Orthopedics 3

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Orthopedics 3
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2011-07-18 15:53:36
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DPAP2012 Orthopedics
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  1. Components of the MS System
    Bone, Articular Tissue, Connective Tissue
  2. Articular Tissue
    Cartilage, Synovium
  3. Connective Tissue
    Muscle, Ligaments, Tendons
  4. Bones: Numbers
    80 in axial skeleton; 126 in appendicular skeleton; 27 in the hand
  5. Regions of long bones
    Epiphysis; Physis; Metaphysis; Diaphysis
  6. Epiphysis =
    above growth plate
  7. Physis =
    growth plate
  8. Diaphysis =
    Shaft
  9. Physis in children:
    is open (i.e., growth plate)
  10. Types of Bone
    Cortical; Cancellous
  11. Cortical bone =
    Compact, makes up 80% of skeleton (e.g., diaphysis of long bones)
  12. Cancellous bone =
    Spongy or trabecular ; more prominent in spine & pelvis (e.g., metaphysis of long bones)
  13. Periosteum =
    Highly vascular membrane that covers bone; more prominent in children
  14. Bone Marrow =
    Source of hematopoietic progenitor cells
  15. Highly vascular membrane that covers bone; more prominent in children
    Periosteum
  16. Source of hematopoietic progenitor cells Bone
    Marrow
  17. Change in bone marrow with aging
    Red (active) marrow changes to yellow (fatty, inactive) marrow
  18. Organic Bone Matrix wrt weight
    Organic matrix composes 40% of bone dry wt
  19. Organic Bone Matrix =
    Type I Collagen, Proteoglycans, Noncollagenous matrix proteins, GFs & cytokines
  20. Type I Collagen =
    90% of organic matrix
  21. Bone strength from:
    Type I Collagen (tensile strength); Proteoglycans (compressive strength)
  22. Noncollagenous matrix proteins promote:
    mineralization & bone formation
  23. Growth factors & cytokines =
    Interleukins, transforming growth factor
  24. Inorganic Bone Matrix =
    Calcium hydroxyapatite; Osteocalcium phosphate (Brushite)
  25. Mineral components wrt weight
    Mineral components compose 60% of the dry wt of bone
  26. Metaphyseal - Epiphyseal System
    Arises from periarticular vascular plexus
  27. Periosteal System
    Low pressure capillary system supplies outer 1/3 of diaphyseal cortex
  28. Bone maintained by metabolism of:
    Ca & PO4
  29. Amount Ca & PO4 in bone
    99% of Ca & 85% of PO4 found in Bone
  30. Needed for gut Ca absorption:
    Vitamin D
  31. Increases plasma Ca by increasing gut absorption & bone resorption:
    PTH
  32. Peak bone mass at age:
    16 to 25 y.o.
  33. Estrogen prevents:
    bone loss
  34. Examples of bone loss
    Osteoporosis, FAS (amenorrhea, anorexia, osteoporosis)
  35. Dietary requirement of Ca:
    1000-1500 mg/day
  36. Osteoblasts =
    Cells that form bone, producing type I collagen
  37. Osteoclasts =
    Cells that resorb bone
  38. Osteocytes =
    Cells that maintain bone; make up 90% of mature skeleton
  39. Fracture Healing: stages
    Inflammation, Repair, Remodeling
  40. Fracture Healing: Remodeling stage
    Begins mid repair phase; continues for several months
  41. Types of Cartilage
    Fibrocartilage, Elastic cartilage, Fibroelastic cartilage, Articular cartilage
  42. Fibrocartilage
    Area for bone & tendon insertion
  43. Elastic cartilage
    Nose, auricle
  44. Fibroelastic cartilage:
    Menisci (functions to deepen articular surface & stabilize joint)
  45. Articular cartilage:
    Hyaline (aids in load distribution & decreasing joint friction)
  46. Synovium =
    Membrane lines the joint; mediates exchange of nutrients between blood & joint fluid
  47. Synovial (Joint) Fluid:
    Nourishes articular cartilage; lubricates articular surfaces
  48. Bursa:
    Fluid-filled potential space over areas of friction
  49. Combine into myofibrils:
    Actin & Myosin filaments
  50. Myofibrils combine into:
    muscle fibers
  51. Muscle fibers combine into:
    muscle fascicles
  52. Fascicles combine into:
    muscle body
  53. Slow twitch (type I) muscle
    Oxidative; Aerobic; Endurance
  54. Fast twitch (type II) muscle
    Glycolytic (ATP system); Anaerobic; Speed/ Strength
  55. Muscle Action: stimulus in neuron:
    carried down axon to neuromuscular junction
  56. At NMJ:
    ACTH released from pre-synaptic vesicles & diffuses across synapse to receptor on muscle
  57. Muscle Action: binding at receptor triggers:
    depolarization, releasing Ca
  58. Muscle Action: Calcium binds:
    Troponin
  59. Muscle Action: troponin is bound; then:
    Actin-myosin cross bridges form; muscle contracts
  60. Isotonic contraction:
    Constant tension through ROM
  61. Concentric contraction:
    muscle shortens
  62. Eccentric contraction:
    muscle elongates
  63. Isometric contraction:
    Muscle tension with length constant
  64. Isokinetic contraction:
    Concentric or eccentric contraction at constant speed over ROM
  65. Open chain exercise:
    Distal end of limb is free, isolates mx (i.e., seated leg extension, biceps curl)
  66. Closed chain exercise:
    Distal end is fixed, recruits accessory muscles (e.g., push-ups, squats)
  67. Tendon:
    Attaches mx to bone; transfers mx action to bone; enclosed within a tendon sheath
  68. Ligament:
    Attaches bone to bone; provides stability to the joint
  69. Fat Embolism Syndrome: most common with:
    femoral shaft fracture
  70. Fat Embolism Syndrome occurs when?
    Within several days of fracture
  71. Rhabdomyolysis =
    Breakdown of mx fibers with release of cellular contents into circulation
  72. Rhabdomyolysis S/S
    Muscle pain, dark urine
  73. Rhabdomyolysis: Labs
    Myoglobinuria; CK elevated 5-10x normal (37-200)
  74. Rhabdomyolysis: Rx
    Fluids; Correct imbalances; tx underlying cause
  75. Carpal tunnel syndrome:
    with distal radial Fx, or overuse
  76. Ulna nerve palsy:
    with elbow Fx / dislocation, or impingement
  77. Peroneal nerve palsy:
    with hip, fibular head, or ankle fracture/dislocation
  78. Sciatic nerve neurapraxia:
    with L-S spine, pelvic, hip Fx, or HNP
  79. Neurapraxia:
    Blunt injuries may produce nerve contusion
  80. Neurapraxia: assoc with:
    fracture; recovers in 6-12 weeks
  81. Axonotmesis:
    Crush injury; also seen in traction injuries; recovers at 1mm/day or 1 inch/month
  82. Neurotmesis:
    Sharp trauma results in a severed nerve; primary surgical repair indicated
  83. Reflex Sympathetic Dystrophy =
    Chronic Regional Pain Syndrome
  84. Reflex Sympathetic Dystrophy =
    Persistent pain & hyperesthesia after an injury
  85. Venus Thromboembolism: DVT common in:
    spine, pelvic, hip, femur fx.
  86. Venus Thromboembolism: Risk factors
    Trauma, smoking, prolonged inactivity, hormone therapy, surgery
  87. Venus Thromboembolism: Screen with:
    duplex Doppler venous ultrasound
  88. Venus Thromboembolism: Calf pain
    Calf pain in post-op hip or knee patient deserves US
  89. PE may be first sign of:
    DVT
  90. Myositis Ossificans =
    Heterotrophic bone formation
  91. Myositis Ossificans: must R/O:
    R/O osteosarcoma
  92. Myositis Ossificans: tx
    Ice, compression; excision for impairment after stabilization in 6-8 months
  93. Fracture Complications
    Delayed union; Nonunion; Infxn; N/V injury
  94. (Fx comp) Delayed union:
    Slow callus formation
  95. (Fx comp) Nonunion:
    No clinical or radiographic signs of progression to bony union after 3 months
  96. (Fx comp) Infection: esp. with:
    open fractures
  97. Osteomyelitis:
    S. aureus, Beta strep
  98. (Fx comp) N/V injury
    Evaluate circulation & sensation distal to injury site.
  99. MS H&P: AMPLE =
    Allergies, meds, Past Hx , Last meal, Events of trauma; PE
  100. ROM: Hand
    • CMC flex: 0-15;
    • CMC ext: 0-30;
    • MCP: 0-90;
    • PIP: 0-100;
    • DIP: 0-70
  101. ROM: Elbow
    • Flexion: 0-150;
    • Pronation/supination: 0-80
  102. ROM: Wrist
    • Extension: 0-60;
    • Flexion: 0-70;
    • Ulnar deviation: 0-30;
    • Radial deviation: 0-20
  103. ROM: Hip
    • Flexion: 0-100;
    • Ext: 0-30;
    • Abd: 0-40;
    • Add: 0-20;
    • IR: 0-40;
    • ER: 0-70
  104. ROM: Knee
    Flex: 0-140
  105. ROM: Ankle
    • Dorsiflexion: 0-20;
    • Plantar flexion: 0-40;
    • Inversion: 0-30;
    • Eversion: 0-20
  106. ROM: Cervical Spine
    • Flexion: 0-45;
    • Extension: 0-45;
    • Lateral flexion: 0-45;
    • Rotation: 0-80
  107. ROM: Thoracolumbar Spine
    • Flexion: 0-90;
    • Extension: 0-30;
    • Lateral flexion: 0-30;
    • Rotation: 0-30
  108. Resisted ROM: Neck Flex/Extend:
    C1-2
  109. Resisted ROM: Neck Lateral Flexion:
    C3
  110. Resisted ROM: Shoulder Shrug:
    C4, CN XI
  111. Resisted ROM: Shoulder Abduction:
    C5
  112. Resisted ROM: Elbow Flex-Wrist Extend:
    C6
  113. Resisted ROM: Elbow Extend:
    C7
  114. Resisted ROM: Hand Grip:
    C8
  115. Resisted ROM: Abduction of Fingers:
    T1
  116. Resisted ROM: Opposition of Fingers/Pincer
    Interosseous muscles
  117. Resisted ROM: Hip flexion:
    L1-L3
  118. Resisted ROM: Knee extension / Ankle dorsiflexion :
    L4
  119. Resisted ROM: Great toe extension:
    L5
  120. Resisted ROM: Ankle plantar flexion:
    S1
  121. Light touch: Side of Neck:
    C2-3
  122. Light touch: Tip of Shoulder:
    C4
  123. Light touch: Lateral Deltoid:
    C5
  124. Light touch: Thumb:
    C6
  125. Light touch: Middle Finger:
    C7
  126. Light touch: Pinky Finger:
    C8
  127. Light touch: Medial Forearm at elbow:
    T1
  128. Light touch: 1st Dorsal web:
    Radial nerve
  129. Light touch: Palmar middle pad:
    Median
  130. Light touch: Palmar small pad:
    Ulna
  131. Light touch: Groin:
    L1
  132. Light touch: Upper thigh:
    L2
  133. Light touch: Outer thigh at knee:
    L3
  134. Light touch: Medial ankle:
    L4
  135. Light touch: Dorsal 1st web space:
    L5
  136. Light touch: Lateral ankle:
    S1
  137. Light touch: Buttock:
    L2-3
  138. Light touch: Perianal:
    L4
  139. DTR: Biceps:
    C5
  140. DTR: Brachioradialis:
    C6
  141. DTR: Triceps:
    C7
  142. DTR: Knee:
    L 3,4
  143. DTR: Ankle:
    S1
  144. DTR: 0:
    Absent
  145. DTR: 1:
    Diminished
  146. DTR: 2:
    Average
  147. DTR: 3:
    Exaggerated
  148. DTR: 4:
    Clonus
  149. Pulses : normal =
    2+
  150. Gait categories
    Normal, Unsteady, Cautious, Antalgic, Use of assisted devices
  151. Skin: examine:
    Moisture; Turgor; Trauma
  152. Sprain:
    Stretched or torn ligament
  153. Sprain: 1st degree
    partial tear
  154. Sprain: 2nd degree
    partial/instability
  155. Sprain: 3rd degree
    complete tear
  156. Strain:
    Musculo-tendinous unit injury; first, second, third degree; Pulled muscle
  157. Contusion:
    Bruise; Hematoma ; Abrasions, lacerations
  158. Tendonitis =
    Overuse, mechanical irritation of tendon
  159. Tendonitis: Shoulder:
    Supraspinatus
  160. Tendonitis: Elbow:
    Medial/lateral epicondylitis
  161. Tendonitis: Wrist:
    DeQuervain
  162. Tendonitis: Hand:
    Trigger finger
  163. Tendonitis: Hip:
    ITB
  164. Tendonitis: Knee:
    ITB, Patella, Quadriceps
  165. Tendonitis: Ankle:
    Peroneal tendon, Posterior tibial tendon, Achilles
  166. Tendonitis: Foot:
    Plantar Fasciitis
  167. Nonspecific NSAIDs: Side effects:
    HTN, GI, altered renal function, MI (ibuprofen and diclofenac)
  168. Nonspecific NSAIDs: appropriate for:
    impingement & inflammatory disorders
  169. Nonspecific NSAIDs: not appropriate for:
    chronic tendonitis
  170. Nonspecific NSAIDs: Topical:
    Flector patch, Voltaren gel
  171. COX-2 Inhibitors: Not indicated for:
    soft tissue injury
  172. COX-2 Inhibitors: Concern about:
    cardiovascular effects
  173. Low dose Celebrex for:
    RA and OA
  174. Tylenol: effective as pain relief for:
    soft tissue injuries & as opioid sparing combination
  175. Goody powder:
    APAP/ASA/Caffeine
  176. BC powder:
    ASA/Caffeine/Salicylamide
  177. Joint & Soft Tissue Injections: should be limited to:
    4 per year, per site
  178. Do not inject corticosteroids into:
    a septic joint or thru cellulitic skin
  179. Glucosamine
    Analgesic effect & cartilage repair for OA; no support for soft tissue injury
  180. Osteoarthritis: Rx:
    NSAIDs, ROM, Glucosamine
  181. Rheumatoid Arthritis
    Early, sudden onset, bilateral & symmetric; Bony erosion; systemic illness
  182. Rheumatoid Arthritis: Rx:
    DMARDs, steroids
  183. Seronegative spondyloarthropathy
    Ankylosing Spondylitis
  184. Plain Films: Consider:
    Consider joint above & below injury
  185. CT scan:
    Defines bony anatomy
  186. MRI:
    Defines soft tissues
  187. Nuclear medicine studies:
    Help define tumors, etc
  188. EMG:
    Evaluates denervation of muscle units
  189. NCS:
    Evaluate conduction velocities
  190. Fracture: Region of bone:
    diaphysis, metaphysis, epiphysis
  191. Direction of fracture:
    transverse, oblique, spiral
  192. Fracture: Condition of bone:
    comminuted, incomplete
  193. Fracture: Condition of soft tissue:
    closed, open, open joint
  194. Fracture: Deformities of fracture:
    displaced, angulated
  195. Fracture: Peds:
    greenstick, torus, Salter-Harris
  196. Salter-Harris Growth Plate injury classification: I (S):
    Straight
  197. Salter-Harris: II (A):
    Above
  198. Salter-Harris: III (L):
    Lower
  199. Salter-Harris: IV (T):
    Through
  200. Salter-Harris: V (R):
    Ram
  201. Femoral Neck Fx: Garden type I
    Incomplete fx w/ valgus impaction; ORIF
  202. Femoral Neck Fx: Garden type II
    Complete fx w/o displacement; ORIF
  203. Femoral Neck Fx: Garden type III
    Complete fx / partial displacement; prosthetic replacement
  204. Femoral Neck Fx: Garden type IV
    Complete fx w/ total displacement; prosthetic replacement
  205. Radial head fx (Mason) Class I:
    Undisplaced
  206. Radial head fx (Mason) Class II:
    Displaced
  207. Radial head fx (Mason) Class III:
    Comminuted
  208. Radial head fx (Mason) Class IV:
    Dislocated
  209. Fracture Description
    Anatomic location; Region; Direction of fracture; Condition of bone
  210. Splinting
    Plaster or ready to use (Orthoglass); acutely, 10 thick, use padding
  211. Casting
    Fiberglass; after swelling subsides, check NV status
  212. Closed reduction
    Hematoma block, digital block, exaggeration of Fx & reduction with traction
  213. CRPP/ORPP =
    (open/closed reduction percutaneous pinning)
  214. ORIF
    Screws, plates
  215. Bone Grafts
    act as framework for new bone growth
  216. Autograft
    from same patient
  217. Xenograft (heterograft)
    from another species
  218. Allograft
    from cadaveric bone bank
  219. Bone Grafts: Types
    Autograft; Xenograft; Allograft; Ceramics
  220. Tumors: prevalence in ortho
    Benign bone tumors common; malignant tumors rare
  221. Metastases to bone are common in:
    Pts > 40 y.o.
  222. Benign tumors:
    Osteoblastoma, Osteoid osteoma
  223. Malignant tumors:
    Ewing sarcoma, Osteosarcoma, Chondrosarcoma
  224. Benign soft tissue tumors
    Ganglia, giant cell tumor, lipoma, hemangioma, angiomyoma
  225. Malignant soft tissue tumors
    Fibrosarcoma, liposarcoma, rhabdomyosarcoma
  226. Autosomal Dominant Disorders
    Heterozygote (Aa) manifests dz (Marfan; Achondroplasia)
  227. Autosomal Recessive Disorders
    Homozygote (AA) manifests dz (Hurler Syndrome, osteogenesis Imperfecta type II & III)
  228. Blood supply to long bones
    Nutrient Artery System; Metaphyseal-Epiphyseal System; Periosteal System
  229. Nutrient Artery System:
    Nutrient a. enters diaphyseal cortex thru nutrient foramen into medullary canal
  230. Bone remodeling MOA
    Osteoclasts resorb bone followed by new bone deposition by osteoblasts
  231. Wolff’s law
    Increase in external stress leads to bone formation; removal of external stress leads to bone resorption
  232. Fracture Healing: inflammation stage
    Hematoma forms at fracture site; Osteoclasts remove necrotic bone; Hematopoietic cells in clot secrete growth factors
  233. Fracture Healing: Repair stage
    Soft callus stage: fibrous tissue unites fragments; Hard callus stage: callus converts to bone
  234. Fat Embolism Syndrome results from:
    Embolic marrow fat damaging pulmonary capillary beds leading to ARDS
  235. Fat Embolism Syndrome: Pt presents with:
    hypoxemia, dyspnea, altered mental status, tachycardia, and petechia
  236. Fat Embolism Syndrome: Rx:
    Maintain perfusion with O2, inotropics, maintain hematocrit, correct metabolic acidosis; mechanical ventilation may be required.
  237. Rhabdomyolysis etiology
    Blunt trauma, seizures, burns, strenuous exercise, electric shock, drugs (Lipitor), viruses
  238. Rhabdomyolysis: Clinical sequelae
    Hypovolemia, Hyperkalemia, Metabolic acidosis, Acute renal failure, DIC
  239. Nerve Compression Syndromes
    Carpal tunnel syn; Ulna n. palsy; peroneal n. palsy; sciatic n. neurapraxia
  240. Reflex Sympathetic Dystrophy: S/S
    Intense burning pain, edema, stiffness, skin discoloration and atrophy
  241. Reflex Sympathetic Dystrophy: Rx
    Early referral to a pain specialist; neuroleptic pain meds (Neurontin, Lyrica); Regional sympathetic nerve blocks; PT
  242. Venus Thromboembolism: Rx:
    Anticoagulation; prophylactic anticoagulation in trauma admissions & certain ortho surgeries
  243. Myositis Ossificans: Cause
    Focal trauma to mx; calcification of hematoma in 3 months, ossification in 5 months
  244. ROM: Shoulder
    Flexion: 0-170; Extension: 0-40; Abduction: 0-150; Adduction: 0-30; External rotation: 0-90; Internal Rotation: 0-80
  245. Tendonitis: tx
    Conservative therapy: Relative rest, stretch, ice, NSAIDs, correct biomechanics; PT/ OT; ROM, Iontophoresis; Corticosteroid Injection
  246. Joint & Soft Tissue Injections/ Aspirations: Indications
    Obtaining dx samples; assess pain relief as a dx tool; administer meds for pain/ inflammation
  247. Joint & Soft Tissue Injections/ Aspirations: CI
    Intra-tendinous injections (future rupture likely); drug allergies; steroids are immunosuppressive
  248. Joint & Soft Tissue Injections/ Aspirations: Technique:
    Ethyl chloride spray, Marcaine/Lidocaine, Kenalog
  249. PRICEMMM
    • Protect/ prevent damage;
    • Rest 24-48 hr;
    • Ice 20 min q 1-4 hr ASAP & for 2-3 d;
    • Compression/ prevent more swelling;
    • Elevation to drain fluid;
    • Motion early/ speed recovery;
    • Meds;
    • Modalities: Iontophoresis, US, etc
  250. Joint & Soft Tissue Injections/ Aspirations: Side effects
    Tendon rupture, Infection, Hypopigmentation, Fat atrophy, Steroid flare; caution in diabetics
  251. Iontophoresis
    Application of electric current to skin to transport anti-inflammatory drugs across skin to affected tendon
  252. Phonophoresis
    Application of ultrasound to skin to create pores for transport of anti-inflammatory drugs across skin to affected tendon
  253. Sonorex
    Extracorporeal shock wave tx; provides local anesthesia & promotes neovascularization (Plantar Fasciitis)
  254. Prolotherapy
    Injection of sclerosant (phenol of hypertonic glucose); no support for soft tissue injuries; low level support for back pain and OA
  255. Botulism Toxin
    Inhibits neurotransmitters & mx contraction; low level evidence for chronic lateral epicondylitis
  256. Osteoarthritis
    >40 y/o, asymmetric, hands, weight bearing joints; AM stiffness < 1 hour; decreased joint space and bony spurring
  257. Osteoarthritis: Injections:
    Corticosteroids, Visco-supplementation (Synvisc : 3 weekly injection, Hyalgan (hyaluronate): 5)
  258. Crystal arthropathies:
    Gout (monosodium urate crystals); CPPD: Ca pyrophosphate deposition (pseudogout)
  259. Gender-Linked Dominant Disorders
    Heterozygote (XX or XY) manifests condition (Vitamin D resistant rickets)
  260. Gender-Linked Recessive Disorders
    Heterozygote male (XY) is affected; hetero female (XX) not affected (Duchenne MD; Hunter Syndrome)
  261. Chromosomal Abnormalities
    Abnormality in specific region of a chromosome or an abnormal number of chromosomes (Down Syndrome & Polydactyly)

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