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define dislocation
complete loss of contact b/w the articular surfaces of a joint
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define subluxation
incomplete dislocation, results in nonconcentric joint surface
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define reduction
a maneuver whereby a fracture or dislocation is returned to anatomic alignment
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define nonunion
- failure of the bony edges to unite
- (hypertrophic, atrophic)
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define malunion
healing of the bony fragments in a faulty position --> causing an imperfect alignment, deformity or rotation
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what causes a traumatic #
normal bone + abnormal force = traumatic fracture
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what causes a pathological #
abnormal bone + normal force = pathological fracture
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what causes a stress #
normal bone + repetitive force = stress fracture
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what do we need to include in any description of a #
- 1. location
- 2. fracture pattern (may be more than 1)
- 3. open vs. closed
- 4. displacement
- 5. angulation
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what may cause a pathological fracture
- 1. generalized bone disease (paget, metabolic - osteoporosis - hyper PTH - osteomalacia, EtOH, poor diet
- 2. local disease (cyst, chronic infection)
- 3. malignancy (met, sarcoma, multiple myeloma)
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which malignancies metastasize to bone?
- breast
- lung
- prostate
- kidney
- thyroid
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what do we require for adequate x-ray of a fracture
- minimum 2 views
- joints above and below
- before and after reduction
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what are the principles of fracture treatment
- obtain reduction
- maintain reduction
- early mobilization
- pain management
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what complications may arise from casting
- compartment syndrome
- soft tissue/skin injury
- pressure sores
- chaffing/pruritus
- swelling
- muscle atrophy
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what investigations are recommended for pathologic fractures
- serum Calcium, phosphate, alk phos, PTH, TSH, T3/T4
- serum protein electrophoresis
- bone density
- bone scan
- bone biopsy
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how is compartment syndrome diagnosed
- ***pain out of proportion to the injury
- loss of muscle function followed by pain with passive stretch
- use intracompartmental pressure readings for obtunded pts
- pulselessness, paresthesia, pallor, paralysis, pain are LATE signs
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how are stress fractures treated
- avoidance of the painful activity (immobilization if pain present at rest)
- surgical treat in rare cases (nonunion, fracture propagation...)
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name the rotator cuff muscles
- SITS
- subscapularis
- infraspinatus
- teres minor
- supraspinatus
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name the 4 articulations of the shoulder
- sterno-clavicular
- acromio - clavicular
- gleno - humeral
- scapulothoracic
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how to r/o referred pain as source of shoulder pain
- poorly localized
- full ROM w/o pain
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treatment of an open fracture
- remove gross debris
- splint extremity
- start Abx
- check Tetanus status
- NPO, prep for OR
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what components of a closed fracture indicate need for open reduction/consult ortho?
- neurovascular compromise
- intra-articular fracture
- salter harris II-V
- non-union obtained
- compartment syndrome
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which conditions are associated with
trauma + shoulder pain
- fractures - clavicle, humerus, scapula
- dislocation - AC joint, GH joint
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which conditions are associated with
shoulder pain + GH joint
- frozen shoulder (adhesive capsulitis)
- GH arthritis (OA, RA, crystalline)
- GH instability
- SLAP lesion (injury to the glenoid labrum - Superior Labral tear from Anterior to Posterior)
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which conditions are associated with shoulder pain + periarticular
- AC arthritis
- rotator cuff injury (impingement, tendiopathy, tear)
- biceps tendinopathy/rupture
- subacromial bursitis
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which conditions are associated with referred shoulder pain
- neurologic - disc herniation/stenosis, brachial plexus injury
- abdo - splenic injury, hepatobiliary
- thoracic - apical lung tumour, upper lobe pneumonia
- cardiac - MI (left shoulder only)
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etiology of a GH dislocation
85% are anterior - abduction and external rotation of th earm or hyperextension (usually traumatic)
- 15% are posterior - high energy force when an arm in adduction and internal rotation
- associated with the Es (epilepsy, EtOH, electrical shock, encephalitis)
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signs and symptoms of an anterior GH dislocation
- "squared off shoulder"
- arm held in abduction/internal rotation
- humeral head may be palpable
- may/not be nerve injury
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signs and symptoms of posterior GH dislocation
- flattening of anterior shoulder
- prominent coracoid
- arm held in adduction/internal rotation
- limited abduction/external rotation
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treatment of a clavicle fracture
proximal and middle fractures: sling 2-3 wks, rehab to increase ROM, strengthening
distal third - if unstable may need ORIF
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what should you suspect with posterior shoulder pain
- (not common)
- usually from rotator cuff tendinopathy or referred pain from the cervical spine
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what is rotator cuff impingement
- compression of the rotator cuff tendons (and the subacromial bursa) between the acromion and the humeral head
- related to narrowing of supraspinatus outlet or muscular dysfunction/capsular tightness
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signs and symptoms of rotator cuff impingement
- shoulder pain with overhead activities
- painful arc (60' to 120')
- positive impingement tests - Neer, Hawkins
- atrophy of muscles around the joint if chronic
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risk factors for rotator cuff impingement
- acromial morphology
- rotator cuff dysfunction
- repetitive overhead activities
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how is rotator cuff impingement treated
- NSAIDs
- physio
- subacromial decompression
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what are the signs and symptoms of rotator cuff tendinopathy
- pain along lateral deltoid with over head activity (reaching, pulling)
- positive painful arc test
- increased pain when sleeping on the affected side
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how is rotator cuff tendinopathy treated
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signs and symptoms of a rotator cuff tear
- anterolateral pain
- night pain
- shoulder weakness (unable to reach overhead)
- popping/catching of shoulder with movement
- positive drop arm test if tear is complete
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treatment of rotator cuff tear
- acutely:
- heat
- exercise
- local anesthetic injection
- after 3 weeks:
- young/active --> surgical repair
- elderly/sedentary --> conservative tx
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what is a SLAP lesion
tear of labrum at the point of biceps tendon attachment leading to labrum and biceps tendon tear
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what conditions can lead to adhesive capsulitis
- rotator cuff injury (most common)
- DM
- use of sling
- stroke
- axillary surgery
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signs and symptoms of capsulitis
- stiffness
- decrease ROM (external rotation > abduction > internal rotation)
- unable to reach up/put on clothes
- may have pain w mov't or direct pressure
- predictable stages (freezing, frozen, thawing)
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what is the tx for capsulitis (frozen shoulder)
- NSAIDs
- local heat
- PT to increase ROM and prevent further stiffening (NOT in freezing stage)
- may use injection of local anesthetic/corticosteroids
- arthroscopic release prn
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signs and symptoms of acromioclavicular OA
grinding/popping sensation when reaching overhead or across the chest
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signs and symptoms of glenohumeral OA
chronic and progressively worsening stiffness and pain (esp w abduction and external rotation)
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treatment of glenohumeral OA
- NSAIDs
- PT to increase ROM
- steroid injections
- shoulder replacement prn
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