PA Study Sesh

Coronary Artery Disease

* Atherosclerosis #1 cause

* Fatty streak formation: lipid deposition in white blood cells=1ststep

* Risk Factors:

* Diabetes

* Smoking

* Hyperlipidemia

* HTN

* Male

* Age (>45 men >55 women)

* Family Hx

Stable Angina

Check out the Stable Angina Picmonic!

* Chest pain

* Substernal

* Poorly localized

* Exertional

* Radiation to arm, teeth, lower jaw

* Typically 1-5 minutes, but less than 30 by definition

* Relieved with rest or nitroglycerin

* Levine’s sign

* Clenched fist over chest

* Dx:

* EKG: ST depression, but normal in 50%

* Stress Testing:

* EKG

* + ST depressions

* Echo

* Used in pts with baseline EKG abnormalities

* Helps localize ischemia

* Pharmacologic therapy used with exercise contraindicated

* Pharmacologic=dobutamine

* Increase force of heart contractions

* Increases O2 demand

* Myocardial Perfusion Imaging

* Localizes Ischemia

* Pharmacologic=adenosine or dipyridamole

* Vasodilate normal arteries

* CI: asthmatics

* Coronary Angiogram

* GOLD STANDARD

* Gold standards are usually the test that gives us a definitive picture.

* Defines anatomy=definitive diagnosis

* Tx:

* Statin Therapy

* Helps stabilize lipid plaques

* MI is typically caused from plaque rupture vs occlusion

* Nitrates

* Venodilator (increases supply)

* Caution with use of PDE-5 inhibitors (sildenafil)

* Used for acute pain

* Advised to go to ER if used 3 doses (Q 5min)

* B blockers

* Used for daily, chronic management

* Reduces demand (negative chronotrope/inotrope)

* CCB

* Non-dihydropyridines (verapamil/diltiazem)

* Decrease vasospasm (increase supply)

* Decreases heart rate & contractility (decreases demand)

* For those who B blockers are contraindicated

* ASA

* Doesn’t address supply/demand

* Helps with platelet aggregation to prevent ACS

Unstable Angina

* Chest pain>30 minutes

* Negative cardiac enzymes

NSTEMI

* Chest pain >30 minutes

* Positive cardiac enzymes

* 3 sets Q8hours

* Creatinine Kinase (muscle breakdown marker)

* Troponin (most sensitive & specific)

* Negative

* Unstable Angina

* Treatment for Unstable Angina & NSTEMI is the same

* MONA

* Bblockers

* Heparin

STEMI

* ST elevations greater than 1 mm

* 2 contiguous leads

* May have reciprocal changes in opposite leads

* New LBB is STEMI equivalent (Carrot in V1)

* Anterior=V1-V4

* Left Anterior Descending

* Lateral= I, aVL, V5,V6

* Circumflex

* Anterolateral=I, aVL, V4-V6

* Inferior= II, III, aVF

* Right coronary artery

* Posterior Wall=V1-V2

* ST DEPRESSIONS

Heart murmurs continue with congenital heart diseases.

A Picmonic is available for EVERY topic in today’s episode. Start by checking out our first topic here.

Ventricular Septal Defect

* #1 type of congenital heart disease

* Loud, high-pitched harsh, holosystolic murmur at LLSB

* Typically a left to right shunt (restrictive)

* May switch to right to left 2/2 pulmonary HTN (non-restrictive)

* “Eisenmenger’s syndrome”

* Dx: echocardiogram

* Tx:

* Observe if small

* Most close by age 10

* Surgery

* Symptomatic

* CHF

* Growth Delay

* Large VSDs repaired by age 2

Atrial Septal Defect

* Ostium secundum fails to close

* Often asymptomatic until >30y.o.

* Systolic ejection crescendo-decrescendo flow murmur @ pulmonic area (Left sternal border)

* Mimics pulmonic stenosis

* Widely split, fixed s2

* Does not vary with inspiration

* It’s not on either side of the heart

* Surgery if symptomatic

Coarctation of the aorta

* Narrowing of descending thoracic aorta

* Males>females

* 70% also have bicuspid aortic valve

* Symptoms

* Systolic murmur that radiates to the back/scapula/chest

* HTN (secondary)

* BP upper>lower extremities

* Delayed/weak femoral pulses

* Diagnosis

* Angiogram=gold standard

* CXR:

* Rib notching

* Increased flow in intercostal aa.

* 3 sign

* Narrowed aorta looks like the notch of a 3

* Tx: surgical

Patent Ductus Arteriosus (PDA)

* Connection between descending thoracic aorta & pulmonary artery

* Continuous, machinery murmur loudest @ pulmonic area

* Wide pulse pressure, bounding peripheral pulses

* Dx: echocardiogram

* Tx: indomethacin

* Inhibits prostaglandin production=closes PDA

Hypertrophic Cardiomyopathy

* Subaortic outflow obstruction secondary to hypertrophied septum

* Harsh, systolic, crescendo-decrescendo murmur at LLSB (similar to AS)

* DECREASES with INCREASED venous return

* Squatting, lying supine, etc

* Increased blood pushes septum out of the way

* INCREASES WITH DECREASED VENOUS RETURN

* Valsalva/standing

* Symptoms:

* Dyspnea usually 1st

* Chest pain

* Sudden cardiac death

* Especially during extreme exertion

* Secondary to v fib.

* Dx: echocardiogram

* Management:

* Avoid dehydration & extreme exertion

* B blockers 1st line medical

* Increases diastolic filling time

* Caution with digoxin, nitrates, and diuretics

* Surgical: myomectomy or alcohol septal ablation

Tetralogy of Fallot

* #1 cyanotic congenital heart disease

* Definition

* RV hypertrophy

* Rv outflow obstruction

* Pulmonary artery stenosis

* Overriding aorta

* VSD

* Right to left shunt=cyanotic

* “tet spells”

* Episodes of cyanosis

* Relieved by squatting

* Harsh,

During this week’s episode, we’ll be discussing valvular disorders, in essence, heart murmurs.

There are LOADS of Picmonics available for heart murmurs. A couple of my favorites Mitral Regurgitation and Aortic Stenosis.

Systole=ventricles contracting

Diastole=ventricles relaxing & refilling

S1=beginning of systole. AV valves (mitral & tricuspid) are closing. “lub”

S2=end of systole. Semilunar valves closing (aortic & pulmonic) “dub”

Lub, dub, rest, lub, dub, rest

 

Murmur Accentuation Maneuvers

The following applies to all murmurs except that of hypertrophic cardiomyopathy, in which the opposite is true

* Position:

* Aortic=increased with leaning forward

* Mitral=LLD

* Increased venous return

* Squatting

* Leg raise

* Lying down

* Later click in MVP

* Inspiration

* Right sided murmurs only

* Also due to increased venous return

* Expiration

* Left sided murmurs only

* Also due to increased venous return

* Increased Afterload

* Handgrip

* Increases regurgitation murmurs

* Pushes backward

Aortic Stenosis

* #1 valvular disease

* Etiologies:

* Calcification

* Bicuspid valve (if under 70y.o.)

* Systolic, crescendo-descrescendo ejection murmur

* At right upper sternal border (the location of the aortic valve)

* With radiation to the carotids

* Narrowed pulse pressure

* Pulsus parvus et tardus

* Small, delayed, carotid pulse

* Not specific to aortic stenosis

* Can lead to angina, syncope, LVH, and CHF

* Tx:

* VALVE REPLACEMENT

* Once symptomatic

* Mechanical valves (vs bioprosthetic) require lifelong anticoagulation

Mitral Stenosis

* Etio: rheumatic heart disease

* Early mid-diastolic rumble preceded by an opening snap

* At apex (location of mitral valve)

* Increased in left lateral decubitus position

* Prominent S1 (stenotic mitral valve closes forcefully)

* Symptoms

* Pulmonary symptoms

* Blood backs into lungs

* Pulmonary htn

* Atrial fibrillation

* 2/2 atrial enlargement

* “mitral facies”

* Flushed cheeks with facial pallor

* Treatment:

* Percutaneous balloon valvuloplasty

* Younger patients

* Non-calcified valves

* Valve replacement otherwise

Mitral Regurgitation

* Etio:

* mitral valve prolapse #1

* papillary muscle dysfunction

* ischemia/infarction

* Blowing, holosystolic murmur

* At Apex (location of mitral valve)

* Radiation to axilla

* Blowing=regurg

* Widely split S2

* Aortic valve closes early due to decreased LV ejection time

* Pulmonic valve closes late due to pulmonary htn (increased pressure to overcome)

This week on PA Study Sesh we are starting the cardio chapter and discussing conduction disorders.

Sinus Arrhythmia

* Appears as normal sinus rhythm, but rhythm is irregular

* Normal variant

* INcreases during INspiration

Sinus Bradycardia

* <60BPM

* #1cause=vagal stimulation=increased acetylcholine (increased parasympathetic activity)

* Tx: Atropine (anticholinergic)

Sinus Tachycardia

* >100BPM

* Tx: Vagal maneuvers, adenosine, bblockers, CCB, Digoxin (ABCDs)

Sick-Sinus Syndrome

* Combo of sinus arrest with paroxysms of tachy & brady arrhythmias

* TX: permament pacemaker if symptomatic

* If V-tach=with automatic implanatable cardioverter-defibrillator

Premature Atrial Contraction (PAC)

* Abnormal P wave followed by QRS

* May be unifocal or multifocal

* Non-compensatory pause

* Next normal p wave is not where expected

* Usually benign, though may increase risk of arrhythmias if combined with other heart abnormalities.

Atrial flutter

* “saw tooth” waves

* Tx:

* Stable: vagal maneuvers, b-blockers, ccbs

* Unstable: synchronized cardioversion

* Definitive= ablation

Atrial fibrillation

* #1 chronic arrhythmia

* Irregularly irregular with narrow QRS

* No distinct P waves

* Loads of causes

* Often associated with hyperthyroid

* Also atrial enlargement

* Increased risk of clots (blood isn’t moving properly out of atria)

* Tx:

* Stable: rate control

* B blockers #1: metoprolol

* CCBs: Diltiazem or Verapamil (nondihydropyridines)

* Digoxin if hypotensive or CHF

* Unstable:

* Synchronized cardioversion

* Management:

* Anticoagulation

* Factor Xa inhibitors

* “Xabans”

* Bind to antithrombin III

* Dabigatran

* Direct thrombin inhibitor

* Warfarin

* If other drugs contraindicated

* Dual anti-platelet therapy

* Aspirin + Clopidogrel

* Less effective than anticoagulant monotherapy

Paroxysmal Supraventricular Tachycardia (PSVT)

* 2 types

* AV nodal reentry #1

* 2 paths within AV node (one slow & one fast)

* Av reciprocating

* Accessory pathway outside the av node

* Wolff-Parkinson White

* Lown-Ganong-Levine Syndrome

* Wide or narrow QRS complex

* Depends on which pathway is taken first

* Wolf-Parkinson White

* Accessory pathway=bundle of Kent

* Ventricles are “pre-excited”

* Can develop tachyarrhyhmias

* EKG:

* Delta wave

* Slurred QRS

* Candle

* Wide QRS

* Short PR Interval

* Management:

* Avoid av nodal blockers because current may preferentially travel down accessory pathway

* Lown-Ganong-Levine Syndrome

* Short PR interval with normal QRS

* Bundle of James

* Management (of all PSVT)

* Narrow complex

* Vagal maneuvers

* =increased acetylcholine=decreased heartrate

* Adenosine#1

* B or CCBs

* Wide Complex

* Amiodarone

This week on PA Study Sesh, we’ll learn about Rheumatology.

A note about ANA, RF, ESR, CRP

ANA: Antinuclear antibodies

Shows antibodies against self

Can be positive in healthy people

Also induced by certain drugs & cancers

NONSPECIFIC

CRP: C-reactive protein

Produced in the early stages of inflammatory process.

NONSPECIFIC

ESR: erythrocyte sedimentation rate “sed rate”

Rate at which rbcs settle

NONSPECIFIC

RF: Rheumatoid Factor

Autoantibody to a fragment of IgG

NONSPECIFIC

 

In Summary: These are all NONSPECIFIC and only clue you in to the presence of inflammation and auto-immune disease. They do not help you definitively distinguish one disease from another and therefore (in my opinion) are not worth memorizing their absence/presence in each disease for PANCE/PANRE purposes.

Fibromyagia

* Chronic, widespread muscle pain

* Middle aged women

* Associated fatigue, fibro fog

* Diffuse pain in 11/18 trigger points >3 months

* Clinical diagnosis

* Tx: exercise (swimming), OTC pain medication, TCA

Reactive Arthritis (Reiter Syndrome)

* Autoimmune response to an infection elsewhere

* Young males most common

* Arthritis, conjunctivitis/uveitis, urethritis

* Keratoderma blenorrhagicum (hyperkeratotic lesions on palms/soles)

* s/p chlamydia #1, may also follow gonorrhea or GI infections

* Labs: Often HLA B-27 + (young males like ankylosing spondylitis)

* Can’t pee, can’t see, can’t climb a (bamboo) tree, can’t sleep with me

* Tx: NSAIDS

* Abx if infection not treated

Gout

* Uric acid

* Most patients are under excretors, which explains why associated with food consumption

* Purine-rich foods, TZD, ACE/ARBs, ASA, Pyrazinamide, Ethambutol (TAPE)

* Men most common

* 1st MTP joint = podagra

* Red, swollen, tender joint

* Arthrocentesis=gold standard

* Negatively birefringent, needle shaped urate crystals

* Tophi: colletion of solid uric acid (ears, eyelids, fingers)

* X-ray

* Rate bite erosions (recurrent)

* Tx:

* Acute: NSAIDS (indomethacin), but avoid ASA

* 2nd line= colchicine

* Chronic:

* Colchicine (can be used in both!)

* Probenecid (uricosuric drug)= increase excretion

* Allopurinol (Xanthine Oxidase Inhibitor)- decreases uric acid production, so not used in acute disease.

Pseudogout

* Calcium pyrophosphate

* Large joints. Knee #1

* Red, swollen, tender joint

* Arthrocentesis:

* Postitively birefringent prism shaped (rhomboid)

* Tx: NSAIDS, steroid injection

* Colchicine also used acute & chronic.

* Prophylaxis if more than 3 attacks per year

Juvenile RA

* AKA juvenile idiopathic arthritis

* Prior to age 16, typically resolves by puberty

* 3 types

* Oligoarticular (50%)

* Less than 5 joints involved in the first 6 months (typically large joints)

* Swollen, tender, warm, without erythema

* May have concomitant anterior uveitis

* Refer to ophthomology

* + ANA

* Symptomatic treatment (NSAIDS)

* Polyarticular (30%)

* Most similar to adult RA

* If in a teenager, consider early RA presentation

* >5 joints involved during 1st 6 months (usually symmetric)

* Eye involvement less common, but possible

* + ANA +/- RF

* TX: NSAIDS

*

* Systemic (20%) Still’s Disease

* Intermittent,

This week on PA Study Sesh, we will talk disorders of the hip as well as a hodgepodge of other orthopedic topics.

* Pelvic Fx:

* High impact or osteoporotic

* CT scan= gold standard

* Tx: pelvic binder & specialist consult

* Hip Fx:

* Osteoporotic women common

* Externally rotated, Abducted,(first 2 are opposite a dislocation) shortened limb: BREAKS

* Groin pain

* Increased risk of avascular necrosis with femoral neck frature

* Increases risk for DVT/PE

* Hip Dislocation:

* Posteriorly #1

* Adducted, internally rotated, shortened

* HIP is HID

* Exact opposite of shoulder

* Risk to sciatic nerve

* Tx: REDUCE (the answer for all dislocations)

* Legg-Calve Perthes

* Idiopathic avascular osteonecrosis of femoral head & epiphysis in children

* Boys 4-10, often active & thin

* Painless limp, worse at end of day

* Decreased abduction and internal rotation

* X-ray

* Early: increased femoral head density, widening of cartilage space

* Advanced: crescent sign (microfx with collapse)

* Tx:

* Non-weightbearing initially

* Ortho referral

* Resolves spontaneously

* SCFE (slipped capitofemoral syndrome)

* Slipped ice cream off cone

* 7-16 obese, African American male (during growth spurt)

* Hip, KNEE, thigh pain with limp

* Increased external rotation (like a hip fx)

* Tx: non-weight bearing + ORIF

* Developmental Dysplasia of the Hip

* Risk factors

* 1st born (less space in the pelvis)

* Female

* Family hx

* Breech

* Physical exam tests

* Barlow

* Apply posterior pressure (since hips dislocate posteriorly)

* += clunk

* Ortolani

* Abduct & Apply anterior pressure

* + = clunk

* Galeazzi (assess for LLD)

* Flex knees with feet on table, ankles touching buttocks

* Affected hip is shortened

* Clinical diagnosis

* Stress U/S at 3-4 weeks

* Femoral head can’t be seen on x-ray until 3-4 months

* Tx:

* Pavlik Harness

* Avoid swaddling

* Avoid tight fitting clothing

* Monitored with U/S

* FAI (femoral acetabular impingement)

* Pain may be dull or sharp groin pain

* Pincer lesion= acetabulum

* Cam lesion = femoral head

* FADIR= most sensitive, may also have + FABER

* Dx: X-rays, MRI to evaluate soft tissues

* Tx: decrease activity, NSAIDS, PT, Surgical referral

* Labral tear

* Dull or sharp groin pain with possible radiation

* Atrauamatic or insidious onset

* Catching/clicking

* FADIR/FABER +

* Test of choice= MRI Arthrogram

* Conservative vs surgical tx

* Snapping Hip

* Snapping/popping with walking, getting up from a chair, swinging leg

* +/- pain

* Caused from iliopsoas tendon movement

* Increased risk in adolescents, athletes with hyperflexion motion (DANCERS)

* TX: conservative

* Greater Trochanteric Pain Syndrome

* Aka trochanteric bursitis

* #1 cause of lateral hip pain in adults

* Tender to palpation

* Increased with walking, stairs, incline, prolonged standing

* Muscles that insert here are responsible for maintaining upright posture & abduction (the rotator cuff of the hip)

* Pain with resisted abduction

* + Trendelenburg sign

This week on PA Study Sesh, we’ll be covering disorders of the spine and demystifying the dermatomes.

* Cauda Equina

* SURGICAL EMERGENCY

* Symptoms

* Urinary/bowel retention/incontinence

* Saddle anesthesia

* Decreased anal sphincter tone (no anal wink)

* Tx: steroids (decrease inflammation) and emergent surgery

* Spinal stenosis (pseudoclaudication)

* Narrowing of spinal canal

* > 60 y.o. (but can be congenital)

* low back + BIL leg pain

* increased with walking/standing (extension)

* Dcreased with sitting/walking uphill (flexion)

* Diagnose with Xray or MRI

* Tx:

* Injections

* PT

* Sy

* Sprain/Strain

* MOI: lifting/twisting (or whiplash)

* Muscle spasms

* Decreased ROM 2/2 pain

* NORMAL NEURO

* Tx:

* Brief rest (1-2 days)

* Nsaids scheduled

* +/- muscle relaxants

* pt for prolonged pain & to improve mechanics

* majority recover by 4 weeks

* Scoliosis

* Females >10 y.o.

* >10 degrees of lateral curvature

* Typically not painful

* 90% are to the right, left curve requires further evaluation

* Look for shoulder or pelvic obliquity & LLD

* Adams forward flexion exam

* Xrays indiciated if scoliometer >5 degrees

* Evaluate Cobb angle

* Tx:

* Observe if small

* Brace at 20 degrees

* Sy greater than 40 degrees

* Kyphosis

* Increased convex curvature of T spine

* 1/3 also have scoliosis

* brace >60

* Spondylolysis

* Repetitive hyperextension injury (gymnasts, football players)

* Defect of pars interarticularis

* #1 form of back pain in children/adolescents

* Most commonly L5-S1

* X ray:

* Scotty dog sign

* Oblique view x ray

* + dog has a collar

* May progress to spondylolisthesis

* Spondylolisthesis

* Vertebrae slips forward

* Possible step off

* >50% displacement = surgical

* Conservative (same for spondylolysis)

* Symptomatic

* PT

* Bracing

* Happens at C2=hangman’s fx

* Jefferson Fracture

* C1 fx (Atlas)

* Burst fx

* Associated with axial loading (shallow dive or certain MVAs)

* Compression fx

* Fall from a height or non-traumatic

* X-ray: vertebral height narrowing

* Risk factors: chronic steroid use, tobacco use, postmenopausal, osteoporosis, low body weight

* Point tenderness

* Ankylosing Spondylitis (ankly=stiff, spondyl=spine, itis=inflammation)

* White males 15-30

* Axial skeleton & SI joint with increasing stiffness

* Progresses from inferior to superior

* AM stiffness with decreased ROM

* Decreases with activity (most autoimmune arthropathies do)

* Labs

* Increased ESR

* + HLA B-27

* Negative ANA & RF (seronegative)

* X ray:

* Bamboo spine (squaring of vertebral bodies)

* Tx:

* NSAIDS

* PT

* TNF alpha blockers

* Herniated Disc

* Herniation of nucleus pulposus

* Most often posterolateral

* Pain in a dermatomal pattern

* Increases with coughing, sitting

* L5-S1#1

* Physical Exam Tests:

* + SLR

* + Crossover Test

This week on PA Study Sesh we will be discussing disorders of the foot and ankle, bone tumors, and compartment syndrome.

* Ankle Dislocation

* Most commonly posteriorly (calcaneus goes posterior)

* Risk to peroneal n

* Sx: foot drop

* Tx: closed reduction & posterior splint

* Ankle Sprain

* MOI: inversion

* Anterior talofibular ligament (ATFL) #1

* Eversion injury = deltoid ligament

* Test= anterior drawer

* X-ray criteria

* Ankle: TTP along medial or lateral malleolus

* Foot: Midfoot tenderness (navicular) or 5th metatarsal TTP

* Unable to weight bear 4 steps following injury or in office

* Are you concerned about a fx? Get an X-ray. 

* Grading

* 1: stretch

* 2: partial

* 3: complete

* Achilles Tendon Rupture

* Major risk factor: fluoroquinolone (“floxacin”) use, recent increase in activity

* Thompson test: weak/absent plantar flexion when the gastroc is squeezed

* Tx: Progressive equinus splinting vs surgical repair.

* Lateral Ankle/Fibula Fx

* Weber Classification

* A: below ankle

* B: even with syndesmosis

* C: above syndesmosis

* Often with medial malleolar fx and deltoid avulsion

* Unstable

* Spiral=concerning

* Called Maisonneuve fx if proximal fibula

* Recall monteggia fx

* Transverse less concerning as usually direct trauma

* Take away: look for syndesmosis injury

* March fx

* Common military stress fracture

* 3rd metatarsal #1

* Plantar Fasciitis

* First step pain

* Tx: Conservative

* Tarsal Tunnel

* Tibial Nerve

* Medial malleolus, heel, sole numbness

* Bunion (Hallux Valgus)

* Risk factors: poorly fitted shoes #1, flat feet (pes planus)

* 1st metatarsal lateral deviation

* tx: wide toe box

* Hammertoe

* Flexion of PIP, hyperxtension of MTP & DIP

* Typically cause pain due to shoe contact

* Charcot Foot

* Joint damage & destruction 2/2 DM neuropathy

* Microtrauma leads to bone resorption & weakness (autonomic dysfunction)

* Redness decreases with elevation

* Midfoot deformity (foot becomes concave)

* Increased ESR, WBC, CRP

* Tx: NWB!!!! Splint & refer. Ultimately will get total contact cast

* Jones fx

* Transverse fx through diaphysis of 5th metatarsal (distal to 4/5 articulation)

* Risk of avascular necrosis

* Tx: boot/cast vs surgery

* Avulsion fx (pseudojones)

* Below 4/5 articulation

* Lisfranc injury

* Disruption of 2nd metatarsal and medial cuneiform articulation

* MOI: Step off a hole

* Plantar ecchymosis

* Fleck sign: fx at base of 2nd metatarsal= pathognomonic

* WEIGHT BEARING XRAYS

* Tx: NWB!! & boot/cast.

* Surgery if any displacement

* Calcaneus fx

* Fall from a height

* Compartment Syndrome

* Most common after long bone fractures

* Crush injuries

* Tight cast

* Pain out of proportion

* 6 Ps- PAIN, pulselessness, poikilothermia, pallor, paresthesia, paralysis,

* Pain on passive stretching = 1st indicator

* Tx: fasciotomy

* Primary Bone Malignancies

* “have sarcoma” in the name

* Present with bone pain

* Night pain= red flag

This week on PA Study Sesh, we will be covering disorders of the knee and proximal tibia.

* Medial and lateral collateral ligament injuries (MCL & LCL)

* MCL=valgus stress LCL= varus stress

* MCL more common than LCL injury

* Grade I & II (sprain & incomplete tear)= conservative

* Grade III (complete) = surgical

* ACL (anterior cruciate ligament) injury

* #1 knee ligament injury

* MOI: pivoting injury, may also be hyperextension

* Females > Males

* May have associated meniscus injury

* Unhappy (O’Donoghue’s) triad: ACL, MCL, medial meniscus tear

* May also have associated lateral tibial condyle avulsion= Segond fx

* Pathognomonic for ACL tear

* Symptoms: swelling +/- hemarthrosis, “buckling”

* Lachman’s test= most sensitive

* Patient supine

* Knee flexed 20-30 degrees

* Stabilize femur and pull tibia forward

* Lack of firm endpoint is positive

* Compare both sides

* Patient needs to be fully relaxed

* Anterior Drawer

* Hip & knee bent to 90

* Stabilize foot (sit on it)

* Thumbs on joint line & pull forward

* + translates anterior without a firm endpoint

* Diagnosis MRI. May consider Xray

* PT vs Surgery (primarily surgical for younger patients)

* PCL (posterior cruciate ligament)

* Dashboard injury

* Anterior force while knees are flexed

* Typically not seen in athletes

* Posterior Drawer Test

* Posterior Sag Sign

* Elevate leg and will see the leg “sag”

* Tx: surgical

* Meniscal Tears

* Medial 3x>>> lateral (lateral is injured less)

* Less mobile & more stress is able to be applied medially

* Degenerative or traumatic (twisting or hyperflexion)

* Joint line pain

* “locking”, popping, giving way

* Difficulty with stairs (up or down) & squats

* McMurray’s Test

* Lots of ways to describe

* Grab heel with one hand and joint line with another

* Medial= externally rotate heel, flex knee, extend while providing valgus stress

* Lateral= internally rotate heel, flex knee, extend while providing varus stress

* Tx: Conservative vs Surgical

* PFPS (patellofemoral pain syndrome) aka chondromalacia

* #1 knee complaint in primary care

* Injury to patellar cartilage

* Commonly seen in runners

* Pain “under” or “behind” patella

* crepitation

* + Long car ride or theatre sign

* Difficulty with stairs

* Look for malignment and improper patellar tracking

* + patellar glide, patellar grind, patellar apprehension. Used to assess mobility and associated pain with patellar movement

* Tx: conservative, NSAIDS, rest, PT

* Patellar Tendonitis

* “jumpers knee”

* Pain of patellar tendon

* Conservative tx

* IT Band Syndrome

* #1 cause of knee pain in runners

* Lateral knee pain

* + Ober Test

* Conservative tx

* Baker’s Cyst

* Pain & swelling with prolonged standing

* May be asymptomatic

* Tx: NSAIDS, Aspiration/Injection, Compression Brace. Surgery rare

* Patellar Fracture

* MOI: direct blow

* extreme contraction of quads [kiddos (patellar sleeve)]

* X-ray: AP, lateral & Sunrise views

* Tx: immobilized in extension. Refer to ortho for cast vs surgery

* Patellar Dislocation

* MOI: Twisting on a flexed knee

This week on PA Study Sesh, we will be finishing the upper extremity.

* Supracondylar fx

* MOI: FOOSH with hyperextended elbow

* Kids 5-10

* X-Ray:

* Normal: anterior humeral line must intersect capitulum (lateral view)

* May still be in alignment with fx

* Fat Pad sign=refer

* Anterior to humerus = sometimes normal

* Posterior to humerus = always abnormal

* Darkness=blood

* Anterior interosseous nerve @ risk (branch of median n)

* “ok” sign (A-ok)

* if not=immediate surgery

* Brachial artery @ risk

* Can lead to Volkmann Ischemic Contracture

* Contracture of wrist 2/2 ischemia

* Radial Head fx

* #1 elbow fx in adults

* MOI: FOOSH

* Xray:

* Often difficult to see

* + fat pad sign

* Unable to fully extend elbow

* Elbow Dislocation

* Rare

* Posterior most common (olecranon goes backwards)

* Often associated with medial condyle fx

* R/o brachial a, median, ulnar, radial n injury

* Tx: emergent reduction, splint/sling

* Nursemaid’s elbow

* Dislocation of radial head, stretched annular ligament

* Annular= ring shaped, radius=circle

* MOI: sudden pull of a pronated arm

* Grabbing from street

* Playing airplane

* Kids 1-4

* Presentation:

* Arm fully extended or slightly flexed and pronated

* REFUSES to use

* Pain increases with supination. Mild tenderness

* Usually no swelling

* Reduction:

* hyperpronation with pressure over radial head

* supination and flexion with pressure over radial head

* Lollipop test

* Imaging after 2 failed reduction of child continues to refuse to use arm.

* Olecranon fx

* Ulnar n at risk

* Olecranon bursitis

* Repetitive trauma or rhematologic conditions

* “goose egg” swelling

* +/- decreased ROM and tenderness

* Erythema and warmth may suggest infection

* Tx:

* Ice

* NSAIDS

* Avoid pressure

* Pads/sleeves

* Lateral epicondylitis

* “tennis elbow”

* extensor/supination muscle group

* local pain and swelling

* pain with wrist extension against resistance (elbow fully extended)

* Medial epicondylitis

* “golfer’s elbow”

* flexors & pronators (golf & flexor both have f)

* pain with wrist flexion against resistance (elbow fully extended0

* Tx: for epicondylitis (both)

* Acute: sling, wrist brace, Ice, NSAIDS

* Preventative: forearm strap

* Recurrent: steroid injections, surgical debridement

* Nightstick fx:

* Ulnar shaft fx

* Defensive injury

* Tx: Cast or ORIF

* Monteggia fx

* Proximal ulnar shaft with radial head dislocation

* May have radial n injury (wrist drop)

* Galeazzi fx

* mid distal radial shaft f x with dislocation of DRUJ

* both Galeazzi & Monteggia are unstable (any joint dislocation)

* TAKE HOME; evaluate elbow and wrist with forearm injury

* Cubital tunnel

* Ulnar nerve compression

* RF/SM tingling/numbness

* Increases with elbow flexion

* Decreased grip strength

* Tinel’s sign:

* Tap groove between olecranon process and medial epicondyle