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