8/12/2011
Shoulder Joint
Basic Structures:
. Clavicle
. Scapula
. AC joint
. Proximal humerus
. Greater tuberosity
. Rotator cuff muscles
http://commons.wikimedia.org/wiki/File:Shoulderjoint.PNG
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Acromioclavicular Injury Young, active person with direct fall onto shoulder S/S::--painpain at top of shoulder, radiates to neck -tender, swollen AC joint, decreased ROM -positive crossover test
Dx::--clinical,clinical, x-x-raysrays if unsure
Tx::--ice,ice, sling 22--44 wks, NSAIDs, early ROM --gradesgrades IV-IV-VIVI f/u with orthopedic surgeon
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Grading Scale for AC Injury
II-- contusion/sprain of AC joint IIII-- rupture of AC ligament III- minor displacement of clavicle IVIV--VIVI-- coracoclavicular ligament rupture, significant displacement of clavicle
UMDNJ PANCE/PANRE Review Course
1 8/12/2011
http://commons.wikimedia.org/wiki/File:Shoulder_joint_anatomy_quiz.jpg
UMDNJ PANCE/PANRE Review Course
Clavicle Fracture Most common bone fractured in children, due to direct trauma (sporting events) or fall on outstretched hand
S/S: -pain over clavicle, possible deformity or tenting of skin --decreaseddecreased shoulder ROM --documentdocument pulses, sensation, strength --mostmost fractured at middle 1/3
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Clavicle Fracture cont’d
Dx::--clavicleclavicle xx--ray,ray, if medial 1/3 fractured, study for subclavian artery or intrathoracic injjyury
Tx::--slingsling or figure of 8 splint, 33--44 wks --afterafter 33--44 wks start range of motion
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2 8/12/2011
http://commons.wikimedia.org/wiki/File:Claviculafraktur_median_tangential.jpg
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Rotator Cuff SITS Muscles
Supraspinatus (most commonly injured) Infraspinatus Teres Minor Subscapularis
Top 3 insert on the greater tuberosity
http://upload.wikimedia.org/wikipedia/commons/9/90/Shoulderjoint.PNG
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Rotator Cuff Disorders Chronic, overhead work or fall on hand. Pain begins as inflammation, then becomes impingement then progresses to tear
S/S::--painpain at greater tuberosity, lateral shoulder -pain and difficulty abducting arm -positive Neer impingement sign
Dx::--MRIMRI
Tx::--rest,rest, ice, NSAIDs, PT, steroid injection --ifif no better after 66--1212 wks, consider surgery
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3 8/12/2011
Biceps Tendonitis Caused by overuse of the biceps muscles, usually heavy or excessive lifting
S/S::--presentspresents as anterior shoulder pain -bicipital groove tenderness --painpain with resisted supination of forearm
Dx::--clinical,clinical, x-x-rayray to r/o other injury
Tx::--rest,rest, ice, sling, NSAINSAIDs,Ds, steroid injectioninjection-- not into tendon sheath UMDNJ PANCE/PANRE Review Course
http://upload.wikimedia.org/wikipedia/commons/9/90/Shoulderjoint.PNG
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Proximal Humerus Fracture Fall onto outstretched hand, common in elderly women with osteoporosis
S/S::--pain,pain, swelling proximal humerus with decreased shoulder ROM --evaluateevaluate axillary artery/nerve
Dx::--xx--rayray (Y(Y--viewview to r/o dislocation)
Tx::--slingsling and swath 4 wks, early ROM -surgery if head displaced or compound fx
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4 8/12/2011
Proximal Humerus Fracture
Impacted, stable fracture
http://upload.wikimedia.org/wikipedia/commons/2/20/Surgical_neck_fracture_of_humerus.jpg
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Shoulder Dislocations
Fall on externally rotated, abducted arm (trying to catch self while falling)
S/S::--presentpresent with arm abducted and in ER --shouldershoulder appears “squared off” --evaluateevaluate axillary nerve and artery
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Shoulder Dislocations cont’d Dx::--xx--rayray (A/P, lateral, Y-Y-view)view) -97% are anterior dislocations, posterior RARE (usually due to electric shock or seizure)
Tx::--immediate closed reduction with postpost--reductionreduction xx--rayray --sling/swathsling/swath 4 wks, start ROM at 2 wks
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5 8/12/2011
http://upload.wikimedia.org/wikipedia/commons/e/ea/Luxation_epaule.PNG
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A patient c/o right shoulder pain after a fall. He has no weakness but a + crossover test. What is the most likely diagnosis? 87% 1. Acromioclavicular injury 2. Adhesive capsulitis 10% 3. Biceps tendonitis 1% 3% 4. Rotator cuff is is e it ulit injury s on ptur p rupture a f ru c f tend u s c ive p e or c t ta Bi o Adhes R
Acromioclavicular UMDNJ PANCE/PANRE Review Course
Of the SITS muscles, which is most likely to be torn?
95% 1. Infraspinatus 2. Subscapularis 3. Supraspinatus 4. Teres minor
1% 3% 1%
s r
inatus mino p pularis s a e aspinatu r fras r n Te I Subsc Sup UMDNJ PANCE/PANRE Review Course
6 8/12/2011
Elbow Joint
Basic Structures:
. Proximal ulna
. Proximal radius
. Distal humerus
. Radial nerve
. Ulnar nerve
http://upload.wikimedia.org/wikipedia/commons/7/73/Gray331.png
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Lateral Epicondylitis (Tennis Elbow) OveruseOveruse--repetitiverepetitive supination and wrist extension
S/S::--pointpoint tenderness over lateral epicondyle, pain on resisted wrist extension
Dx::--clinical,clinical, x-x-rayray to r/o arthritis or loose body
Tx::--rest,rest, ice, NSAIDs, counter force strap, steroid injection
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Medial Epicondylitis (Golfer’s Elbow, Pitcher’s Elbow) OveruseOveruse--repetitiverepetitive wrist flexion and pronation
S/S::--pointpoint tenderness over medial epicondyle, pain on resisted wrist flexion
Dx::--clinical,clinical, x-x-rayray to r/o arthritis or loose body
Tx::--rest,rest, ice, NSAIDs, steroid injection, stretching exercises
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7 8/12/2011
Supracondylar Fracture Common in children, caused by direct blow or fall on outstretched hand
S/S::--painpain and swelling over distal humerus -evaluate radial/ulnar nerve and artery
Dx::--xx--ray,ray, look for posterior fat pad sign --bilateralbilateral x-x-raysrays helpful
Tx::--nonnon--displaceddisplaced--longlong arm cast --displaceddisplaced-- refer to surgeon
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http://upload.wikimedia.org/wikipedia/commons/thumb/7/7a/Healing_supracondylar_fracture.jpg/485pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/7/7a/Healing_supracondylar_fracture.jpg/485px--Healing_supracondylar_fractureHealing_supracondylar_fracture.jpg.jpg
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Radial Head Fracture Result of a fall on outstretched hand
S/S::--presentpresent splinting in flexion --swellingswelling and diffuse elbow pain over lateral elbow
Dx::--xx--ray,ray, look for posterior fat pad sign (demonstrates blood in joint)
Tx::--nonnon--displaceddisplaced or occultoccult--slingsling 22--44 wks
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8 8/12/2011
http://upload.wikimedia.org/wikipedia/commons/thumb/8/89/Fettpolsterzeichen_pathologisch_Ellenbogen.png/585pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/8/89/Fettpolsterzeichen_pathologisch_Ellenbogen.png/585px--FettpolsterzeichenFettpolsterzeichen_pathologisch_Ellenbogen.png_pathologisch_Ellenbogen.png
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Wrist and Hand
Basic Structures:
. Distal radius
. Distal ulna
. Carpals
. Metacarpals
. Phalanges
http://upload.wikimedia.org/wikipedia/commons/1/1c/Gray1237.png
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Colles Fracture (distal radius fracture)
Elderly person, fall on an outstretched hand
S/S::--swelling,swelling, tenderness and contusion over distal radius/ulna --appearanceappearance often called a “silverfork” deformity
UMDNJ PANCE/PANRE Review Course
9 8/12/2011
Colles Fracture cont’d
Dx::--xx--ray,ray, distal radius fracturefracture with dorsal angulation (Smith’s fxfx-- distal radius fracture with volar angg)ulation)
Tx::--closedclosed reduction and cast 66--88 wks --ifif intraintra--articulararticular requires surgery
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http://upload.wikimedia.org/wikipedia/commons/thumb/4/4a/Displaced_distal_radius_fracture.jpg/592pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/4/4a/Displaced_distal_radius_fracture.jpg/592px--Displaced_distal_radius_fracDisplaced_distal_radius_fracture.jpgture.jpg
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http://upload.wikimedia.org/wikipedia/commons/0/02/DistUArm2.png
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10 8/12/2011
http://upload.wikimedia.org/wikipedia/commons/thumb/0/0f/DistUArm1.png/800pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/0/0f/DistUArm1.png/800px--DistUArm1.pngDistUArm1.png
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Gamekeeper’s Thumb Thumb forced into radial deviation, stresses ulnar collateral ligament (ski pole)
S/S::--painpain with radial stress of thumb
Dx::--radialradial deviation > than opposite side
Tx::--partialpartial lig. rupture-rupture- thumb spica cast --completecomplete lig. rupture-rupture-ORIFORIF
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Scaphoid Fracture Most common carpal fracture, due to fall on outstretched hand
S/SS::--snuff box tenderness,,p pain with ulnar deviation of the wrist --highhigh index of suspicion with negative xx--raysrays
Dx::--xx--ray,ray, all views may be negative --bonebone scan will confirm diagnosis UMDNJ PANCE/PANRE Review Course
11 8/12/2011
Scaphoid Fracture cont’d
Tx::--nonnon--displaceddisplaced-- thumb spica cast 66--2020 wks -if suspect - immobilize and repeat x -ray in 1 wk or r/o with bone scan
High nonnon--unionunion rate with waist and proximal fractures
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http://upload.wikimedia.org/wikipedia/commons/thumb/2/22/Scaphoid_waist_fracture.gif/478pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/2/22/Scaphoid_waist_fracture.gif/478px--Scaphoid_waist_fracture.gifScaphoid_waist_fracture.gif
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http://upload.wikimedia.org/wikipedia/commons/thumb/c/cd/Scaphoidhttp://upload.wikimedia.org/wikipedia/commons/thumb/c/cd/Scaphoid--Pseudarthrose1.jpg/800pxPseudarthrose1.jpg/800px--ScaphoidScaphoid--Pseudarthrose1.jpgPseudarthrose1.jpg
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12 8/12/2011
Boxer Fracture
Closed fist injury, usually a wall or person
S/S: -swelling, tenderness over 4th/5th metacarpals
Dx::--xx--ray,ray, fracture of neck of metacarpal with volar angulation
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Boxer Fracture cont’d
Tx::--closedclosed reduction and ulnar gutter splint -close f/u for loss of reduction
Always suspect “closed fist syndrome”; punch to teeth= human bite= OR + IV antibiotics.
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http://upload.wikimedia.org/wikipedia/commons/thumb/3/3f/Boxers_fracture.JPG/450pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/3/3f/Boxers_fracture.JPG/450px--Boxers_fracture.JPGBoxers_fracture.JPG
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13 8/12/2011
http://upload.wikimedia.org/wikipedia/commons/thumb/7/74/Boxers_fracturehttp://upload.wikimedia.org/wikipedia/commons/thumb/7/74/Boxers_fracture--lateral_xray.JPG/450pxlateral_xray.JPG/450px--Boxers_fractureBoxers_fracture--lateral_xray.JPGlateral_xray.JPG
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de Quervain’s Tenosynovitis
Overuse due to repetitive gripping
S/S::--painpain along radial aspect of wrist -positive Finkelstein test
Dx::--clinicalclinical
Tx::--thumbthumb spica splint for rest, NSAIDs, steroid
injection UMDNJ PANCE/PANRE Review Course
Trigger Finger Stenosing tenosynovitis
S/S::--painless nodule in flexor tendon -snap when tendon passes thru sheath
Dx::--clinicalclinical
Tx::--steroidsteroid injection into tendon sheath --surgicalsurgical release
UMDNJ PANCE/PANRE Review Course
14 8/12/2011
http://upload.wikimedia.org/wikipedia/commons/0/0f/Trigger_finger.jpg
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Carpal Tunnel Syndrome
Median nerve compression, due to repetitive wrist flexion
S/S::--numbnessnumbness and nightnight--timetime pain in thumb, index and middle finger --+/+/-- thenar muscle wasting (late in disease) -positive Phalen & Tinel sign
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Carpal Tunnel Syndrome cont’d
Dx::--clinical,clinical, EMG/NCV if unsure of diagnosis
Tx::--nightnight--timetime splinting, steroid injection, surgical release
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15 8/12/2011
http://www.healcentral.org/content/collections/RCSI/ILLul006.JPG
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http://upload.wikimedia.org/wikipedia/commons/thumb/7/7a/Carpal_Tunnel_Syndrome_operation.jpg/800pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/7/7a/Carpal_Tunnel_Syndrome_operation.jpg/800px--Carpal_Tunnel_Syndrome_operaCarpal_Tunnel_Syndrome_operation.jpgtion.jpg
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A new mother presents with pain on the radial aspect of her wrist when she picks up her baby. What test on physical exam will most likely be positive? 90%
1. Finkelstein test 2. NiNeer sign 3. Phalen maneuver
4. Tinel sign 4% 2% 3%
t r n e ig ign s s in tes l e e t eer aneuv in s N m T inkel len F a Ph UMDNJ PANCE/PANRE Review Course
16 8/12/2011
A patient c/o medial elbow pain when he flexes his wrist. He is a big golfer, what is your treatment plan?
96% 1. Elbow immobilization 2. Joint aspiration 3. Rest, ice & NSAIDs 2% 1% 2% 4. Steroid injection .. . . . i.. t... t c ra NS.. obili i p & m s e im t a ic t, w oin s J Re Steroid inje Elbo UMDNJ PANCE/PANRE Review Course
Spine
Basic Structures:
. Vertebral bodies
. Spinal cord
. Nerve roots
. Vertebral discs
http://upload.wikimedia.org/wikipedia/commons/1/19/Discusprolaps.jpg
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Cervical Fracture
50 % of all CC--spinespine injuries are due to MVA
S/S::--posteriorposterior midline tenderness, focal neurolildfiitlogical deficits
Dx::--lateral xx--rayray picks up 90% of fractures --mostmost injuries occur at C4C4--66
Tx::--immobilizationimmobilization and surgical fixation
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17 8/12/2011
http://upload.wikimedia.org/wikipedia/commons/0/0c/Teardrop_fracture.jpg
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Ankylosing Spondylitis Chronic inflammatory disease affecting the spine Males > Females, usually presents in early adulthood
S/S::--initialinitial c/o diffuse low back pain with morning stiffness --earlyearly exam often negative -progresses to ↓ spine mobility and limited chest expansion
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Ankylosing Spondylitis cont’d
Dx::--xx--rayray--earlyearly shows sacroiliitis, late shows classic bamboo spine -90% HLA -B27 “++”, usually RF ””--””
Tx::--PTPT for flexibility, NSAIDs and posture management
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18 8/12/2011
Ankylosing Sppyondylitis
Bamboo Spine
http://upload.wikimedia.org/wikipedia/commons/thumb/b/b0/Bamboo_spine_ankylosing_spondylitis.jpg/427pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/b/b0/Bamboo_spine_ankylosing_spondylitis.jpg/427px--Bamboo_spine_ankylosing_sBamboo_spine_ankylosing_spondylitis.jpgpondylitis.jpg
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Kyphosis Progressive increase in dorsal curve of T-T- spine due to collapse of vertebrae Causes: osteoporosis, cancer, trauma, fracture
S/S::--presentpresent with pain from acute fracture or deconditioning of back muscles --gradualgradual loss of height --hunchbackhunchback deformity w/ ↓ mobility
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Kyphosis cont’d
Dx::--clinicalclinical --xx--rayray may show narrow disc spaces, osteoporosis and old or new fractures
Tx::--PTPT for strengthening exercises, analgesics, light support --KyphoplastyKyphoplasty for new fractures
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19 8/12/2011
Scoliosis Idiopathic lateral curvature of spine > 10°, often diagnosed in prepre--adolescentadolescent girls
S/S::--oftenoften asymptomatic and discovered on routine exam --painlesspainless spinal asymmetry --paraspinalparaspinal hump, uneven shoulders and iliac crests
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Scoliosis cont’d
Dx::--clinicalclinical and x-x-rayray to measure Cobb angle
Tx: Treatment depends on angle and age --<< 20° observation only --2020°--4040° treated with brace -->> 40° should be evaluated surgically
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http://upload.wikimedia.org/wikipedia/commons/a/a3/Initial_diagnosis_of_scoliosis_with_adams_test_and_xhttp://upload.wikimedia.org/wikipedia/commons/a/a3/Initial_diagnosis_of_scoliosis_with_adams_test_and_x--rays.jpgrays.jpg
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20 8/12/2011
Low Back Pain
80% of US population will have episode of back pain, caused by overuse-overuse- heavy lifting/twisting
S/S::--lowlow back pain that may radiate to buttock or leg, worse with long periods of standing --tendernesstenderness over paraspinal muscles and ↓ lumbar ROM -neurologic exam will be normal
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Low Back Pain
Dx: --clinicalclinical --xx--rayray to r/o other causes, especially if symptoms persist
Tx::--rest,rest, ice/heat, NSAIDs, PT education --narcoticsnarcotics and muscle relaxants for short period of time (3 days)
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Herniated Disc
Can be cervical or lumbar, usually due to DDD or recurrent trauma
S/S::--paiiin in nerve di ditibtistribution, worse with flexion or valsalva --maymay have motor weakness and diminished reflexes --LumbarLumbar disc = “+” straight leg raise and crossed straight leg raise
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21 8/12/2011
Herniated Disc
Dx::--MRI
Tx: -rest, ice/heat, NSAIDs, PT education , epidural steroid injections --considerconsider surgery if symptoms not resolved in 66--1212 weeks
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Dermatomes
Nerve Root Motor exam Reflex Sensory Area L4 Dorsiflexion Knee jerk Medial calf of foot & foot L5 Dorsiflexion None Lat. calf & of great toe dorsal foot S1 Eversion of Ankle jerk Lat. foot & foot plantar foot
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http://upload.wikimedia.org/wikipedia/commons/2/22/LUMBAR_DISC_HERNIATION.jpg
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22 8/12/2011
http://upload.wikimedia.org/wikipedia/commons/9/9f/LumbarDiscHerniation.jpg
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Cauda Equina Syndrome Sudden compression of L2L2--S4S4 nerve roots CausesCauses-- central disc herniationherniation,, epidural abscess, hematoma, tumor
S/S::--LELE radicular pain and numbness -saddle anesthesia, bowel and bladder dysfuntion --LELE motor and sensory loss/loss of sphincter tone
Dx::--MRIMRI to determine cause
Tx::--emergencyemergency treatment, find cause and fix it
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Spinal Stenosis
. Narrowing of spinal canal or neural foramina causing compression of thecal sac or nerve root. Patients usually over 60 y/o and males affected more often.
. CausesCauses-- hypertrophy of ligamentum flavum, facet capsule hypertrophy, spondylolisthesis, osteophytes or bulging discs
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23 8/12/2011
Spinal Stenosis cont’d S/S::--insidious onset of buttock and leg pain
--numbnessnumbness with ambulation or prolonged sitting --c/oc/o poor balance, unsteady gait or “spag he tti legs” -relief with sitting or flexion of spine -few neurologic findings-findings- < 10% have “+” SLR 25% have diminished reflexes 65% have LE weakness
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Spinal Stenosis cont’d
Dx::--MRIMRI best, CT or CTCT--myelogrammyelogram if MRI contraindicated -x-rays show DJD w/ disc degeneration
Tx::--rest,rest, PT, NSAIDs, weight reduction --epiduralepidural steroids, nerve blocks --surgerysurgery when QOL impaired
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http://upload.wikimedia.org/wikipedia/commons/4/44/STENOTIC_CANAL.JPG
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24 8/12/2011
http://upload.wikimedia.org/wikipedia/commons/c/cd/SPINAL_STENOSIS.JPG
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A furniture mover c/o low back pain that radiates to his R-R-buttock,buttock, lat leg and foot. PE shows a + SLR at 40 degrees. What is the most likely diagnosis? 68%
1. Cauda equina syndrome 2. Compression 27% fracture L5 3. Herniated L3L3--44 disc 2% 3% 4. Herniated L5L5--S1S1 disc c isc is d d -4 1 3 -S 5 syndrome L a ted L d te rnia e rnia H e H Cauda equin Compression fractur... UMDNJ PANCE/PANRE Review Course
The highest degree of curvature that is acceptable for conservative treatment of scoliosis with bracing is? 74%
1. 20 degrees 2. 30 degrees 3. 40 degrees 4. 70 degrees 15% 6% 5%
s s s e e e rees e e e gr gr gr e e e deg d d 0 0 0 2 3 4 70 d UMDNJ PANCE/PANRE Review Course
25 8/12/2011
Hip Joint Basic Structures:
. Pelvis
. Acetabulum
. Proximal femur
. Femoral head
. Greater trochanter
http://upload.wikimedia.org/wikipedia/commons/c/c4/Gray342.png
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Avascular Necrosis (Aseptic Necrosis) Loss of blood supply to the femoral head CausesCauses-- trauma, alcoholism, steroid and antianti-- retroviral use
S/S::--dull,dull, aching groin pain, & antalgic gait --painpain on IR and ER, ↓ hip ROM
Dx::--MRI
Tx::--referrefer for orthopedic evaluation
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http://upload.wikimedia.org/wikipedia/commons/thumb/1/1a/LeggCalvePerthes1.jpg/800pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/1/1a/LeggCalvePerthes1.jpg/800px--LeggCalvePerthes1.jpgLeggCalvePerthes1.jpg
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26 8/12/2011
Hip Fracture
Usually due to fall in elderly women Femoral neck or IT fracture most common
S/S: -leg will be shortened and ER or IR --painpain on ROM of hip
Dx::--xx--ray,ray, MRI for occult fractures
Tx::--ORIFORIF
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http://upload.wikimedia.org/wikipedia/commons/thumb/1/11/Cdm_hip_fracture_343.jpg/792pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/1/11/Cdm_hip_fracture_343.jpg/792px--Cdm_hip_fracture_343.jpgCdm_hip_fracture_343.jpg
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http://upload.wikimedia.org/wikipedia/commons/thumb/5/5c/Cdm_hip_implant_348.jpg/454pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/5/5c/Cdm_hip_implant_348.jpg/454px--Cdm_hip_implant_348.jpgCdm_hip_implant_348.jpg
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27 8/12/2011
http://upload.wikimedia.org/wikipedia/commons/f/f7/Hueftgelenkhttp://upload.wikimedia.org/wikipedia/commons/f/f7/Hueftgelenk--Oberschenkelhalsbruch.jpgOberschenkelhalsbruch.jpg
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Hip Dislocation High impact trauma, 90% MVAs
S/S::--limblimb shortened and internally rotated, severe pain (most posterior) --25%25% sustain related knee injury --15%15% sustain sciatic nerve injury
Dx::--xx--ray,ray, CT to r/o fracture of acetabulum
Tx::--immediate reduction with postpost--reductionreduction film
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http://upload.wikimedia.org/wikipedia/commons/thumb/6/63/Hueftluxation_links.png/781pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/6/63/Hueftluxation_links.png/781px--Hueftluxation_links.pngHueftluxation_links.png
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28 8/12/2011
A patient c/o aching pain in his R-R-groin.groin. His ROM is decreased but his x-x-rayray is neg. What study would confirm your suspected diagnosis?
94%
1. Arthrogram 2. Bone scan 3. MRI 4. Repeat x-x-rayray 1% 3% 2%
n m a ra c g s MRI ne eat x-ray o p Arthro B Re UMDNJ PANCE/PANRE Review Course
Knee Joint
Basic Structures:
. Distal femur
. Proximal tibia
. Proximal fibula
. ACL/PCL
. MCL/LCL
. Menisci
http://www.healcentral.org/content/collections/RCSI/ower055.JPG
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Tibial Plateau Fracture
Occurs in patients who have had an axial load injury, i.e. fall from a high place
S/S: -present-present with knee pain & swelling --maymay be unable to bear weight
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29 8/12/2011
Tibial Plateau Fracture
Dx::--xx--ray;ray; use CT or MRI if unsure --looklook for tibial depression
Tx::--initialinitial treatment; immobilization and nonnon--weightweight bearing --dependsdepends on type of fracture, cast immobilization or if tibial defect surgery
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http://upload.wikimedia.org/wikipedia/commons/8/8c/TibPlateauF.PNG
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Patellar Fracture
Usually caused by a direct blow or forced flexion of the quadriceps muscle
S/S::--painpain and swelling of the soft tissues of anterior knee, may feel defect in bone -inability to actively extend knee
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30 8/12/2011
Patellar Fracture
Dx: -physical -physical exam and xx--rayray
Tx: -8 weeks immobilization if displaced < 3mm --ORIFORIF if displaced > 3mm or stepstep--offoff --patellapatella excision in extreme cases
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http://www.healcentral.org/content/collections/RCSI/ower055.JPG
UMDNJ PANCE/PANRE Review Course
ACL Injury Forceful internal rotation of knee w/ planted foot Common causescauses--skiing,skiing, basketball, soccer
S/S: -patient hears “pop” , sudden swelling, instability -acute hemarthrosis --“+”“+” Lachman test & anterior drawer sign
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ACL Injury cont’d
Dx::--clinical,clinical, confirm with MRI
Tx: -rest/ice, NSAIDs, bracing , PT with activity changes --youngyoung athletes=arthroscopic ACL reconstruction
UMDNJ PANCE/PANRE Review Course
http://upload.wikimedia.org/wikipedia/commons/b/bd/MRT_ACL_PCL_01.jpg
UMDNJ PANCE/PANRE Review Course
http://upload.wikimedia.org/wikipedia/commons/thumb/b/bd/VKBhttp://upload.wikimedia.org/wikipedia/commons/thumb/b/bd/VKB--Riss_MRT_T1_PDW_sag.jpg/753pxRiss_MRT_T1_PDW_sag.jpg/753px--VKBVKB--Riss_MRT_T1_PDW_sag.jpgRiss_MRT_T1_PDW_sag.jpg
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Meniscal Injuries
Most common knee injury (medial most often), history of knee trauma, usually twisting or slipping
S/S::--triad of joint line pain, effusion (develops overnight) and locking or clicking --positivepositive McMurray & Apley test
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Meniscal Injuries cont’d
Dx::--clinical,clinical, confirm with MRI
Tx::--RICE,RICE, NSAIDs and PT --arthroscopyarthroscopy for persistent symptoms
UMDNJ PANCE/PANRE Review Course
http://upload.wikimedia.org/wikipedia/commons/thumb/d/d2/Meniscofemorale_Baender_MRT_Haemarthros_Pseudotear.png/602pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/d/d2/Meniscofemorale_Baender_MRT_Haemarthros_Pseudotear.png/602px-- Meniscofemorale_Baender_MRT_Haemarthros_Pseudotear.png
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http://upload.wikimedia.org/wikipedia/commons/b/b0/Tear_of_medial_meniscus.jpg
UMDNJ PANCE/PANRE Review Course
Prepatellar Bursitis (Housemaid’s Knee) Caused by excessive kneeling or trauma to knee
S/S::--palpable boggy swelling over patella -if red/ pai nf ul , worry ab out i nf ecti on
Dx::--clinicalclinical
Tx::--RICE,RICE, NSAIDs, usually selfself--limitinglimiting
UMDNJ PANCE/PANRE Review Course
http://upload.wikimedia.org/wikipedia/commons/thumb/e/e8/Prepatellar_bursitis.JPG/800pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/e/e8/Prepatellar_bursitis.JPG/800px--Prepatellar_bursitis.JPGPrepatellar_bursitis.JPG
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Which is the most accurate PE procedure for evaluation of ACL integrity?
83% 1. Anterior drawer sign 2. Lachman test 3. McMurray test 15% 4. Varus/valgus 1% 1% stress t s s s ign te e tr r s n test s e ray w a ma ur us M lg r dr a io Lach Mc /v r us te r n A Va UMDNJ PANCE/PANRE Review Course
Which of the following is often caused by a direct fall onto the knee?
89% 1. ACL rupture 2. Meniscal injury 3. Patellar fracture 4. Tibial plateau 9% fracture 1% 2%
re ry re u ju u pt l in ru a fracture L c C s A teau fract la Meni p Patellar l ia Tib UMDNJ PANCE/PANRE Review Course
Ankle and Foot Basic Structures: . Distal tibia . Distal fibula . Talus . Calcaneus . Tarsal & metatarsal bones . Phalanges . Lateral and medial ligaments
http://upload.wikimedia.org/wikipedia/commons/8/8d/Ospied.jpg
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http://upload.wikimedia.org/wikipedia/commons/5/5d/Ankle.PNG
UMDNJ PANCE/PANRE Review Course
Ankle Sprain Represents most common musculoskeletal injury, 85% of injuries are inversion with plantar flexion. ATF most commonly injured.
S/S::--Pt.Pt. may hear “pop” followed by swelling and contusion --painpain mostly over ligaments vs. bone --palpatepalpate all 4 ligaments (ATF, CF, PTF, DL) and medial/lateral malleoli
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Ankle Sprain cont’d
Dx::--clinical,clinical, xx--rayray if bony tenderness or patient unable to weight bear
Tx::--RICE,RICE, NSAIDs, supportive brace with WBAT for 44--66 wks
UMDNJ PANCE/PANRE Review Course
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http://upload.wikimedia.org/wikipedia/commons/5/5d/Ankle.PNG http://upload.wikimedia.org/wikipedia/commons/4/46/Gray354.png
UMDNJ PANCE/PANRE Review Course
Ankle Fracture
Caused by eversion, inversion or lateral rotation of ankle, more likely to injure deltoid ligament
S/S::--pain,pain, swelling, ecchymosis,ecchymosis, instability --painpain will be over bone vs. ligaments --checkcheck proximal fibula for tenderness --checkcheck peroneal nerve (foot drop)
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Ankle Fracture cont’d
Dx::--AP/latAP/lat and mortise view of ankle
Tx::--stablestable fracture 44--66 wks immobilization and WBAT --unstableunstable fractures require ORIF
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http://upload.wikimedia.org/wikipedia/commons/thumb/c/c1/Bimall2.png/450pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/c/c1/Bimall2.png/450px--Bimall2.pngBimall2.png
UMDNJ PANCE/PANRE Review Course
http://upload.wikimedia.org/wikipedia/commons/thumb/c/c9/AnkleFractureDislocation2008.jpg/450pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/c/c9/AnkleFractureDislocation2008.jpg/450px--AnkleFractureDislocation2008.jpgAnkleFractureDislocation2008.jpg
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Achilles Tendon Rupture Caused by pushing off or forcible plantar flexion --commoncommon 3030--5050 y/o and weekend warrior
S/S: -“II was jumping and it felt like someone kicked me in the calf” --reportreport a “pop” and feel weakness when walking --deformitydeformity noted proximal to attachment -positive Thompson test UMDNJ PANCE/PANRE Review Course
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Achilles Tendon Rupture cont’d
Dx::--clinical,clinical, MRI used for surgical planning
Tx::--plantarplantar flexion cast 88--1212 weeks --acuteacute surgical repair = less re-re-rupturerupture
UMDNJ PANCE/PANRE Review Course
http://upload.wikimedia.org/wikipedia/commons/thumb/c/cb/Ruptured_achilles_tendon.jpg/800pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/c/cb/Ruptured_achilles_tendon.jpg/800px--Ruptured_achilles_tendon.jpgRuptured_achilles_tendon.jpg
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Avulsion Fracture Avulsion fracture of 5th metatarsal, inversion of foot causes a chip fracture off bone
S/S::--pain/ecchymosispain/ecchymosis at base of 5th MT
Dx::--xx--raysrays
Tx::--hardhard shoe or cast with rapid return to wt. bearing --goodgood healing rate
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http://upload.wikimedia.org/wikipedia/commons/thumb/2/25/AvulsionfractureXRay.jpg/392pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/2/25/AvulsionfractureXRay.jpg/392px--AvulsionfractureXRay.jpgAvulsionfractureXRay.jpg
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Stress Fractures Repetitive stress leads to bony resorption before new bone can be placed, continued stress leads to fracture. Young, active, starting new activity.
S/S::--painpain over bone with no history of trauma --fracturesfractures usually occur at tibia, metatarsals, calcaneus, or sacrum
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Stress Fractures cont’d
Dx::--clinical,clinical, x-x-rayray not “+” for 33--44 wks --bonebone scan will confirm early suspicion
Tx::--rest,rest, activity modifimodificationcation or non wt-wt- bearing for 44--88 wks --maymay need cast
UMDNJ PANCE/PANRE Review Course
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http://upload.wikimedia.org/wikipedia/commons/thumb/2/22/Jonesfracture.jpg/424pxhttp://upload.wikimedia.org/wikipedia/commons/thumb/2/22/Jonesfracture.jpg/424px--Jonesfracture.jpgJonesfracture.jpg
UMDNJ PANCE/PANRE Review Course
A new military recruit presents with “shin splints”. X-X-raysrays are negative, what test would you order next? 75% 1. Bone scan 2. CT scan 3. MRI
4. Repeat x-x-rayray in 1 10% 13% week 2%
an c can MRI s s e n CT o in 1 week B
eat x-ray p Re UMDNJ PANCE/PANRE Review Course
What is the most commonly injured ligament in an inversion ankle sprain?
88% 1. Anterior talofibular (ATF) 2. Calcaneofibular (CF)
3. Deltoid 11% 1% 1% 4. Posterior
. talofibular (PTF) .. (CF) ltoid r e lar u D fibula lo a neofib r t a o ri te Calc s o Anterior talofibular (ATF) P UMDNJ PANCE/PANRE Review Course
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References
11-- Current Medical Diagnosis and Treatment, 50th anniversary edition, 2011 22-- Current Diagnosis and Treatment in Orthopedics, 4rd edition, 2006 3-Review of Orthopaedics (Miller), 4 th edition, 2004 44--CecilCecil Textbook of Medicine, 23nd edition, 2008 55--Bate’sBate’s Guide to Physical ExExaminationamination and History Taking, 9th edition, 2007 66--PhysicalPhysical Examination of the Spine & Extremities (Hoppenfeld), 1st edition, 1976 77--OrthopedicOrthopedic Neurology, A DiagnosticDiagnostic Guide to Neurologic Levels (Hoppenfeld), 1st edition, 1977
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