; Back of ton:arm. back of tenid (first 3.digits);' ' Humeral fracture" (wriM drop).

; Back of ton:arm. back of tenid (first 3.digits);' ' Humeral fracture" (wriM drop).

Carpal' tunnel., Immer,

Upper humcrafdUilocaiiöii/tracture'

. 'lateral shoiildet 'ßärytl foot and lateral !<•;.;

Important points:

1. To test for anterior cruciate ligament (ACL) integrity, do the anterior drawer test. Hie .knee is placed in 90° of flexion and pulled forward (like opening a drawer). If the tibia pulls forward, the test is positive, and the patient has an ACL tear.

2. Pain in the anatomic snuff-box after trauma (fall on an outstretched hand, especially in young adults) usually is due to a scaphoid bone fracture.

3. After falling on an outstretched hand, the most likely fracture in older adults is a Colles' fracture (distal end of radius).

Lumbar disc herniation: common correctable cause of low back pain m The most common site is the L5-S1 disc. Herniation affects the SI nerve root. Look for decreased ankle jerk, weakness of plantarflexors in foot, pain from midgluteal area to the posterior calf, and sciatica with the straight-leg raise test.

s The second most common site is L4—L5. Herniation affects the L5 nerve root. Look for decreased biceps femoris reflex, weakness of foot extensors, and pain in the hip or groin.

m Diagnosis is made by CT/MRI or myelogram.

■ Conservative treatment consists of bed rest and analgesics. Surgery (discectomy) is an option if conservative treatment fails.

b Cervical disc disease (classic symptom — neck pain) is less common than lumbar disease. The C6--C7 disc is the most common site. Herniation affects the C7 nerve root, Look for decreased triceps reflex/strength and weakness of forearm extension.

Charcot joints and neuropathic joints are seen most commonly in diabetes melli tus and other conditions causing peripheral neuropathy (e.g., tertiary syphilis). Lack of proprioception causes gradual arthritis and arthropathy and joint deformity. Do x-rays for any (even minor) trauma in neuropathic patients, who may not feel even a severe fracture.

The most common cause of osteomyelitis is Staphylococcus aureus, but think of grain negative organisms in immunocompromised patients and IV drug abusers, and Salmonella sp. in sickle cell disease. Aspirate the joint and do Gram stain, cultures and. sensitivities, blood cultures and complete blood cell count with differential if you are. suspicious.

Septic arthritis also is most commonly due to S. aureus, but in a sexually active adult (especially if promiscuous), suspect, gonocoeci. Aspirate the joint and do Gram stain, culture and itie.s, blood cultures and complete blood cell count with differential if you are suspicious.

Important points:

1. With a true posterior knee dislocation, get an angiogram

2. The most common type of bone tumor is metastatic (from the breast, lung, or prostate).

3. The most common cause of a pathologic fracture is osteoporosis (especially in elderly, thin women).

4. A hip dislocation, fracture, or inflammation can. refer pain to the. knee (classic in children). Pediatric hip problems

NAME .':"■'■ km . . . EMKEMIOLOGT .. . .SYMPTOMS/SIGNS' ■ .: 'TREATMENT. -

' G-JD ' At birth f'cumlc. first -I*vh, hivi-d; driivwy ■ ..Barlow's, Ortolani's signs' Harness '

ICP disease -.4-1.0 yr Male', short with-delayed bono agi •■ • • fHigh,. arid groin-pahv limp.' • Ortliqses"

SCS-'H 9-1 3 yr '. .Overweight; lisitk", adolescent . ., thigh, gmuj'paiu, limp ''. .' Surgical pinning

CHP -' congenital hip dysplasia, LCP-~. l.egg- Calve^Perdsts disease, SCffi = Kltpped capUal femoral, epiphysis, .

Note: All three of the above pediatric hip problems may present in an adult as arthritis of the hip. Given the correct history (especially age of onset of symptoms!), you should be able to tell which disorder they had. X-rays may be taken, but history gives it away.

Osgood- Schlatter disease is osteochondritis of the tibial tubercle. It is often bilateral and usu ally presents in males 10-15 years old with pain, swelling, and tenderness in the knee. Pediatric hip problems (see above) give referred pain to the knee, but the patient has no knee swelling or pain with palpation of the knee. Treat with rest, activity restriction, and NSAlDs.The disease usually resolves on its own.

Scoliosis usually affects prepubertal females and is idiopathic.Treat with a brace unless the deformity is severe (with rapidly progressive respiratory compromise); then consider surgery. Ask the patient to touch her toes, and look at the spine. With scoliosis, a lateral curvature is seen.

Whenever intracranial hemorrhage is suspected, order a CT without: contrast. Blood shows up as white and may cause a midline shift.

1. Subdural hematoma: due to bleeding from veins that bridge the cortex and dural sinuses; crescent-shaped; common in alcoholics and after head trauma. Patients may present immediately after trauma or up to 1-2 months later. If the question includes a history of bead trauma, always consider the diagnosis of a subdural hematoma. Treat with surgical evacuation.

2. Epidural hematoma: due to bleeding from meningeal arteries (classically, the middle meningeal artery); lenticular-shaped; almost always associated with a skull fracture (classically, fracture of the temporal bone; see below). More than 50% of patients have an ipsilateral "blown" pupil (see below). The classic history is a head trauma with loss of consciousness, followed by a lucid, interval of minutes to hours, then neurologic deterioration. Treat with surgical evacuation.

3. Subarachnoid hemorr hage: due to blood between the arachnoid and pi a mater. The most common cause is trauma, followed by ruptured berry aneurysms. Blood is seen in ventricles and around (but not in) the brain/brainstem. Patients classically present with the "worst headache of my hie," although many die before they reach the hospital or may be unconscious. Awake patients have signs of meningitis (positive Kernig's and Brudzinski's signs). Remember the association between polycystic kidney disease and berry aneurysms. Although CT is the test of choice, a lumbar tap shows grossly bloody cerebrospinal fluid. Treat with support, anticonvulsants, and observation. Once the patient is stable, do a cerebral angiogram/MR angiogram to look for aneurysms and arteriovenous malformations, which are treated with surgical clipping.

4. Intracerebral hemorrhage: results from bleeding into the brain, parenchyma.'The most common cause is hypertension; other causes include arteriovenous malformations, coagulopathies, tumor, and trauma. Two-thirds occur in the basal ganglia. Patients often presents with coma, if awake, they have contralateral hemiplegia and hemisensory deficits. Blood (white) is seen in brain parenchyma and perhaps in the ventricles. Surgery is reserved for large bleeds that are accessible.

After a history of trauma, a dilated, unreactive ("blown") pupil on only one side most likely represents impingement of the ipsilateral third cranial, nerve and impending herniation due to increased intracranial pressure. Of the different intracranial bleeds, this is most commonly seen with epidural hematomas. Do not do a lumbar tap on any patient with a "blown" pupil; you may precipitate uncal herniation and death. First do a Ci'/MRl.

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