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290 terms

Rheum & Muscu

STUDY
PLAY
monoarticular joint patterns
gout, septic arthritis, Lyme
CCP is 96% sensitive for
rheumatoid arthritis
nonspecific marker of inflammation
ESR
if ANA is negative, assume
pt does not have SLE
<25% PMNs typically is
non-inflammatory
the initial joint manifestation involved in ~50% of gout
podagra (1st Meta-Tarso-Phalangeal joint)
collections of uric acid crystals in the soft tissues, frequently occurs after 10 yrs of untreated gout
tophi
calcium pyrophosphate, prism-shaped crystals, positive birefringence in synovial fluid indicates
pseudogout
needle shaped crystals, negative birefringence, uric acid crystals
gout
mainstay (tx of choice) for acute gouty attacks
NSAIDs (indomethacin)
tx for pt who cannot take NSAIDs for gout
corticosteroids
tx for pt who cannot take NSAIDs or corticosteroids for gout
colchicine
side effects of colcichine
cramping, nausea, vomiting, diarrhea
gout pts should
- avoid high urine foods (red meats, alcohol, yeasts, beans, lentils)
- manage obesity
- decrease ETOH (cruise)
- stop offending meds
drugs that exacerbate gout are
- thiazide, loop diuretics
- aspirin (may give low dose)
- niacin (use fish oil instead)
tx for chronic gout or recurrent attacks
uricosuric drugs (probenecid or allopurinol)
mechanism of allopurinol
blocks xanthine oxidase and thus decreases uric acid production. Thus, it should be used in overproducers
epidemiology of rheumatoid arthritis
female, 20 - 40 yo
30yo female with insidious symmetric swelling with redness, warmth, tenderness and pain with movement. morning stiffness >30 mins.
rheumatoid arthritis
flexion of the PIP joint and extension of the DIP joint of the affected finger
boutonniere deformity
extension of the PIP joint and flexion of the distal interphalangeal (DIP) joint
swan neck deformity
xray findings of rheumatoid arthritis
- juxta-articular demineralization/osteoporosis
- erosions of joint
- space narrowing
rheumatoid arthritis may be associated with
Sjogren's syndrome
tx of rheumatoid arthritis
- pt education, PT/OT, exercise to preserve joint motion (swimming), assistive devices

- NSAIDS

- DMARDs (disease modifying antirheumatic)
name some DMARDs (disease modifying antirheumatic)
- methotrexate (anti-folate)
- tumor necrosis factor inhibitors
- corticosteroids (do not help in suppression of dz)
- azthioprine (Imuran)
1st line med in rheumatoid arthritis
NSAIDs
2nd line med in rheumatoid arthritis
methotrexate (tx of choice after NSAIDs)
- it is the initial tx of choice for suppressing the progress of RA
side effects of methotrexate
- gastritis/stomatitis
- it is an anti-folate drug

- rare but severe life-threatening interstitial pneumonitis (tx by discontinuing drug)
3rd line med in rheumatoid arthritis
- examples
- side effects
tumor necrosis factor inhibitors (after fail methotrexate)

- etanercept, infliximab

- side effecs: leukopenia (rare), reactivation of latent TB
side effects of corticosteroids
- avascular necrosis
- gastritis/ulcers
- cataracts
- immunosuppression
- cushing syndrome
- osteoporosis
features of SLE
1. joint pain & swelling (95%)
2. renal disease
3. malar rash/photosensitivity
4. pleuritis
5. pericarditis
6. neurologic disease
7. spontaneous abortions
8. oral ulcers
9. seroritis
10. anemia of chronic dz (~100%)/thrombocytopenia
most helpful screening tool for SLE. very sensitive but not specific
ANA
the antibodies in SLE causes difficulty to maintain pregnancy
antiphospholipid antibodies
Tx of SLE
- antimalarials (hydroxychloroquine)
- prednisone (mainstay of therapy)
- if proteinuria for biopsy, refer to nephro
side effect of hydroxychloroquine
- pigmentary retinitis (opth exam q 6 - 12 months); it is rare
20% of SLE pts have false positive
VDRL
drugs that induce ANA
- procainamide (mc)
- hydralazine
- isoniazid
50yo female c/o dry eyes, burning & dry mouth. she has RA or SLE
Sjogren's syndrome
Sjogren's syndrome is usually associated with
rheumatoid arthritis, SLE, or other connective tissue disease (+RF)
condition characterizes as lymphocytic invasion of lacrimal and salivary glands. it increases incidence of lymphoma
Sjogren's syndrome
most common type of scleroderma
CREST (limited)
CREST syndrome stands for
- C alcinosis
- R aynaud phenomenon
- E sophageal
- S clerydactyly (skin thickening limited to face & hands)
- Telangiectasias
if ANA and RF are both negative, next step is to get
HLA-B27 (seronegative sphondyloarthropathies)
4 seronegative sphondyloarthropathies (- ANA & RF, but +HLAB27)
- ankylosing spondylitis
- reiter's syndrome
- psoriatic arthritis
- colitis arthritis
Tx of seronegative sphondyloarthropathies
tumor necrosis factors (TNF)
<40 man, stiff painful back, fusion of spine.
ESR is elevated.
ANA & RF are negative.
HLA-B27 is specific.
Xray shows bamboo spine.
ankylosing spondylitis
young man with urethritis + conjunctivitis/uveitis + asymmetric arthritis of knee or ankle + then GI infection or Chlamydia
Reiter's (Reactive) arthritis
can't pee, can't see, can't climb tree, can't sleep with me
Reiter's (Reactive) arthritis
psoriasis precedes arthritis. asymmetric sausage fingers and toes. sacroilitis (sarcoiliac joint disease) is common.
psoriatic arthritis
Tx of psoriatic arthritis
- short-term: aspirin or NSAIDs
- severe or chronic dz: DMARDS (ex: sulfasalazine)
nondeforming arthritis, IBD (20% of pts), anemia
colitic arthritis
Tx of colitic arthritis
tx intestinal inflammation
temporal arteritis (giant cell) is concurrent with _________ in 50% of pts
polymyalgia rheumatica
>50yo female with fever, malaise, anorexia, headache, jaw claudication, scalp tender. sudden monocular blindness (optic neuropathy). think
temporal arteritis
palpable tender inflamed cord in temporal region + headache in >50yo. think
temporal arteritis
most helpful initial test to order for temporal arteritis
ESR (always >70)
labs for temporal arteritis
- ESR elevated >70
- normal WBC (despite fever)
- biopsy
diagnostic test for temporal arteritis
temporal artery biopsy

*do not delay giving prednisone pending biopsy
tx of temporal arteritis
- prednisone 60 - 120 mgm PO QD immediately
then perform biopsy
complications of temporal arteritis
- can cause irreversible blindness without appropriate therapy
- thoracic aneurysm is 17x more common in pts with hx of TA
young 30yo Asian woman with fever, malaise, weight loss, arthralgias, erythema multiforme, pulseless disease, and involvement of aortic arch and abdominal aorta (including renal arteries)
takyasu's arteritis
polyarteritis nodosa is associated with ______
Hep B
meds that can cause polyarteritis nodosa are
sufa, gold, (penicillamine used for Wilson's dz)
middle-aged man with disease involving all organ systems but lungs. fever, malaise, weight loss, arthralgias, myalgias, coronary, mesenteric, acute MI, HTN, abdominal pain, GI hemorrhage/infarct. elevated ESR. normochromic normocytic anemia.
polyarteritis nodosa
Diagnostic for polyarteritis nodosa
biopsy
small vessel, necrotizing, granulomatous arteritis with c-ANCA positive. think
wegener's granulomatosis
triad
- upper respiratory symptoms
- lower respiratory symptoms
- focal segmental glomerulonephritis
wegener's granulomatosis
40yo caucasian with epistaxis, recurrent sinusitis, rhinorrhea (despite tx), crusting ulcers or nasal mucosa.
CXR shows granuloma
Think
wegener's granulomatosis
saddle nose deformity
wegener's granulomatosis
male with oral and genital uclers. iritis. polyarthralgias. dementia. parkinsonism. erythema nodosum. associate with HLA
Behcet disease
>50yo with pain and stiffness of shoulder, pelvic girdle, & neck that is worse with rest and better with activity. NO WEAKNESS. +fever (of unknown origin), malaise, weight loss, muscle pain & tender points, limited ROM. High ESR. think
polymyalgia rheumatica
50% polymyalgia rheumatica is associated with
temporal arteritis (tx with high dose steroids)
proximal muscle WEAKNESS + heliotrope rash. elevated CK
polymyositis/dermatomyositis
polymyositis/dermatomyositis has increased risk of
malignancy
Tx of polymyositis/dermatomyositis
steroids
30yo with widespread muscular pain (upper and lower extremities). multiple tender points (pinpoints; 11 of 18).
No signs of inflammation (nl ESR/labs).
fibromyalgia
tx of fibromyalgia
- exercise
- amitriptyline (elavil) is tx of choice/most appropriate med
- pregabalin (lyrica)
- duloxetine hcl (cymbalta)
bone to bone is
ligament
muscle to bone is
tendon
sTrain is _______; sPrain is ______
TR = muscle
PR = tendon
unilateral contraction of sternocleidomastoid muscle
torticollis (wry neck) = twisted neck
infant or child prefers to holdhead toward the shortened SCM and chin rotates to opposite side. there is a mass palpable in the inferior 1/3 of affect SCM.
torticollis (wry neck)
tx of torticollis (wry neck)
- usually resolves spontaneously in 2 - 4 weeks
- Xrays to r/o congenital bone abnormalities
- passive stretching
- follow-up in 2 - 4 week intervals
- refer if no improvement in 2 - 3 mths
cervical strain/sprain (whiplash)
...
cervical radiculopathy
C5 is for
C6 is for
C7 is for
C8 is for
C5 (deltoid) - abduction of arm

C6 (biceps) - sensation for thumb & index; elbow/arm flexion, wrist extension; brachioradialis reflex

C7 (triceps) - sensation for middle; elbow/arm extension, wrist flexion; triceps radii

C8 - sensation for 4th & 5th fingers
test specific and sensitive for dx cervical spondylosis or cervical (neck) radiculopathy aka cervical nerve root impingement
** Spurling test
which test?
provider extends the neck, rotating the head, and then applies downward pressure on the head
** spurling test
contraindications of MRI
pacemaker (no MRI)
Tx of cervical radiculopathy
- most pts have spontaneous resolution of all or most symptoms within first 6 - 12 weeks
Jefferson fracture (C1)
- dx
- mechanism
- seen best on odontoid view

- caused by diving accident
avulsion of C6, C7, or T1 is which fracture?
clay shoveler's fracture
bilateral C2 pedicle fracture secondary to hyperextension
Hangman's fracture
compression of brachial plexus, subclavian arteries & veins as they exit the shoulder girdle and the first rib
thoracic outlet syndrome
woman with triad: numbness + weakness + sensation of upper extremity swelling
thoracic outlet syndrome
adson's test
...
roos test
...
tx of thoracic outlet syndrome
- tx with PT and irritant avoidance
- surgical rib resection
woman with LATERAL curvature of the spine
scoliosis
asymmetry, paraspinal humping
- One shoulder higher than another
- Uneven waistline
- One shoulder blade sticking out further than the other one
- Rib hump deformity
scoliosis
- screening for scoliosis with _______

- most accurate using AP & lateral xray of entire spine
- scoliometer

- Cobb angle
scoliosis + pain, need to get
MRI
Tx of scoliosis
- less than 20 degrees: conservative (watch/follow)

- 20 - 40: brace

- 40 degrees or more: surgery
adolescence with increased kyphotic curvature and anterior thoracic spine wedging
scheuermann's disease
shmorl's nodes on xray
scheuermann's disease
Tx of scheuermann's disease
- hyperEXTension exercise
- proper posture
- bracing
- surgery
most common site of compression fractures
T10 - L2
spinal pain upon movement and better with rest
compression fracture
most common cause of compression fractures
osteoporosis
elder with 2 inch height loss,
suspect?
next step?
compression fractures
X-ray PA and lateral and check PA for pedicle widening
Tx of compression fracture
- NSAIDs & analgesia. Brace. Walk.
- work up for osteoporosis
- consider bisphosphonate
- miacalcin for pain
- kyphoplasty/vertebroplasty
low back pain, impairing function for days to weeks, precipitated by repetitive twisting or lifting. difficult standing erect. worse with activity but better with rest
acute low back pain (strain)
Tx of back strain
- rest for 1 - 2 days. ice vs heat. NSAIDs. education. MUST follow-up
spinous stenosis vs herniated disc
spinous stenosis - pain worse with stand & walk; better with sitting

herniated disc - oppposite
Laseque's sign
ankle dorsiflexoin worsens pain from lumbar radiculopathy
straight leg test
lumbar radiculopathy
Lumbar myotomes & deep tendon reflexes

L4
L5
S1
L4 (quadriceps) = knee extension; patellar reflex
L5 (anterior tibialis) = heel walking; extensor hallucis longus strength
S2 (gastrocnemius) = toe walking; achilles reflex
narrowing of the spinal canal
spinal stenosis
anterior slippage of vertebral body on inferior counterpart; degenerative slip.
spondylolisthesis
spondylolisthesis occurs most commonly at
L4/L5 or L5/S1
pars interarticularits defect or stress fracture. usually pt is asymptomatic, except for pain with exertion. Pt is fine when bending over to tie shoes, but hurts when stands back up.
spondylolysis
spondylolysis is common in
* gymnasts & football lineman *
scotty dog on xray
spondylolysis
Xray views for spondylolysis
oblique and lateral
normal xray and pain with extension, consider
consider bone scan
spondylolysis
tx of consider bone scan and spondylolisthesis
- rest, conservative tx with <50%
- PT & bracing
25yo with back pain and progressive stiffness of spine. originates in lumbar/sacral spine and progresses cephalad. uveitis.
ankylosing spondylitis
MOST COMMON EXTRAARTICULAR COMPLICATION OF ANKYLOSING SPONDYLITIS
UVEITIS (know for the board!)
Xray findings in anylosing spondylitis
bamboo spine
failure of posterior vertebral arches to close
spina bifida
pain over acromioclavicular joint resulting fro a fall on lateral (tip of the shoulder). pain is worse with lifting arm, but is not possible.
Dx?
Next step?
acromioclavicular sprain
X-rays
grades of acromioclavicular sprain
1
2
3
1 - strain of AC ligament
2 - tear of AC ligament & sprain of coracoclavicular ligament
3 - tear of both ligaments
Tx of acromioclavicular sprain
- 1st & 2nd grade: immobilize
- 3rd grade: surgery
most common pediatric fracture
clavicle (middle 1/3)
child struck on clavicle and not able to lift arm secondary to pain
clavicle fracture
Tx of clavicle fracture
- figure 8 strap or cradle sling
- surgery is rare & if very severe
- follow up for up to 8 weeks
most humerus fracture are _______ displaced and treated with _____ and _____ movement
minimally
sling
early
elder female with hx of osteoporosis FOOSH. severe pain and ecchymosis following the fall.
humerus fracture
most common joint dislocation
shoulder (anterior)
squared off appearance of shoulder, pt typically hold arm in abduction
...
by holding your arm in abduction (away from your body), you test which muscle
supraspinatus
management of shoulder dislocation
- Xray with Y-view before & after reduction (look for Hill-Sachs deformity)
- immobilize and check axillary nerve
- follow up 2-3 wks and begin PT
squared off humeral head
Hill-Sachs deformity for shoulder dislocation
a compression fracture at the posterolateral head of the humerus due to impingement against anterior rim of glenoid fossa when the humeral head dislocates
Hill-Sachs deformity for shoulder dislocation
fall onto abducted/externally rotated arm
anterior shoulder dislocation
direct blow to anterior shoulder, *seizures*, or electrocution
posterior should dislocation
Rotator cuff is the group of tendons in the shoulder joint.
SITS

- S upraspinatus
- I nfraspinatus
- T eres minor
- S ucscapularis
pt >40yo with recurrent pain for months.
- Pain, weakness, and loss of shoulder motion.
- Pain or ache is felt over the FRONT and OUTER shoulder.
- It is worse leaning on the elbow and pushing upwards on the shoulder (such as leaning on the armrest of a reclining chair), with OVERHEAD activities, when reaching forward (ex: unable to lift a galloon of milk from the refrigerator), and at NIGHT when lying on the affected shoulder.
rotator cuff tear
Abduct the patient's shoulder to 90° and ask the patient to lower the arm slowly to the side in the same arc of movement. Pain or inability to do this is
+drop-arm test indicates rotator cuff tear
The shoulder is forcibly forward flexed and internally rotated, causing the greater tuberosity to jam against the anterior inferior surface of the acromion. Pain is
+Neer impingement test, indicates rotator cuff tear (impingement) and overuse injury to the supraspinatus muscle
gold standard for rotator cuff tear
MRI with arthrogram
Xray finding for rotator cuff tear
high riding humeral head
tx of rotator cuff tear
- rest, NSAIDs, PT
- steroid injections
- surgery
shoulder pain worse with reaching. pain with resisted midarc abudction and external rotation
rotator cuff tendonitis
tx of rotator cuff tendonitis
ice, NSAIDs, PT, steroid injection
pain in the front of the shoulder. "popping" with abduction and external rotation. tendon unstable with intertubercular groove
biceps tendonitis
Yergason's test
- define
- indicate
- shake pt's hand & pt resists supination (palm up); forearm supinated against resistance
- tests for biceps tendonitis
diagnostic test for biceps tendonitis
MRI
tx of biceps tendonitis
- analgesics & NSAIDs
- immobilize if very acute
- steroid injection, PT, follow-up
usually painless swelling and inflammation of the bursa in the back of the elbow
olecranon bursitis
management of olecranon bursitis
- xray if acute trauma
- aspirate & bursal fluid should be sent for culture, gram stain, examination for crystals & WBCs
- RICE
- corticosteroid if not thinking infection
severe pain/tenderness worse with extension of wrist (backhand)
lateral epicondylitis (tennis elbow)
severe pain/tenderness worse with flexion of wrist
medial epicondylitis (golfer's elbow)
epicondylitis with characteristically occurs with wrist flexor activity and pronation
medial (much less common)
management of epicondylitis
- Xray if acute trauma
- stop activities that cause the pain
- analgesics & NSAIDs
- splint & PT
- steroid injections
subluxation of radial head
nursemaid's elbow
2.5 yo child suffered a pulling injury child while forearm pronated and elbow extended. Presents PRONATED hand/arm, elbow SLIGHTLY FLEXED, and resisting use/extension. Pain over radial head and resists movement.
nursemaid's elbow (subluxation of radial head)
Subluxation occurs after longitudinal traction is placed on a pronated extended arm
nursemaid's elbow
xrays in nursemaid's elbow
NORMAL. Usually negative.
tx of nursemaid's elbow
- reduction by supinate hand and fully flex elbow
- splint if recurrent
- follow-up with proper education to prevent reoccurrence
radial head
...
fat pad and sail sign indicate
radial head fracture
sail sign (or thorn sign)
Displacement of the anterior fat pad. indicates radial head fracture
posterior fat pad sign is always a/an _______ finding
abnormal
most common nerve entrapment syndrome
carpal tunnel syndrome
median nerve
- sensory
- motor
- sensation to thumb to half of middle finger (1st - 3rd) digits
- motor to thenar muscle
Phalen sign
pain when Pushing the back of your hands together
Tinel sign
Tapping the median nerve along its course in the wrist causes pain
diagnostics for carpal tunnel syndrome
- phalen
- tinel
- EMG (electromyogram)/NCV (nerve conduction velocity test)
tx of carpal tunnel syndrome
- decrease use
- splint (wrist cock up)
- NSAIDs, steroid injection
- surgery
- refer for persistent weakness and/or thenar muscle atrophy
inflammation of the extensor pollicis brevis and abductor pollicis longus tendons
DeQuervain's Tenosynovitis
overuse of hand & wrist. swelling & tenderness in the area of the distal radius. pain is elicited when pt clenches fist over the thumb followed by ulnar deviation
DeQuervain's Tenosynovitis
diagnostic for DeQuervain's Tenosynovitis
Finkelstein test

* also can get xray r/o bone problem
tx of DeQuervain's Tenosynovitis
- thumb spica to immobilize
- NSAIDs, steroid injection
- surgery
unexplained lump or swelling
- usually painless
- usually on dorsal side of wrist/hand (back or opposite of palm)

Dx?
need to get
ganglion cyst
xrays mandatory to r/o bone pathology
tx of ganglion cyst
- pt reassurance and observation
- surgical excision if seriously bothers pt
wrist fractures
- colles
- smith
- torus = buckle
fracture of distal radius, "dinner fork", dorsal angulation; extension fracture of radius; mechanism is FOOSH
Colles fracture
fracture of distal radius, "gardens spade" volar angulation; flexion fracture of radius
Smith fracture
fracture of proximal ulna with dislocation of radial head
Monteggia fracture
fracture of distal radius with subluxation of radioulna
Galeazzi
anatomic snuff box tenderness caused by hypertension or axial load
scaphoid (navicular) fracture
tx of scaphoid (navicular) fracture
- thumb spica splint
- repeat X-ray in 7 -10 days and refer to ortho
UCL tear; disruption of * ulnar collateral ligament *
gamekeeper's thumb
pt usually remembers instant of injury. thumb forced radially. pain, swelling, ecchymosis on ulnar side of MP joint. radial stress to MCP joint assess stability.
Dx?
next step?
gamekeeper's thumb
x-ray to rule out avulsion fracture
Avulsion fractures of the ulnar base of the proximal phalanx of the thumb (1st digit)
gamekeeper's thumb
tx of gamekeeper's thumb
- thumb spica splint for 3 - 6 weeks
- surgery for complete tears
- refer, thumb most important digit
jamming injury to the extensor tendon. pt becomes unable to extend distal phalanx (DIP)
Dx?
next step
maller finger
xray
tx of mallet finger
- immobilize with splint for 6 weeks in extension then follow-up
inflammation of the flexor tendon sheath
trigger finger
most common sites of trigger finger
thumb, index, and middle finger
>40yo, with DM and rheumatoid arthritis, reports pain and "catching" when flexing finger. thickening of the flexor mechanism typically at the MCP joint
trigger finger
dx of trigger finger
clinical dx. no x-rays needed
tx of trigger finger
- NSAIDs
- steroid injection
- surgical relesae of flexor pulley, if 2 injections fail
thickening and contraction ofthe palmar fascia
Dupuytren's contracture
>40 man, northern european descent, who is a laborer and alcoholic, presents initially with 1 or more painless nodules near distal palmar crease. Pt cannot fully extend digits (typically 4th and 5th digits = ring & pinky)
Dupuytren's contracture
dx of Dupuytren's contracture
clinical dx. no x-rays needed
tx of Dupuytren's contracture
- observation and follow-up
- surgery to release adhesions
tear in central portion of EXTENSOR TENDON. trauma causes inability to extend PIP joint
boutonniere deformity
tx of boutonniere deformity
- PIP splint for 6 weeks and DIP free
- surgery if full extension is not achieved
neck fracture of 5th metacarpal (pinky)
boxer's fracture

* always check rotation
bony swelling of distal interphalangeal joints (DIP); osteoarthritis
Heberden's nodes
bony swelling of proximal interphalangeal joints (PIP); osteoarthritis
Bouchard's nodes
most comon site of fractures in osteoarthritis
proximal femur
pain & point tenderness over the greater trochanter. worse with flexion, standing out of seated position and feels better after a few steps.
trochanteric bursitis

* xrays to r/o bone pathology. order labs if suspect infection.
tx of trochanteric bursitis
- rest NSAIDs, analgesics
- PT, steroid injection
extraskeletal calcification within the muscle
MYOsitis ossificans

typically follows a contusion ***(football helmet). X-ray shows calcifications. Typically not disabling.
high impact trauma causing limb to be shortened and INTERNALLY rotated
hip dislocation
most shoulder dislocations are


most hip dislocations are
shoulder = anterior


hip = posterior
tx of hip dislocation
- requires prompt reduction
- xray/CT to rule out associated fractures before and after reduction
shortened limb and EXTERNALLY rotated
hip fracture (femoral neck)

* need repair/surgery
idiopathic osteonecrosis (avascular necrosis) of the femoral head. typically unilateral and in 4 - 12 yo males.
Legg-Calve-Perthes
8yo boy with unilateral limp, and hip pain radiating into groin & thigh. Xray shows increased density and shortening of femoral head
Legg-Calve-Perthes
Tx of Legg-Calve-Perthes
- conservation (rest/traction)

- surgery
displacement of femoral epiphysis (head of femur)
Slipped Capital Femoral Epiphysis (SCFE)
BOY 14 - 16yo or girl 11 - 13yo
- constant knee or hip pain
- he is obese and waddling gait
Slipped Capital Femoral Epiphysis (SCFE)
Xrays of Slipped Capital Femoral Epiphysis (SCFE)
ice-cream coming off the cone
tx of Slipped Capital Femoral Epiphysis (SCFE)
- conservative: bedrest with traction

- most require some measure of surgery. surgical pinning to hold in place if symptomatic
first born, 18-24mo girl, with hx of breech presentation. she is currently asymptomatic but unequal thigh folds are visible. (ex: groin cresae is below anus)
hip dysplasia
define barlow test
adduction/internal rotation with axial loading to measure stability (towards middle of the body = in & up)

tests for hip dysplasia in children
define ortolani test
"clunk" with passive abduction/external rotation (away from the body = out & down); Ortolani = OUT

tests for hip dysplasia in children
imaging of hip dysplasia
- ultrasound under 3 months

- xrays if older
tx of hip dysplasia
- harness. surgery
pain in groin. worse with activity. better with rest. limited ROM.
osteoarthritis
tx of osteoarthritis
- exercise to strengthen muscles; lose weight; pt education
- acetaminophen 7 NSAIDs
- intraarticular glucocorticoids
- hip replacement
lachman test
- test for
- define
- for anterior cruciate ligament tear (ACL)
-
anterior drawer test
...
sag sign
...
posterior drawer test
...
tx of cruciate ligament inury
- conservative: PT &/bracing
- surgery: patellar tendon or hamstring
triad of meniscal injury
- joint line pain
- effusion (typically 6 - 24 hrs after injury)
- locking

* meniscal injury is due to significant twisting
features of cruciate ligament injury
- twisting injury or injury in which tibia is forced forward
- ~75% *sustain acute <6 hrs hemarthrosis*
- 25% have associated meniscal tear
- pt c/o instability
McMurray test
- for
- define
- meniscal tear
- pt supine, knee FLEXED & externally (medial meniscus) OR internally (lateral meniscus), then EXTENDED

+ = pain = tear
Apley test
- for
- define
- meniscal tear
- pt prone, knee to 90 degrees, axial loading with rotation causes pain
knee forced into valgus resulting a
medical collateral ligament injury
knee forced into varus resulting a
lateral collateral ligament injury
definitive study for all soft tissue knee injuries
MRI

* including meniscal tear, ligament injury
tx of collateral ligament injury
- conservative: bracing & PT typically effective
- if no instability: RICE, NSAIDs, gradual return to activity
- if with instabiltiy: surgery
cyst develops into the medial border of the popliteal fossa. waxes & wanes.
condition?
tx?
baker's cyst

- tx with rest or aspiration. rarely surgery ncessary for the cyst
female adolescent with knee pain that feels "crunchy." Pain is worse when walking stairs, standing from a seated position.
patellofemoral syndrome
chondromalacia of the patella
patellofemoral syndrome
vastus medialis weakness
patellofemoral syndrome
patella femoral grinding test
...
Xray view of patellofemoral syndrome
sunrise or merchant view
tx of patellofemoral syndrome
- rest, NSAIDs, bracing
- PT & follow-up
- emphasize SHORT-arc (0-15') exercises. AVOID FULL-ARC qua exercises.
8 - 18yo adolescent male with swelling & pain over tibial tubercle when JUMPING. it results from repetitive injury and small avulsion injury.
Osgood-Schlatter's disease
tenderness, thickening at tibial tubercle (anterior knee). Pain exacerbated by running, jumping, kneeling, and sitting with knees flexed
Osgood-Schlatter's disease
apophysitis at insertion of the patellar tendon
Osgood-Schlatter's disease
management of Osgood-Schlatter's disease
- typically self-limiting. start with REST, ice, compression, stop sports 2 - 3 months, NSAIDs

- Bracing, PT, follow up
most common form of arthritis
osteoarthritis
most common mechanism of ankle sprainis
inversion with plantar flexion (>85%)

* tears lateral ligament
* ecchymosis, edema, pain
management of ankle sprain
- X-ray
- RICE
- splint vs. cast
- therapy & follow-up
achilles tendon injury
- "I got kicked/shot in the back of my ankle"
- "pushing off" mechanism
5th metatarsal fracture (pinky toe) is common in
recreational & competitive athletes
plantar heel pain that occurs where plantar fascia arises from teh medial calcaneal tuberosity. pain is worse with first few steps then resolves.
plantar fasciitis
management of plantar fasciitis
- Xray to r/o contributing spur
- heel cups
- therapy, NSAIDs, injections, follow-up
woman with burning pain between toes. mostly between 3rd & 4th metatarsal (toes)
morton's neuroma
tx of morton's neuroma
- NSAIDs, rest, injections
- excision (definitive)
defintive tx of morton's neuroma
excision
bad fracture often from a fall from a ladder, tree, roof. usually bilateral. may have lumbar compression fracture with it.
calcaneous fracture (heel bone)
fracture at the BASE of the 5th metatarsal (proximal pinky toe)
Jone's fracture
tarsometatarsal fracture and dislocation
Lisfranc fracture
stress fracture of the metatarsal (typically midshaft 3rd)
March fracture
most common primary malignant bone tumor
osteosarcoma (malignant)

* usually 10 - 25 yo boys; affects long bones
xray findings of osteosarcoma
sun ray or sun burst
most common bone cancer in children and adolescents
osteosarcoma (malignant)
osteosarcoma (malignant) most commonly affects
- teenage boys during growth spurt
- long bones: DISTAL FEMUR (mc site), then proximal tibia, proximal humerus
teenage boy
- pain, swelling in child's leg or arm
- limp
- pain wakes child at NIGHT
osteosarcoma (malignant)
Diagnostics of osteosarcoma (malignant)
- Xray
- Biopsy
Tx of osteosarcoma (malignant)
chemotherapy, surgery
cartilaginous based malignant tumor affecting 35 - 50yo males
chondrosarcoma
Salter Harris Fracture
1
2
3
4
5
1 S eparate/slipped; transverse fx through growth plate (physis)
2 A bove (through physis & metaphysis)
3 L ower (through physis & epiphysis)
4 T otal all 3 (through growth plate)
5 R ammed, reduce, crush, or compression injury to the physis
Salter-Harris Type II fractures are the
most commom

* Above = through physis & metaphysis
When growth plate injuries are suspected, the imaging modality of choice
is xrays
persistent noninfectious arthritis (morning stiffness, joint pain) lasting more than 6 wks to 3 mths after other etiologies have been ruled out
Juvenile rheumatoid arthritis
Juvenile rheumatoid arthritis is diagnosed before age _____ and is more common in ______
before 16

more common in females
3 types of Juvenile rheumatoid arthritis
- pauciarticular: most common. 4 joints or less. large joints

- polyarticular: 5 joints or more. small joints. symmetrical

- systemic: fever, rash
Tx of Juvenile rheumatoid arthritis
- NSAIDs, methotrexate, steroids

- prognosis varies - systemic onset worse
Green stick fracture
bone cracks on only ONE side, not all the way through; other side is bent. A break in the cortx of one side of the bony shaft without separation or break of the opposite cortex.
Torus/Buckle fracture
one side of the bone may buckle upon itself without disrupting the other side. A bowing, bending, or buckling without a break in the cortex.
most common benign tumor in children
osteochondroma

* occur in metaphysic long bone