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What is the difference between pectus excavatum and pectus carinatum?
pectus excavatum: concave deformity of the anterior chest wall
pectus carinatum: convex deformity of the anterior chest wall
What is a flail chest?
>2 contiguous rib fractures with each rib broken in at least 2 places
What classic sign is seen with respirations in a flail chest?
Paradoxical movements of the chest wall
What injury is commonly seen associated with a flail chest?
Underlying pulmonary contusion
What lower extremity fracture is most commonly associated with compartment syndrome?
Tibial shaft fx
What compartment does compartment syndrome most commonly affect?
Anterior leg compartment
What are the classic symptoms of compartment syndrome?
6Ps. Pain-out of proportion with passive ROM
Pallor, Paresthesia, , poikilothermia, pulselessness, paralysis,
What intercompartmental pressure is diagnostic for compartment syndrome?
> 30mmHg, Delta pressure <30mmHg: difference b/t compartment pressure and diastolic BP
What is the treatment for compartment syndrome?
What are the classic signs and symptoms of Osteoarthritis?
Joint px and stiffness that is worse with activity and better with rest
Heberden's nodes (DIP) ,Brouchard's nodes (PIP)-hand OA
No systemic symptoms or extraarticular findings
What would you see on x-ray in a patient with osteoarthritis?
-asymmetric joint space narrowing
What are the treatment options for OA?
-intraarticular corticosteroid injections
-surgery (joint replacement)
What is the most common organism responsible for both osteomyelitis and septic arthritis?
What organism is associated with osteomyelitis of the foot following a puncture wound through the shoe?
What antibiotic is used as a prophylaxis in puncture wound to a foot?
What organism should be considered in a pt <35Y old w/ septic arthritis?
What organism should be considered if osteomyelitis occurs in a pt with sickle cell anemia?
What are the most commonly affect joints in septic arthritis?
What is the best diagnostic test for septic arthritis?
Joint aspiration w/ synovial fluid analysis
What would be seen on synovial fluid analysis in a pt with septic arthritis?
What are some common causes of avascular necrosis (AVN) of the hip?
-Chronic steroid use
-sickle cell anemia
-Hx of hip dislocation, fx, Sx
What is Legg-Calve-Perthes?
Idiopathic AVN of the proximal femoral epiphysis in kids
What is the most common presentation of Legg-Calve-Perthes?
Painless limp, knee px, limited hip ROM
What is the most common cause of hip px in a PEDS pt that is associated w/Hx of a URI in the absence of fever, elevated WBC, ESR, or CRP? And What is the treatment?
-Transient medications synovitis
-Anti-inflammatory (Toradol challenge)
What is developmental dysplasia of the hip (DDH)?
Abnormal acetabular development resulting in a shallow socket with femoral head subluxation or dislocation
What are some risk factors for developmental dysplasia of the hip (DDH)?
What 2 PE maneuvers are used to test for DDH?
Barlow: adduction and depression of the femur-dislocates the hip
Ortolani-abduction and elevation of the femur-reduces dislocated hip
What is the Galeazzi sign?
Limb length discrepancy noted at the top of the knee when the pt is supine w/hips and knees flexed 90 degrees
What imaging modalities are used to screen for DDH?
Femoral head begins to ossify at 4M of age
What is the treatment for DDH in pts <6M?
What is the Salter-Harris fracture classification for pediatric fractures?
-type 1: Straight through physis
-type 2: traverses the physis, exits the metaphysis (Above)
-Type 3: traverses the physis, exits the epiphysis (beLow)
-Type 4: involves the metaphysis, physis and epiphysis (Through)
-Type 5: crush inj to the physis (Rammed)
What is the difference b/t greenstick and the buckle/torus fracture?
-Greenstick: incomplete fx w/ failure along the tension (convex) side, plastic deformation
-Buckle/torus: incomplete, unicortical compression fx
Patients with pelvic ring fx are at risk for what major complication?
How will the lower extremity appear following a hip fx?
leg shorter and externally rotated
What type of hip dislocation is most common?
How will the lower extremity appear following a posterior hip dislocation?
Leg shortened, adducted, and internally rotated
What is a complication of posterior knee dislocation?
Popliteal artery injury
What imaging should be performed following a posterior knee dislocation?
What is a Maisonneuve fx?
Proximal fibular fx w/ associated unstable ankle/syndesmotic injury
What is associated with a Maisonneuve fx?
Eversion ankle injury
What is a Lisfranc injury?
-Tarsometatarsal fracture dislocation b/t medial cuneiform and base of the second metatarsal
What is the classic PE finding for a Lisfranc injury?
What is the difference b/t a jones fx and a pseudo-jones fx? How are they treated?
-Jones fx: fracture at the base of the 5th metatarsal at the metaphyseal diaphyseal junction
-Tx: non-wt bearing w/ short leg splint/cast , Sx in athletics
-Pseudo-Jones fx: proximal tubercle avulsion fx of the 5th metatarsal
-Tx: protected wt bearing w/ stiff soled shoe/ walking boot
What is Osgood-Schlatter disease?
Tibial tubercle apophysitis that commonly occurs in adolescent boys who participate in running and jumping sports
How does Osgood-Schlatter disease present?
Anterior knee px and swelling that is worse w/activity and relieved with rest
What is the treatment for Osgood-Schlatter disease?
Activity modification, ice/heat, NSAIDs, bracing
What is a slipped capital femoral epiphysis (SCFE)?
Slippage of the proximal femoral metaphysis anteriorly relative to the epiphysis
What patient population is slipped capital femoral epiphysis (SCFE) most common in?
Obese adolescent boys
Who does slipped capital femoral epiphysis (SCFE) typically present?
Painful limp, hip/knee px, obligatory external rotation w/passive hip flexion (Drehmann sign)
-may have referred px to the medial side of the knee from the obturator nerve
What would you see on X-ray in slipped capital femoral epiphysis (SCFE)?
A line down the superior femoral neck, does not intersect the femoral head (Klein's line)
What is the classic presentation of trochanteric bursitis?
Lateral hip px/tenderness that is worse at night when lying down on the affected hip
What is the treatment for trochanteric bursitis?
PT, NSAIDs, corticosteroid injection
Are medial or lateral meniscal injuries more common?
How does a patient typically present with a meniscal injury?
Mechanical symptoms- locking, clicking, catching, popping
What positive PE test s are highly suggestive of a meniscal injury?
McMurray's, Apley's Compression test
What imaging should be obtained if you suspect a meniscal injury?
How do ACL injuries classically present?
Non-contact twisting mechanism, audible "pop" with immediate swelling (hemarthrosis)
What PE tests are used to diagnose ACL injuries?
Lachman's (most sensitive), anterior drawer, pivot shift
What imaging should be obtained if you suspect an ACL injury
Which ligaments are injured with inversion and eversion ankle injuries?
-Inversion-lateral: Anterior talofibular ligament (ATFL), Calcaneofibular ligament (CFL) and Posterior talofibular ligament (PTFL)
-Eversion-medial: deltoid ligament
What deformities contribute to clubfoot?
CAVE: Cavus (midfoot), Adductus (forefoot), Varus (hindfoot), Equinus (Hindfoot)
What is the treatment of choice for clubfoot in kids?
What is Sever's disease?
What is Sever's disease associated with?
Sports that require cleats
What class of antibiotics is associated with Achilles tendon rupture?
What PE finding is highly suggestive of an Achilles tendon rupture?
Thompson test: with pt in lying prone, squeezing of the calf should cause ankle to plantar flex. If Achilles tendon is torn, the ankle will not flex.
What is the treatment for Achilles tendon rupture?
Serial casting (20-30 degrees plantarflexed), boot with heel lift, or Sx correction
Tarsal tunnel syndrome involves what nerve?
Tarsal tunnel syndrome is analogous to what disorder that occurs in the hand/wrist?
Carpal tunnel syndrome
What is hallux valgus?
bunion-valgus deformity of the MTP of the great toe (plantarflexed and pronated)
How do Morton's neuromas most commonly present?
Px and paresthesias of the web space of the foot that is worse with activity and relieved with rest
How does plantar fasciitis most commonly present?
Px in the heel of the foot that is worse with first step in the morning and after prolonged standing
What are some treatment options for plantar fasciitis?
Stretching/massage, orthotics, NSAIDs, PT, Corticosteroid inj, Sx.
What signs and symptoms are concerning for bone neoplasms?
Pain at night (esp if it wakes from sleep), fever/chills, wt loss, palpable mass, pathologic fx
What type of bone neoplasm is associated with pain at night, but relieved by NSAIDs?
Which bone neoplasm occurs in kids and young adults and often mimics an infection?
How does fibromyalgia typically present?
Extraarticular px/tenderness that occurs in 11/18 trigger points in addition to sleep/cognitive disturbances in a patient w/Hx of rheum disorder, IBS, anxiety, depression
What are some common risk factors for gout?
-diet high in purines (red meat, seafood)
What is the difference between gout and pseudo gout crystals on microscopy?
-Gout (monosodium urate)-needle shaped
-pseudo gout (calcium pyrophosphate)- rhomboid-shaped, positively birefringent
What joint is most commonly affected by gout?
MTP of great toe (Podagra)
What medications are used to treat an acute flare of gout or pseudogout?
What medication is used in chronic maintenance of gout, but should not be used during acute flares?
What is the name for the condition that presents w/ joint px, extraarticular symptoms, and increased ESR/CRP in kids <16Y?
What are the different type of this condition?
-Juvenile RA/ Juvenile Idiopathic arthritic (JIA)
systemic/Still's disease, Pauciarticular and Polyarticular
What are the definitions of osteopenia and osteoporosis based on T-scores?
Osteopenia- T-score b/t -1 and -2.5
Osteoporosis: T-score <-2.5
What class of medications is considered first line treatment for Osteoporosis?
What pt education information must be given for bisphosphonates?
Remain upright for at least 30 minutes after ingestion and take with a full glass of water
What side effects are associated with bisphosphonates?
GERD, esophagitis, jaw necrosis, atypical fractures
What is polyarteritis nodosa (PAN)?
Inflammation of small-medium arteries
What disease is most commonly associated with polyarteritis nodosa (PAN)?
What is the treatment for polyarteritis nodosa (PAN)?
High dose corticosteroids
What are the classic symptoms of Polymyalgia Rheumatica (PMR)?
Proximal muscle pain and stiffness (no muscle weakness), low-grade fever, anemia, fatigue
What condition commonly occurs with Polymyalgia Rheumatica?
Giant cell arteritis (GCA)
What lab markers would be elevated in PMR?
What are the classic symptoms for polymyositis (PM) and Dermatomyositis (DM)?
-PM: painless proximal muscle weakness
-DM: painless proximal muscle weakness + rash (heliotrope rash, shawl sign, Gottron's papules)
What lab markers would be elevated in PM/DM?
What is another name for reactive arthritis?
What are some common causes of reactive arthritis?
-STI (chlamydia), or food-borne illness (salmonella, campylobacter, shigella, Yersinia)
What are the signs and symptoms of reactive arthritis?
Remember" Can't see, can't pee, can't climb a tree
What lab marker is associated with reactive arthritis?
What are the classic signs and symptoms of rheumatoid arthritis (RA)?
-B/L joint px and stiffness that is better w/ activity and -worse with rest (MCP, PIP, DIP spared)
-Swan neck and Boutonniere deformities-hand RA
-systemic symptoms (fever, fatigue)
extraarticular findings (skin, heart, lungs, kidneys, eyes)
What lab markers are associated with RA?
+ anti-CCP (most specific)
What would you see on x-ray in an RA patient?
symmetric joint space narrowing
What are the treatment options for RA?
-DMARDs (MTX, Plaquenil, SSZ)
What are the signs and symptoms of Sjogren's?
- dry mucous membranes (eye, mouth, vagina), excessive thirst, joint px
What tests are used to diagnose Sjogren's?
-Schirmer tear test
What are the signs and symptoms of Systemic Lupus Erythematous (SLE)?
SOAP BRAIN MD
-Serositis (pericarditis, pleuritis, -Oral ulcers, -Arthritis,
-Blood d/o, -Renal dz, -ANA+, -Immunologic (anti-Sm, anti-dsDNA), Neurologic d/o
-Malar rash, -Discoid rash
What are the treatment options for SLE?
What are the differences b/t limited scleroderma/CREST syndrome and diffuse scleroderma?
Limited scleroderma/CREST syndrome:
-skin changes to the face (Mauskopf face) and hands only
-CREST-Calcinosis, Raynaud's syndrome, Esophageal dysmotility, Sclerodactyly, Telangiectasias
-skin changes to the face (Mauskopf face) and extending proximally beyond the wrist
-Multisystemic involvement (heart, lungs, kidney, GI) and worse prognosis
What is Raynaud's syndrome?
Vasospasm that causes reduced blood flow to the distal extremities
How is Raynaud's syndrome treated?
-avoid cold temps, vasodilators (CCB)
How does Raynaud's syndrome typically present?
-Distal extremity px and skin changes (white-blue-red) following exposure to cold temps
Who does ankylosing spondylitis (AS) most commonly affect?
young adults/ middle-aged men
What are the sxs of ankylosing spondylitis (AS)?
Ascending back px, and stiffness that begins at the SI joint, decreased chest wall expansion, uveitis
What PE test is used as part of the diagnosis for ankylosing spondylitis (AS)?
Schober test- measures lumbar spine flexion
What lab markers are associated with ankylosing spondylitis (AS)?
What radiographic findings are suggestive of ankylosing spondylitis (AS)?
-Vertebral scalloping (bamboo spine)
What are the treatment options for ankylosing spondylitis (AS)?
What is a positive straight leg raise test and what does it indicate?
Px radiating below the knee that occurs with passive hip flexion beyond 30 degrees when the pt is lying supine with the knee fully extended
What defines thoracic Kyphosis?
>40 degree convex curvature of the thoracic spine
What is sclerosis?
>10 degree lateral curvature of the spine
-named for the side of convexity
What tests are used in the diagnosis of scoliosis?
Adam's forward bend-scoliometer reading of 7-20 degrees spinal curvature
X-ray: Cobb angle >10 degrees
What is the treatment for scoliosis based on the degree of curvature?
10-24 degrees- observation
25-49 degrees- bracing
What is the classic presentation of spinal stenosis?
leg/back px that is worse w/walking and extending of the spine and relieved w/ flexion of the spine (shopping cart sign)
What PE test is used to diagnose thoracic outlet syndrome?
Adson's test- absent radial pulse with head turned to ipsilateral side
What is spondylitis?
Anatomic defect of the pars interarticularis
What sport may predispose a patient to spondylitis?
Gymnastics, diving, football, rowing (hyperextension sports)
What radiographic sign is seen on oblique x-rays in spondylitis?
Scotty dog sign
What is spondylolisthesis?
forward translation of one vertebral segment relative to the next caudal segment
What part of the clavicle is most commonly fractured?
What is the treatment for a clavicle fracture w/o significant shortening and displacement?
nonoperative, sling immobilization
What is the most common type of shoulder dislocation?
What is the typical mechanism of a shoulder injury?
opposing force when arm is abducted , extended and externally rotated
What are the most common causes of a posterior shoulder dislocation?
-internal rotation of the shoulder (pectoralis muscles) overpower the external rotators
What are the 2 most common complications that occur as a result of an anterior shoulder dislocation?
-Bankart lesion: anterior inferior labral tear
-Hill-Sachs lesion: cortical compression of the posterolateral humeral head
What nerve injuries are most common with proximal humerus humeral shaft, and pediatric supracondylar humerus fractures?
-proximal humerus fx-axillary nerve
-humeral shaft: radial nerve
-PED supracondylar humerus fracture-anterior interosseous nerve (AIN)
What is a Monteggia fx?
Proximal Ulnar fx w/ associated radial head dislocation
What is a Galeazzi fx?
fx of the distal 3rd of the Radius with associated dislocation of the distal radioulnar joint
"MUGR"-Monteggia, Ulna, Galeazzi, Radius
What radiographic finding on the lateral elbow x-ray is consistent with an occult fx?
-Posterior fat pad: always normal
Anterior fat pad may be normal if the elbow is flexed
What is nursemaid's elbow?
subluxation of the radial head under the annular ligament
What is the most common mechanism of nursemaid's elbow?
Sudden traction of an extended arm, commonly associated with swinging a kid of lifting by one arm
What are 2 methods for reducing a nursemaid's elbow?
What is a Colles' fx?
dorsally angulated distal radial fx
What is a Smith's fx?
volarly angulated distal radial fx
Tenderness in the anatomical snuffbox is suggestive of what fx?
If there is a high suspicion for a scaphoid fx, but x-rays are negative, What is the appropriate management and why?
Thumb spica cast and f/u x-ray in 2-3 weeks
-high risk of AVN
What is a Boxer's fx?
Fx of the 5th metacarpal neck
What are the muscles of the rotator cuff and which PE tests are used to evaluate each?
-Supraspinatus: empty can, drop arm
-Infraspinatus: external rotation
-Teres minor: horn blower's
-Subscapularis: belly press, lift off
What underlying d/o are commonly associated with adhesive capsulitis?
What would you see on PE in adhesive capsulitis?
Loss of active and passive ROM (most notably in ER)
What PE sign is associated with a proximal bicep tendon rupture?
What are the common names for medial and lateral epicondylitis?
What PE maneuvers are used to assess medial and lateral epicondylitis
Medial-golfer's elbow: resisted wrist flexion and pronation
lateral-tennis elbow: resisted wrist/middle finger extension
What is the classic presentation of a ganglion cyst?
soft, nontender mass on the dorsum of wrist that transilluminates
What is the treatment for a ganglion cyst?
-symptomatic: aspiration, corticosteroid inj or Sx resection (high rate of recurrence)
What PE maneuver is used in the diagnosis of DeQuervain's tenosynovitis?
Finklestein's test-ulnar deviation of the wrist w/ the thumb held in closed fist
What is Dupuytren's contracture?
thickening and tightening of the palmar fascia leading to flexion of contracture of the fingers
-occurs most commonly in the 4-5th digits
Who is the Dupuytren's contracture most commonly seen in?
Northern European descent
What are the most common names for the ulnar collateral ligament (UCL) injury in the thumb?
What is a mallet finger?
Rupture of the extensor tendon on the distal phalanx
What is the most common mechanism of injury for the mallet finger?
forced flexion of the DIP (catching a ball, jamming a finger)
What complication can develop if a mallet finger injury if left untreated?
Swan neck deformity
What is a trigger finger?
stenosing tenosynovitis involving flexor tendon sheath under the A1 pulley; results in "clicking" during flexion/extension
What is a jersey finger?
Avulsion injury of the flexor digitorum profundus (FDP) tendon from the distal phalange.
What are the Kanavel signs of flexor tenosynovitis?
-px w/passive extension of the finger
-fusiform swelling of the finger (sausage finger)
-tenderness over the length of the tendon sheath
-flexed posturing of the finger
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