Differential Diagnosis A1 Midterm

T or F: Differential diagnosis can be used as both a noun and a verb

True

What is obtained as a result of the process of differential diagnosis?

Working diagnosis

What key conditions should be ruled out with acute traumatic pain?

Fracture

Dislocation

Gross instability

What conditions should be ruled out with Non-traumatic pain?

Tumors

Inflammatory processes

Arthritis

Infections

Visceral referrals

What are two common erroneous assumptions when making a differential diagnosis?

All joints are different

All joints act independently

What is the acronyms for determining ethology of disorders?

CATBITES

Congenital

Arthritis

Trauma

Blood

Infection

Tumors

Endocrine

Soft tissue / surgical

Lesions to what can result in pain, tingling, and numbness?

Spinal nerve root

Peripheral nerve

Nerve plexus

Central nervous system (brain or spinal cord)

What is the most important tool do distinguish the difference between radiculopathy and peripheral neuropathy?

Neurological exam

What are the purposes of an orthopedic evaluation?

Reproduce a patient's complaint

Reveal laxity

Demonstrate weakness

Demonstrate restriction

What ar the 3 approaches of an orthopedic examination?

Stretch

Compress

Contract

What is a 4+ DTR?

Hyperactive with transient clonus

What is a 5+ DTR?

Hyperactive with sustained clonus

What is the primary consideration when deciding whether to order imaging?

Will the information provided by the study dictate or alter the treatment?

What are secondary considerations when deciding whether to order imaging?

What are there risks to the patient?

What is the cost?

Are there less expensive methods of arriving at the same diagnosis?

Are there any legal ramifications if the study or studies are not performed?

What is the degree of x-ray sensitivity for early disease?

Low

What condition is CT most useful for?

bony spinal stenosis

What conditions are bone scans most useful for?

Stress fracture

metastasis to bone

AVN

What is the law, similar to Wolff's, that applies to the growth plate before maturity?

Hueter-bolkmann

What is the law, similar to Wolff's, that applies to soft tissue?

Davis's law

What responses can occur in Davis;s law?

Tissue thickening

Fat deposition

Texture change in response to trauma

Trigger point formation, adhesions

What is the law that states a nerve supply a joint also supplies the muscles and skin in the area of that joint?

Hilton's law

What is the law of reciprocal innervation of muscle tissue?

Sherrington's law

T or F: The shoulder is easy to diagnose and treat

False (difficult)

Which dermatomes affect the shoulder

C4-C7

T2-T6

What conditions can refer pain to the shoulder?

Cervical radiculopathy

cervical/cervicothoracic facet referral

Thoracic outlet syndrome

burner/stinger

Double-crush syndrome

Which organs can refer pain to the shoulder?

Diaphragm

Gallbladder

Lungs

Heart

Which shoulder injuries can be caused by FOOSH?

Rotator cuff tear

Glenoid Labrum tear

Posterior Dislocation

Clavicular fracture

Which shoulder injuries can be caused by forceful abduction and external rotation?

Anterior dislocation

Anterior muscle strain

Which shoulder injuries can be caused a blow to the shoulder region?

Fracture

AC separation

Dislocation

Which shoulder injuries can be caused by a fall onto the top of the shoulder?

Shoulder pointer

AC separation

Distal clavicular fracture

Which shoulder injuries are caused by traction of the arm?

Plexus injury

Subluxation

What is the term for axillary folds being unequal side to side in the geriatric population?

Bryant's sign

What does pain in 60-120 degree range of the shoulder abduction arc indicate?

Glenohumeral injury

What does pain in the 170-180 degree range of the shoulder abduction arc indicate?

AC injury

What are 3 important shoulder orthopedic tests?

Apley's scratch test

Yergason's

Dawbarn's sign

What are the risk factors for peripheral nerve entrapment?

Increased BMI

Repetitive movements

Hypothyroidism

Genetics

What are the MRI findings of peripheral nerve entrapment?

Enlarged nerve

increased SI

T or F: peripheral nerve entrapments have a mostly dermatomal pattern

True

Where can the axillary nerve become entrapped?

Quadrangular/Quadrilateral space

What are the potential causes of axillary nerve entrapment?

Fracture of humerus

Fracture of scapula

Shoulder dislocation

Shoulder abduction narrowing the hiatus

Teres muscle hypertrophy

Fibrous band

Throwing injury

Poorly fitted crutches

What are the symptoms of long thoracic nerve entrapment?

Scapular winging

Pain on flexing extended arm

Unable to flex extended arm

What structure is found on the anteromedial (subooracoid) region?

subscapularis tendon

What structures are found on the anterolateral (subacromial) space?

bicep tendon

supraspinatus tendon

subacromial bursa

What structures are found on the posterolateral space?

posterior labrum

infraspinatus/teres minor tendons

What are the symptoms of glenohumeral impingement syndrome?

+ painful arc

+ Neer's

+hawkins-kennedy

+relocation

In a patient with posterior impingement , this suggests anterior instability as the cause

Muscle strength may be diminished due to pain

What is the lateral x-ray view of the shoulder?

lateral, angled towards head

What is the Zanca view of the shoulder?

A-P, angled towards head

What is the term for breakdown of the shoulder side of the clavicle resulting from prior damage?

Osteolysis

What type of patient usually presents with osteolysis of the distal clavicle?

bodybuilder, weightlifter, or upper body resistance athlete

Which ortho will be painful with osteolysis of the distal clavicle?

Apley's 3

T or F: X-ray is necessary for diagnosis of osteolysis of the distal clavicle

False

T or F: AP clavicle is the best x-ray for viewing the AC joint

False (Zanca is)

What is the AKA of little leaguer's shoulder?

proximal humeral epiphysitis

What type of injury is little leaguer's shoulder?

Salter Harris 1 (sometimes 2)

Where is pain located in little leaguer's shoulder?

lateral proximal humerus

What movement is painful with little leaguer's shoulder

Shoulder rotation

What does painful internal shoulder rotation indicate?

deficits of the glenohumeral joint

What are the x-ray findings of little leaguer's shoulder?

widening of proximal humeral physis

demineralization

Sclerosis

Fragmentation

T or F: In little leaguer's shoulder, it is best to compare the proximal physis to the distal physis on the same side

False (compare it to the proximal physis of the other shoulder)

What is the most common cause of biceps tendonitis?

Overuse (repeated elbow flexion)

What is a structural risk factor for biceps tendonitis?

Shallow bicipital groove

What range of motion is painful for biceps tendonitis patients?

Horizontal adduction

What is the best initial diagnostic tool for biceps tendonitis?

Ultrasound (to see how the tendon moves)

What are the 3 types of labrum tear?

SLAP

Bankart lesion

Bennett lesion

What does SLAP stand for?

Superior labrum anterior posterior

What is the term for lesion to the lower half of the labrum and inferior glenohumeral ligament?

Bankart lesion

What is the term for posterior labral tear?

Bennett lesion

What orthopedic tests are positive for labral tear?

+ clunk test

+ crank test

+ O'brien sign

+ anterior slide test

+ biceps load test

How many main types of AC separation are there?

3

What is the term for a sprained AC ligament and intact CC ligament?

Type 1 AC separation

What is the term for a ruptured AC ligament and sprained CC ligament?

Type 2 AC separation

What are the x-ray findings of a type 2 AC joint separation?

AC joint widened greater than 2mm compared to uninjured side with 50% upward displacement of clavicle

What is the term for a ruptured AC ligament and ruptured CC ligament?

Type 3 AC separation

What is the primary x-ray finding of a type 3 AC separation?

Upward dislocation of clavicle greater than width of acromion (coracoclavicular space greater than 1.3 cm)

What is the primary MOI of AC separation?

Fall on shoulder or outstretched arm

What motion is palliative for AC separation?

Adduction of the arm

What motion is provocative for AC separation?

Abduction of the arm

What are the exam findings of AC separation?

Possible bump visible at AC joint (step defect)

Tenderness to palpation over AC

+ AC joint compression test

+ horizontal abduction test

What x-rays should be taken in the event of suspected AC separation?

Weighted and unweighted

What ar the muscles of the rotator cuff?

Supraspinatus

Infraspinatus

Teres minor

Subscapularis

T or F: "Rotator cuff sprain" is an acceptable diagnosis?

False (must identify which muscle is involved

Where is pain present in rotator cuff sprain/strain?

Typically the lateral anterior shoulder

What motions are painful in rotator cuff sprain/strain?

Lifting weight

Overhead motion

Which orthos are positive for supraspinatus sprain/strain?

+empty can test

+ Codman's drop arm

+ apley's scratch test

+ rent test

+ supine impingement test

What orthos are positive for infraspinatus sprain/strain?

+ external rotation lag sign

+ infraspinatus muscle test

Which orthos are positive for teres minor strain/sprain?

+ hornblower test

Which orthos are positive for subscapularis sprain/strain?

+ bear hug test

+ internal rotation lag sign

+ lift-off test

What imaging modality is best for visualizing rotator cuff tears?

MRI

T or F: Shoulder instability may have a non-traumatic etiology

True

What is the MOI of traumatic shoulder instability?

FOOSH

What is the MOI of non-traumatic shoulder instability?

Repetitive stress

Ligament laxity

Where can pain present with traumatic shoulder instability?

anterior-inferior aspect or posterior lateral aspect of glenohumeral joint

What motion can contribute to non-traumatic shoulder instability?

Overhead activity

What orthos are positive for chronic shoulder instability?

+ apprehension test

+ clunk test

What orthos are positive for acute shoulder dislocation?

+ Sulcus sign

+ Dugas sign

What is the primary complication of shoulder instability?

Peripheral nerve injury

What is the AKA of adhesive capsulitis?

Frozen Shoulder

What demographic is most affected by frozen shoulder?

Women aged 40-60

What is the quality of adhesive capsulitis pain?

Deep local ache that interferes with sleep

What are the typical comoribities of frozen shoulder?

diabetes

hyperthyroidism

lung disease

history of heart attack