Burn rehab

--burns are number one case of accidental death in children < 2 yrs, majority of which are due to abuse
--number 2 in children under 4

--systemic response to burns: loss of fluid, hyperventilation, inhalation injury, increase followed by increase in cardiac output, multi-organ system failure
--electrical burns cause more severe injury to deeper tissue (muscle and bone)

--newer burn categorization:
• Superficial partial thickness: epidermis and upper part of dermis injured
• Deep partial thickness: epidermis and large upper portion of dermis
• Full thickness: all layers destroyed

--Rule of 9’s (% body surface area burned):
• Head: 9%
• Each UE: 9%
• Each LE: 18%
• Anterior trunk: 18%
• Posterior trunk: 18%
• Perineum: 1%

--Worse prognosis associated with age (very young or very old), great BSA burned, depth of burn, and associated injuries

--Contractures: occur in first 1.5 years
*need 25 mm of pressure to counteract contraction of scars
--Position patient in extension and abduction
--Splinting can be used with ROM
--Compression garments are used to decrease hypertrophic scarring, worn 23 hours per day
--Silastic gel can reduce hypertrophic scarring in the absence of pressure
--Local steroids may reduce hypotrophic scarring

--Body is in highly catabolic state and may need 2000-2200 cal/day and 15gm nitrogen per sq meter of BSA

--Peripheral neuropathy present in 15-20% of burn patients with BSA of 20% or greater
--Osteophytes may occur near elbow and olecranon or coracoid process
--HO common --> most common at elbow
--Subluxation can be seen in MCP and MTP joints, prevent with splinting

Cancer rehab

--most common rehab problems in cancer: general weakness, ADL deficits, pain, difficulty with ambulation
*also have problems with speech, swallowing, respiratory, neuro impairment, skin problems, nutritional deficits, lymphedema, skeletal disease, psych
--keep high index of suspicion for swallowing problems, which are assoc with cognitive impairment, CNS involvement, radiation, and gen deconditioning
--keep high index of suspicion for metastatic involvement of spine and extremities

--Most prevalent cancer in children: 1) leukemia, 2) brain tumors
--most common posterior fossa tumor in childhood: 1) cerebellar astrocytoma (best prognosis), 2) medulloblastoma (most common in kids < 7 yrs)
--25% of patients with cancer have brain mets:
• Most common symptom: HA
• Most common focal sign: weakness
• Common first presenting sign: seixures
• Best diagnostic test: contrast CT or MRI

--Radiation effects on spinal cord:
• Induced transient myelopathy: most common, develops after 1-30 months, peak onset 4-6 months, with transient demyelination of sensory neurons in posterior column and lateral spinothalamic tract --> symmetric paresthesias. Resolves in 1-9 months
• Delayed radiation myelopathy: irreversible, begins 9-18 months after radiation, most within 30 mo. Lower extremity paresthesias followed by bowel dysfunction and weakness
--Radiation can cause peripheral nerve damage due to effects on nerve itself or by involvement of surrounding tissue
--Radiation plexopathy is uncommon, usually presenting with numbness, paresthesias, and involvement of the upper trunk, myokymia on EMG
*differentiation from Pancoast’s syndrome, caused by tumor extension into superior pulmonary sulcus, producing pain in C8-T2 nerves and Horner’s syndrome
--cognitive effects of radiation likely dose related, presents slowly, and is higher risk in children

--Chemotherapy can cause a distal, symmetrical neuropathy
*often associated with vincristine (distal axonal degeneration)
*vincristine and cisplatin can also cause autonomic neuropathies

--carcinomatous myopathy: seen in metastatic disease, c/w muscle necrosis, symptoms are prox muscle weakness
--carcinomatous neuropathy: affects peripheral nerves and muscle, often occurring with lung cancer, type II muscle atrophy

--lymphedema: damage or blockage of lymphatic system, in which accumulation of protein occurs in interstitium, drawing fluid into the interstitial space
*3 grades: pitting (reversible), nonpitting, elephantiasis
--sequential pumps help resorb water into the capillaries, but proteins remain in interstitium so must be used daily, should not be used when there are multiple edematous areas
--following mastectomy, immed post-op therapy: hand pumping, hand and elbow ROM, positioning techniques, postural exercises, and shoulder ROM exercises to 40 degrees flexion and abduction

--most common mets to bone: breast, lung, prostate
--most consistent symptom of bony mets: pain, most severe at night or with weightbearing
--skeletal mets are rarely solitary
--70% spinal mets in T-spine, 95% extradural and involve vertebral body anterior to spinal cord
--bone scans pick up met disease early, but are nonspecific
--more than 90% of UE mets involve the humerus
--most LE mets involve the hip and femur
--indications for surgical treatment of met bone disease: intractable pain, impending fx, fx
--lytic lesions (occurring w/ breast, lung, kidney, thyroid, GI, lymphoma, melanoma) are thought to be more prone to fracture than blastic lesions
--blastic lesions more likely in prostate ca

--most common primary malignant tumor of the bone in children: osteosarcoma
*occurs in adolescence, commonly involving knee and prox humerus
--multiple myeloma: punched out lytic lesions, presents with pain, usually leads to renal failure

Cancer Pain:
--from tumor invasion, chemo, peripheral neuropathy, plexopathy, postsurgical pain, procedures, other
--3 step analgesic ladder: nonopiate analgesics, tricyclics --> add step 2 opioid analgesic --> increase dose or add step 3 opioid

--serotonin antagonists (Zofran) effective as anti-emetics in cancer pts
*lack of extrapyramidal side effects
*mild HA common

Pulmonary rehab

--Benefits of pulmonary rehab: increases arterial venous oxygen (AVO2) difference for improved oxygen extraction from arteries, improved exercise tolerance, reduced dyspnea, improved ambulation, decreased hospitalizations

--Moser classification of functional pulmonary disability:
1. Normal at rest, dyspnea with stenuous exertion
2. Normal ADLs, dyspnea on stairs
3. Dyspnea with some ADLs, able to walk 1 block
4. Dependent with some ADLs, dyspnea with minimal exertion
5. Housebound, dyspnea at rest

--Patients who would benefit most from pulmonary rehab:
• Respiratory limitation of exercise at 75% max O2 consumption
• Irreversible airway obstruction with FEV1 < 2000ml or FEV1/FCV < 60%
• Restrictive lung disease with CO diffusion capacity < 80% predicted

--Maximal oxygen consumption (VO2 max) = (HR x SV) x AVO2 diff (Fick’s equation)
*dependent on body weight, age, sex, natural endowment, pathological conditions, endurance exercise training

--Obstructive Pulmonary Disease:
• increased airway resistance due to bronchospasm
• air trapping
• increased compliance
• impaired blood oxygenation (hypoxia) 2/2 perfusion/ventilation mismatch
• Flattening of diaphragm
• Causes: chronic bronchitis, emphysema, cystic fibrosis, asthma
--Emphysema: distention of air spaces distal to terminal bronchioles with destruction of alveoli --> airway collapse on exhalation, decreased gas exchange --> severe mulmonary artery HTN and RV failure
--Cystic fibrosis: generalized disease of exocrine glands, respiratory failure due to inadequate removal of secretions from bronchioles
*aerobic exercise helps increase sputum expectoration, improves mucous transport, and reduces airway resistance
--Impairment develops when FEV1 falls below 3 L/sec
--Increased RV, TLC

--Restrictive lung disease: impaired lung ventilation as a result of mechanical dysfunction of the lungs or chest wall --> stiffness of the chest wall or lung tissue
--Causes of restrictive lung disease: neuromuscular disease, thoracic deformities (kyphoscoliosis), scoliosis > 90 deg, ank spond, cervical SCI, interstitial lung disease, pleural disease, surgical removal of lung
--Respiratory complications of Duchenne’s MD: atelectasis, pna, chronic alveolar hypoventilation, ventilatory failure
--Decreased VC, TLC, RV, but normal FEV1

--Aging --> decreased VC, FEV1 (rate of 30 cc/yr), PO2, increased RV and FRC
--In smokers, FEV1 decrease will be 2-3 times as fast

--Pulmonary changes in C5 quad: 60% inspiratory capacity, weak cough, difficulty clearing secretions, decreased VC, increased RV

--Duchenne’s MD: initiate vent support when pt has dyspnea at rest, VC 40% predicted, maximal inspiratory pressure < 30% predicted, hypercapnea

--ALS: monitor PFTs, functional VC is best prognostic indicator

--Asthma: for reversible bronchospasm, can try methylxanthines, beta-2 agonists, anticholincholinergics
*young patients with moderate asthma may benefit from theophylline
--O2 recommended for pts who desat below 90% during exercise
--Benefits of home O2: reduced polycythemia, improved pulm HTN, reduced perceived effort during exercise, prolonged life expectancy, improved cognition, reduced hospital needs
--Benefits of diaphragmatic breathing: incr TV, decr FRC, incr max oxygen uptake
--Benefits of pursed-lip breathing: prevents air trapping, greater gas exchange in alveoli, incr TV, reduced dyspnea and work of breathing in COPD
--Benefits of preoperative and postoperative chest therapy: decreased pna, decreases atelectasis
--Aerobic exercises for CF: trunk exercises (sit-ups), swimming, jogging

--Glossopharyngeal breathing: can be used in restrictive lung disease in the case of ventilator equipment failure for up to 4 hours, improves volume of voice and rhythm of speech, prevents micro-atelectasis, allows deeper breaths for better cough, improves pulmonary compliance

--Intermittent abdominal pressure ventilator (pneumobelt): abdominal corset which created forced expiration by moving diaphragm cephalad, works only in sitting position, liberates hands and mouth for other activities
*contraindicated in obesity, scoliosis, and patients with decreased pulmonary compliance or increased airway resistance
--Rocking bed: rocks patient along vertical axis, using gravity to assist ventilation --> useful in diaphragm paralysis
*benefits include preventing venous stasis, improved clearance of secretions, prevents decubs, benefits bowel motility
*disadvantages: not portable, not useful in patients with decreased pulmonary compliance or increased airway resistance

--Fenestrated trach tubes: used in pts who can speak and require only intermittent vent assist  when inner unfenestrated cannula is out and tube is plugged, pt may speak
--Nonfenestrated trach: for pts who require continueous vent or are unable to protect their airway during swallowing
*one-way talking valve may be installed
--Speaking trach tubes: used in alert pts who require inflated cuff for ventilation, and have intact vocal cords
*need to speak in short sentences, quality of speech altered
*manual dexterity and strength required to occlude external port
--One-way speaking valves (Passy-Muir): air directed through trachea and up through vocal cords
*requires less work
*cannot be used in COPD patients because lung has lost elasticity so air can’t be forced out

cardiac rehab

--Total oxygen consumption (VO2) = oxygen consumption of entire body
--Myocardial oxygen consumption (MVO2) = oxygen consumption by heart, can be measured by cardiac cath
--Rate Pressure Product (RPP) = SBP x HR = work required of heart
--Cardiac Output (CO) = HR x stroke volume
--MET: 1 met = 3.5 ml O2 consumed per kg wt per minute

--Benefits of cardiac rehab: improved exercise tolerance, symptoms, and cholesterol, reduction of smoking, stress reduction, reduced mortality

--Absolute contraindications to exercise training:
• Unstable angina
• Resting SBP > 200, DBP > 110
• Significant drop (20) in SBP
• Mod to severe aortic stenosis
• Acute illness
• Uncontrolled atrial or ventricular arrhythmia
• Uncontrolled tachycardia
• Symptomatic CHF
• 3rd degree heart block w/o pacemaker
• Active pericarditis/myocarditis
• Recent embolism
• Thrombophlebitis
• Resting ST displacement > 3mm
• Uncontrolled DM
• Orthopedic restrictions

--Activities to avoid during acute period of rehab (CCU): isometrics (increases HR), valsalva (causes arrhythmia), raising legs above heart (increases preload)

--Graded exercise stress tests (GXT) = assesses ability to tolerate increase stress  functional rather than diagnostic tool, can give risk stratification and limits for therapy
--For GXT, heart rate limit is 130-140 BPM
--Most ADLs in home require < 4 mets
--Benefits of cycle ergometer over treadmill: less space, less cost, minimized movement of arm and thorax for better recording, but treadmill is more physiological
--Arm ergometer used in LE amputees
--Bruce Protocol: exercise testing on treadmill with stages of 2-3 mets each

Cardiac Functional Classification:
--Class I: can do >= 7 mets
--Class II: can do >= 5 mets, < 7 mets
--Class III: can do >= 2 mets, < 5 mets
--Class IV: can do < 2 mets only

--Exercises for cardiovascular conditioning: isotonic, rhythmic, aerobic
--Small isometric component for cardiac patients
--Resistance exercises are safe and effective for improving strength and CV endurance in low risk patients  increases aerobic capacity of both Type I and Type II fibers
--Contraindications to resistance exercises: CHF, uncontrolled arrhythmia, severe vascular disease, uncontrolled HTN, SBP>160, DBP>100, aerobic capacity < 5 mets
--Optimum O2 consumption during exercise: 55-65% max VO2, 70% max HR  exercise 20-30 mins
--Borg scale: rating from 6-20 of perceived exertion

--Heart transplant: higher resting heart rate, lower peak exercise heart rate
*Monitor ECG changes during exercise testing b/c no angina

--Greatest % increase in energy for ambulation for amputees is for bilateral AK with prostheses (280%): 3 mets to 11.4 mets
--50% increase for no prosthesis with crutches
--50% increase for hemiplegic ambulation

--For >7 mets maximum work load, patient can do any job
--For >5 mets, patient can return to sedentary job and household chores

Dysphagia following stroke

1. What are the three phases of swallowing?
2. What is required for the pharyngeal phase of swallowing?
3. What is chin tuck?
4. What % of patients have silent aspiration not detected by bedside swallow? How can this be diagnosed?
5. When does recovery of swallowing function usually occur in brainstem strokes?
6. What is nasal speech?

Answers:
1. Oral, pharyngeal, esophageal.
2. Tongue elevation, soft palate elevation, laryngeal elevation, coordination of pharyngeal constriction and cricopharyngeal relaxation.
3. Compensatory technique that prevents entry of liquid into the larynx.
4. 40-60% have silent aspiration that can be diagnosed by video fluoro study.
5. First three weeks post-stroke.
6. Hypernasality caused by partial or complete failure of soft palate to close off the nasal cavity from the oral cavity.

Stroke rehabilitation

1. What are poor predictors of motor recovery in stroke?
2. What is the treatment of shoulder subluxation?
3. What is traction neuropathy?

Answers:
1. Severe arm weakness at onset, no return of hand function by 4 weeks, severe proximal spasticity, prolonged flaccidity period, later return of proprioceptive facilitation.
2. Sling not indicated but can be used for support during ambulation, FES, armboard, overhead slings.
3. Due to hemiparetic patient sustaining a brachial plexus injury due to traction.

Pediatric motor neuron disease

1. What is the pathophysiology behind spinal muscular atrophy?
2. What is another name for SMA I, when does it present, and what muscles are spared?
3. What weakness is characteristic of SMA type II?
4. What is another name for SMA III, what is the onset, and what is the prognosis?
5. What is the inheritance of Friedreich's ataxia and what protein is abnormal?
6. What is the most effective treatment of progressive scoliosis?

Answers:
1. Inherited disorders characterized by weakness and muscle wasting, secondary to degeneration of anterior horn cells and brain stem motor nuclei. There are three subtypes.
2. Severe SMA or Werdnig-Hoffman disease presents within first few months of life with severe hypotonia and weakness, with respiratory problems, sucking and swallowing difficulties. Extraocular and cardiac muscles are spared.
3. SMA II is intermediate and results in predominent leg weakness so that patient may sit unsupported but not stand.
4. Mild SMA or Kugelberg-Welander syndrome has onset >18 mo, with walking limitations, but good long-term survival depending on respiratory function.
5. Autosomal recessive, liked to chromosome 9q21, with abnormal Frataxin protein.
6. Spinal arthrodesis prior to curvature of 35 deg and prior to VC below 35%. Bracing can be used to improve sitting balance in nonambulatory patients.

Pediatric neuromuscular junction disorders

1. How does juvenile myasthenia present?
2. How is junenile myasthenia diagnosed?
3. What does repetitive nerve stim show in autoimmune myasthenia gravis?

Answers:
1. Often in adolescent girls, often severe, with ptosis and ophthalmoplegia, weakness in face, jaw, swallowing, speech, respiration, proximal muscles.
2. Fatigability of muscle after stim of nerve at 4-10 Hz, response to Tensilon, single fiber EMG.
3. Decrement in CMAP with slow stimulation greater than 12-15%.

Other pediatric muscle disorders

1. What is one of the cardinal clinical signs of fascioscapulohumeral dystrophy?
2. What are the presenting symptoms of myotonia congenita?

Answers:
1. Facial weakness --> inability to whistle.
2. Stiffness after rest and in cold weather, difficulty releasing grip, sustained eye closing in infants.

Pediatric neuromuscular disease

1. What is pseudohypertrophy and where is it seen?
2. What is Gower's sign?
3. What gait patterns are seen in neuromuscular disease?
4. What is the genetics behind Duchenne's muscular dystrophy?

Answers:
1. Seen in Duchenne's and Becker's MD, caused by increase in fat and connective tissue.
2. From proximal weakness of pelvic girdle muscles. Children compensate for hip extension weakness by moving hands up thighs into upright stance.
3. Toe walking/lumbar lordosis from hip extension weakness, Trendelenberg gait, steppage gait.
4. Abnormality of Xp21 gene loci, resulting in dystrophin deficiency.

Treatment of spina bifida

1. At what age is self-independent catheterization achieved?
2. What mental age is required for crutch walking?

Answers:
1. 5-6 years.
2. 2-3 years in a low lumbar, 4-5 years in low thoracic or upper lumbar.

Spina bifida

1. What is spina bifida occulta?
2. What is spina bifida cystica?
3. What is a common complication of myelomeningocele?
4. What is the incidence of urinary incontinence in spina bifida?
5. How does level of lesion correlate with IQ?

Answers:
1. Primarily vertebrae are affected with no herniation through the skin, usually occurring in the lumbosacral or sacral segments. It is not associated with Arnold-Chiari.
2. Designates meningocele, myelomeningocele, and other cystic lesions where the spinal canal contents herniate through the posterior vertebral opening.
3. Arnold-Chiari malformation, 90% of which are complicated by hydrocephalus.
4. 95% have incontinence, hypertonic bladder in thoracic lesions, hypotonic in sacral lesions.
5. Higher lesions result in lower IQ.

Reflexes in babies

1. What is asymmetric tonic neck reflex and when is it suppressed?
2. What is symmetric tonic neck reflex and when is it suppressed?
3. When is the palmar grasp reflex suppressed?
4. When is the plantar grasp reflex suppressed?

Answers:
1. When head turned to side, extremities extend on face side and flex on occiput side. This disappears by 6-7 months.
2. With neck flexion, arms flex and legs extend. With neck extension, arms extend and legs flex. This disappears by 6-7 months.
3. 5-6 months.
4. 12-14 months, when walking.

Cerebral palsy: associated deficits

1. What is an important indicator of whether a child with CP will walk?
2. What is an important indicator of intellectual potential?
3. What is the characteristic hearing loss in CP and in what type of CP is it most commonly seen?
4. What is the incidence of mental retardation in CP and in what types of CP is it most commonly seen?

Answers:
1. Being able to sit independently by age 2.
2. Speaking in 2-3 word sentences by age three.
3. Sensory neural impairment of hearing, most common with athetosis.
4. 50% incidence, most common in rigid atonic and severely spastic quadriplegia.

Cerebral palsy

1. What is the definition of cerebral palsy?
2. What are risk factors for CP?
3. What is the most common cause of CP?
4. What are the symptoms of spastic CP?
5. What is dyskinetic CP? What other deficiency is it associated with?

Answers:
1. CP is the result of a nonprogressive lesion to an immature brain (within first three years of life) and is the leading cause of childhood disability.
2. Prenatal intracranial hemorrhage, placental complications, gestational toxins, teratogens, TORCH infections, congenital brain malformations, maternal causes (seizures, hyperthyroidism), socioeconomic factors, reproductive inefficiency, prenatal hypoxia (from mult gestation, maternal bleeding or drug use).
3. Prematurity (birth < 32 weeks, wt < 2500 gm).
4. Hyperreflexia, clonus, Babinski, persistent primitive reflexes, overflow reflexes.
5. Extrapyramidal movement patterns secondary to abnormal regulation of tone, deficits in postural control, and coordination deficits. It is associated with a high incidence of sensorineural hearing loss.

Pediatrics: TBI

1. What are the leading causes of TBI in the pediatric population?
2. Does the presence of skull fracture indicate the severity of brain injury?
3. How does a Klumpke's palsy occur? What sort of syndrome is associated with it?


Answers:
1. Transportation related is #1, followed by falls, then sports, then assault.
2. No.
3. Violent upward pull on shoulder resulting in damage to C8-T1 cervical roots. Horner's syndrome is associated with Klumpke's palsy, related to injury to the superior cervical sympathetic ganglion.

Pediatric cancer

1. Where is the most common location of pediatric brain tumors?
2. What is Wilm's tumor?
3. What are the two most common types of malignant bone tumors and where are they commonly found?

Answers:
1. Posterior fossa.
2. Wilm's tumor or nephroblastoma develops in the renal parenchyma in children 2-5 years, and may be associated with congenital anomalies.
3. Osteosarcoma most common, followed by Ewing's sarcoma. Osteosarcoma is in the metaphysis of long bones, most commonly in the distal femur. Ewing's arises in long and flat bones, including pelvis, typically in diaphysis.

Pediatric burns

1. What is the rule of 9s in children?
2. What does placing a burn victim in a comfortable position promote?
3. What is the prime location for acute decubiti in children?

Answers:
1. For a child <1 year, 9% is taken from the legs and added to the head. For each subsequent year, 1% is returned to the legs until 9 years old.
2. Contracture.
3. Occiput.

Rheumatic fever and hemophilia

1. What are the major Jones criteria for Rheumatic fever?
2. What are the minor Jones criteria for Rheumatic fever?
3. What is the hallmark of hemophilia?

Answers:
1. Two major or one major and two minor required: Carditis, polyarthritis, chorea, erythema marginatum, subQ nodules.
2. Fever, arthralgia, elev ESR or CRP, prolonged PR interval.
3. Hemarthrosis.

Juvenile RA

1. What is the most common connective tissue disease in children?
2. What eye condition is associated with pauciarticular type I JRA? What percentage of patients develop this?
3. Which JRA subtype has the most severe arthritis?
4. What JRA subtype is associated with pauciarticular type II?

Answers:
1. Juvenile rheumatoid arthritis?
2. Iridocyclitis in 50%.
3. Polyarticular rheumatoid factor positive: severe arthritis in >50%.
4. HLA-B27.

pediatric LE amputation

1. What is the most common congenital lower limb deformity?
2. What is partial proximal femoral focal deficiency?
3. When can a child start using a motorized WC?
4. What is the most common complication after amputation in a child?

Answers:
1. Fibular longitudinal deficiency or fibula hemimelia.
2. Absence of the development of the proximal femur, resulting in stunting or shortening of the entire femur.
3. 5-6 years.
4. Terminal overgrowth.

NOTE

This method of studying is no longer working for me, so from now on, I am only going to focus on book icons. I will do 4-5 book icons per entry.

(I don't know if anyone is reading this blog or cares. If you're reading, please drop a comment so I know you're out there!)

Transhumeral congenital deficiency

1. At what age can a body-powered elbow be used?
*2. What is the Krukenberg procedure?
3. What is the Vilkke procedure?

Answers:
1. 2-3 years.
2. Reconstruction of forearm for children with absent hands by separation of ulna and radius.
3. Attaches a toe to the residual limb.

Congenital limb deficiency

1. When does limb development occur in utero?
2. What is the preferred classification system for limb deficiency?
3. What are five syndromes associated with limb deficiency?
*4. What is the most common congenital limb deficiency?
*5. When should the initial upper extremity prosthetic first be fitted? When should a terminal device first be fitted?

Answers:
1. First trimester, day 26 of gestation till 8 weeks.
2. ISPO, which divides deformities into transverse and longitudinal.
3. TAR syndrome, Fanconi's syndrome, Holt-Oram Syndrome, Baller-Gerold Syndrome, VACTERL.
4. Left terminal transradial.
5. First fitting when child achieves sitting balance at 6-7 months. TD provided at 11-13 months, when child begins to walk and performs simple grasp.

Pediatrics: hip pain

*1. What is the most common hip-related cause of limping and pain in children?
2. How is toxic synovitis of the hip diagnosed? How is it treated?
3. What is Legg-Calve-Perthes disease? What is the treatment and prognosis?
4. What is slipped capital femoral epiphysis? What population is it seen in?
5. What is the treatment of SCFE?

Answers:
1. Toxic synovitis.
2. Diagnosis is with limited IR of hip on exam, increased WBC and ESR, normal X-ray. Treatment is rest and NSAIDs, avoid full activity.
3. Avascular necrosis of the ossification center of the femoral head. Conservative treatment includes rest and abduction brace vs. varus osteotomy. There is a good prognosis if detected early with less than 50% femoral head involvement.
4. SCFE is separation of proximal femoral epiphysis through the growth plate, often seen in obese children, preadolescent/adolescent.
5. Treated with surgical pinning to prevent further epiphyseal displacement.

Pediatrics: elbow and knee injury

1. What is nursemaid's elbow? How is it treated?
2. What is Little Leaguer's elbow and how is treated?
3. What is Osgood-Schlatter's disease? How is it diagnosed and treated?

Answers:
1. Displacement of the radial head and neck distal to the annular ligament, with normal hand function and elbow X-ray. Treatment is by supination of the forearm.
2. Medial epicondylitis from repetitive stress on the apophysis of the medial humeral epicondyle ossification center, usually from baseball throwing. Treatment is rest.
3. Common self-limited disease of anterior tibial tubercle, which results in microfractures in the apophyseal cartilage and pain. X-ray may be normal or reveal fragmentation of ossified portion of the tibial tubercle. Treatment is activity restriction for 4-8 weeks, especially activities requiring deep knee bends.

Congenital torticollis

*1. What is congenital torticollis and what is the most common cause?
2. What does X-ray show in torticollis?
3. What is the treatment?

Answers:
1. Head is tilted laterally toward one shoulder with chin rotated away. Most common cause is fibrosis of the SCM, possibly due to birth trauma and ischemia. Other causes include hemivertebra or atlantoaxial rotary subluxation.
2. Rotation of C1-C2.
3. Stretching exercises. If cervical ROM is regained by one year, facial asymmetry will resolve. If torticollis is persistent or there is a hemivertebra, surgery is needed.

Pediatrics: leg and hip

1. When does genu varus resolve in infants?
*2. What is Blount's disease? What group is it most common in? What is the treatment?
3. What is developmental dysplasia of the hip? How common is it and what factors increase risk?
4. What is Galeazzi's test?
5. What are the Barlow and Ortolani tests?
6. What is the treatment of DDH?

Answers:
1. 12-18 months.
2. Abnormal function of medial portion of proximal tibial growth plate, causing bowing in proximal tibia, most common in obese African-Americans who walk early. Treatment is usually osteotomy of the proximal tibia and fibula.
3. DDH includes hip subluxation, hip dislocation, and acetabular dysplasia. It occurs in 1/1000 births, more common in breech and females.
4. Flexion of hip and knees bilaterally and look at level of knees. If one knee is lower than the other, this implies DDH.
5. Barlow involves pushing laterally on the hip with the leg in a flexed and adducted position, resulting in hip dislocation. Ortolani test reduces the hip back in place by pushing anteriorly with the long finger over the greater trochanter to left the femoral head over the posterior lip of the acetabulum, which should result in a palpable clunk if positive.
6. In the first few months of life, infant can be treated with closed reduction and Pavlik harness or hip spica cast. Surgery may be needed if diagnosed at walking age.

Pediatrics: feet and toes

1. What is metatarsus varus?
2. What is talipes equinovarus (clubfoot) and what percent require correction?
3 What is talipes calcaneovalgus?
4. What conditions are associated with cavus foot?

Answers:
1. Adduction of forefoot on hindfoot with heel in normal position. 85% correct by age 3-4 years.
2. Equinus or PF of foot, varus or inversion deformity at heel, forefoot varus. 50% require surgical correction.
3. excessive DF of ankle and eversion of foot, usually due to intrauterine position.
4. Poliomyelitis, Charcot-Marie-Tooth, Friedrich's ataxia. Usually associated with claw toes.

Spondylolisthesis in children

*1. What are the most common causes of spondylolisthesis in children? At what levels?
2. What is the difference between isthmic and dysplastic spondy?
3. What determines the need for treatment?

Answers:
1. Dysplastic and isthmic are most common. The most frequent level is L5-S1, then L4-5.
2. Isthmic is the result of a slip at a previoius spondy or a pars defect. Dysplastic has lenthening of the lamina and is more likely to cause cauda equina compression.
3. Over 50% slippage requires surgical fusion, less than 50% depends on severity of symptoms. Surgery rarely needed for <25% slippage.

Scheuermann's kyphosis

1. What is Scheuermann's kyphosis?
2. What do X-rays show?
3. What is the treatment?

Answers:
1. Three or greater consecutive vertebrae are wedged greater than 5 degrees.
2. Irregular vertebral endplates and protrusion of disc material into vertebral bodies (Schmorl's nodes). There is also narrowed disc space and anterior wedging.
3. No physical exercises if there is pain with irregular vertebral bodies, TLSO for pain control, rest, ice, gentle stretching, NSAIDs.

Evaluation and treatment of scoliosis

1. What is the Adams test?
2. What is the Cobb method?
3. When are PFTs done? What is the most common abnormality on PFTs?
4. What is the treatment for scoliosis based on the degree of curvature?
5. How much does curvature generally progress during adolescent growth?

Answers:
1. Have patient bend forward with legs straight at knees. Posterior trunk is prominent at convex side of curve.
2. On radiograph, draw line through superior endplate of apex of curve, then inferior endplate of bottom of curve, calculate angle.
3. If thoracic scoliosis is >50-60 deg, there may be PFT abnormalities. Most common is decreased VC.
4. 1-20 degrees: observe. 20-40 degrees: brace if idiopathic, surgery if neuromuscular. >40 deg: surgery.

Scoliosis

1. What is functional scoliosis? How does it differ from structural scoliosis?
2. What are the three periods of idiopathic scoliosis?
3. What is the most common presentation of congenital scoliosis? What other abnormality is it often associated with?
4. What neuromuscular diseases are commonly associated with acquired scoliosis?

Answers:
1. Functional scoliosis is due to malpositioning or unilateral paraspinal muscle pull, associated with back pain and muscle spasm. Unlike structural scoliosis, it is reversible.
2. Infantile: 0-3 yrs. Juvenile: 4 yrs-puberty onset. Adolescent: puberty to just prior to epiphyseal closure.
3. Hemivertebra in which lateral half of vert fails to form. Commonly associated with unilateral renal agenesis.
4. CP (spastic quadriplegia), Duchenne's MD (after WC bound), spinal bifida, spinal muscular atrophy.

Development and growth

1. How long does it take for the birth length to double? For the birth weight to triple?
2. How many fontanels are present at birth and when do they close?
3. How many ossification centers are present in an infant? What is the first bone to calcify in utero?
4. What is the earliest marker of abnormal neurological maturation?

Answers:
1. Birth length doubles in four years. Weight triples in one year, quadruples in two years.
2. Six fontanels (anterior, posterior, 2 sphenoid, 2 mastoid). Anterior normally closes at 10-14 mo, posterior at 4 months.
3. 5 ossification centers: distal femur, proximal tibia, calcaneus, talus, cuboid. Clavicle is the first to calcify in utero, during fifth fetal week.
4. Obligatory or persistent primitive reflexes.

Chromosomal syndromes

1. What are signs associated with Down Syndrome (Trisomy 21)?
2. What are signs associated with Turner Syndrome (45X)?
3. What are signs associated with Klinefelter Syndrome (47XXY)?
4. What infectious agents that cause interuterine malformations?
5. What drugs and maternal diseases are teratogenic?

Answers:
1. Mongoloid slant of eyes, Brushfield spots on iris, protruding tongue, low set auricles, excess nuchal skin, Simian lines, incurving of 5th fingers, increased distance between first toes, mottling of skin, hypotonia, heart disease (VSD).
2. Triangular face, abnormal ears, webbed neck, broad chest, wide niples, short stature, cubitus valgus, primary amenorrhea, CHD (coarctation of aorta), normal IQ, infertility.
3. Tall, small testicles, gynecomastia, eunuchoid build, mild mental retardation, infertility.
4. Rubella, CMV, toxoplasma, herpes, varicella.
5. Alcohol, cocaine, anticonvulsants, Vit A, DM, phenylketonuria.

Knee orthoses

1. What are the functions of a flexible knee orthosis?
2. What is the Swedish knee cage?
3. What is the Lenox-Hill derotation orthosis?

Answers:
1. Comfort for patients with OA, knee sprains, mild edema, proprioceptive feedback, kinesthetic reminder, minimal mechanical support, retains body heat, and stabilizes patellar tracking.
2. Controls minor to mod knee hyperextension, may be articulated or nonarticulated.
3. Controls knee axial rotation in addition to AP and mediolat, and is used for prevention and management of sports injuries (ACL).

KAFOs/HKAFOs

1. What are the purposes of a KAFO?
2. What are indications for a HKAFO?
*3. What is a Scott-Craig orthosis?
*4. What is a reciprocal gait orthosis?

Answers:
1. Control genu recurvatum, valgum, and varum, provide skeletal support following surgery or fracture, knee flexion contractures, prevent knee buckling.
2. Hip flexion/extension instability, hip adduction/abduction weakness, hip internal/external rotation instability.
3. For standing and ambulation in paraplegics of level L1 or higher, allowing unsupported standing. Ambulation is achieved using crutches and walker with swing-to or swing-through gait.
4. Used for upper lumbar paralysis in which active hip flexion is preserved. Hip joints are coupled together with cables to provide mechanical assistance to hip extension. Ambulation requires two crutches or walker with a four-point gait.

Ankle Foot Orthoses

1. What are the three different types of plastic AFOs?
2. What are indications for using a metal AFO over a plastic AFO?
3. What are indications for an AFO?

Answers:
1. Posterior leaf spring has a plastic band behind the ankle that allows the patient to overpower the brace during push-off, used for flaccid foot drop. Semi-rigid allows less motion, providing mediolateral stability, used for foot drop with extensor tone or mediolateral instability. Rigid (or solid) is used for high level of spasticity, where complete immobilization of the ankle is necessary.
2. Risk of excessive pressure or skin breakdown on the leg or foot, insensate foot, fluctuating edema.
3. Paralysis of ankle motion, prevention and correctio of deformities, reduction of WBing, reduce energy cost of ambulation.

Orthotics

1. How many points of pressure are needed for proper control of a joint?
*2. During standing, where does the center of gravity pass with respect to the hip, knee, and ankle?
3. What are different materials used in fabrication of orthotics?
*4. What are thermoplastics?

Answers:
1. 3
2. Posterior to hip, anterior to knee and ankle.
3. Steel, aluminum, titanium, magnesium, leather, rubber, plastics.
4. Thermoplastics soften when heated and harden when cooled, so can be remolded. They can be shaped by body without need for a cast.

Problem-specific shoe modifications

1. What can be done for an insensate foot?
2. What shoe modifications are made for an arthritic foot?
3. What factors contribute to foot pain associated with running?
4. What problems are associated with a pronated foot?

Answers:
1. Soft molded insole, extra depth shoes, relief under bony prominences (metatarsal bar or rocker bar), daily foot care, daily foot soaks.
2. Wide shoe, soft upper, flexible sole, soft heel counter, extra depth, soft toe box, metatarsal pad, insole, metatarsal bar.
3. Training errors, poor flexibility, poor training surface, inadequate warm-up, biomechanical abnormalities, poor footwear, growth.
4. Associated with a pronated foot are tibial stress syndrome, patellofemoral syndrome, posterior tibial tendinitis, Achilles tendinitis, plantar fasciitis.

Shoe modifications

1. What are some internal shoe modifications and their functions?
2. What are some external shoe modifications and their functions?
3. What is a rocker bar?
4. What are heel modifications and their functions?

Answers:
1. Heel cushion (soft pad for under heel - spurs), inner sole relief (pressure relief, usu for metatarsal heads), scaphoid pads (medial long arch support), metatarsal pads (transfers pressure from metatarsal heads to shafts), internal heel wedges (promotes foot inversion for pes planus), toe crest (toe pressure relief, for hammertoe).
2. Rocker bar, metatarsal bar (posterior to metatarsal heads, transfers load to shafts), sole wedge (can promote forefoot eversion or inversion), toe wedge (assist in intoing or outtoing), sole flare (widens base of support of shoe), shank filler (supports medial or lateral arch), steel shank (prevents motion of anterior sole, used with rocker bar).
3. Rocker bar is a convex strip placed across sole just posterior to metatarsal head (longer than metatarsal bar) thatis used to relieve metatarsal pain, assist rollover during stance, assist DF or push-off.
4. Heel wedge, heel flare, heel extension (to support arch), cushioned heel (stabilizes knee), heel lift (correct LLD of more than 1/4-1/2 inch).

Walkers

1. What are indications for using a walker?
2. What are advantages of a walker?
3. What are disadvantages of a walker?

Answers:
1. Bilateral weakness or incoordination nof LEs or body, relieve weightbearing, unilateral weakness with mild general weakness, and general support to aid mobility and confidence.
2. Provides a wider and more stable base of suppport, as well as sense of security.
3. Conspicuous appearance, interferes with smooth reciprocal gait pattern, interferes with stairs, difficult to maneuver doorways.

Crutches

1. What are the advantages and disadvantages of an axillary crutch?
2. What are disadvantages and advantages of a Lofstrand crutch?
3. What are disadvantages and advantages of a platform crutch?

Answers:
1. Crutches are inexpensive, adjustable, easy to use, but need good strength and ROM in upper limbs, ties up hands. Incr cardiac demand.
2. Lightweight, easily adjustable, hands are free, but requires more skill and better trunk balance.
3. No weightbearing through wrist and hand, but are awkward and heavy.

Canes

1. What are the functions of a cane?
2. What are the different types of canes?
3. What is the difference between a crutch and a cane?
4. What is the proper height of a cane?

Answers:
1. Increases base of support, decreases loading and demand on lower limbs, provides additional sensor information, assists in accel/decel during locomotion, decreases pain.
2. C-handle (crook top) cane, adjustable metal cane, functional grip cane, quadruped (wide-based) cane.
3. Cane has one point of contact with body while crutch has 2.
4. To allow 20 degrees of elbow flexion or height of greater trochanter.

Pain in the amputee

1. What are the characteristics of incisional pain?
2. What is the etiology of phantom pain? What is the time course?
3. What are treatments for pain in amputees?

Answers:
1. Incisional pain should subside with healing and can persist if there is an unprotected neuroma (nerve ending left exposed).
2. Etiology is neuron deafferentation hyperexcitability, and it is described as cramping, aching, burning, and occ lancinating. 50-85% of amputees experience some phantom limb pain, and there is no correlation between phantom pain and time after amputation, but does not occur in congenital amputation. It usually diminishes with time.
3. Modalities, medications, psychological interventions. Procedures are generally less effective.

Skin and bone problems associated with amputation

1. What are common skin problems associated with amputation?
*2. What is choked stump syndrome?
*3. What is verrucous hyperplasia?
4. What are common bone-related causes of pain?

Answers:
1. Folliculitis, boils, abscesses, epidermoid cysts, tinea corporis, tinea cruris, hyperhydrosis, allergic dermatitis.
2. Brawny edema, induration, discoloration of stump, resulting from proximal constriction of the stump and distal edema.
3. Wartlike skin overgrowth, usually from inadequate socket wall contact. Can be a sequela of choked stump syndrome.
4. Bone spurs due to incorrect stripping of periosteum, hypermobile fibula left longer than tibia, bone overgrowth in children where skin growth does not keep up with bone.

Prosthetic Knee units

What are the different kinds of knees?

1. Constant friction knee: single walking speed, can be used in kids, inexpensive and reliable.
2. Stance control knee: single axis with stance control, used in geriatrics, short residual limb, general disability, weak hip extensors. Can't be used in B/L AKA because can't bend both knees. Can't do step over step stair descent.
3. Polycentric/4-bar knee: inherently stable, short knee use, improved cosmesis.
4. Manual locking knee: automatically locks if standing, good stability, awkward gait and sitting.
5. Fluid-controlled knee units: hydraulic or pneumatic, allows for either swing phase or swing and stance phase control. For active walkers, gives smoothest gait. Greatest cost and maintenance.

Sockets for AKA

What are the two major kinds of AKA socket designs?

1. Quadrilateral transfemoral socket (quad socket): Narrow AP and wide mediolat, prominent bulge over Scarpa's triangle for wide pressure distribution, ischial tuberosity on top of post brim. Disadvantages are discomfort while sitting, skin irritation at ischium and pubis, poor cosmesis, poor control of residual limb.

2. Narrow mediolateral/ischial containment/CAT-CAM socket: more normal anatomic alignment with ischial tuberosity contained in socket. Advantages include increased comfort in groin area, can accommodate smaller residual limb, more efficient ambulation. Disadvantages include expense.

Prosthetic feet

What are the different kinds of prosthetic feet?

1. SACH: durable, light, inexpensive. Best on flat, level surfaces.
2. Single axis: ankle movement in one plane, heavier.
3. Multi-axis: good for active amputee, greater weight and maintenance.
4. Flexible keel (SAFE, STEN): ambulation on uneven surfaces
5. Energy storing/dynamic response (flexfoot): good for running and jumping

BKA suspension

What are commonly used suspension systems for BKAs?

Answers:
1. Supracondylar cuff suspension socket: cuff wraps around thigh.
2. Supracondylar or suprapatellar brim suspension: used with short stumps.
3. Rubber or neoprene sleeve: need longer stump and stable knee, may cause perspiration.
4. Silicone suction suspension: has attached distal pin or ring, good suspension and skin protection, expensive.
5. Thigh corset: use if patellar tendon can't tolerate WBing or knee unstable.

LE Prosthesis prescription

1. What is the best prosthetic option for a hindfoot amputation?
*2. What sort of prosthetics are used with a Syme amputation?
*3. What is a patellar tendon bearing socket?
*4. What are pressure tolerant areas in the lower extremity?
5. What are pressure-sensitive areas?

Answers:
1. Custom prosthetic foot with a self-suspending split socket.
2. Canadian Syme socket with either posterior or medial opening, which requires removal of a portion of the socket wall to get the stump in, and has poor cosmesis. Available feet include a SACH, SAFE, Seattle Syme foot, Syme flex foot, carbon copy Syme foot.
3. This is the standard socket, which is a plastic custom-molded socket that distributes pressure to tolerant areas and relief to sensitive areas. Bar in anterior wall applies pressure to patellar tendon.
4. Patellar tendon, pretibial muscles, popliteal fossa, lateral shaft of fibula, medial tibial flare.
5. Tibial crest, tubercle, condyles, fibular head, distal tibia and fibula, hamstring tendons.

Residual limb management

1. What is the ideal shape for transtibial and transfemoral residual limb?
2. When should whirlpool treatments be used on wounds?
3. What is the first kind of postoperative dressing that is used on the residual limb?
4. How often should a shrinkage device be worn?
5. What behaviors should be avoided to prevent contractures?

Answers:
1. Transtibial: cylindrical. Transfemoral: conical.
2. If wound is infected. If uninfected, whirlpool causes edema.
3. A removable rigid dressing, made of plaster or fiberglass cast, which may be adjusted by adding or removing socks.
4. 24 hrs per day except for bathing.
5. Avoid lying on overly soft mattress, placing a pillow between the legs or under the knee, lying with residual limb hanging off edge of bed, sitting for prolonged periods. Crutch walking encourages good ROM and lying prone 15 min TID.

BKA and above

1. What is the reported healing rate for ischemic BKA?
2. What are advantages and disadvantages of knee disarticulation over AKA?
3. What percentage of AKAs are secondary to vascular disease?
4. What are indications for hip disarticulation or hemipelvectomy?

Answers:
1. 80-90%.
2. Knee disartic is less traumatic to tissue, minimizes blood loss, and has a long strong stump with good end-bearing quality. Disadvantages include poorer healing in dysvascular patient, and cosmesis of the prosthesis.
3. 85%.
4. Malignant tumor, extensive trauma, uncontrolled infection (gas gangrene).

Common levels of amputation

1. What are three unsatisfactory levels for leg amputation?
2. What are pros and cons of partial foot vs. toe amputations?
3. What are the advantages of transmetatarsal amputation?
*4. What is the difference betwen a Lisfranc and Chopart amputation? What is a common complication of both?
*5. What is a Syme's amputation and what are the pros/cons?

Answers:
1. Distal 2/5 of tibia (below gastrocsoleus) due to skin breakdown, very short below knee amputation due to loss of knee extension resulting in flexion contractures, and very high above-knee amputation due to flexion/abduction contractures.
2. Pros of toe amputation include improved mechanical advantage and better gait pattern. Cons include possible progression of the vascular problems in a compromised patient.
3. Preserves attachment of DFs and PFs, which gives patient good mechanical advantage.
4. A Lisfranc amputation is at the tarso-metatarsal junction. A Chopart amputation is distal to the talus and calcaneus bones. In both amputations, the foot develops a significant equinus deformity, resulting in skin breakdown. This can be prevented by DF tendon implantation with Achilles lengthening.
5. Syme's amputation is an ankle disarticulation with attachment of the distal heel pad to the end of the tibia. Pros include maintenance of limb length, excellent wt bearing, good prosthetic tolerance. Cons include poor cosmesis of prosthetic.

Lower limb amputation

1. What are the most common causes of lower extremity amputation in various age groups?
2. What is myodesis?
3. What is myoplasty?
4. What are the functions of a temporary prosthesis?
5. How often is a permanent prosthesis usually replaced?

Answers:
1. 0-5: congenital. 5-15: cancer. 15-50: trauma. 50+: vascular disease.
2. Muscles and fascia sutured directly to bone through drill holes, resulting in a more structurally stable limb.
3. Opposing muscles sutured to each other and to periosteum with minimal tension, which takes less time and better for dysvascular limbs.
4. Can be used before limb volume stabilizes, helps in shrinking and shaping, allows early prosthetic training, maybe used as a trial to test patient's success with prosthesis. It is usually used for first 3-6 months.
5. Every 3-5 years.

Prosthetic training

1. What is the basic motion for opening the terminal device on a transradial prosthetic?
2. What are activities that are important to practice for a unilateral transradial amputee?
3. How is elbow flexion and extension achieved in a transhumeral prosthetic?
4. How is the TD operated with a transhumeral prosthetic?

Answers:
1. Forward flexion of the humerus.
2. Two handed activities such as cutting food or tying shoelaces.
3. Flexion of the elbow is achieved by humeral flexion, and extension of the elbow is achieved by elbow extension back to neutral.
4. When the elbow is locked, use additional humeral flexion to open or close the TD.

Amputee care and rehab

1. What are the most important three things to consider in a clinical decision for a prosthesis?
2. What does preprosthetic therapy include?
3. What types of rotation are most seriously affected in UE amputation?

Answers:
1. Amputation level, proximal muscle strength and ROM, general health.
2. Stump shrinkage, muscle strength, ROM, postural problems, desensitization, scar mobilization, and home exercise program.
3. Humeral rotation in transhumeral amputees, and forearm rotation in transradial amputees.

Above elbow prostheses

1. What are two types of elbow joints? Which is preferred?
2. What sort of elbow locking system is used in elbow disarticulations?
*3. What harness designs are used most frequently for transhumeral prostheses?

Answers:
1. Internal and external locking elbow. Internal elbow is preferred because of greater durability and used in level of amputation 4 cm or more proximal to the level of the epicondyle. External elbow is used for longer limbs.
2. External locking.
3. Modifications of the figure-8 and chest-strap patterns used with transradial prostheses.

Below elbow amputation prostheses

1. What is the difference between a split socket and a Muenster socket?
2. What are different harness suspension and control systems?
3. What are two kinds of control-cable systems?

Answers:
1. A split socket is used with very short stumps and encases the residual limb, attempted to a separate forearm shell to which the wrist unit and terminal device are attached. The Muenster socket is self-suspended, encapsulating the olecranon and humeral epicondyle with greater ease of use.
2. A figure-8 harness is most commonly used, with an axilla loop, worn at the normal side, which acts as a reaction point to transmit body force to the terminal device. The figure-9 is often used with the Muenster socket and is used only for controlling the TD and not for suspension. The chest-strap with shoulder saddle is used if an axilla loop can't be tolerated or for heavy lifting.
3. The Bowden control cable system is used with the purpose of operating the terminal device using body power. The dual-control cable system is used with very short transradial limbs with locking elbows, so can flex the elbow with the elbow is unlocked and operate the TD whe the elbow is locked.

Terminal devices

1. What are the advantages and disadvantages of a passive TD?
2. What is a three-jaw chuck pinch?
*3. What is the difference between a voluntary-opening and voluntary-closing terminal device?
4. What are externally powered TD?
*5. What are the two types of prosthetic wrists?

Answers:
1. Lighter, but with no functional mechanism and no grasp, intended for cosmetics only. Flexible passive TD may absorb shock.
2. Grip with thumb, index, and middle fingers, which is provided by a prosthetic hand.
3. VO is most common and practical type, powered by proximal muscles to open the TD against springs. VC is most physiological, but is heavier and less durable.
4. Controlled by switches or myoelectric signals and powered with energy from external batteries.
5. Friction and locking. Friction permits pronation and supination of TD and hold it in selected position via friction. A locking wrist permits manual rotation then locks the TD in the selected position, which is an advantage in that it prevents inadvertent rotation of the TD when a heavy object is grasped.

Upper limb prosthetics

1. What is the benefit of a wrist disarticulation over a BEA?
2. What is the most common level of arm amputation?
3. What are the pros and cons of elbow disarticulation?
4. What are two methods of suspension of a transhumeral amputation?
5. What sort of prosthesis is generally used in a forequarter amputation?

Answers:
1. Spares distal radial-ulnar articulation --> full forearm supination and pronation.
2. Transradial.
3. Pros include simpler surgery, improved prosthesis self-suspension. Cons include the cosmetic appearance and inability to use an externally powered elbow.
4. Figure-8 or shoulder saddle and chest strap.
5. Passive ultralight cosmetic prosthesis due to poor outcome with functional prosthesis.

Gait pathology

1. What is the cause of foot slap?
2. What is the cause of genu recurvatum?
3. What is the cause of excessive trunk extension?
4. What is the cause of excessive knee flexion?
5. What is the cause of pelvic drop?
6. What is the cause of a waddling gait?
7. What is the cause of excessive foot pronation?
8. What is the cause of steppage gait?
9. What is the cause of hip circumduction?
10. What is the cause of hip hike?

Answers:
1. Moderately weak ankle dorsiflexors.
2. Weak, short or spastic quads, hamstring weakness, Achilles contracture, PF spasticity.
3. Weak hip extensors or flexors, hip pain, decreased knee ROM.
4. Hamstring contracture, increased ankle DF, weak PF, long limb, hip flexion contracture.
5. Contralateral gluteus medius weakness.
6. Bilateral GM weakness.
7. Compensationed forefoot or rearfoot varus deformity, uncompensated valgus deformity, pes planus, decreased ankle DF, increased tibial varum, long limb, uncompensated internal rotation of tibia or femur, weak tibialis posterior.
8. Severely weak DF, equinus deformity, PF spasticity.
9. Long limb, abductor muscle shortening or overuse.
10. Long limb, weak hamstring, quad lumborum shortening.

Energy expenditure in gait

1. What type of amputation has the greatest increase in metabolic cost for ambulation? Least increase?
*2. What is the increase in energy expenditure for wheelchair propulsion?
3. Which requires more energy: prosthesis or crutch walking?
*4. What muscles need to be strengthened for crutch walking?

Answers:
1. Greatest increase: vascular transfemoral (100%), least increase: Syme's (15%).
2. 9%.
3. Crutch.
4. Latissimus dorsi, triceps, biceps, quads, hip extensors, hip abductors.

Determinants of gait

What are the six determinants of gait?

1. Pelvic rotation: lengthens limb as it prepares to accept weight.

2. Pelvic tilt: Pelvis on the side of the swinging leg is lowered to lower COG at midstance.

3. Knee flexion in stance: lowers COG and absorbs shock of impact at heel strike.

4. Foot mechanisms: Ankle PF at heel strike smooths curve of falling pelvis.

5. Knee mechanisms: after midstance, knee extends as ankle PFs and foot supinates.

6. Lateral displacement of pelvis: toward the stance limb to make COG over base of support.

Gait characteristics

1. What is the stride length? Step length?
*2. What is the normal distribution between stance and swing phases?
3. What is the distribution between double limb and single limb support?
4. What is cadence?
5. What is a comfortable walking speed?
6. Where is the center of gravity?


Answers:
1. Stride is measured from successive points of contact of same foot. Step length is measured from points of contact of opposite feet (approx 15-20 in).
2. 60% in stance phase, 40% swing phase. Faster walking decreases time in stance phase.
3. Double support is 20% of gait cycle, single support is 80%.
4. Cadance is the number of steps per unit of time.
5. 3 MPH.
6. 5 cm anterior to the 2nd sacral vertebra.

Gait: swing phase

What are the swing phase subdivisions?

Answers:
In My Teapot

1. Initial swing: from lift of extremity off ground to maximum knee flexion

2. Midswing: from immediately following knee flexion to vertical tibia position

3. Terminal swing: from vertical tibia position just prior to initial contact.

Swing phase makes up 40% of the gait cycle.

Gait: stance phase

What are the five subdivisions of the stance phase?

Answer:
I Like My Tea Pre-sweetened

1. Initial contact: instant foot contacts ground

2. Loading response: from initial contact to lift of contralateral extremity from ground (wt shift)

3. Midstance: from lift of contralateral extremity to when ankles of both extremities are aligned.

4. Terminal stance: from ankle alignment in the frontal plane to just prior to inital contact of the contralateral (swinging) extremity.

5. Preswing: From initial contact of contralat extremity to just prior to lift off of ipsilateral extremity (wt shift)

Stance phase makes up 60% of gait cycle.

Finger deformities

1. What is the etiology of trigger finger?
*2. What is the etiology of mallet finger?
3. What is the treatment of mallet finger?

Answers:
1. Trauma to the flexor tendon, resulting in thickening and a nodule. Clicking or locking is felt when the nodule passes through the tendon sheath.
2. Rupture of the extensor tendon in the distal phalanx secondary to forceful flexion, resulting flexed DIP.
3. Splint to immobilize distal phalanx in hyperextension 6-12 wks. Surgical treatment for poor healing, volar subluxation, or avulsion > 1/3 of the bone.

Dupuytren's contracture

1. What is a Dupuytren's contracture?
2. What diseases are associated with Dupuytren's contracture?
3. What are the clinical symptoms of Dupuytren's contracture?
4. What is the treatment of Dupuytren's contracture?

Answers:
1. Fibrous contracture of the palmar fascia creating a flexion contracture at the MCP and PIP.
2. Epilepsy, pulmonary TB, alcoholism, DM.
3. Painless thickening of palmar surface and underlying fascia, most common at 4th and 5th digits.
4. Injection followed by forceful extension, rupturing skin and fascia. Modalitis. Surgical treatments including fasciotomy or amputation.

Complex Regional Pain Disorder

1. What are the clinical features of CRPS?
2. What are the clinical stages of CRPS?
3. What are the radiographic findings of CRPS?
4. What is the treatment of CRPS?
*5. What are four tests used to determine if the pain is sympathetically mediated?

Answers:
1. Pain, deep burning exacerbated by movement, allodynia, hyperalgesia. local edema and vasomotor changes (initially warm and red, then becomes cool and cyanotic), muscle weakness, dystrophic changes.
2. Acute (pain, hypersensitivity, swelling, vasomotor changes), dystrophic (atrophic skin changes, decreased temp, hyperhidrosis), atrophic (atrophy, contractures, skin glossy, cool, and dry).
3. Sudeck's atrophy shows up on plain radiographs as patchy osteopenia. Three-phase bone scan is non-specific in first two phases, in third phase is abnormal with enhanced uptake in peri-articular structures.
4. Immediate mobilization, pain control. Corticosteroids for two weeks then gradual taper. Sympathetic ganglion block.
5. Sympathetic block with local anesthetic, guanethidine test (inject distal to suprasystolic cuff --> positive if pain reproduced after injection and relieved after cuff released), pentolamine test (reprod pain with IV pentolamine), ischemia test (inflation of suprasystolic cuff decreases pain).

Fibromyalgia

1. What are the clinical features of fibromyalgia?
2. What are the ARA criteria for diagnosis of fibromyalgia?
3. What is the treatment of fibromyalgia?

Answers:
1. Diffuse aching stiffness, tender points, headaches, neck/upper trap discomfort, UE paresthesias, fatigue. May be associated with IBS, RA, Lyme, hyperthyroidism.
2. Widespread pain in left and right side of body above and below waist with axial involvement. Also must have at least 11/18 tender points (occiput, lower cervical, traps, supraspinatus, second rib, lateral epicondyle, gluteal, greater trochanter, knee).
3. Nortriptyline, NSAIDs, steroids, combination therapy, biofeedback, tender point injection, acupuncture, aerobic exercise.

Avascular necrosis

What are the causes of avascular necrosis?

Pancreatitis
Lupus
Alcohol
Steroids
Trauma
Idiopathic, Infection
Collagen vascular disease

Radiation
Amyloid
Gaucher's disease
Sickle cell

Neuropathic arthropathy (Charcot's joint)

1. What are the causes of Charcot's joint?
2. What are the clinical symptoms of Charcot's jt?
3. What are the radiologic findings of Charcot's jt?
4. What is the treatment of Charcot's jt?

Answers:
1. Syringomyelia (shoulder), tabes dorsalis from syphilis (knee), and diabetic neuropathy (ankle).
2. Early there are painless swelling, effusion, and joint destruction. Late there is crepitation and destruction of cartilage and bones.
3. Joint destruction with hypertrophic osteophytes, loose bodies, subluxxation, and periarticular debris.
4. Immobilization and restriction of wt bearing.

Deposition and storage disease

1. What are the symptoms of hemochromatosis?
2. What are the symptoms of alkaptonuria?
*3. What is ochronosis?
4. What are the symptoms of Wilson's disease?
5. What are the symptoms of Gaucher's disease?

Answers:
1. Hepatic cirrhosis, cardiomyopathy, DM, pituitary dysfunction, skin pigmentation, arthritis in the hands and hips.
2. Autosomal recessive. Darkening of skin and urine, progressive degenerative arthropathy involving the spinal column and large joints.
3. Ochronosis is the darkening of tissue parts in alkaptonuria, resulting in bluish urine, cartilage, skin, and sclera.
4. Deposition of copper leading to liver cirrhosis, brain and kidney dysfunction, and Kayser-Fleisher rings in the eyes, OA in wrists, MCP, knees, spine.
5. Autosomal recessive, glucocerebroside accumulates in cells of spleen, liver, bone marrow, also resulting in hip and knee degeneration.

Other infectious causes of arthritis

1. What are viral causes of arthritis?
*2. What joints are involved in TB arthritis?
*3. What sort of arthritis is seen with Lyme disease?

Answers:
1. Rubella, infectious hepatitis.
2. Thoracic spine (Pott's disease), hips, knees.
3. Intermittent migratory episodes of polyarthritis.

Septic arthritis

1. What is the clinical picture of septic arthritis?
*2. What are the most common bacterial causes of septic arthritis in different age groups?
3. How is septic arthritis diagnosed?
4. What is the treatment of septic arthritis?
5. What are risk factors for septic arthritis?

Answers:
1. Rapid onset of monoarticular joint pain, erythema, decreased ROM. Most common in the knee.
2. Neonates: S aureus and GBS. Infants: H flu. Children: S aureus. Adults: gonorrhea.
3. Synovial fluid analysis with pos culture, >100,000 WBC, >85% PMN. Plain films with show soft tissue swelling early with later joint space narrowing, erosions, and gas formation.
4. Antibiotics, frequent needle aspirations with arthroscopic lavage.
5. Risk factors include age, prosthetic joints, anemia, chronic disease, hemophilia.

Sjogren's syndrome

*1. What is the clinical presentation of Sjogren's?
2. What do labs show in Sjogren's?
3. What are extraglandular manifestations of Sjogren's?

Answers:
1. Dry eyes, dry mouth, skin lesions, parotid involvement.
2. Primary form shows ANA+, RF+. Secondary form involves Sjogren's plus SLE, RA, PSS, or polymyositis.
3. Arthralgias, Raynaud's.

Vasculitis

1. What is polyarteritis nodosa?
2. What is temporal arteritis?
*3. What is polymyalgia rheumatica?
4. What is Wegener's granulomatosis?
5. What organs does Goodpasture's disease involve?

Answers:
1. Systemic necrotizing vasculitis with palpable purpura and arthritis, in which glomerulonephritis is the leading cause of death.
2. Involves tenderness of scalp, abrupt vision loss, and is treated with high dose steroids.
3. Possibly a form of giant cell arteritis, involving fever, wt loss, malaise. It affects proximal muscles, myalgias, arthralgia. Diagnosis by elev ESR, treated with steroids.
4. Small artery involvement, "saddle-nose" deformity. Necrotizing granulomatous vasculitis involves respiratory tract and glomerulonephritis.
5. Pulmonary and kidney involvement.

Polymyositis/dermatomyositis

1. What muscles are affected?
*2. What are the five subtypes?
*3. What are the clinical features?
*4. What does muscle biopsy and EMG show?
5. What is the treatment?
*6. What are the features of juvenile dermatomyositis?

Answers:
1. Symmetrical weakness of proximal muscles, including shoulder and hip girdle, anterior neck flexors, pharyngeal involvement.
2. I: Primary idiopathic polymyositis (insidious). II: primary idiopathic dermatomyositis (acute). III: Polymyositis/dermatomyositis associated with malignancy. IV: Childhood dermatomyositis/polymyositis --> severe joint contractures. V: Associated with collagen vascular disease.
3. Symmetric proximal weakness which may involve respiratory muscles and cause dysphagia. Skin features include lilac heliotrope rash with periorbital edema and Gotton's papules.
4. Muscle biopsy shows perifascicular atrophy with necrosis of type I and II fibers. EMG shows myopathic cahnges (PSW, fibs, CRD), small short MUAPs with early recruitment.
5. Steroids, azathioprine, methotrexate. ROM, isometric exercises. Follow strength and serum enzymes.
6. Heliotrope rash is predominant, clumsiness, transient arthritis. Responds well to steroids.

Scleroderma

1. What are the characteristics of scleroderma?
2. What is CREST syndrome?
3. What are the symptoms of scleroderma?
*4. What is Raynaud's phenomena? What are other causes of Raynaud's?
5. What is the treatment of scleroderma?
*6. What is eosinophilic fasciitis?

Answers:
1. Skin thickening with fibrosis-like changes in the skin and epithelial tissues of affected organs.
2. CREST (variant of scleroderma) = Calcinosis, Raynaud's, Esophageal dysmotility, Sclerodactyly, Telangiectasia.
3. Skin thickening, symmetric arthritis, Raynaud's.
4. Raynaud's involves vasospasm of digital arteries causing ischemia and ulceration of fingertips, triggered by cold or stress. Other causes include SLE, RA, dermatomyositis, arterial occlusive disease, pulmonary HTN, SCI, CVA, blood dyscrasia, medications.
5. Maintain ROM BID, strengthening. For Raynaud's, educate against triggers, rewarming, Ca channel blockers, biofeedback.
6. Eosinophilic fasciitis is a variant of scleroderma precipitated by strenuous exercise, resulting in pain and swelling. It is treated with steroids.

Systemic Lupus Erythematosis

1. What are the criteria for diagnosis of SLE?
2. What are the arthritic symptoms of SLE?
3. What is Jaccoud's arthritis?
4. What labs are positive in SLE?
5. What is the treatment of SLE?

Answers:
1. 4/11 of the following: malar butterfly rash, discoid rash, photosensitivity, oral painless ulcers, arthritis (nonerosive), serositis, renal d/o, neurologic d/o, hematologic d/o, immunologic test positive (LE cell, anti-DNA, anti-SM, or false pos syphilis), ANA positive.
2. Involves small jts of hands, wrist, knees; symmetric; nonerosive; subQ nodules; Jaccoud's arthritis.
3. Nonerosive deforming arthritis, resulting in ulnar deviations of fingers and subluxation that is reversible early.
4. Depressed complement C3 and C4, Ds-DNA, anti-SM.
5. NSAIDs, steroids, antimalarials, methotrexate, cyclophosphamide, azathioprine, cyclosporine A.

Enteropathic arthropathy

1. What is enteropathic arthropathy and what is its frequency?
*2. What are the clinical joint manifestations of enteropathic arthropathy?
3. What are the extra-articular manifestations?
4. What are the lab findings of enteropathic arthropathy?

Answers:
1. Arthritis 2/2 inflammatory bowel disease (Crohn's, UC), occuring in 10-20% of those with IBD.
2. Asymmetric, involving large joints (knees, ankles, feet), sacroiliitis.
3. Erythema nodosa (Crohn's), pyoderma gangraenosa (UC), deep oral ulcers, uveitis, fever, wt loss.
4. Anemia, elev ESR/CRP, RF-, ANA-, pos anti-neutrophil cytoplasmic ab, incr HLA-B27.

Psoriatic arthritis

*1. What are the manifestations of HIV-associated psoriatic arthritis? What is the treatment?
2. What are the clinical manifestations of psoriatic arthritis?
3. What are the clinical manifestations of psoriasis?
4. What are the radiographic findings in psoriatic arthritis?
*5. What is the treatment of psoriatic arthritis?

Answers:
1. Foot and ankle involvement is most common. Treatment is the same as for psoriatic arthritis, including NSAIDs, with no oral steroids or methotrexate.
2. Morning stiffness in spine ~ 30 min, asymmetric, oligoarticular, arthritis mutilans (telescoping of finger), enthesopathy, spondylitis, sacroiliitis.
3. Erythematous silvery scales on extensor surfaces, Auspitz sign (scraping of lesions -> pinpoint bleeding), nail pitting, conjunctivitis, aortic insufficiency.
4. Pencil in cup appearance of DIP, asymmetric sacroiliitis, "fluffy periostitis", syndesmophytes, and bone erosions.
5. ROM, similar meds to RA, PUVA, steroid injections.

Reiter's syndrome

1. What is the triad seen in Reiter's syndrome?
2. What infections are associated with Reiter's syndrome? What % progress to AS?
*3. What are the joint-associated manifestations of Reiter's syndrome?
4. What are other manifestations of Reiter's?
*5. What are the radiographic findings of Reiter's syndrome?

Answers:
1. Conjunctivitis, arthritis, nongonococcal urethritis.
2. Chlamydia, campylobacter, yersinia, shigella, salmonella, HIV. 3-10% progress to AS.
3. Asymmetric arthritis starting 2-4 weeks after infection, avg of 4 joints affected (distal LE>UE), sausage digits, enthesopathies, sacroiliitis.
4. Ocular, urethritis, balanitis circinata (painless ulcers on penis), keratoderma blennorrhagia, Reiter's nails, cardiac conduction defects, weight loss, fever, amyloidosis.
5. Lover's heel (erosion and periosteal changes at insertion of plantar fascia and Achilles), asymmetric SI joint involvement, syndesmophytes, pencil in cup deformities.

Diagnosis and treatment of ankylosing spondylitis

1. What are the lab findings in AS?
2. What are the radiographic findings in AS?
3. What physical exam test is used in AS?
4. What is the non-drug treatment for AS?
5. What medications are used to treat AS?


Answers:
1. 90% have +HLA B27, incr ESR/CRP, anemia (normocytic, normochromic), RF-, ANA-.
2. SI joint narrowing, pseudowidening of joint space due to subchondral bone resorption and erosion sclerosis, bamboo spine, syndesmophyte formation (squaring of lumbar vertebrae's anterior concavity), osteopenia, straightening of C-spine.
3. Schober test: place landmark midline at a pt 5cm below iliac crest and 10cm above. On forward flexion, the line should increase to greater than 20cm. Any less is a restriction.
4. Good posture, firm mattress, prevent flexion contractures, PT (extension exercises), deep breathing exercises, no smoking.
5. NSAIDs (indocin), steroid (taper, PO, injections, eye drops), sulfasalazine, methotrexate.

Ankylosing spondylitis

1. What are the major seronegative spondyloarthropathies?
2. What is the hallmark of ankylosing spondylitis?
3. What genetic marker is associated with AS?
4. What skeletal symptoms are associated with AS? What is the frequency of different sites of involvement?
5. What are the extraskeletal manifestations of AS?
*6. What are the HLA B27 pos diseases?

Answers:
1. Ankylosing spondylitis, Reiter's syndrome, psoriatic arthritis, and arthritis of inflammatory bowel disease. Most are RF- and HLA B27+.
2. Bilateral sacroiliitis.
3. HLA-B27 pos in 90%.
4. Sites of involvement: (1) SI jt, (2) Lumbar vertebrae, (3) Thoracic vertebrae, (4) Cervical vertebrae. Initially may be assymetric, lumbar morning stiffness, decreased lumbar lordosis and incr thoracic kyphosis, enthesitis, respiratory restriction.
5. Fatigue, weight loss, low grade fever, acute iritis (pain, photophobia, blurred vision), aortitis, apical pulmonary fibrosis, amyloidosis, cauda equina syndrome, C1-C2 subluxation.
*6. AS, Reiter's syndrome, psoriatic arthritis, enteropathic arthropathy, pauciarticular JRA.

Pseudogout

1. What sort of crystals are seen in pseudogout?
*2. What disorders are associated with pseudogout?
3. What is the clinical presentation of pseudogout?
4. What are the radiologic findings in pseudogout?
5. What is the treatment of pseudogout?

Answers:
1. Calcium pyrophosphate dihydrate crystals with positive birefringence.
2. Hypothyroidism, hyperparathyroidism, hemochromatosis, amyloidosis, hypomagnesemia, hypophosphatemia.
3. Inflammation in one or more large joints (most commonly in the knee), symmetric, flexion contractures, less painful than gout, lasts ~2wks.
4. Punctate fine line of crystals in articular hyaline or fibrocartilage tissues.
5. NSAIDs, corticosteroids, and colchicine.

Gout

*1. What sort of crystals are seen in gout?
2. What is the epidemiology of gout?
3. What is the clinical presentation of gout?
4. What are provocative factors for gout?
5. What are the lab and radiographic findings in gout?
6. What is the treatment for gout?

Answers:
1. Monosodium or sodium urate crystals with negative birefringence.
2. Male >> female, 30-50 years.
3. Exquisite pain in first MTP (podagra), monoarticular, may also be seen in midfoot, ankles, heels, knees. May last days to wks. Tophi form after years of attacks.
4. Trauma, alcohol, drugs (thiazides).
5. Hyperuricemia. Radiograph shows soft tissue swelling around joint, asymmetric, with joint space preserved, no osteopenia.
6. For acute attacks: colchicine inhibits phagocytosis of urate crystals, indocin, corticosteroids. For chronic: allopurinal (decr urate synthesis), probenecid (incr renal excretion of urate).

Treatment of osteoarthritis

1. What is the standard non-pharm treatment of OA?
2. What medications are used to treat OA?
3. When are steroids used in OA?

Answers:
1. Weight loss, ROM, strengthening, assistive devices, joint protection.
2. NSAIDs, Tylenol, rarely narcotics.
3. Intra-articular steroids for acute flares, oral steroids contraindicated.

Radiographic findings in osteoarthritis

1. What are the major radiographic findings in OA?
2. Are erosive changes seen on X-ray in OA?
3. Is osteopenia seen on X-ray in OA?
4. Where is joint space narrowing seen in knee and hip OA?

Answers:
1. Asymmetric narrowing of the joint space, new bone formation, osteophytes, osseous cysts, loose bodies.
2. No, this is seen in RA.
3. No, this is seen in RA.
4. Knee: medial joint space narrowing. Hip: superior lateral joint space narrowing.

Symptoms of osteoarthritis

1. What is articular gelling?
2. How long should morning stiffness last in OA?
3. What is the name for the spur formation that occurs at the DIP and PIP joints?
4. What is DISH?

Answers:
1. Stiffness lasting short periods that dissipates after initial ROM.
2. Less than 30 minutes. Symptoms become worse as day goes on.
3. DIP: Heberden's nodes. PIP: Bouchard's nodes.
4. Diffuse Idiopathic Skeletal Hyperostosis is a variant of primary OA when osteophytes extending along the spine lead to spinal fusion, spanning at least three discs. It is most common in the T and TL spine, most prevalent in white males >60.

Osteoarthritis

1. What is the definition of OA?
2. What is the most common type of arthritis?
3. Which joints are usually affected by primary idiopathic OA?
4. Which joints are usually affected by secondary OA with a recognizable cause?

Answers:
1. A noninflammatory progressive disorder of the joints leading to deterioration of articular cartilage and new bone formation.
2. OA.
3. Knees, MTP, DIP, CMC, hips, spine.
4. Elbows and shoulders.

Disease modifying anti-rheumatic drugs

1. What are poor prognostic factors for RA?
2. What are the safest disease-modifying drugs for RA?
3. What are the moderately toxic disease-modifying drugs for RA?
4. What are the most toxic disease-modifying drugs for RA?
5. What are non disease modifying drugs for RA?

Answers:
1. Rheumatoid nodules, RF+, erosive disease on X-ray, persistent synovitis, insidious onset.
2. Hydroxychloroquine, sulfasalazine, auranofin.
3. Methotrexate, cyclosporine, gold, azathioprine, D-penicillamine.
4. Chlorambucil, cyclophosphamide.
5. NSAIDs, corticosteroids.

Treatment of rheumatoid arthritis

1. What sort of non-medicinal treatment program is indicated for acute disease?
*2. What sort of exercise program is indicated for mild disease?
3. What modalities are used in RA?
4. What are indications for orthotics in RA?
5. What is the major function of a hand orthosis in RA?

Answers:
1. Splinting to prevent immobilization with slow PROM to prevent contracture.
2. Isometric exercise to restore and maintain strength. Avoid isotonic and isokinetic exercises.
3. Superficial moist heat can decrease pain but causes increased joint destruction and should not be used on an acutely inflamed joint, cryotherapy for pain relief.
4. Decrease pain and inflammation, reduce weight through joint, joint stabilization, and joint rest.
5. Prevention of MCP flexion. (Cannot actually be prevented, but can be slowed.)

Other extra-articular manifestations of RA

1. What are cardiac manifestations of RA?
2. What are GI manifestations of RA?
3. What are neurological manifestations of RA?
4. What are hematologic manifestations of RA?
5. What is Felty's syndrome?

Answers:
1. Pericarditis (1/2 of pts, rarely symptomatic), valvular heart disease.
2. Xerostomia (dry mouth), PUD (from NSAIDs)
3. Cervical myelopathy at C1-C2, entrapment neuropathies, mononeuritis multiplex.
4. Hypochromic microcytic anemia, Felty's syndrome.
5. Triad of RA, splenomegaly, and leukopenia. Often associated with leg ulcers.

Extra-articular manifestations of RA

1. What sort of patients are most likely to have extra-articular manifestations of RA?
*2. What are skin manifestations of RA?
3. What are ocular manifestations of RA?
4. What are pulmonary manifestations of RA?
5. What is Caplan's syndrome?

Answers:
1. RF+, with rheum nodules, severe articular disease, and MHC class HLA DRB1 alleles.
2. SubQ nodules (also seen in gout) are present in 50% of RA patients, forming subQ in bursae and along tendon sheaths, and may be enhanced by methotrexate. There may also be vasculitis lesions such as leukocytoclastic vasculitis and palpable purpura.
3. Keratoconjunctivitis sicca (dry eyes), episcleritis (benign), scleritis (severe inflammation).
4. Interstitial lung disease (fibrosis), pulm fibrosis, pleurisy, bronchiolitis obliterans.
5. Caplan's syndrome is interpulmonary nodules, similar to rheum nodules, associated with RF+ rheum arthritis and pneumoconiosis in coal works.

Joint deformities in RA

1. What is the most common type of atlantoaxial subluxation in RA? What is the maximum atlantoaxial space that is considered normal?
2. What type of foot deformities are seen in RA?
3. What type of ankle deformities are seen in RA?
4. What kind of hip deformities are seen in RA?
5. What kind of shoulder deformities are seen in RA?
6. What kind of elbow deformities are seen in RA?
7. What kind of knee deformities are seen in RA?

Answers:
1. Anterior subluxation is the most common. Any space larger than 2.5-3 mm is abnormal.
2. Hammer toe, claw toe, hallux valgus, lateral deviation of toes.
3. Increased hindfoot pronation, tarsal tunnel syndrome.
4. Protrusio acetabulum, which is inward bulging of acetabulum into pelvic cavity. Arthritis of hip joint.
5. Glenohumeral arthritis with early loss of int rot, effusions, frozen shoulder, rotator cuff injuries.
6. Subcutaneous nodules, olecranon bursitis, flexion deformities, ulnar neuropathies.
7. Loss of full knee extesnion, quad atrophy, Baker's cysts.

Wrist manifestations of RA

1. What is the cause of carpal bones rotating in a zig-zig fashion?
2. What is the piano key sign?
3. What is resorptive arthropathy?

Answers:
1. Caused by ligament laxity: proximal row rotates volarly, distal row rotates dorsally.
2. Proliferating synovium leads to rupture or destruction of ulnar collateral ligament, so there is floating of the ulnar head.
3. Digits are shortened and phalanges appear retracted with skin folds, resulting in telescoping appearance of digits.

Hand deformities in rheumatoid arthritis

*1. What is a Boutonniere's deformity? How is it treated?
2. What is a swan neck deformity? How is it treated?
3. What is the mechanism of ulnar deviation of the fingers? How is it treated?
4. What occurs in tenosynovitis of the flexor tendon sheath?
5. What is a pseudobenediction sign?

Answers:
1. Caused by weakness/rupture of terminal portion of extensor hood resulting in extensors of the PIP slipping and becoming flexors. This causes flexion of the PIP, hyperextension of the DIP and MCP. (Position of finger as if buttoning a button.) Treat with tripoint finger splint.
2. Caused by contracture of intrinsic and deep flexor muscles and tendons of fingers, resulting in flexion contracture of MCP, hyperextension of PIP, and flexion of DIP. Treat with swan neck ring splint.
3. Weakening of ECU, ulnar and radial collateral ligaments, resulting in wrist and finger deviation in the ulnar direction. Treated with ulnar deviation splint.
4. Diffuse swelling of volar surfaces of the phalanges between the joints with grating of flexor tendon sheath.
5. Extensor tendons rupture due to abrasion from rubbing on sharp elevated ulnar styloid, resulting in inability to extend 4th and 5th digits.

Radiographic findings in rheumatoid arthritis

1. What general radiographic findings are seen in RA?
2. What C-spine findings are seen in RA?
3. What are early radiographic findings of RA?
4. What are late radiographic findings of RA?

Answers:
1. Marginal bone erosions, juxta-articular osteopenia.
2. Atlantoaxial subluxation.
3. Soft tissue swelling, increased joint space.
4. Uniform joint space narrowing, axial migration of hip, malalignment and fusion of joints.

Diagnostic criteria for rheumatoid arthritis

*1. What are the 7 diagnostic criteria for RA? How many must be satisfied for diagnosis?
*2. What joints of the hand are usually affected by RA?
3. What lab tests are ordered to assess for RA?
*4. What does the synovial fluid show in RA?
*5. What percentage of RA patients are RF+?
6. What are diseases may show +RF?

Answers:
1. Must satisfy 4/7: morning stiffness >1hr, arthritis of >3 jts, arthritis of at least one joint in hand, symmetric, rheumatoid nodules, RF+, radiographic changes (erosions, bony decalcification, symm jt space narrowing).
2. PIP, MCP, MTP.
3. RF, ESR, CRP, CBC, synovial fluid.
4. Low viscosity, 1000-75,000 WBC (>70% PMN).
5. 85%, often assoc with severe active disease.
6. SLE, scleroderma, Sjogren's, viral, parasitic, bacterial, neoplasms, hyperglobulinemic.

Rheumatoid arthritis

1. What is the definition of RA?
*2. What is a pannus?
3. What is the prevalence and age range of RA?
4. What is the pattern of onset for RA?

Answers:
1. RA is a systemic autoimmune inflammatory disorder resulting in chronic, symmetric erosive synovitis.
2. Pannus is a membrane of granulation tissue that covers the articular cartilage at joint margins containing fibroblasts that destroy periarticular bone and cartilage. It is the most destructive element in RA.
3. 1% of population, 2x as common in females. Age 20-60 years, peak in 4th and 5th decades.
4. Most have insidious onset over weeks to months with fatigue, malaise, morning stiffness, msk pain usually symmetric, and low grade fever.

Siesta

Hello all! Will be taking a break from Cuccurullo for the rest of January in order to study for SAE's. I'll be back in February with Rheumatology.

Nonorganic back pain

What are Waddell's signs?

Answers:
3 or more Waddell's signs are cause for suspicion. DO ReST:

1. Distraction: Normal seated straight leg raise.
2. Overreaction: exaggerated reaction to exam.
3. Regionalization: Motor/sensory abnormalities without an anatomic basis.
4. Simulation: Pain axial load on skull.
5. Tenderness: Exaggerated sensitivity or dramatic pain with light touch.

Infection of the spine

*1. What are risk factors for vertebral body osteomyelitis and discitis?
*2. What are the most common infectious agents?
3. What diagnostic studies are used for spine infection?
4. What is the treatment of spine infection?

Answers:
1. Age, diabetes, immunodeficiency, penetrating trauma, GU procedures, invasive spinal procedures, intravenous drug abuse (incr cervical risk), TB (thoracolumbar jxn).
2. Staph aureus (most common), pseudomonas (IV drugs), TB (Pott's disease).
3. By 2 wks, X-ray shows disc space narrowing and blurred endplates. MRI most sensitive: T1 hypointensity, T2 hyperintensity, gadolineum enhancing. Leukocytosis, increased ESR, CRP, positive bone bx.
4. Conservative care icludes spinal immobilization and antibiotics with early ambulation. Surgical care includes decompression or fusion.

Soft tissue spine disorders

1. What is the presentation of lumbosacral strain?
2. What are causes of lumbosacral strain?
3. What is myofascial pain syndrome?
4. How does myofascial pain present?
5. What is the treatment of myofascial pain?

Answers:
1. Muscle ache with spasm and guarding, can occur up to 24-48 hours after injury. Normal neuro exam.
2. Overuse, excessive eccentric contraction, accel-decel injuries, acute trauma.
3. Regional pain with local muscle tenderness and trigger points.
4. Muscle tenderness, trigger points, paresthesias, poor sleep, fatigue, normal neuro exam.
5. Correction of underlying causes, analgesics, tricyclics, rehab focusing on flexibility, strengthening and aerobic exercises. Trigger point injections. Psych counseling.