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Week 9 LOs

Terms in this set (39)

For chronic lower back pain which treatment is best vs. acute?

NOTE: early PT is better for LBP
Exercise is best for chronic lower back pain

For acute & subacute it is usually self limiting
What is the treatment for achilles tendinopathy?
1st: reduce pain (isometric training- hold heel raise for 40/60seconds)

2nd: load it-->improve strength

3d: develop stretch-shorten cycle (load it but faster)

4th: sports specific rehibilitation
The GH joint is a shallow joint but therefore allows lots of range of motion

What are the dynamic vs. static stabilizers of the GH joint?
Ligaments are the static stabilizers
Rotator cuff muscles are the dynamic joint stabilizers
1)What are the mechanisms of action of a GH joint disslocation

2)what are the symptoms?

3)Tx?
1) direct (posterior blow) OR indirect (abduction & external rotation pressure or blow)

2)pain, prominent posterior acromion, decreased ROM, arm will be adduction & internally rotated

3)Tx: acute reduction, PT, surgery

Also check for sensation of the axilla & distal, vascular capillary refill, wrist extension & flexion

ALSO get radiographs (2 views) after reduction
If someone comes in with their arm internally rotated and adducted what should you think about?
GH disslocation
What sort of physical exam should you do when someone gets an GH dislocation?

What sort of imaging?
check for sensation (axillary & distal because brachial plexus can be involved)

Check for vascular capillary refill

check for wrist extension & flexion (before & after reduction)

IMAGING: radiographs esp. after reduction to make sure properly reduced
If someone comes in with recent GH disslocation and has weakness and numbness over the deltoid area, what is this and should you be conernced?
axillary nerve neuropraxia and is super common and typically resolves in hours to days
NOTE: in GH disslocations, the labral usually tearsm
...
What are the types of AC joint separation?
Type I: no ligaments are torn, will have pain and NORMAL radiographs

Type II: AC ligament torn but CC ligament intact, pain, slight elevation of clavicle

Type III: All ligaments torn, elevation of clavicle

Type IV: anterior force causing dislocation, not reducible, need surgery

Type V: LOTS of clavicle elevation, concerns about skin tenting

Type VI: inferior displacment, need to worry about neurovascular injury (subclavian vein & artery)
What do you need to check for type III and V for AC joint separation?

What is the Tx for type I-->III for AC joint separation
Type III & V: skin tenting because clavicle could be so far superior that can damage skin and lead to necrosis

Tx: types 1-III-->rest, PT
always be left with deformity
What are the common clinical features of adhesive capsulitis?

What are the risk factors?

Treatment?
Shoulder pain followed by decreased range of motion (can occur over 2 years to get better)

Risk factors: more common in 30-60yr females, and if diabetic (thyroid problems, burn victims)

Tx: ignore it or can do steroid injection (works better if catch early)
What sort of diagnosis things do you need for adhesive capsulitis?
It is a clinical diagnosis so don't technically need anything but cal get radiographs (most cases want) and then also maybe MRI but not necessary
What are the most likely causes of ACL tears?

What are the risk factors?

What is the common presentation?

What is involved in the diagnostic workup?

Treatment?
Non-contact (from stepping and pushing off werid) is most common (70%) but also can be from contact sports from hyperextension and valgus pressure

Risk factors: 8x more common in females, previous ACL tear, playing on turf, neuromuscular deficits

Presentation: effusion (blood pooling), decreased ROM, heard a "pop", inability to contract quad

Diagnosis: effusion, Lachmans +, anterior drawer too, MRI is gold standard, Radiographs segond fracture

Treatment= ACL reconstruction, PT, return to sport 9-12mo later
Most common force for MCl tears?

What are the grades?

Treatment?
Valgus force

Grade1= sprain
Grade 2= partial tear
Grade 3= full tear

Treamtent= usually just heals on own
Patellar dislocation:
Patella dislocated laterally
Reduce patella right there
Rest, ice, brace
PT
Usually no longer than 2 weeks
...
What is the most common force for ankle sprain?

Which ligaments are most common?

What other sort of physcial exam do you need to do?
inversion injury

ATFL>CFL>PTFL

Squeze test: squeeze up by tibia and fibular heads to see if fracture
When is it indicated to get radiographs for ankle sprains?
if pain with palpation at the:
-lateral mal
-medial mal
-navicular bone
-base of 5th metatarsal
What are the indications for soft tissue tumors of they are likely benign vs. sarocmas?
If subcutaneous and less than 5cm then likely benign

If subfascial and greater than 5cm then likely sarcoma and should do MRI and possibly biopsy
What is a common presentation symptom of osteosarcoma?
pain
If a younger child presents with a osteolytic mass on its radiographs what should you think about?
Ewing Sarcoma

Treatment involves chemo, surgery or radiation
1)What are the most common sites for metastatic disease?

2)What is involved in the workup?

3)Treatment options>?
1)vertebrae (spine is #1), pevlis, femurs, and humerus

2)labs (CBC, ESR, LFT, etc), imaging (xrays, CT of chest), biopsy

3)Treatment= radiation or chemo of primary tumor. No surgery unless refractory to chemo & radiation
What are the common genetic abnormalities associated with Ewing sarcoma and Synovial sarcoma?
Ewing sarcoma= t(11:22) EWS-FLI1

Synovial sarcoma: t(X:18) SS18-SSX1
Achondroplasia: AD disorder with defect in what?
fibroblast growth factor gene 3
If someone comes with with multiple fractures and bone deformities (after minimal trauma)

has blue sclerae

tooth abnormalities

conductive hearing loss (abnormal ossicles)

what might they have?
Osteogenesis imperfecta-->collagen type I genetic disorder

Commonly confused with child abuse

Pateints can't BITE:
-B=bones
-I (eye)= blue sclerae
T=teeth (dental abnormalities)
E=hearing loss
What is on the differential and how do you distinguish between them for a popliteal mass?
-DVT

-Baker's cyst: painful, fluid filled within synovial capsule??. Treat with aspiration & steroids

-soft tissue mass: lipoma, fat, squishy, surgery to treat, can be painful

-nerve sheath tumor: schwanoma or neurofibromas, if press on tumor get electric shocks down leg. Treatment is surgery

-muscle strain

-popliteal artery aneurysm

-sarcoma
Know what normal vs. fibers from tendonitis (esp. of ankle) look like on histology
...
What is an adequate evaluation for a trauma patient?
ABCs: airway, breathing, circulation
Radiographs: chest, AP pelvis, lateral C-spine "Pan-Scan"

Head to toe exam

Clear Cervical Spine: do once awake, sober, neuro intact, not distracted-->Palapate C-spine spinous processes, Turn head 45 degrees side to side, Flex and extend neck if no pain then clear

Secondary exam: typically the next day (pain anywhere, head-to-toe exam, palpate, ROM)
What amount of blood loss is necessary to inducle a shock state?
Class I: less than 750 ml and will have no vital sign changes
Class II: 750-1500 ml loss and will have increase in pulse
Class III: 2000 ml loss (30-40% of blood) and will have a decrease in systolic BP (and also increase in pulse)
Class IV: more than 40% of blood loss
Explain the contribution of musculoskeletal injuries to physiologic instability in patient with multiple traumatic injuries.
Stop hemorrhage, reverse ischemia
Stabilize long bone fracture (skeletal or external fixation
Treat within 24hrs if: Lactate <4.0 pH>7.25 No severe chest injury
What part of which arch does the plantar calcaneonavicular/spring ligament support?

Which arch does the long plantar ligament support?

Where is the deltoid ligament and what does it support?

What ligaments prevent inversion?
Supports the highest point of the medial longitudinal arch

Long plantar ligament (from calcaneus to cuboid-lateral bone) supports the longitudinal arch

Deltoid ligament is on the medial side and limits eversion of the foot

Prevent inversion= anterior talofibular ligament and posterior talofibular ligament and calcaneofibular ligament
Which condyle of the knee (lateral or medial) is longer?
Medial condyle is longer

As the femoral condyles slide posterior on a fixed tibia the lateral condyle will stop sliding first because it is shorter but the medial condyle will continue to slide posterior resulting in medial rotation of the femur
No muscle action is required to maintain the knee joint in the fully extended position

There is no muscle activity to maintain the lower limbs in anatomical position-->but the ligaments of the hip and knee are "taut"
...
MCL and LCL prevent hyerextension when the let is taut and limits rotation when the knee is flexed

IN addition to their normal actions to limit side to side

MCL and LCL located outside the fibrous capsule vs. the ACL and PCL are located inside the fibrous capsule (but outside the synovial membrane)

Which motions does the ACL and PCL prevent?
ACL: prevents anterior displacement of the tibia on a fixed femur

PCL: prevents anterior displacement of the femur on a fixed tibia
What are some good distinctions between radiculopathy and neuropathy?
Radiculopathy: pain from spine down, sensory more all over the place
- + spurlings
- normal SNAP
-abnormal paraspinals

Neuropathy: pain more distal, sensory more localized,
-+tinnels, phalens
- abnormal SNAP
-abnormal paraspinals
What are some classic clinical signs of carpal tunnel?
worse at night

gets better with shaking

better with wrist splints
what is a good way to tell the difference between distal or proximal nerve intrapment?
Proximal will loss of sensory of the palmar and dorsal hand on the digits 4 and 5

If more distal than might just be the palmar side and digits 4 and 5
If quadratus plantae (innervated by tibial N) doesn't act on the _____ what will that look like clinically?
If quadratus doesn't exhert a posterior pull on flexor digitorum longus then the foot will have unopposed medialpull of FDL so foot will be more medially or inverted?
What nerves run with the greater and less saphenous veins?

NOTE: the greater saphenous vein runs the entire length of the leg vs. the lesser saphenous vein is distal to the knee
Sural nerve (branch if tibial nerve) runs with the lesser saphenous vein

Saphenous nerve (branch of femoral nerve) runs with the greater saphenous vein
The sural and saphenous nerve are branches of which nerves?
Sural nerve is branch of tibial nerve

Saphenous nerve is branch of femoral nerve
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