Ch17: Musculoskeletal Flashcards
in orthopedics, when the patient is otherwise systemically well, the condition is typically limited to…. (2)
the bones and joints
e.g., osteoarthritis, osteoporosis, gouty arthritis
in orthopedics, when the patient is systemically ill (e.g., fever, weight loss, anemia of chronic disease, rash, joint swelling)…. the patient usually has –
the orthopedic manifestation o fa systemic disease
e. g.,
- rheumatoid arthritis
- SLE
- polymyalgia rheumatica
presentation of acute gouty arthritis
- erythema and enlargement at the first metartarsophalangeal joint (base of the great toe)
in order for the urate crystals to precipitate out, the part of the body for them to precipitate out at has to be thermally cool. that’s why the great toe is such a common location, and the external ear is common for tophi
medications for acute gouty arthritis (3)
- NSAIDs (e.g., naproxen)
- colchicine
- intraarticular corticosteroid injection (generally limited to those who cant take other meds)
controller meds for preventing gouty arthritis
- febuxostat (Uloric)
- allopurinol
possible triggers for acute gouty arthritis
- use of a thiazide or loop diuretic
- alcohol consumption
- renal insufficiency
- aspirin
- PURINE RICH FOODS:
+- consumption of organ meats
+seafood (sardines, anchovies)
+ spinach
+ oatmeal
Match the orthopedic test with the condition: McMurray test
meniscal tear (knee)
Match the orthopedic test with the condition: Talar tilt
ankle instability
Match the orthopedic test with the condition: Spurling test
cervical nerve root compression (neck)
Match the orthopedic test with the condition: Phalen’s sign
carpal tunnel syndrome (median nerve compression)
Match the orthopedic test with the condition: Lachman sign
ACL tear (knee)
Match the orthopedic test with the condition: Straight leg raise
lumbar nerve root compression
not that great of a test
Match the orthopedic test with the condition: Phalen’s sign
carpal tunnel syndrome (median nerve compression)
Match the orthopedic test with the condition: Drop Arm Test
rotator cuff injury
Match the orthopedic test with the condition: Finkelstein test
DeQuervain’s tenosynovitis (thumb)
70yo F
PMH: HTN, HLD, hypothyroid
Meds: statin, ACEI, thiazide diuretic, levothyroxine
CC: fatigue & aching sensation with morning stiffness in hips/shoulders x2 months
+unintentional weight loss
+ weakness
Physical exam:
5/5 limb strength, decreased ROM to hips and shoulders, no muscle tenderness, no erythema
Labs: Hgb 10.8 (LOW) Hct 32% (LOW) MCV 86 (WNL) RDW 12.2% (WNL) ESR 112 (ELEVATED)
the anemia on labs is….
condition you suspect….
the intervention you recommend is….
anemia of chronic disease
polymyalgia rheumatica
systemic corticosteroids
DISCUSSION:
normocytic, normal RDW, elevated ESR
large joint arthritis & systemically ill –> orthopedic manifestation of a systemic disease
new onset RA could cause elevated ESR and fatigue, weight loss, anemia of chronic disease - however - general rule is RA starts in the SMALL JOINTS
PMR is on the pathologic spectrum with giant cell arteritis (always consider both) - high dose long term corticosteroids is generally the treatment
best differentiator between RA and PMR?
RA = small joints (fingers, toes), younger women
PMR = large joints (hips, shoulders), older women
general treatment options for polymyalgia rheumatica
- long term systemic corticosteroids
- physical therapy
PMR is on the same spectrum of disease as ______< thus always check for both conditions, and treatments are similar
giant cell arteritis (temporal arteritis) –> inflammatory vasculitis
lumbar spinal stenosis presentation
- age >50 yo or older, typically
- positive straight leg raise
- pain is improved by forward flexion (CLASSIC FINDING)
- pseudoclaudication (leg pain that worsens with activity and imrpvoes with rest)
- back pain is often worse with standing
- bilateral leg numbness and weakness
when/what are diagnostics needed in the work-up of lumbar spinal stenosis
can be diagnosed clinically initially
for symptoms persisting >1 month, consider:
- MRI
- EMG (electromyelogram)
- NCV (nerve conduction velocity)
interventions for lumbar spinal stenosis
- physical therapy
- NSAIDs
- epidural corticosteroid injection
- surgery, possibly (carefully selected, not everyone will benefit from surgery)
MRI is better at ______ than CT
soft tissue (e.g., nerve compression)
28yo M
CC: L knee pain and swelling x1 month
+ redness and tearing in L eye x1 week
+ intermittent dysuria
+ loose stools x2 weeks
No fever or weightloss
Physical exam:
- smooth swollen red warm left knee with decreased ROM
- PERRLA with conjunctival redness
- erythematous urinary meatus
you suspect….
next most important test to confirm….
treatment will be…..
reactive arthritis (Reiter’s syndrome) –> typically triggered by infection like gonorrhea or chlamydia
urinary PCR testing for N. gonorrhoeae and C. trachomatis
recommend antibiotics and NSAIDs
DISCUSSION:
joint involvement + eye involvement + GU involvement + lower GI involvement
Can’t see, Can’t pee, Can’t climb a tree …. mnemonic for Reactive Arthritis
- conjunctivitis
- urethritis
- ankle/knee joint involvement
14yo M
CC: anterior knee pain, intermittent, x3 months
+ worse with squatting and walking up stairs, better with rest
- denies fever, weight loss, joint redness, or skin rash
physical exam:
- NAD
- tender, swollen tibial tuberosity
- pain reproduced with resisted active extension and passive hyperflexion of the knee
you suspect….
you recommend…..
osgood-schlatter disease
avoid sports that have heavy quadriceps load-bearing or deep knee bending –> ok to still participate but these will exacerbate
DISCUSSION:
- ortho-problem alone, no systemic symptoms
- adolescent, growth spurt
what is osgood-schlatter disease & etiology
irritation of the patellar tendon at the tibial tuberosity
mismatch of connective tissue with bone growth because is most common with growth spurt
ETIOLOGY
there is patellar swelling and pain in adolescents who participate in sports involving running and jumping. repeated stress causes inflammation below the patellar tendon where it attaches to the tibia. new bone growth can occur where the tendon pulls away from the tibia, resulting in a bony lump
what is an acceptable team sport for a college-age young adult with a bleeding disorder to participate in
non-collision, non-contact, e.g., swimming
most common reason for low back pain
lumbar-sacral muscle sprain
etiology of lumbrosacral muscle sprain
spasm and irritation of the lumbral-sacral spine-supporting muscles
presentation of lumbrosacral muscle sprain
HISTORY:
- spasm, muscle ache, stiffness
- affected by position and activity
- relieved by rest
PHYSICAL:
- paraspinal muscle tenderness and spasm
- lumbar-sacral curve straitening
- decreased lumbar-sacral flexion
- neuro exam WNL!!!!!!!!!!
interventions for lumbrosacral muscle sprain
- NSAIDs or acetaminophen
- physical therapy
- do NOT limit physical activity (harmful)
- heat or ice, whichever helps
- muscle relaxers can be useful but all of them are sedating and some have abuse potential
etiology of lumbar radiculopathy
irritation or damage of the neural structures such as vertebral discs, typically L4-L5 or L5-S1
most common site of a herniated vertebral disc
L4-L5 or L5-S1
clinical presentation of lumbar radiculopathy
HISTORY:
- sharp, burning, electric-shock sensation
- worse when increased spinal fluid pressure thus pressure on the nerve root
- sneak, cough, straining evokes sharp pain
PHYSICAL: - all the same findings of lumbar-sacral strain (e.g., paraspinal tenderness) plus NEURO ABNORMALITIES \+ abnormal straight-leg raise \+ sensory loss \+ altered DTRs
interventions for lumbar radiculopathy by the AGPCNP generalist
- 4-6 weeks of conservative therapy (like lumbar-sacral strain - NSAIDs, acetaminophen, heat/ice, PT, do not limit activity) because most of the time is self-resolving
- specialty eval and intervention for a rapidly evolving defect, persistent defect without resolution after 4-6 weeks of conservative therapy
anticipatory guidance for someone with lumbar radiculopathy
most are self-resolving in 4-6 weeks
Neuro testing with lumbar vertebral problems: L4 nerve root
MOTOR: - foot dorsiflexion REFLEX: - patellar (knee) jerk reflex SENSORY AREA: - medial calf
Neuro testing with lumbar vertebral problems: L5 nerve root
MOTOR: - great toe dorsiflexion REFLEX: - none SENSORY AREA: - medial foot
Neuro testing with lumbar vertebral problems: S1 nerve root
MOTOR: - foot eversion REFLEX: - Achilles (ankle) jerk reflex SENSORY AREA: - lateral foot