Neer's impingement sign
press on the scapula to prevent it from moving and with one hand, raise patients arm with the other
compresses the greater tuberosity of humerous against acromion causing rotator cuff tendons to press against the acromion
hawkins impingement sign
flex the shoulder and elbow to 90, internally rotate arm
compresses greater tuberosity against the acromion
empty can test
what specific muscle does it test?
flex arm at shoulder to 90 and internall rotate so thumbs are pointing down (like emptying a can, duh)
have the patient resist against downward pressure on the arm
tests supraspinatus muscle
infraspinatus and teres minor test
how is this test performed?
flex at elbows 90 in front of the body with thumbs up
provide resistance against patient externally rotating
Lift off test
what muscle does this test?
place arm behind back with palm facing out and lift off against restistance
abduct the arm so it is over the head and ask the patient to slowly lower it
if supraspinatus is torn, then at 90* it will fall
feel the lateral epidcondyl of the humerus and 2 cm distal to it
apply resistance as the patient extends and soupinates their wrist
since the muscles that do this attach to the lateral epidcondyl, this will cause pain which can indicate inflammation
apply resistance as the patient flexes and pronates
the flexor and pronation muscles attach here so if pain could indicate inflammation
what two muscles does this specifically test?
place thumb inside of formed fist, deviate towards the ulna
stretches extensor pollics brevis and abductor pollicis longus over radial styloid
lightly tap over the median nerve in the carpal tunnel on the volar aspect of the wrist
aching and numbness is a positive test
press dorsal aspects of the hands together to form right angles
this compresses the median nerve
numbness and tingling for 60 seconds is a positive test
passively laterally flex and extend the neck with downward compression
radiating symptoms down neck and shoulder is positive for cervical nerve impingement
in neutral position, put one hand under the occiput and one hand under the chin and lift head
positive test is reduction where symptoms are eliminated suggesting cervical nerve inpingement
press on the top of the skull in neutral position
positive test is reproduction of symptoms indicating cervical nerve inpingement
make a 4 shape and press hands on ASIS and knee at the same time
positive test: pain in the SIJT
if pain is in the groin, could be hip involvement too
flick the middle nail of middle finger and look for index and thum flexion
indicates upper motor neuron disease
(eg proximal central cord compression)
what is it and what are four benign maneuvers to stimulate pain?
SLR placing hands on heels, if no pressure than person not exhibiting true effort
benign maneuvers to stimulate pain
1. skin roll
2. twist at hips
3. head compression of 5 pounds
4. SLR, standing and seated, should cause radiating pain
with leg extended place pressure on the suprapatellar pouch
apply medial pressure, and tap latterally with right hand to watch for fluid wave
positive test: bulge on the medial side between the patella and the femur
basically: grab either side of the patella, squeeze with the left hand and look for any fluid displacement to under the right hand
valgus stress test
flex thigh to 30*, push medially at the knee and pull laterally at the ankle
tests medial collateral lig
varus stress test
tests lateral collateral lig
lateral force at knee medial force at ankle
anterior drawer sign
patient lays supine, flex knee to 90*, cups hands around the knee and pull tibia forward compare with opposite knee for amount of forward motion
forward jerking motion shows positive test and suggests ACL tear!
NOT THE FOOTBALL PLAYERS! Fantasy sports!
place knee in 15* flexion and external rotation, pull tibia forward and push distal femur backwards at the same time, suggests ACL tear
posterior knee test
patient supine knee at 90, push back on the tibia
flex knee holding knee and foot
externally rotate: stresses medial meniscus
interally rotate: stresses lateral meniscus
in click is felt or heard or pain at the joint line then this is suggestive of a meniscus tear
foot and ankle
with patient lying prone (on stomache) with feet hanging off table
squeeze the calf of affected side
test is positive if foot remails in the neutral position or there is minimal plantar flexion
aka, it doesn't move!
ottowa ankle and foot rules
what are the 3 locations that warrent a xray film?
posterior edge 6cm
tendernous at base of 5th metatarsal
flexor tenosynovitis-Kanavel criteria
tenderness along the course of flexor tendon
fusiform symmetrical swelling of finger
flexed posture of finger
-repetitive strain injury
-decreased grip strength, pain on radial surface that increases with thumb or ulnar deviation
carpel tunnel syndrome
median neuropathy from compression of the flexor retinaculum
nerve conduction or velocity test
fall on outstretched hand
pain at anatomical snuffbox
immobalize the thumb 6-12 weeks
complication: osteonecrosis since has minimal blood supply
start with Xray, go to MRI if necrosis is suspected
spinal epidural abscess
also, what are four risk factors?
what are three major indications?
what must you cover for when treating?
classic triad: back pain, fevers, neurologic defects
must cover for methylcillin resistant staph aureus
RF: immunosuppression, renal failure, IV drug abuse, ETOH
cauda equina syndrome
compression of the nerves at the end of the spinal cord within the canal
urinary retention, incontinence of bladded/bowel
numbness or tingling in buttocks, lower extremities
EMERGENCY!! usually requires surgical decompression
what are the symptoms associated with cauda equina syndrome?
motor and sensory loss
saddled anesthesia pattern
confirm with CT/MRI
congenital dyplasia of the hip
shallow socket, so femor can slip out
exam: leg length discrepancy, outward rotation, folds on buttock skin uneven
wider space between legs
galeazi sign, ortolani test, barlows test
what is this test and what is it used to diagnose?
(assuming somone was holding the legs)
ortolini's test (this is on porth 1103)
developmental dysplasia where the hip socket is shallow and the femor can slip out
where does the pain present? where is it most common? and what are 3 risk factors?
most common in femur head
RF: chronic ETOH, corticosteroid use, sickle cell
can be a complication from dislocation or fracture
painful hip, buttock, thigh or knee in setting with no trauma
avascular necrosis of the femoral head usually seen in young children
early hip pain with limp
unilateral in 85%
slipped capital femoral epiphysis (SCFE)
what type of fracture do you see? how is the femor head displaced? what age and what type of child? what type of measurement are you looking for on a xray?
salter-harris type 1 fracture on femoral capital epiphysis
posterior and inferior displacement of head of femor
common in children >10 years old
mildly obese kids with hip pain and limp
URGENT ORTHOPEDIC EVAL
what are the two common feelings you can have with this? where do you find tenderness? what two tests do you want to do to help diagnose this? what image testing do you want to do for this? is it an emergency?
nagging non specific pain medial or lateral
can lock up which is orthopedic emergency
"giving away" is URGENT
fullness behind the knee
joint line tendernous
Mcmurray test and Apley's comrpession test
MRI: check for joint space, if no space then there is a tear
patellofemoral pain syndrome
most common cause of knee pain
anterior pain made worse with climbing, kneeling, jumping or sittitng
Exam: patellar crepitus possible
which way does the patella usually deviate? why?
displacement usually laterally of the patella
AP, lateral, tunnel, and axial (sunrise) views
if untreated may lead to quadriceps weakness and patellar arthrosis
achy knee pain, "stiffness"
Exam: place hand on patella, flex and extend knee to observe crepitus
one of the few true orthopedic emergencies
limb threatening 2* to vascular comprimise
Osgood Schlatter Disease
rupture of the growth plate at the tibial tuberosity
stresses the patellar tendon
rapidly growing adolescents
what is this common from? where does this happen the most? when does this start and become symptomatic?
most common, medial femoral condyle
starts in childhood may not become symptomatic till adolescene or adulthood
surgery or nonweightbearing treatment
is a joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. This bone and cartilage can then break loose, causing pain and possibly hinder joint motion
"starburst" or "sunburst" on xray
appear in long bones of children, most commonly distal femur, proximal tibia, and proximal humerus
2nd- 6th decade
anterior curciate ligament tear (ACL)
most common sports injury
postive drawer test, lachman (be careful because there can be a lot of fluid that makes this difficult to see)
MRI is diagnostic
what test? what two things increase the risk of this happening?
common men 30-50
sport related usually
risk goes up with chronic corticosteroid and fluoroquinolones
testing: Thompson's squeeze, squeeze the back of the calf should get plantar flexion
what are the most common types (percentages) ? what is the most commonly injured ligament?
inversion is most common 90%
only 10% eversion
most common injured ligament is: anterior talofibular
follow Ottawa rules for xray.
explain the grading for ligament injury
2. Partial tear
3. complete disruption of ligament
Ottawa Ankle rules
What are the two regions of the foot that are concerning? what needs to be present in each of these regions for a xray to be indicated? (3 things in each region)
malleolar zone and midfoot zone
HERES SOME PICS!
what do you want to do ASAP? what 3 things should you be concerned about?
severe fractures can cause dislocations
be concerned about neuro, sensory, vascular
what do you always want to do with a traumatic fracture or dislocation of the ankle?
always xray top of fibula with traumatic fracture or ankle dislocation
check for: maisonneuve fracture
given anatomy, fractures can easily hide and allow for ambulation
get xray!! stress fractures may not show up early so whole fracture is missed
what is a jones fracture?
fracture of proximal 5th metatarsal, common in athletes
comes from inversion
lateral deviation of big toe
most common neuroma of the foot
between third and fourth toes
burning or sharp stabbing, worse with ambulation, tight shoes
TX: steroid injection, roomier shoes, surgery
what happens in this? what is the most common cause?
distal portion goes down, middle hunches upwards
2nd toe most common
most common cause, poorly fitting shoes, high heels with narrow toe boxes
what is there always for a focused visit? what doesn't it include?
chief complaint and HPI
rarely includes ALL subjective and objective components (unless for billing)
where are you likely to see focused visits?
what two factors do documentation influence?
qualitiy of care
what are 3 things the effect the reimbursement?
1. new or established patient
2. time required for evaluation
3. complexity of the visit
what are problem focused visits?
presenting problem are self limiting
~10 mins for visit
low complexity of medical decision
aka plantar wart
what are the characteristics of a expanded, detailed visti?
presentation are low to moderately severe
provider spends 20-30 mins
low to moderate complexity
what are the characteristics of a comprehensive visit?
presentation is moderate to severe
high complexity of medical decision making
CF with biabetes with pneumonia, etc
what is a tip about the buinsness of medicine?
observe preceptors documentation technique from start to finish
what do you need to include for the subjective portion of a focused visit?
some but not all,
only stuff that is relevant to chief complaint
what are the 6 things that need to be included in the first sentence of HPI
present/absence or pertinent pos/neg
how does the HPI relate to the CC?
amplifies chief complaint, describes how symptoms developed
can pull in pertinent pos/neg from ROS
what does the OPQRST pneumonic stand for HPI?
pallidating and provoking
quality of pain
severity of pain
what should be included in the past medical history?
medical (always psych and obstetric)
what are 3 things you want to include as part of the health maitenance portion?
what are two things you always want to do even in a focused visit?
cardiac and respiratory
what should guide your focused visit?
where do the laboratory and dianostic tests fit on the SOAP note?
last part of objective portion before A and P
related to chief complaint
related to chronic disease or new disease that was secondarily discovered during disease
what are 5 things you want to make sure you do during your focused visit to inolve patient?
1. share impression
2. address any concerns
3. make sure she agrees to steps ahead
4. provide written information
5. include health promotion and disease prevention
what 3 things does a successful plan take into consideration?
patients goal/ preference
1. what does it mean?
2. what signs would be present
3. what is the treatment?
literally means "inflammation of the tendon"
all the normal signs seen with inflammation, red, hot swollen, painful
treatment: RICE NSAIDS
explain what tendinosis is? how is it different than tendonitis?
describes long term pathophysiology of tendons
under a microscope see "bowl of spaghetti" rather than "box of spaghetti" like in tendonitis
this is what happens after the inflammatory process passes, so if someone has long term tendonitis, it is more likely it has become tendonosis
not warm or red like tendonitis, but decreased ROM and strength
Treatment: PT with eccentric exercises, which strengthen and stretch tendon
what is deposited in the joint? what symptoms are typically present? what imagine do you want to do to diagnose this? what are 4 treatment options?
tendons develop calcium deposits, commonly in rotator cuff
early on causes pain and mechanical symtpms or blockage, similiar symtpms to impingement or tendonitis
Dx: xray or MRI, see a little piece of bone floating in the joint, generally self limiting
TX: PT, dry needling, shock therapy wave to break it down, surgical removal
what tendon is involved here? what two motions will the patient have a difficult time performing?
tendonitis along the long head of the bicep tendon
painful when flexing the shoulder or the elbow
runs through the tubercles on the head of the humerus
what joint degrades here? what is it caused by? what syndrome can this lead to? what image study do you want to do? what is the treatment?
degeneration of the acromioclavicular joint
can lead to impingement syndrome because arthritis will narrow the subacromial space
decrease shoulder ROM, pain
Xray: will see degredation
Tx: RICE, NSAIDs, can also do surgery to clean out the mess
what is this commonly associated with?
thenar eminence atrophy
seen with carpal syndrome
need to treat carpal syndrome
infection of the finger tip possibly due to splinter or cut
most common: staph aureus
what is this? where does it commonly develop? what is the really stange thing people used to do to get rid of it? what do they do now with it?
cyst that develops randomly
often seen on the back of the wrist
used to treat with "bible therapy"....have person put their hand face down on the table and smash the cyst
aspiration or surgical removal if symptomatic
congenital problem of the hips in childhood
bloos supply to femoral head is disrupted and it begins to misform as a result of necrosis
what happens in this? what does this feel like? what are your two treatment options?
sandpapery wear and tear of the cartilage on the back of the patella
presents like patellofemoral pain
TX: PT or surgery to clean out damaged cartilage
joint condition in which bone underneath the cartilage of a joint dies due to lack of blood flow. This bone and cartilage can then break loose, causing pain and possibly hinder joint motion. Osteochondritis dissecans occurs most often in children and adolescents
-most common in the knee but can occure in other joints as well
-PT and surgery for treatment
Lis Franc Fracture
where does this fracture take place? where does this most commonly take place within that region? how does this injury occur? what is important to do when getting an xray?!
fracture of the mid-foot
needs to be splinted in walking boot or casted
commonly first and second metatarsal and nacicular
forced plantar flexion "like riding a horse and you fall off and your foot gets stuck in the stirrup, or football player tackled in plantar flexion"
need to get a non weight bearing and weight bearing xray to see how the bones change between the two
where does this injury occur? why is this injury improtant? what motion does this injury commonly occur with? imaging options?
acute or stress fracture at the base of the 5th metarsal, often seen with inversion of the ankle
important because of the blood supply, they don't heal well so you want to want to identify early to prevent necrosis
2nd: MRI if xray is negative and high clinical suspiscion
when do you use a volar splint? (4 things)
what are the four splinting wetting techniques?
1. water bottle
2. open sling cover technique (peel back one side of backing to get the water in)
3. water bottle/faucet technique (put under running water and then ring)
4. dipping in bucket technique (immerse in water ring out excess water)
what would you use to look at someone's appendix?
physical qualities of an object that determines how much radiation it absorbs from the X-Ray beam
determined by composition and thickness
Does not permit the passage of x-rays. Representative areas appear light or white on the x-ray film. Usually the property of denser materials, such as bone.
darker gray but not white or black
Permits the passage of x-rays while offering some resistance (depending on the density of the material). Representative areas are dark on exposed film, such as air.
on an xray how would you expect these to appeare:
soft tissue (fat):
what acronym should you use when looking at the different densities on a xray?
how do the boarders apear if the densities are similar or different?
if there is a sharp contrast between densities, you will see crisp line
if they are similar than the board will be fuzzy
if closer to the film you use _____ and get ____ image
if closer to the film you use less magnification and get sharper image
if farther from the film you use _____ and get ____ image
if farther from the film you use more magnification and get fuzzier image
to tell the different between a AP and PA....
look at the heart!!
what view is this?
what view is this?
what view is this?
shape distortion can happen with what?
mammogram, Dexa, and fluoroscopt are types of what imaging?
Dexa scan is a screening for...
bone densitiy aka osteoporosis
bone absorbes the xray, determines the density
what are the reading for a dexa scane?
<1 is normal
what does this testing allow you to do? what are two examples?
continuous beam passes through the patient and allows you to see what they are doing in real time
swallow studies, heart angiograms
computerized tomography (CT-Scan)
focused radiographic images for one slice of the patient
need to know the relative densities between organs to interpret
view from the FEET UP, making the left on the right!
how many times more is a chest CT than a xray!?!
100-400X xray dose greater!!!
what can metal cause on a CT scan?
what is the benefit of a reformatted CT?
YOU GET 3D IMAGE! formatted in multiple planes
ex: CT angiogram (tell because it is colored and looks generated)
magnetic resonance imaging
how do they work and what do you use?
Uses powerful magnets
Imaging of H+ atoms in fat and water
H+ align in magnetic field, pulsed waves of scanning knock the atoms out of alignment.
H+ atoms emit radiofrequency waves which produce the image during re-alignment (relaxation time)
High signal strength items appear_____
Low signal strength items appear_____
High signal strength items appear white
Low signal strength items appear dark (blood and bone)
signal strength refers the H+ atom ability to move, so if more dense they don't move and you get darker color.
what is the name of the contrast you use in MRI? If indicated, what must you check for the patient?
in T1 weighted images on MRI, fats appeare___
in T2 weighted images on MRI, inflammation, tumors, and fluids appear_____
When should you not use a MRI? what two things are ok to use?
metal or programmable things like pacemaker, icd
if the patient can't lay still for 35-45 mins
can use with titanium and stainless steel
explain how sound waves are used in Ultrasound?
hyperechoic/echoic if solid: they bounch back creating a light image
hypoechoic/hypoechoic if fluid filled: light passes through, produces dark image
ex: normal tissue vs fluid filled
radioisotope (nuclear) scanning
nuclear isotope is attached to a normal compound used in organ metabolism so it lights up
usually two part study
radioactive isotop used in radioactive scanning
half life 6 hours useful use in thyroid scanning, pulmonary scans, and bone scans
radioactive isoptope used in radioactive scans
half life 73 hours for myocardial blood flow
Small tipped catheter advanced under fluoroscopy into an artery (usually the femoral)
take xrays to see the vessels
digital subtraction angiography
same as conventional but digitally saved so you can subract parts
Patient injected with bolus of contrast material to opacify the blood vessels while CT is performed
BVs and bone are white, and bones can be subtracted out with 3D reconstruction
magnetic resonance angiogram
Stack of contiguous MR images converted into 3D vascular images
Safer for patients in renal failure, but contrast can enhance images
image? view? whats it mean?
sail sign=radial head fracture
salter harris frature classification
image? view? what is it?
cresant sign on femoral head means avascular necrosis
imagine? view? weight? what does it show?
T1 weight since not as bright as T2 would look
image? view? what is this?
*don't forget looking from patients feet up!*
image? what does it show?
MRA (since reconstructed and 3D)
shows artery stenosis (narrowing)!