#so in 3 days ive progressed 2 months and raised hundreds of thousands of gold. lmfao.
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I played stardew valley for about 6 hours straight
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#speculation nation#i really said 'im going to speedrun this game as fast as possible and im gonna do it NOW'#im midway through fall. i am probably the richest i have ever been in a stardew valley game by this point#regularly making like 5-10k a day...#ive been going for elliott in this game and i had him at 3 hearts at the start of fall#bc ive largely been ignoring social stuff in favor of deep diving in the mines lol#but i have the horse now (got it in summer) and so talking is easier#and i gave him a gift he loved for his bday and got him up to 7 hearts right there#and i was just like.... Wait a Sec. I Can Do This.#so i am AGGRESSIVELY romancing him so i can marry him before winter comes. so i dont have to wait for spring lol#ive gotten him up to 9 hearts. and it is the 12th of fall. i can totally do this#got the house upgrade so that's dealt with. got a silver quality duck feather im gonna give him once the week resets#ive got ONE HUNDRED AND TWELVE (112!!!) pumpkins planted in addition to all my normal crops#any day now and im gonna have an EXPLOSION of money#i have a coop and barn. both of which have been upgraded once each.#all my skills are at like 8-9 range#and yes of Course i have reached the bottom of the mines.#i started up this game again just a few days ago. on the 26th. & the game was on day 11 of spring then#so in 3 days ive progressed 2 months and raised hundreds of thousands of gold. lmfao.#i have also completed much of the community center. boiler room Done. pantry just needs a large goat milk and a pumpkin#i still need winter foraging items & then the craft room will be done#fishing just needs specialty fish. which r annoying lol i totally missed the pufferfish. hoping to find it for sale in the cart#the vault is completely not done but i probably will start putting money into that once i get my pumpkin harvest#all my money has been going towards back to back buildings and expansions. robin has been BUSY lmfao#oh also the animals. 2 chickens 2 ducks 2 cows 2 goats. i could have twice that amount but im waiting on that#there keep being signs of new content everywhere and i dont know what to do about it#caught this like shadow salmon in the forest lake and i was just like. what the Fuck are you.#+ them saying pufferfish is available year round at the island but i cant go there until i get a pufferfish </3 heartbreaking#anyways yea thats why ive been so absent. ive just been spending every waking moment that i can dedicated to this game#sometimes stardew valley is a casual game of exploration and love. & sometimes. it's whatever intensely driven thing im doing here lol
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Stuff I Learned: Ortho Seminar
October 31, 2017: You Can’t Afford to Wait
Treatment of open fractures
Antibiotics + anti-tetanus toxoid
Soft tissue debridement (second look on Day 2-3)
Bony compartment: external fixation
Life-saving > limb-saving > function-saving
Limb threatening injures: open fractures, compartment syndrome, vascular injury, dislocation of major joints
FAST has largely been replaced by rapid CT
Compartment pressure measurement: digital manometer or syringe + manometer
November 2, 2017: Foot and Ankle Disorders
Arch of foot is maintained by plantar fascia
In plantar fasciitis, the tender spot is the medial aspect of the calcaneal bone
The navicular tubercle is the attachment of the tibialis posterior tendone, the dynamic control factor of the arch
Tibialis posterior dysfunction leads to adult flat foot
Unlike calcaneal fracture, medial/lateral malleolar fractures are low energy
Ankle sprains are most commonly inward, affecting the anterior talofibular ligament (ATFL) and calcaneo-fibular ligament (CFL); usually the posterior talofibular ligament (PTFL) is not affected
November 4, 2017: Peripheral Neuropaties
Cubitus valgus deformity stretches the ulnar nerve
Osteoarthritis causes compressive neuropathy by osteophyte formation or deformity
Surgical management is by anterior transposition; post-operative mortality is worse if symptomatic for > 1.5 years
November 11, 2017: Lower Back Pain
Myotome with exclusive L5 innervation: big toe dorsiflexion and hip abduction
Deformities due to back pain: loss of lumbar lordosis, listing
Prolapsed intervertebral disk causes pain during forward flexion of the spine (unlike spinal stenosis)
Consider for surgery in disk prolapse if there is still pain after conservative treatment for 6 weeks
MRI: TR few hundred = T1, few thousand = T2
Straight leg raising test positive on contralateral side = cross sciatica
November 11, 2017: Arthritis
Ficat classification of AVN
Stage I: normal
Stage II: subchondral sclerosis
Stage III: subchondral collapse, crescent sign
Stage IV: secondary OA
DDx finger drop in RA
Radial nerve palsy (posterior interosseous nerve)
Extensor tendon rupture
Volar subluxation of MCPJ
Ulnar dislocation of extensor at MCPJ
November 21, 2017: Basic Science
T scores are used for post menopausal women and for men more than 50 years old; Z scores for pre menopausal women and for men less than 50 years old + children
DEXA looks at hip and spine
Surgical treatment of axial compression fracture: posterior instrumentation and correction of kyphosis, anterior decompression and fusion
3 column theory: flexion compression affects 1 column, axial compression affects 2
November 21, 2017: Cervical Spine Disorders
Hoffmann: disinhibition of C8
Lhermitte’s sign: a sign of C1/C2 subluxation, paresthesia upon neck flexion
Cervical myelopathy: 75% episodic progression, 20% steady progression, 5% rapid deterioration
Oblique XR to look at neural foramina
Cervical radiculopathy: 80% recover completely with conservative treatment
Causes of cervical myelopathy: spondylosis, PID, instability
OPLL = ossified posterior longitudinal ligament (more common in Asian, obesity)
November 25, 2017: Common Shoulder Problems
Most common bone involved in osteoporosis of shoulder: neck of humerus (surgical)
Ligament will not lead to chronic pain of shoulder but labrum will (anterior, posterior, superior, inferior): apprehension for anterior, superior lead to chronic pain
Frozen shoulder stages: freezing (inflammatory), frozen, thawing
Combing hair (shoulder movement): flexion, abduction (front only), external rotation (back)
Wearing coat: external rotation
November 25, 2017: Common Knee Problems
ACL is intra articular and MCL is extra articular; ACL will swell immediately after trauma; MCL delayed
Immediate swelling of knee DDx
ACL tear (72%)
Osteochondral fracture (14%)
Patellar dislocation (6%)
The meniscus is avascular, aneural, and alymphatic
To prevent DVT, must exercise gastrosoleus
Majority of knee location is after a high energy trauma and majority will reduce, leaving no trace on XR
Knee dislocation = Grade 3 laxity in collateral ligament + cruciate ligament
November 27, 2017: Common Orthopedic Problems
Injection of steroid into tendon sheath = high risk of tendon rupture
Trigger finger is due to inflammation of the flexor tendon leading to narrowing of tendon sheath, therefore stuck at A1 pulley region at the MCPJ of 3rd or 4th digit
Mallet finger: caused by acute forced flexion of extended digit
Wall test: ask patient to lean against wall on back and touch wall on other points of the body to check for ankylosing spondylitis
Why spine fracture in AS patient won’t heal: abnormal curvature, stiff joint
November 27, 2017: Hand Injuries
Principles of fracture management
Reduce if necessary
Immobilize if necessary
Always rehabilitate
Nerve entrapment: if there is muscle atrophy, it is advanced; do not manage conservatively
Tinel sign: tap from distal to proximal
Froment’s sign: adductor pollicis paralysis due to ulnar nerve palsy; patient uses flexion via median nerve to compensate when asked addut thumb
November 30, 2017: Common Hip Disorders
Shenton’s line is broken in any disruption of the normal intracapsular anatomy (e.g. hip location, DDH)
Blood supply to the femoral head is retrograde = distal to proximal
AVN treatment
Ficat I-II: core decompression
Ficat II-III: vascular bone graft
Ficat IV: total hip replacement
Joint aspirate cell count
Normal: < 200
Septic arthritis: 80,000 to 200,000
Joint aspiration: anterior approach to avoid femoral blood supply, causing iatrogenic AVN
XR of AVN vs simple hip OA: unilateral, joint space initially preserved, collapsed femoral head
November 30, 2017: Childhood Injuries
Children’s bones are less dense, more porotic, more vascular with a thicker periosteum: form callus quicker
Capitulum always articulates with the radius
Children: physis not ossified, so a fracture on XR may look like a dislocation
Elbow dislocation is RARE! Consider physeal fracture
Physeal fracture: if germinal zone is damaged there is growth retardation/arrest
Supracondylar fractures occur around 6-7 years old
Type I: undisplaced
Type II: displaced, posterior cortex contact
Type III: displaced, no cortical contact (extension type)
November 30, 2017: They are too important to miss
Fracture stages: hematoma, inflammation, callus formation, lamellar consolidation, bone remodeling
Callus formation happens at around 3-6 weeks
Osteosarcoma: metaphysis most commonly affected
Osteosarcoma radiographic features
Codman’s triangle (due to periosteal elevation, early, not specific)
Sunburst appearnace (specific, late)
In children, hematogenous osteomyelitis occurs in the metaphysis since the blood vessel loops back the avascular cartilage, resulting in slower flow; in adults , who do not have metaphysis, it is septic arthritis
Codman’s triangle DDx: tumor, trauma, infection, hematoma
Acetabular fractures are high energy
December 12, 2017: Common Pediatric Problems
Breech presentation in the 3rd trimester is the single most important risk factor for DDH: increase risk by 10-15x
Ossificaiton of bone occurs at around 5-6 months for boys and 4-5 months for girls
Ultrasound is oversensitive, leading to many false positives
Acetabular index angle > 30 degrees is abnormal
Pavlik harness carries at 1% risk of AVN
Perthes is a self-limiting condition with onset between 4 and 8, but the outcome is variable depending on the extent of the collapse
Gold standard treatment for talipes equinovarus is non-operative
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