Chapter 2 - Orthopedics (Part 2) Flashcards
___ occurs mostly in women who do repetitive hand work (such as typing).
Carpal tunnel syndrome
Presentation of carpal tunnel syndrome?
Numbness and tingling in the hands, particularly at night, and in the distribution of the median nerve (radial 3 1/2 fingers)
Symptoms can be reproduced by hanging the hand limply for a few minutes, or by tapping, percussing, or pressing the median nerve over the carpal tunnel
Rx carpal tunnel syndrome?
Initial - splints and anti-inflammatory agents
If unsuccessful, electro-diagnostic studies of nerve conduction are done to justify the need for surgery (endoscopic release)
Presentation of trigger finger?
Women
Patients wake up in the middle of the night with a finger acutely flexed, unable to extend it unless they pull it with the other hand. When they do, there is a painful “snap”
Rx trigger finger?
First line - steroid therapy
Last resort - surgery
Presentation of De Quervain tenosynovitis
Young mothers who, as they carry their baby, force their hand into wrist flexion and thumb extension to hold the baby’s head; pain along the radial side of the wrist and the first dorsal compartment
On exam, pain can be reproduced by asking the patient to hold her thumb inside her closed fist, then forcing the wrist into ulnar deviation
Rx De Quervain tenosynovitis?
Splint and antiinflammatory agents can help, but steroid injection is best
Surgery is rarely needed
Common population affected by Dupuytren’s contracture?
Older men of Norwegian ancestry
Presentation of Dupuytren contracture?
Contracture of the palm of the hand; palmar fascial nodules can be felt
Rx Dupytren contracture?
Steroid or collagenase injections can be helpful; if not, surgery may be needed when the hand can no longer be placed flat on a table
What is a felon and what causes it?
Abscess in the pulp of a fingertip, caused by a neglected penetrating injury
Presentation of felon?
Throbbing pain, classic findings of an abscess, including fever
Rx felon?
Surgical drainage done urgently, as the pulp is a closed space with multiple fascial trabecula, where pressure can build up and cause tissue necrosis
What is a gamekeeper thumb and what causes it?
Injury of the ulnar collateral ligament sustained by forced hyperextension of the thumb (historically suffered by gamekeepers when they killed rabbits by dislocating their necks with a violent blow with the thumb extended, now seen as a skiing injury when the thumb gets stuck in the snow or the ski strap during a fall)
Presentation of gamekeeper thumb?
On exam, there is collateral laxity at the thumb-metacarpophalangeal joint; if untreated, it can be dysfunctional and painful and can lead to arthritis
Rx gamekeeper thumb?
Casting
What is jersey finger and what causes it?
Injury to the flexor tendon sustained when the flexed finger is forecefully extended, as in someone unsuccessfully grabbing a running person by the jersey
Presentation of jersey finger?
When making a fist, the distal phalanx of the injured finger does not flex with the others
What is mallet finger and what causes it?
Extended finger is forcefully flexed and the extensor tendon ruptures (common volleyball injury)
Presentation of mallet finger?
Tip fo the affected finger remains flexed when the hand is extended (resembles a mallet)
Rx jersey and mallet finger?
Splinting (first-line)
Rx traumatically amputated digits?
Surgically reattached whenever possible; amputated digit should be cleaned with sterile saline, wrapped in a saline-moistened gauze, placed in a sealed plastic bag, and the bag placed on a bed of ice. With the use of electric nerve stimulation to preserve muscular function, entire amputated extremities can be reattached
Do not place the digit in antiseptic solution or alcohol or on dry ice; do not let it freeze
Lumbar disk herniation occurs almost exclusively at what spinal levels?
L4-L5 or L5-S1
The peak age of incidence of lumbar disk herniation is ___.
45-46
Presentation of lumbar disk herniation?
Several months of vague aching pain (discogenic pain produced by pressure on the anterior spinal ligament) before the sudden onset of neurogenic pain precipitated by an event like attempting to lift a heavy object. The latter is extremely severe, like an electrical shock that shoots down the leg (exiting on the side of the big toe in L4-L5 or the side of the little toe in L5-S1). Worse with coughing, sneezing, or defecating (if the pain is not worse, it is not a herniated disk)
Patients cannot ambulate, they hold the affected leg flexed
Straight leg raise gives excruciating pain.
Dx lumbar dik herniation?
MRI
Management of lumbar disk herniation?
Spontaneous resolution is the rule, as the body reabsorbs the extruded disc. This process used to be very inconvenient for the patient, requiring 3 weeks of strict bed rest. The advent of pain control specialists, who perform nerve blocks under radiological guidance, has made the recovery much easier.
Surgery is needed if neuro deficits are progressing (progressive muscle weakness), and emergency intervention is required if there is cauda equina syndrome
Presentation of cauda equina syndrome?
Distended bladder
Flaccid rectal sphincter
Perineal saddle anesthesia
Management of cauda equina syndrome?
Surgical emergency requiring immediate decompression
Presentation of ankylosing spondylitis?
Young men in their 30s or early 40s who complain of chronic back pain and morning stiffness; worse at rest, better with activity
Symptoms are progressive
HLA B-27, associated with uveitis and IBD
Dx anklyosing spondylitis?
X-rays with bamboo spine
Rx ankylosing spondylitis?
Anti-inflammatory agents
Physical therapy
___ should be suspected in the elderly who have progressive back pain that is worse at night and unrelieved by rest or positional changes.
Metastatic malignancy
Dx metastatic malignancy?
MRI (best tool, more expensive); if advanced, X-rays will show the lesions (women - lytic breast cancer mets at the pedicles, men - blastic mets from the prostate)
Presentation of diabetic ulcers?
Typically indolent, located at pressure points (heel, metatarsal head, tip of toes)
Diabetic ulcers start because of ___, and they fail to heal because of the ___.
Neuropathy; microvascular disease
Management of diabetic ulcers?
Theoretically can be healed with good control of diabetes and by keeping them clean with the leg elevated for many weeks or months. In reality, they often get worse and lead to amputations
Presentation of ulcers from arterial insufficiency?
Usually as far away from the heart as they can be (at the tips o the toes); appear dirty with a pale base devoid of granulation tissue
Patient has other manifestations of arteriosclerotic occlusive disease (absent pulses, trophic changes, claudication, rest pain)
Work-up of ulcers from arterial insufficiency?
Begin with Doppler studies looking for a pressure gradient -> if there isn’t one, there is microvascular disease not amenable to surgical therapy
Then CT angio/MRI angio/arteriograms
Then surgical revascularization or angioplasty and stents
In the evaluation of chronic foot ulcers, what work-up is done in general?
Work-up for both DM and arteriosclerotic occlusive disease (both problems often coexist in the same patient)
Presentation of venous stasis ulcers?
Develop in chronically edematous, indurated, and hyperpigmented skin above the medial malleolus; ulcer is painless with granulating bed
Patient has varicose veins and suffers from frequent bouts of cellulitis
Duplex scan is useful in the work-up
Rx venous stasis ulcers?
Physical support to keep the veins empty, best done with support stockings measured to fit the patient
Surgery ay be required (vein stripping, grafting of the ulcer)
Endovascular ablation with laser or radiofrequency may also be used
What is a marjolin ulcer?
Squamous cell carcinoma of the skin developing in a chronic leg ulcer
Classic presentation of a marjolin ulcer?
Many years of healing and breaking down, such as in untreated third-degree burns that underwent spontaneous healing, or in chronic draining sinuses secondary to osteomyelitis
Dirty-looking, deeper ulcer develops at the site, with heaped up tissue growth around the edges
Dx and Rx marjolin ulcer?
Biopsy is diagnostic; wide local excision and skin grafting are done
Presentation of plantar fasciitis?
Very common but poorly understood problem affecting older, overweight patients who complain of disabling, sharp heel pain every time their foot strikes the ground
Worse in the AM
X-rays show a bony spur matching the location of the pain
Physical exam shows exquisite tenderness to palpation over the spur. Yet, the spur is not the cause of the problem, as many asymptomatic people have similar spurs.
Management of plantar fasciitis?
Spontaneous resolution can be expected in 12-18 months, during which time symptomatic treatment is offered; removal of the spur may help
What is a morton neuroma?
Inflammation of the common digital nerve at the third interspace, between the third and fourth toes
Presentation of morton neruoma?
Palpable as a very tender spot between the 3rd and 4th toes
Cause of morton neuroma?
Use of pointed, high-heeled shoes (or cowboy boots) that force the toes to be bunched together
Rx morton neuroma?
Conservative management with analgesics and more sensible shoes; surgical excision can be done
Presentation of gout?
Typical swelling, redness, and exquisite pain of sudden onset at the first metatarsal-phalangeal joint, in a middle-age obese man with high serum uric acid
Dx gout?
Uric acid crystals in the joint fluid
Rx gout?
Acute attack - indomethacin and colchicine
Chronic control - allopurinol and probenicid
