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
Do you need diagnostic imaging in low back pain?
There is NO criteria for immediate imaging of any kind during a 1-2 month trial of standard, conservative back pain therapy particularly if:
- normal neuro exam
- absence of trauma inciting event
- low risk for vertebral compression fracture
When is an MRI indicated for back pain?
s/s of radiculopathy that persist after standard trial of conservative therapy x4-6 weeks in a patient who is:
+ candidate for surgery, or
+ candidate for epidural corticosteroid injection, or
+ risk factors for, or symptoms of, spinal stenosis who are candidates for surgery
48yo F
non-smoker, social drinker, pre-menopausal
PMH: long-standing intermittent lumbar-sacral strain attributed to work
CC: shooting pain downt he R leg x 2 weeks
+dragging R foot when walking
- no precipitating event or injury
Physical exam:
+ abnormal straight-leg raise
+ diminished R patellar reflex
+ difficulty with heel walking
You suspect….
you recommend as next step….
lumbar radiculopathy s/t L4 nerve root compression
recommend referral to physical therapy, conservative treatment x4-6 weeks (NSAIDs, ice, muscle relaxer)
can consider MRI after 4-6 weeks of conservative therapy without resolution
her favorite muscle relaxer because doesn’t have much abuse potential
cyclobenzaprine (Flexeril)
medication class: cyclobenzaprine (Flexeril)
muscle relaxer
calcium-rich foods
- spinach
- tofu
- almonds and other nuts
- dairy products
- sardines
normal BMD t-score
above -1.0 (aka within 1 standard deviation of healthy young population norm)
osteopenia BMD t-score
-1.0 to -2.5
osteoporosis BMD t-score
-2.5 or below
elevated inflammatory markers in both RA and SLE
ESR
CRP
positive ANA titer is seen in
SLE (>95%)
less commonly in RA (>60%)
% of folks with SLE who have a positive ANA titer
> 95%
% of folks with RA who have a positive ANA titer
~60%
78yo F
CC: progressively worsening aches to hands and fingers, worsened with yard work
physical exam:
bilateral heberden’s and bouchard’s nodes
you suspect….
osteoarthritis
heberden’s nodes
enlargement of the DISTAL interphalangeal joint
bouchard’s nodes
enlargement of the PROXIMAL interphalangeal joints (middle joint in finger)
bilateral heberden’s & bouchard’s nodes are specific to…..
osteoarthritis
21yo M
CC: fell on outstretched right hand (non-syncopal) during a soccer game now with pain x48 hours, worsens with hand grasp
physical exam:
- tenderness to anatomic snuffbox region
- minimal swelling
- xray at urgent care same day as fall showed no broken bones
you suspect….
you recommend….
scaphoid fracture
- apply a spica thumb splint
- NSAIDs or acetaminophen for pain
- refer to orthopedics (need a higher level of evaluation before starting PT because often initial xray is negative in snuff-box injury even though there is a fracture)
most common carpal fracture occurring in FOOSH injury (Fall on Outstretched Hand)
scaphoid fracture (snuff-box fracture)
why should you refer all suspected scaphoid fractures (snuffbox injury) to a specialist
in this type of extension injury, palmar branch of the radial artery supplies blood to the scaphoid’s distal pole and then proximal pole
blood supply can be disrupted by a fracture with the irks of nonunion and avascular necrosis –> hence referral to ortho for expert opinion
Scared Lovers Try Positions That They Can’t Handle –> mnemonic for bones in the wrist
Scaphoid Lunate Triqeutrum Pisiform Trapezium Trapezoid Capitate Hamate
clinical presentation of scaphoid fracture
- pain in the radial aspect of wrist, proximal to thumb (snuff box)
- decreased grip strength
diagnostic evaluation of suspected scaphoid fracture
- standard radiograph (posterior, anterior, lateral, oblique) plus scaphoid view
- consider repeat radiographs within 7-10 days because early fracture can be missed
- CT, MRI, or bone scan can be considered if there is classic presentation of scaphoid fracture but normal xray findings
- early specialist consult
inversion injury on a plantar-flexed foot will give you ____ ankle sprain
lateral
most commonly injured ligament in an ankle sprain
anterior talofibular ligament
(3) ligaments of the ankle that can be affected in a sprain
- anterior talofibular ligament
- calcaneofibular ligament
- posterior talofibular ligament
eversion injury on a plantar-flexed foot will give you ____ ankle sprain
medial
high ankle sprain, aka….
syndesmotic sprain
eversion injury on a dorsi-flexed foot will give you ____ ankle sprain
syndesmotic (high) ankle sprain
Grade I-III ankle sprains
GRADE 1 = mild stretching of the ligament with microscopic tears, no joint instability on exam, can bear weight with mild pain
- does not require immobilization
GRADE 2 = incomplete tear of a ligament, mild-moderate joint instability, decreased ROM, weight bearing and ambulation are painful, mild-moderate swelling and ecchymosis
- requires immobilization with an air cast or split for a few weeks
GRADE 3 = complete tear of a ligament, pain, swelling, tenderness, ecchymosis, loss of function and motion, unable to bear weight and ambulate
- cast, splint, and boot
rule set for determining if you need imaging for an ankle sprain
Ottawa Ankle Rules
interventions for ankle sprain
- RICE
- crutches until able to walk with normal gait
- NSAIDs, acetaminophen
- physical therapy
- orthopedic referral for fracture, dislocation, subluxation, syndesmotic injury, or Grade 2-3 ankle sprain
patients with a grade II ankle sprain should be advised recovery will likely need to include… (2)
- air cast or splint
- 4-6 weeks of recovery
etiology of polymyalgia rheumatica (PMR)
inflammation of unknown origin that affects muscles and joints
typically affects people 50yo and older
clinical presentation of polymyalgia rheumatica (PMR)
- aches in the shoulders often first symptom
- aches in the neck, upper arms, lower back, hips, and thighs
- symptoms tend to onset quickly (over days-weeks)
- symptoms are worse in the morning and improve throughout the day
diagnostic evaluation of polymyalgia rheumatica (PMR)
no one specific test to diagnose PMR
LABS:
- CRP and ESR are typically elevated, indicating inflammation
IMAGING:
- MRI or US of the shoulder and hip joints can detect inflammation in these joints and tend to support the diagnosis
interventions for polymyalgia rheumatica (PMR)
- low-dose corticosteroids (prednisone 10-15mg PO QD ) until symptoms are relieved (typically x2-3 weeks) followed by taper
- remain on lowest dose necessary to suppress symptoms for up to 2-3 years
clinical presentation of osgood-schlatter disease
- pain, swelling, and tenderness in one or both knees that ranges from mild to debilitating
- pain can be constant or can be present only during certain activities such as running or jumping
- pain may be worse on hyperflexion and extension against resistance
- prominence and tenderness of the tibial tuberosity
- typically adolescent during growth spurt
diagnostic evaluation of osgood-schlatter disease
physical exam, clinical diagnosis
can consider an xray to evaluate the patellar tendon and its bone attachment
interventions for osgood-schlatter disease
treatment is symptomatic, reducing pain and swelling
- NSAIDs
- physical therapy
- strengthening exercises for the quadriceps can stabilize the knee joint
- symptoms typically resolve with completion of adolescent growth spurt
etiology of prepatellar bursitis
thickening of the synovial tissue along with excessive fluid within the bursa –> results in knee pain and swelling
caused by joint overuse, trauma, infection, or arthritis conditions
clinical presentation of prepatellar bursitis
abrupt onset of knee pain with focal tenderness and swelling
ROM is usually full, but may be limited by pain
typically a clinical diagnosis
interventions for prepatellar bursitis
- bursal aspiration is first-line!!
- minimize or eliminate activities that make it worse
- apply ice x15 minutes 4x daily
- NSAIDs
- if no improvement in 4-8 weeks, consider intrabursal corticosteroid injection
etiology of meniscal tear
disruption of the meniscus, a C-shaped fibrocartilage pad located between the femoral condyles and the tibial plateaus
often found in athlete’s s/t twist-type injuries to the knee
clinical presentation of meniscal tear
- effusion with knee tightness and stiffness
- ROM limited by pain
- knee locks in larger tears, makes a popping sound, or gives out
- McMurray test (highly specific, not sensitive)
- Apley grinding test (highly specific, not sensitive)
diagnostic evaluation of meniscal tear
MRI to identify type and extent of the tear
interventions for meniscal tear
- RICE
- NSAIDs or acetaminophen
- joint aspiration can be considered if no improvement in 2-4 weeks
- arthroscopy for debridement and repair considered if no improvement in 4-6 weeks or earlier if joint locking and effusion are problematic
etiology of reactive arthritis
- painful inflammatory arthritis
- seen days or weeks after an episode of acute bacterial diarrhea or sexually-transmitted infection
clinical presentation of reactive arthritis
- pain and/or swelling of the knees, ankles, heels, toes, or fingers
- persistent low back pain
- conjunctivitis
- urinary symptoms
diagnostic evaluation of reactive arthritis
- blood tests for infection and inflammation (CBC with diff, ESR, CRP)
- genetic test for HLA-B27 gene (strongly linked to reactive arthritis)
- xray
- urine NAAT for chlamydia and gonorrhea
interventions for reactive arthritis
- NSAIDs
- corticosteroid injections in the affected joints to reduce inflammation can be considered
- TNF blockers can be considered
- antibiotic use is generally not beneficial although when there is documented infection it can help shorten the duration of symptoms
who should undergo BMD testing?
- women 65yo and older; men 70yo and older (regardless of risk factors)
- younger if risk factors
- anyone <50yo who has broken a bone
- adults with conditions (e.g., RA) or medications (e.g., steroids) associated with low bone mass or bone loss
risk factors for osteoporosis include:
- lifestyle = inactivity, low calcium intake, alcohol abuse
- genetic factors (e.g., cystic fibrosis)
- hypogonadal states (e.g., hyperprolactemia, androgen insensitivity)
- endocrine disorders (e.g., diabetes, adrenal insufficiency)
- GI disorders (celiac disease, IBD)
- hematologic disorders (e.g., multiple myeloma, leukemia)
- rheumatologic and autoimmune disorders (e.g., RA, SLE)
- CNS disorders (e.g., MS, epilepsy)
- HIV/AIDs
- CHF
- long term use of steroids
- some anticonvulsants
- thyroid hormones
who should be treated for low bone mass?
- postmenopausal women and men >50yo who have:
- DEXA testing with t-score less than -2.5 (osteoporosis)
- DEXA testing with t-score less than -1.0 but greater than -2.5 (osteopenia) who have a 10-year hip fracture probability of 3% or more, or a 10-year all fractures risk of 20% or more based on FRAX score
- history of hip or vertebral fractures either clinically apparent or found on imaging
treatment options for osteopenia and osteoporosis
- bisphosphonates
- estrogen/hormone therapy
- SERM (raloxifene [Evista])
- parathyroid hormone (teriparatide [Forteo])
- RANKL inhibitor (denosumab [Prolia])
- all of the above should be given with appropriate dose of vitamin D and calcium
recommended vitamin D intake per day
800-1000 IU/day
recommended calcium intake per day
men 50-70yo = 1000mg/day
women >50yo and men >70yo = 1200mg/day
clinical presentation of OA
- pain, tenderness, and stiffness that is more prominent in the morning in the joint
- reduced ROM
- crepitus of the joint
- erythema and redness are typically ABSENT
diagnostic evaluation of OA
xray, which will demonstrate narrowing of the joint space, changes in bone, or the presence of bone spurs (osteophytes)
MRI, CT, or bone scan not usually needed but can be considered if need greater detail on the soft tissues of the joint
interventions for OA
CONSERVATIVE
- low impact aerobic exercise
- strengthening exercises
- physical activity
- weight loss if BMI >25
- cannot recommend acupuncture and glucosamine/chondroitin
PROCEDURES
- unable to recommend for or against the use of intraarticular steroid injections; mixed data
- cannot recommend needle lavage and hyaluronic acid
SURGICAL
- cannot recommend arthroscopy with lavage and/or debridement
- unable to recommend for or against partial meniscectomy for those with OA and torn meniscus
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