normally plantar flex - in Achilles tendon rupture that doesnt happen

With medial gastrocnemius/plantaris muscle tear pain is more _

proximal, mid to upper medial calf

Will Thompson test be negative in plantaris muscle tear as well

NO - positive - squeeze calf and foot plantar flexes

Which orthopedic condition of foot is most underdiagnosed and unrecognized

Posterior tibial tendon insufficiency = "acquired flatfoot"

"Too many toes" sign is sign of _ Posterior tibial tendon insufficiency

Patient presents with pain in medial malleolus, unable to stand on toes Diagnosis?

Posterior tibial tendon insufficiency

Patient complains of morning pain in foot (1st few steps extremely painful) - what should you immediately consider

Plantar fasciitis

What is main treatment of plantar fasciitis Participation to tolerance

Jones fracture is a fracture of _ Base of 5th metatarsal - at metaphyseal-diaphyseal junction

Acute Jones fracture shows _ on x ray sharp margins

Non unions are very common with Jones fracture - T/F

TRUE

Patient presents with compression, pain between fingers - what should you immediately be considering

Mortons neuroma

What is key distinction of claw toes Marked hyperextension of MTP joints

Knee swelling within 4-6 hours of injury indicates _

Hemarthrosis

Fat globules in the blood on aspiration indicate _

Fracture

If aspirate has cloudy appearance you should think about _

Infection

String sign means _ Viscosity of aspirate - indicates infections

Patient presents with knee effusion with joint Infection

pain, warmth, erythema and swelling, what should be you first suspicion What is the location for aspiration of the knee

Superior lateral pole of patella

Patient presents with pain, snapping, swelling, stiffness, decreased ROM, feeling of instability and locking of the knee- diagnosis

Torn meniscus

Patient presents with acute meniscal tear - what is the probable mechanism of injury

Twisting injury with foot planted

Which symptom is not present in chronic meniscal tear

Knee locking

You examine patient with torn meniscus - what would you find

Pain at joint linePositive McMurrays testPopping or catching of kneeKnee lockingSwelling and stiffness

Differential diagnosis for meniscal tear Ligamentous injuryLoose bodiesOsteochondritis dissecans

How would you treat torn meniscus ArthrotomyPT Meds

Patient presents with post traumatic pain and swelling, knee feels unstable and there is immediate effusion - what does this patient have?

ACL rupture

Question AnswerSide

3Over 70% of patients presenting with immediate effusion have _

ACL rupture

Patient presents with ACL tear - what is possible mechanism of injury

Hyperextension or deceleration injury

Patient presents with chronic knee instability after old injury - what should you be thinking

ACL with posterior medial meniscal horn tear

Which test is most sensitive for ACL tear

LACHMANS

You suspect patient has ACL rupture what test would you do ?

Anterior drawer testPivot shift testLachmanns test

Differential diagnosis for ACL tear PCL, MCL, meniscal injury or combination

Which procedure usually fail in treatment of ACL rupture

Primary repair

Which surgical procedures are used in treatment of ACL tear

Grafts (auto/allografts)Radiofrequency heatSimple debridement

Patient presents with PCL tear - what is probable mechanisms of injury

High energy trauma - dashboard, posterior force on anterior tibia

Patient presents with palpable deformity of the knee and the knee is flexed - what is possible diagnosis

Patellar dislocation

Over 90% of patellar dislocations occur _

Laterally

You evaluate patient for patellar dislocation - which test is positive?

Apprehension

Patient has patellar dislocation what is your treatment plan

ReductionImmobilizationBracesArthroscopic procedureOpen procedures (realignment)

Patient presents with pain around knee cap,no history of injury, crepitance and increased pain when going up the stairs - what is most likely diagnosis

Patellofemoral syndrome (chondromalacia)

You examine patient with patellofemoral syndrome - which tests would you perform

Patellofemoral grind testClarks test - compression of patella with contraction of quadsLateral J sign - lateral movement of patella in extension above trochlear groove

Differential diagnosis of patellofemoral syndrome

Patellar malalignmentOsteoarthritisOsteochondritis dissecansPlica syndrome

Patient presents with patellofemoral syndrome - what are surgical options of treatment

ChondroplastyLateral releaseOpen realignmentPatellectomy

Patient presents with painful and swollen prepatellar bursa and increased temperature - diagnosis?

Prepatellar bursitis

Patient presents with collateral ligament tear - what do you find on exam

Pain InstabilityEffusionLocking

You evaluate patient for collateral ligament damage and see

Pellegrini-Stieda disease

calcifications on x rays due to old MCL tear - what is your diagnosis

What is differential diagnosis for collateral ligament rupture

ACL ruptureMeniscal injuryTibial plateau fracture

Patient presents with pain and swelling, popping and locking of the knee - further tests find necrosis of subchondral bone - diagnosis

Osteochondritis dissecans

Which x ray do you order in evaluating patient with osteochondritis dissecans and what would you commonly see

Tunnel view - lesion on lateral aspect of medial femoral condyle

Differential diagnosis for osteochondritis dissecans

ACL ruptureMeniscal injury

Most common cause of loose bodies in the knee

Osteochondritis dissecans

The conservative treatment of osteochondritis dissecans would include

long leg casting

What are the surgical treatments of osteochondritis dissecans

In situ pinningDebridementOATESDrilling/microfractureRemoval of free fragmentAutologous cartilage transfer

What is the best surgical procedure for treatment of osteochondritis dissecans

OATES - take pieces of HA and implant

Patient presents with knee pain and states that it only hurts with weight bearing and doesnt with rest, he also has deformity, decreased ROM, swelling and crepitance/catching of the knee - most likely diagnosis is _

OA of the knee

Most common location of OA of knee is _

Medial femoral condyle

You order weight bearing x ray on patient with OA of knee - what would you see

Density changes on xray - sclerotic bone due to OA, medial femoral condyle space is collapsed, lateral widened

Differential dx for OA of knee Torn meniscusHip pathologyChondromalacia

Conservative treatment of OA of knee PT

would include MedsInjectionsAssistive devices

Surgical options for treatment of OA of knee

High tibial osteotomyUnicompartmental knee replacementTotal knee replacement

Sport with highest percent of reportable and high severity injuries

Female gymnastics

Most common site of injuries in sports in both men and women

Knee and ankle

Patient is taking a banned drug which was banned because it causes liver damage, it significantly increases androgenic plasma serum levels, however patient reports increased psychological and physical well being, you advise patient that drug increases risk of uterine and prostate cancer and also can cause hirsutism, gynecomastia, liver disease and virilization What is the name of the drug patient is taking

DHEADEHYDROEPIANDROSTERONE

Patient is taking a banned drug, his endogenous testosterone is increased (300 mg/day) - what is the name of drug he is taking

Androstendione

Patient is taking banned drug, he reports increase in muscle mass and delay in fatigue - name of drug and mechanism of action

CREATINE - increases formation of ATP

Patient is taking a nutritional supplement that is banned in sports - he reports increased muscle mass and increased rate of recovery after strenuous exercise -what is the name of supplement and what is is a metabolite of

Beta-hydroxy or beta-methylbutyrate - metabolite of leucine

Human growth hormone is restricted in sports because it _

Increases type II fast acting muscle fibers and decreases fat

Which drugs are restricted in sports Diuretics beta blockers Human growth hormone

Why is EPO banned in sports Increases RBC mass (natural hormone produced by kidney)

Men have higher RBC counts - T?F T

Women have significantly higher rates of injury of _

Knee (ACL, collateral ligament, meniscus)

Stress fractures are more common in men/women?

Women - poor nutrition,menstrual irregularities

Your female patient is young athlete, she refuses to maintain normal weight, has intense fear of weight gain, disturbed body image and 3 consecutive months of amenorrhea - diagnosis

Anorexia nervosa

Patient has anorexia nervosa - what would you find on exam

AmenorrheaFat and muscle lossDry hair and skinLanugoCold discolored extremitiesDecreased body tempDizzinessBradycardia

Young female athlete presents with complain of recurrent binge eating, over eating and sense of loss of control, she has recurrent compensatory vomitting and abuses laxatives, she also engages in fasting and over exercise and has negative self image - diagnosis?

Bulimia nervosa

Female athlete triad

Amenorrhea

Eating disorder

Osteoporosis

Question AnswerSide

3

Pregnant patient asks you if she can continue exercising with pregnancy You give following advicematernal heart rate should not exceed _ , strenuous activities should not exceed _ minutes, she should avoid _ maneuver and _ exercise after 4th month, she needs to increase _ and maternal core temp should not exceed _

140 beats per min

15 min

valsalva

supine

caloric intake

38 degrees C

In young athletes under 12 which shoulder injuries are more common

Fractures (dislocations are rare)

Little league shoulder is stress reaction to _

Proximal humeral epiphysis (widening and microfracture)

Microinstability in pediatric shoulder leads to _

Labral tears

Little league elbow includes _

Medial epicondylar apophysitisLateral joint compressionOCD of capitulumUlnohumeral chondromalacia

Madelungs deformity is _ Shortened and deformed distal radius

Pediatric wrist injuries in sports are common among

Weight lifters and gymnasts

47% of all low back pain in young athlete is due to _

Spondylolysis

Spondylolysis occurs due to excessive repetitive _

hyperextension

Young athlete presents with snapping pain in hip with external rotation - what are the possible causes of his condition

Tight iliopsoas, bursitis, inflammation

Young athlete presents with painful snapping at greater trochanter - diagnosis

Snapping iliotibial band

Young athlete presents with posterior heel pain - differential diagnosis?

Severs apophysitisAchilles tendonitisPlantar fasciitis

AVN of navicular bone is called _ Kohlers disease

AVN of 2nd metatarsal head is called _

Friebergs disease

Patient presents with acute onset of muscle soreness which occured during unaccustomed exercise, its accompanied by weakness and easy fatiguebility - diagnosis and probable location

Muscle strain - muscle tendon junctions

Treatment of muscle strains RICE + NSAIDS

Patient complains of pain in lower leg that is brought by exercise and relieved with rest - what is diagnosis, why occurs and possible complication

Chronic exertional compartment syndrome - fascia does not accomodate increased swelling and blood flow, can progress to typical compartment syndrome (watch for 6 P)

In tendon overuse injuries type _ collagen is replaced by type _

Type I by type II

Physical therapy modalities that both use cortisone cream and bring into tissue by electrical stim or sound waves

Iontophoresis Phonophoresis

Patient presents with loss of consciousness after trauma on field, he also experiences retrograde amnesia, tinnitis, blurred vision. He has headache and has trouble concentrating. He complains of nausea, vomitting, disturbed balance, excessive sleep and depression- diagnosis

CONCUSSION

In concussion _ is disrupted which causes stretching of _ . This results in opening of _ channels. Extracellular increase of _ leads to release of _ amino acids which leads to influx of _ to cell which causes neuron injury and death - cerebral blood flow _

Neuronal cell membraneAxonsPotassium PotassiumExcitatoryCaDecreases

Football player presents 2 days post concussion with headache, slower reflexes, impaired memory and concentration, depression and excessive sleep - diagnosis

Post concussion syndrome

Post concussion syndrome is caused by _

Continued NT dysfunctions

Patient is an athlete who has sustained initial head injury, returned to play while still symptomatic and sustained second head injury.Second head injury resulted in loss of cerebral autoregulation, cerebral vascular congestion, increased intracranial pressure and brain herniation - diagnosis

Second impact syndrome

Patient presents after trauma - he didnt lose conscioussnes and had post traumatic amnesia for less then 30 minutes - he has concussion grade _ When can he return to play

ICan return if asymptomatic for one week (if completely asymptomatic can return same day)

Patient sustained trauma, lost consciousness for less then 5

IICan return to play when asymptomatic

minutes and had post traumatic amnesia for more then 30 minutes, he has concussion grade _ When can he return to play

for one week

Patient has sustained trauma during play, he was unconscious for more then 5 minutes and had post traumatic amnesia for more then 24 hours. He has concussion grade _ When can he return to play

IIIHe may not return to play for at least one month - can return then if asymptomatic for one week

Mildest form of heat injury Heat cramps

Patient presents with painful muscle cramps and spasms that occured after intense exercise in high heat, he has mild fever (less then 102) - diagnosis and how would you manage it

Heat cramps - move to cold place and rest, fan patient, give cool sports drinks and stretch cramped muscles

Patient presents with muscle cramps, nausea and vomitting and high fever (over 102), you diagnose patient with heat exhaustion - what is management?

This occured due to loss of electrolytes and water due to excessive sweating - move to cool place and rest, remove excessive clothing, give cool sports drinks, if no improvement give IV fluids

After being several hours in heat patient presents with high fever over 104, warm dry skin, he is confused, lethargic - diagnosis, is condition serious and how do you treat it

LIFE THREATENING - HEAT STROKE - patient can progress to stupor, seizures, coma and death, bodys heat regulation system is overwhelmed - need to move to cool place, call 911, remove excessive clothing, fan, drench skin with cool water, place ice bags in armpits and groin, give cool fluids if alert or IV fluids if not, and monitor urine output

Landmarks for hip PE

Greater trochanterASISIliotibial bandIschial tuberosityGluteal muscle massHip adductors

Ober test evaluates _ Contraction of iliotibial band and fascia lata

Thomas test test for _ flexion contractures

How do you measure true leg length

Measure from ASIS to medial malleoli, then while supine flex knees and place feet together, judge knee discrepancies for tibial vs femoral length discrepancies

Flexion of knee 120 degrees

Extension of knee 180 degrees

External rotation of knee 507 degrees

Landmarks for evaluation of knee

PatellaTibial tuberclePatellar tendonAdduction tubercleFibular headPopliteal spacePopliteal arterySuprapatellar pouchMedial and lateral femoral condylesVMO

Apprehension sign checks to see if patella is prone to _

Lateral subluxation or dislocation

Drawer test evaluates _ ACL and PCL

How is Lachman test different from anterior drawer

Leg flexed approximately 20 degrees

Clark maneuver tests for _ Patellar grind

Apley compression test - patient is _ (prone/supine) with one leg _ to _ degrees - perform downward compression and _ - elicits pain

ProneFlexed to 90 degreesInternal/external rotation

Mcmurray test includes _ Valgus stress and external rotation - take from flexion to extension

Varus and valgus stress tests are done at _ degrees of flexion and check for _

30 degrees

MCL, LCL

Ankle plantar fkexion _ degreesdorsal flexion _ degrees

50

20 Which pulses do you measure on foot

Dorsalis pedisPosterior tibial

To perform Ober test you place patient in _ position, _ knee, let knee drop - if knee stays abducted it demonstrates tight _

Lateral positionAbduct kneeIliotibial band or fascia lata

In Thomas test you place patient _ , _ hip to 90 degrees and try to _ opposite extremity

SupineFlexExtend

Question AnswerSide

3

Internal/External rotation of knee 10 degrees

Q angle Line from ASIS to center of patella, then second line from patella to tibial tubercle

Anterior drawer test of the ankle assesses stability of anterior talofibular ligament

How do you test for pes planovalgus Look from behind for "too many toes", also look at arch height, compare both sides

Finkelstein tests for what disease deQuervains disease - active and passive ulnar deviation of wrist

Thumb grind test tests for _ OA at base of thumb

When testing for Froment sign you ask patient to _

hold paper between thumb and index finger

Adsons test should show what_ Radial pulse and tingling with shoulder abduction

Spurling test Head tilted and rotated then downward pressure - facet and nerve root impinges

Biceps reflex level C5

Brachioradialis reflex level C6

Triceps reflex level C7

Biceps innervation level C5-C6

Triceps innervation level C7

Wrist flexion innervation evel C7

Wrist extension innervation level C6

Shoulder abduction (deltoid)innervation level C5

Patellar tendon reflex level L4

Achilles tendon reflex level S1

Which root has no reflex L5

Toe extension innervation level (extensor digitorum longus)

L5

Foot eversion (fibular tendons) innervation level

S1

Anterior tibialis muscle innervation level L4

Sensory level for medial side of leg L4

Sensory level for lateral leg to dorsum of foot L5

Sensory level of lateral foot S1

When you ask patient to toe walk what root are you testing

S1

When you ask patient to heel walk what root are you testing

L4-L5

Lasegues straight lef lifting test suggests _ Nerve root irritation (pain shoots down leg)

Contralateral Lasegues tests _ hip

Straight leg drop test tests _ pull of iliopsoas (hip pain)

Patrick test differentiates hip disorders from _ SI pain

Gaenslens sign is indicative of _ How is it done

SI pain - done by droping leg off table

Mennel sign is done in what position PRONE (extended leg)

Patient presents with loss of sensation on medial leg, EMG showed fibrillation of sharp waves in tibialis anterior, myelogram shows bulge in spinal cord adjacent to disc L3-L4What is the root involved?Reflex?

Root L4Reflex PatellarMuscle - tibialis anterior

Patient presents with loss of sensation in lateral leg and dorsum of foot, EMG shows fibrillation of sharp waves in extensor hallucis longus,myelogram shows bulge in spinal cord adjacent to disk L4-L5Root ?Muscles? Reflex?

Root L5Muscle - extensor hallucis longus (also extensor digitorum longus and brevis, medial hamstring, gluteus medius)No reflex (tibialis posterior)

Patient presents with loss of sensation in lateral foot, EMG shows fibrillation of sharp waves in peroneus longus and brevis, myelogram shows bulge in spinal cord adjacent to disc L5-S1Root?Reflex?Other muscles involved

Root S1Reflex Achilles tendonOther muscles - flexor hallucus longus, gastrocnemius, lateral hamstringm gluteus maximus

Most common level of herniation L5-S1

Drop arm sign tests for _ how is it done

Patient unable to hold arm abduction 90 degrees against gravity - tests for rotator cuff injury or tear

Lift off test tests for _ how is it done

Tests for rotator cuff tear - put patients dorsum of hand on back - unable to lift off against resistance

In Apley scratch test you ask patient to _ touch contralateral superior

Indicates _

medial corner of scapulaIndicates rotator cuff pathology particularly superspinatus

In Neer impingement sign examiner _

stands behind patient and immobilizes scapula then jerks arm into forward and upward position

Yergasons test evaluates function of _ How is it done

long head of bicepsArm beside trunk and flexed 90 degrees at elbow, patient supinates against resistance

Anterior apprehension sign is done _ while posterior apprehension sign is done _

Anterior - seatedPosterior - supine

Anterior and posterior drawer tests of shoulder test for _

Instability

Thompsons test of elbow indicates _ How is it done

Lateral epicondylitisDorsiflex wrist with elbow and wrist on extension

In Golfers elbow sign you ask patient to _ Extend flexed elbow against resistance

Reverse Cozen test tests for _ How is it done

Medial epicondylitisWith arm supinated patient flexes and extends elbow against resistance

Hip joint type Synovial ball and socket

Hip joint involves articulation between _ and _ Head of femur and acetabulum of os coxa

Hip socket is deepened by _ ligament and _

Transverse acetabular ligament (spans opend end of acetabulum) and acetabular labrum (fbrocartilaginous rim attached to bony rim of acetabulum and transverse acetabular ligament)

Capsule of hip joint has 2 attachments _ superior and inferiorSuperior - brim of acetabulum near labrum and transverse acetabular ligamentInferior - anteriorly to intertrochanteric line and junction of neck of femur with trochanters, posteriorly posseses free (unattached) border that covers approximatley 2/3

of proximal femoral neck

Hip capsule is constructed of two laminae of fibers _

Superficial lamina - longitudinally oriented fibers which limit movement of limb in specific directionDeep lamina - "zona orbicularis" - provides "screw home" effec between head of femur and acetabulum - greatly enhances hip joint stability

Hip ligament that assumes position of inverted Y, attaches superiorly to AIIS and inferiorly to intertrochanteric line - name of ligament and which way is it tightest in?

ILIOFEMORAL LIGAMENT - tightest in extension

Ligament that forms medial inferior portion of hip capsule, attaches medially to brim of pubic portion of acetabulum and obturator crest of superior pubic ramus and laterally to neck of femur near lesser trochanter - name of ligament - it becomes tight in _ and limits _

PUBOFEMORAL LIGAMENT - becomes tight in extension and limits abduction

A gap between _ and _ ligaments anteriorly and inferiorly, covered by _ and its bursa - (iliopectineal bursa)

Iliofemoral and pubofemoral Psoas major

This ligament is attached posteriorly to ischial portion of acetabulum, laterally to neck of femur medial to root of greater trochanter, fibers are spiral and form posterior free margin of capsuleThis ligament becomes tight in _

Ischiofemoral ligamentBecomes tight in extension

Ligamentum teres capitis femoris is _ ligamentThis ligament limits _

IntracapsularAdduction

Blood supply to hip joint

Lateral and medial femoral circumflex arteriesSuperior and inferior gluteal arteriesObturator artery provides branch to head of femur via ligamentum teres capitis femoris

Which rotation of hip is greater - lateral or medial

Lateral

Knee joint type Synovial, modified hinge joint (modified because it does allow some rotation)

Knee joint is joint between _ and _ Femoral and tibial condyles and femur with patella

How is knee joint supported Muscular attachments

Capsular ligaments that cross jointIntracapsular ligamentsStrong collateral ligaments

Knee capsule is thickest _ where it reinforced with ligaments

Posteriorly

Knee capsule is buttressed laterally by _ and anteriorly by _

Laterally - iliotibial tractAnteriorly - expansions of fascia lata

Lateral and medial patellar retinacula is expansion of _ muscles

Vastus lateralis and medialis

Oblique popliteal ligament is the expansion of _ muscle

semimebranosus tendon

Arcuate popliteal ligament is an expansion of _ muscle

attachment of biceps femoris to fibular head

2 extracapsular ligaments of knee are _ Ligamentum patellae + collateral ligaments (medial and lateral)

Ligamentum patellae is an extension of _ quadriceps tendon across patella to tibial tuberosity

This knee ligament is broad and thin but tough, it passes from medial femoral epicondyle to upper medial portion of tibia below condyle and attaches to medial meniscus

Medial (tibial) collateral ligament

This knee ligament is "pencil like" cord from lateral femoral epicondyle to head of fibula, it is not attached to lateral meniscus because tendon of popliteus muscle passes between it and capsule of the knee

Lateral (fibular) collateral ligament

Name two intracapsular ligaments of the knee

ACL, PCL

Shape of lateral meniscus is _ , medial _ Lateral - lunar, medial - semi-lunar

_ ligaments attach lateral margins of menisci to margins of tibial plateau

Coronary

Menisci are attached to one another anteriorly via _

Transverse geniculate ligament

Function of menisci Help cushion joint and stabilize articulation by deepening the articular surfaces

ACL prevents _ when foot is _ Posterior displacement of femurFirmly fixed

PCL prevents _ when foot is _ Forward displacement of femur Firmly fixed

Proximal tibiofibular joint is what kind ? Synovial plane glidng joint

Distal tibiofibular joint is what kind of joint Fibrous (tibiofibular syndesmosis)

In proximal tibiofibular joint capsule is strengthened by _

anterior and posterior ligaments of head of fibula

In distal tibiofibular joint which ligaments maintain integrity of joint

Interosseous ligament - thickened inferior portin of interosseous membraneAnterior, posterior and transverse tibiofibular ligaments

Which ligament helps to form "tenon" of talocrural joint (ankle) by extending below the inferior margin of distal talofibular joint

Transverse talofibular ligament

Talocrural joint (ankle) type Synovial hinge joint

Which motions are possible at ankle joint Flexion and extension (dorsiflexion and plantar flexion)

Medial ligament of ankle consists of __ Deltoid ligament - anterior tibiotalar, tibionavicular, tibicalcaneal, posterior tibiotalar

Lateral ligament of ankle consists of _ Anterior talofibularCalcaneofibularPosterior talofibular

Motions allowed at subtalar joint Inversion and eversion of posterior portion of foot

Forms highest portion of medial longitudinal arch

Talocalcaneonavicular joint

Talocalcaneonavicular joint is supported by strong _

Plantar calcaneonavicular ligament (spring ligament)

Forms highest portion of lateral longitudinal arch

Calcaneocuboid joint

Calcaneocuboid joint is supported by _ long and short plantar ligaments

This joint identifies line of division between forefoot and hindfoot which allows foot to function securely on uneven (slanting and irregular) surfaces, allowing forefoot to move on hindfoot in plantar flexion and dorsiflexion, inversion and adduction and eversion and abduction

MIDTARSAL JOINT

Tarsometatarsal and intermetatarsal joints are what type

Plane synovial

Metatarsophalangeal and interphalangeal joints are what types of joints

synovial hinge

Which joints increase joint capsule stability in metatarsophalangeal and interphalangeal joints

Plantar and collateral ligaments

3 arches of feet lateral, medial and transverse

Which foot arch composes a flat rigid component which provides a stable base for upright posture

Lateral arch

Which foot arch composes a higher more resilient curvature that lateral longitudinal arch

Medial arch