Chapter 2 - Orthopedics (Part 2)

Question 1

___ occurs mostly in women who do repetitive hand work (such as typing).

Answer 1

Carpal tunnel syndrome

Question 2

Presentation of carpal tunnel syndrome?

Answer 2

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

Question 3

Rx carpal tunnel syndrome?

Answer 3

Initial - splints and anti-inflammatory agents
If unsuccessful, electro-diagnostic studies of nerve conduction are done to justify the need for surgery (endoscopic release)

Question 4

Presentation of trigger finger?

Answer 4

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”

Question 5

Rx trigger finger?

Answer 5

First line - steroid therapy

Last resort - surgery

Question 6

Presentation of De Quervain tenosynovitis

Answer 6

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

Question 7

Rx De Quervain tenosynovitis?

Answer 7

Splint and antiinflammatory agents can help, but steroid injection is best

Surgery is rarely needed

Question 8

Common population affected by Dupuytren’s contracture?

Answer 8

Older men of Norwegian ancestry

Question 9

Presentation of Dupuytren contracture?

Answer 9

Contracture of the palm of the hand; palmar fascial nodules can be felt

Question 10

Rx Dupytren contracture?

Answer 10

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

Question 11

What is a felon and what causes it?

Answer 11

Abscess in the pulp of a fingertip, caused by a neglected penetrating injury

Question 12

Presentation of felon?

Answer 12

Throbbing pain, classic findings of an abscess, including fever

Question 13

Rx felon?

Answer 13

Surgical drainage done urgently, as the pulp is a closed space with multiple fascial trabecula, where pressure can build up and cause tissue necrosis

Question 14

What is a gamekeeper thumb and what causes it?

Answer 14

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)

Question 15

Presentation of gamekeeper thumb?

Answer 15

On exam, there is collateral laxity at the thumb-metacarpophalangeal joint; if untreated, it can be dysfunctional and painful and can lead to arthritis

Question 16

Rx gamekeeper thumb?

Answer 16

Casting

Question 17

What is jersey finger and what causes it?

Answer 17

Injury to the flexor tendon sustained when the flexed finger is forecefully extended, as in someone unsuccessfully grabbing a running person by the jersey

Question 18

Presentation of jersey finger?

Answer 18

When making a fist, the distal phalanx of the injured finger does not flex with the others

Question 19

What is mallet finger and what causes it?

Answer 19

Extended finger is forcefully flexed and the extensor tendon ruptures (common volleyball injury)

Question 20

Presentation of mallet finger?

Answer 20

Tip fo the affected finger remains flexed when the hand is extended (resembles a mallet)

Question 21

Rx jersey and mallet finger?

Answer 21

Splinting (first-line)

Question 22

Rx traumatically amputated digits?

Answer 22

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

Question 23

Lumbar disk herniation occurs almost exclusively at what spinal levels?

Answer 23

L4-L5 or L5-S1

Question 24

The peak age of incidence of lumbar disk herniation is ___.

Answer 24

45-46

Question 25

Presentation of lumbar disk herniation?

Answer 25

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.

Question 26

Dx lumbar dik herniation?

Answer 26

MRI

Question 27

Management of lumbar disk herniation?

Answer 27

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

Question 28

Presentation of cauda equina syndrome?

Answer 28

Distended bladder
Flaccid rectal sphincter
Perineal saddle anesthesia

Question 29

Management of cauda equina syndrome?

Answer 29

Surgical emergency requiring immediate decompression

Question 30

Presentation of ankylosing spondylitis?

Answer 30

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

Question 31

Dx anklyosing spondylitis?

Answer 31

X-rays with bamboo spine

Question 32

Rx ankylosing spondylitis?

Answer 32

Anti-inflammatory agents

Physical therapy

Question 33

___ should be suspected in the elderly who have progressive back pain that is worse at night and unrelieved by rest or positional changes.

Answer 33

Metastatic malignancy

Question 34

Dx metastatic malignancy?

Answer 34

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)

Question 35

Presentation of diabetic ulcers?

Answer 35

Typically indolent, located at pressure points (heel, metatarsal head, tip of toes)

Question 36

Diabetic ulcers start because of ___, and they fail to heal because of the ___.

Answer 36

Neuropathy; microvascular disease

Question 37

Management of diabetic ulcers?

Answer 37

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

Question 38

Presentation of ulcers from arterial insufficiency?

Answer 38

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)

Question 39

Work-up of ulcers from arterial insufficiency?

Answer 39

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

Question 40

In the evaluation of chronic foot ulcers, what work-up is done in general?

Answer 40

Work-up for both DM and arteriosclerotic occlusive disease (both problems often coexist in the same patient)

Question 41

Presentation of venous stasis ulcers?

Answer 41

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

Question 42

Rx venous stasis ulcers?

Answer 42

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

Question 43

What is a marjolin ulcer?

Answer 43

Squamous cell carcinoma of the skin developing in a chronic leg ulcer

Question 44

Classic presentation of a marjolin ulcer?

Answer 44

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

Question 45

Dx and Rx marjolin ulcer?

Answer 45

Biopsy is diagnostic; wide local excision and skin grafting are done

Question 46

Presentation of plantar fasciitis?

Answer 46

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.

Question 47

Management of plantar fasciitis?

Answer 47

Spontaneous resolution can be expected in 12-18 months, during which time symptomatic treatment is offered; removal of the spur may help

Question 48

What is a morton neuroma?

Answer 48

Inflammation of the common digital nerve at the third interspace, between the third and fourth toes

Question 49

Presentation of morton neruoma?

Answer 49

Palpable as a very tender spot between the 3rd and 4th toes

Question 50

Cause of morton neuroma?

Answer 50

Use of pointed, high-heeled shoes (or cowboy boots) that force the toes to be bunched together

Question 51

Rx morton neuroma?

Answer 51

Conservative management with analgesics and more sensible shoes; surgical excision can be done

Question 52

Presentation of gout?

Answer 52

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

Question 53

Dx gout?

Answer 53

Uric acid crystals in the joint fluid

Question 54

Rx gout?

Answer 54

Acute attack - indomethacin and colchicine

Chronic control - allopurinol and probenicid