Clin Med: MSK 2 - Upper Body Flashcards
Define Orthopedics
branch of surgery concerned w/ conditions involving the musculoskeletal system
Define Sports Medicine
a branch of medicine that deals w/ physical fitness & the tx & prevention of injuries related to sports & exercise
Define Rheumatology
Branch of medicine devoted to the diagnosis & therapy of rheumatic diseases
Osteoarthritis affected joints
- knees
- hips
- hand
- spine
Osteoarthritis RFs
- older Age
- female Gender
- Obesity
- Occupation
What forms during the different stages of Osteoarthritis?
- Narrowed joint space (loss of cartilage)
- Osteophytes
- Fissures in the cartilage
Osteoarthritis Dx
X-ray–> joint loss space, osteophytes, subchondral bone cysts, bone sclerosis
Osteoarthritis Tx
- Acetaminophen (NO pts w/ liver dz)
- NSAIDS (use caution in the elderly- GI bleed & CV risk & kidney dz)
—> Ibuprofen, Naproxen, Diclofenac, Meloxicam, Cox-2 inhibitors, Topical NSAIDS - Joint injections
–> Corticosteroid
–> Sodium hyaluronate - Glucosamine/chondroitin
- Joint replacement
- Avoid high impact exercises
Causes of spine pain
- injuries or trauma
- neoplasm
- infection
- degeneration
- overuse
What is radicular pain/radiculopathy?
- Pain that originates in a nerve root & radiates along a dermatome
- Dermatome: area of skin supplied by a specific nerve
- Pain + paresthesias
What is myelopathy?
an injury to the spinal cord due to severe compression that causes more severe symptoms
What is a strain?
a stretch or tear in muscle or tendon
What is a sprain?
a stretch or tear in ligament
Red flag that would suggest life threatening condition instead of mechanical neck pain?
- numbness
- tingling
- difficulty moving
Mechanical Neck Pain Dx
How do you know if you need x-rays?
- For acute injury: NEXUS or Canadian C-spine rule
- For chronic pain: usually no x-ray needed
- MRI if neurologic deficits or if pain not improved after 4-6wks of conservative therapy
- X-ray may show straightening of the cervical spine due to muscle spasm
Who can we use the NEXUS criteria for?
pts under 65 yo to rule out spinal injury
Describe NEXUS criteria
- No posterior midline tenderness
- No evidence of intoxication
- Normal level of alertness
- No focal neurologic deficit
- No painful distracting injuries
** YES to all these NO IMAGING**
Who automatically gets imaging according to Canadian C-spine Rule?
- > /= 65
- dangerous mechanism
paresthesias
Canadian C- spine criteria
less than 65yo, has safe ROM, able to rotate neck actively
YES to all these NO IMAGNIG
Mechanical Neck Pain: what do we know about treatment
- early motion is good
- NO OPIATES
- NO cervical collars
Mechanical Neck Pain Tx
- Decr irritants
- Proper posture
- Gentle ROM
- NSAIDS
- +/- Muscle relaxers
- Opiates
- PT
- Acupuncture
- Massage therapy
Torticollis Tx
- muscle relaxers
- botulinum toxin
Cervical Spine fracture Imaging?
CT
Cervical spine fractures Tx
surgery (neuro)
When do we used the Spurling test?
To test cervical disc herniation
Describe the Spurling test?
- neck extended w/ head rotated to affected shoulder while axially loaded
- shoulder or arm pain suggests cervical spinal nerve root compression
Describe disc herniation is C4-C5
- root injured:
- weakness:
- numbness:
- root injured: C5
- weakness: deltoid
- numbness: shoulder
Describe disc herniation is C5-C6
- root injured:
- reflex:
- weakness:
- numbness:
- root injured: C6
- reflex: biceps
- weakness: biceps brachii
- numbness: thumb
Describe disc herniation is C6-C7
- root injured:
- reflex:
- weakness:
- numbness:
- root injured: C7
- reflex: Triceps
- weakness: wrist extensors (wrist drop)
- numbness: 2nd & 3rd digits
Describe disc herniation is C7-T1
- root injured:
- weakness:
- numbness:
- root injured: C8
- weakness: Hand intrinsics
- numbness: 4th & 5th digits
When do we used the Straight leg raise?
to test for lumbar disc herniation
Describe the straight leg raise.
- with pt in supine position & legs straight, elevate affected leg by the heel slowly w/o rotation of hip or abduction or adduction of the leg
test (+) if radiating pain in affected leg reproduced at 30-70 degrees of hip flexion
Disc herniation Dx
MRI
General Disc Herniation Tx
Conservative management
- Oral analgesics
- short course steroids
- avoid provocative activities
- PT w/ exercise & gradual mobilization
- cervical tractions
Epidural steroid injection (via fluoroscopy)
Indications for surgery in cervical disc herniation
- S/S of cervical radiculopathy (ie, nerve root dysfunction, pain, or both)
- Evidence of cervical nerve root compression by MRI
- Progressive motor weakness
Indications for surgery in lumbar disc herniation
- cauda equina syndrome
- severe & progressive neurologic deficits
- no improvement after 6 wks of conservative tx if nerve root compression on MRI
Spondylolysis/Spondylolisthesis
Dx:
- X-ray
- MRI if more info needed on soft tissues or if dx unclear
Spondylolysis/Spondylolisthesis Tx
- rest
- NSAIDS
- PT
- Surgery if no improvement w/ conservative tx
Spinal stenosis Dx
MRI
Spinal Stenosis Tx
- Conservative:
–> Oral analgesics
–> Avoidance of provocative activities
–> PT w/ exercise & gradual mobilization - Epidural Corticosteroid Injections
- Surg if conservative tx fails
Incidence of spinal epidural abscesses appears to be rising due to higher rates of:
- Incr rates of spinal anesthesia
- spinal surg & other interventions
- use of indwelling IV catheters & assoc. bloodstream infxs
- IV drug use*
- iatrogenic immunosuppression
4 stages of Epidural abscess
- Stage 1: back pain, fever, & local spine tenderness
- Stage 2 spinal irritation, including radicular pain, hyperreflexia & nuchal rigidity
- Stage 3 the bowel & bladder, w/ symp of fecal or urinary incontinence, also neurologic deficits such as motor weakness
- Stage 4, paralysis
What does a neuro exam consist of?
check motor & sensation, rectal tone, saddle anesthesia, reflexes
What % of people will have 3 ER visits before Dx
75%
Epidural Abscess Dx
- MRI w/ gadolinium (contrast) - test of choice
- CBC (incr WBC & ESR), CRP, blood cultures
Epidural Abscess Tx
- Start BSAbx STAT (after blood cultures)
- Consult neurosurgery
- Conservative tx: abx only or abx & CT guided drainage
- Surg tx: laminectomy w/ evacuation of abscess
RFs for vertebral osteomyelitis
- immunosuppression
- DM
- hepatic dz
- renal failure req hemodialysis
- coronary heart dz
- malignancy
- IV drug use
- prior surgical procedures (including spine surgery & organ transplantations)
Discitis Dx
- MRI most sensitive
- CBC, CRP, blood cultures
Discitis Tx
- IV Abx typically for 2-6 weeks
- May req. surgery if…
–> Not responding to IV Abx (track w/ ESR/CRP)
–> Assoc. w/ hardware - Surg includes debridement of any infected soft tissue & bone
Transverse Myelitis Dx
MRI of entire spine w/ & w/o IV gadolinium
- Labs to assess for autoimmune or infectious dz
- CSF analysis
Transverse Myelitis Tx
- stop progression & accelerate resolution
- new-onset myelitis –> admit for observation & management
Meds: - High dose steroids
- Immunosuppressive drugs
- Tx underlying condition
Define acute low back pain
nonspecific pain lasting <4 wks
Define subacute pain
lasts 4 - 12 wks
Define chronic low back pain
pain lasting >12 wks
Low back sprain/strain RFs
- age > 30 years
- physical inactivity
- obesity
- arthritis
- osteoporosis
- pregnancy
- smoking
- psychosocial factors, including
- stress or depression
- occupational factors
- poor posture
Low back sprain/strain Dx
- no red flags–> conservative tx for 4-6 wks w/o imaging
- X-ray may be obtained 1st, but MRI is the imaging of choice when conservative tx fails
Low back sprain/strain red flag symptoms
- s/s of cauda equina syndrome
- fecal incontinence or saddle anesthesia
- neurologic deficits
Low back sprain/strain conservative Tx
- Heat
- Massage
- Acupuncture
- Spinal Manipulation
- Exercise & PT
Low back sprain/strain pharm Tx
- NSAIDS
- APAP (limited utility)
- Muscle relaxers
- Opiates (limited utility)
Sciatica nerve root L4 involvement suggested by…
- weak quadriceps extension
- positive squat & rise test
- diminished knee-jerk reflex
Sciatica nerve root L5 involvement suggested by…
- weak dorsiflexion of great toe & foot
- impaired heel walking, foot drop
Sciatica nerve root S1 involvement suggested by…
- weak plantar flexion of great toe & foot
- impaired toe walking
- diminished ankle-jerk reflex
Sciatica Dx
- Further dx testing recommended if radicular pain & any of the following:
- incapacitating pain > 2 wks
- advancing neurologic symptoms
- no symptom improvement after 6 wks of conservative tx (reassurance, edu, analgesics, heat, activity, exercise, etc)
- MRI is the test of choice
Sciatica Conservative Tx
Conservative management:
- Heat
- Exercise as tolerated
- NSAIDS
- Muscle relaxers
- Opiates (lowest effective dose, 2 wks max)
- Epidural injections
Sciatica Surg referral if…
- progressive or moderately severe neuromotor deficit, such as foot drop or functional muscle weakness
- persistent neuromotor deficit after 4-6 wks of conservative tx
- uncontrolled radicular pain w/ defined lesion on imaging
Most sciatic pain resolves w/n
2-4 weeks
Most herniations that cause sciatica regress or reabsorb by__ weeks after symptom onset
8 weeks
Describe a wedge fracture
- compression of the anterior segment of the vertebral body
- usually occur in the midthoracic or lumbar region of the spine
Describe a biconcave/concave fracture
collapse of the middle portion of vertebral body, while the anterior & posterior walls remain intact
Describe a burst (crush) fracture
- collapse of entire vertebral column, including anterior, posterior & central elements
- assoc. w/ high-energy trauma, (MVA, fall from great height, or sports trauma)
Thoracolumbar Compression Fracture Dx
- X-rays–> thoracic & lumbar spine
- burst fracture may req CT
- MRI’s usually not needed
- If pt doesn’t have an underlying dz &there is a wedge fracture, be sure to consider osteoporosis or cancer
Thoracolumbar Compression Fracture Tx
- Pain management & manage underlying dz
- Refer to spine surgeon
- Observation if neurologically intact (in wedge fractures)
- May req kyphoplasty or percutaneous vertebroplasty (biconcave)
- Bracing
Cauda Equina Syndrome: Stage 1
bilateral radicular pain
Cauda Equina Syndrome: Stage 2 (incomplete)
urinary difficulties, including:
- altered urinary sensation
- loss of desire to void
- weak urinary stream
- need to strain to micturate
Cauda Equina Syndrome: Stage 4 (complete)
- Bowel & bladder incontinence
- Saddle anesthesia
- Loss of rectal tone
Cauda Equina Syndrome: Stage 3 (retention)
painless urinary retention & overflow incontinence where the bladder is no longer under executive control
Cauda Equina Syndrome Dx
MRI
Cauda Equina Syndrome Tx
- Urgent neurosurgical consult
- Surgical lumbar decompression
–> The sooner, the better
–> Must be done w/n 48 hrs
Conus Medullaris Syndrome Tx
urgent surgical decompression
Conus Medullaris Syndrome Dx
MRI
Scoliosis causes:
- Idiopathic (80%)
- Congenital
- Neuromuscular (Cerebral palsy, spina bifida)
- Syndromic (Genetic syndromes like Marfans)
Scoliosis Dx
- X-ray C7 to iliac crest w/ pt standing
- Lateral curvature (Cobb Angle) > 10 degrees is diagnostic
Scoliosis Tx
- Observe for curves < 25 degrees
- Bracing for 25-45 degrees
- Surgery if over 45 degrees
Function of the rotator cuff
stabilize shoulder & allow for extensive ROM
What are the joints of the shoulder?
- Scapulothoracic joint
- Sternoclavicular
- Acromioclavicular
- Glenohumeral
Rotator Cuff Syndrome/Tear Dx
- initial imaging–> x-ray
- definitive dx–> MRI
What provocative tests are used in suspected Rotator cuff syndrome/tear?
- Hawkins Impingement
- Neer Impingement
- Empty Can
- Drop arm test
Rotator Cuff Syndrome/Tear initial non-operative Tx
- Pts w/ partial thickness tears
- Older pts w/ full-thickness tears but lower demands
- Activity modification for 1-2 wks (don’t immobilize the shoulder)
- NSAIDS
- PT
Rotator Cuff Syndrome/Tear operative Tx
- Partial thickness tear & no improvement for 3-6 months
- Pts w/ significant functional deficit & full thickness tear
Shoulder Dislocations Tx
- Reduction w/ post reduction films
- immobilizer for 1-3 weeks
- Can then assess for soft tissue injury
- PT for shoulder instability
Adhesive Capsulitis Tx
Non operative tx:
- tx of choice: PT, ROM exercises
- If that fails, a manipulation under anesthesia may be performed
Biceps Tendon Rupture Dx
Clinical
- MRI if complicating factors
Biceps Tendon Rupture Tx
- Proximal tendon rupture: usually conservative tx: NSAIDS & PT
- Distal tendon rupture: surgical referral required
Clavicle Fracture Dx
X-ray
Clavicle Fracture Tx
- Sling for 3-4 weeks, then gentle ROM exercises
- Comminuted mid & proximal clavicle fractures may req ORIF
AC Joint Separation Type I & II Tx
- Brief sling immobilization, rest, ice, PT
AC Joint Separation Type III Tx
- Surg if athlete or if req for occupation
- If failed conservative tx
AC Joint Separation Type IV & V
Surg
Thoracic Outlet Syndrome Dx
- Clinical
- Imaging Studies
–> CXR IDs presence of cervical rib
–> MRI w/ arms held in different positions - Angiography confirms intra-arterial or venous obstruction
Thoracic Outlet Syndrome Tx
- analgesic therapy(NSAIDs, muscle relaxants, antidepressants, SSRIs)
- PT
- anticoag/thrombolysis
- surg to remove compressive structure
Scapula Fractures Dx & Tx
- X- ray
- Usually tx non surgically (sling, ice, analgesia)
Proximal Humerus Fractures Dx
- X-ray
- May need CT to further characterize fracture & operative planning
Proximal Humerus Fractures Tx
- Most are handled conservatively- sling, ice, analgesia
- early ROM
- displacement or comminuted = surg
Humeral Shaft Fracture Dx
- X-ray
- always include joint above injury & joint below
Humeral Shaft Fracture Tx
- Most tx non operatively
–> Coaptation splint followed by brace - Surgery if….
–> Severe angulation
–> Open fracture
–> Nerve or vascular injury
Supracondylar Fractures Dx
x-ray
Supracondylar Fractures Tx
- Non-displaced fractures w/ no neurovascular compromise can be casted (long arm cast)
- Any displacement or non-displaced w/ neurovascular compromise req urgent closed reduction as percutaneous pinning
Lateral Epicondylitis Dx
Clinical
Lateral Epicondylitis Tx
Conservative tx:
- Rest, Ice, NSAIDS, “tennis elbow brace”, PT
- Corticosteroid injections
- Surg if pain doesn’t resolve after 6-12 mo
–> Damaged tendon removed & healthy tendon anchored to bone
Medial Epicondylitis Dx
clinical
Medial Epicondylitis Tx
Conservative tx:
- Rest, Ice, NSAIDS, “tennis elbow brace”, PT
- Corticosteroid injections
- Surg if pain doesn’t resolve after 6-12 mo
–> Damaged tendon removed & healthy tendon anchored to bone
Olecranon Bursitis Dx
- imaging if injury
- if septic bursitis suspected:
–> Aspirate bursa& send fluid
*Gram stain & culture
*CBC w/ diff
*crystal analysis - obtainblood tests, including
–> CBC w/ diff
–> CRP/ESR
Aseptic Olecranon Bursitis Tx
initial tx
- rest, ice, compression & elevation
- activity mod & elbow protection
- NSAIDs
- needle aspiration w/ compression wrap
- If conservative tx fails, can do steroid injection
- If all else fails, bursectomy
Septic Olecranon Bursitis Tx
- drainage of bursa fluid + systemic Abx
–> empiricabxafter bursa fluid for C&S (MRSA or staph)
–> IV Abx if severe, or if signs of systemic illness, or if oral tx fails
Elbow Dislocation Dx
x-ray
Elbow Dislocation Tx
- Closed Reduction w/ post reduction films
- Posterior Long Arm Splint for 3 days, then gentle ROM & PT
Nursemaid Elbow Dx
based on classic presentation
Nursemaid Elbow Tx
- Closed reduction w/ post reduction films
- If recurrent, refer to pediatric ortho
Radial Head Fracture Dx
x-ray
(anterior & posterior fat pad)
Radial Head Fracture Tx
- Adult pts w/ a (+) fat pad sign & traumatic elbow pain should be tx having a nondisplaced radial head fracture, despite no fracture on x-ray
- Almost all pts can be managed as outpt
–> Posterior Long Arm Splint - Surg if displacement
Both Bone Forearm Fractures Tx
Depends on angulation
Cubital Tunnel Syndrome Dx
EMG: electromyography, a nerve conduction test
Cubital Tunnel Syndrome Tx
- NSAIDS
- Elbow pad
- If conservative tx fails, surg
–> the nerve is repositioned
Carpal Tunnel Syndrome Dx
clinical
EMG to confirm
Carpal Tunnel Syndrome Tx
Conservative tx first
- NSAIDS
- Wrist splint (esp at night)
–> Cockup splint
- Decr provocative activity
Steroid injection
Surgery
DeQuervain Syndrome Dx
clinical based on Finkelstein test
DeQuervain Syndrome Tx
Conservative tx:
- Thumb Spica splint
- Avoid provocative movements/lifting
- Steroid Injection
- Surgery (rarely needed)
Scaphoid Fracture Dx
x-ray
Scaphoid Fracture Tx
- If non-displaced, immobilization 6 wks
- Imaging obtained at 6 wks & if not healed, another 6 wks of immobilization
- If displaced, surg
- If high suspicion of fracture (+) snuffbox, but x-ray (-), immobilize & recheck x-ray in 10-14 days
Scapholunate Dissociation
x-ray will show widening
Scapholunate Dissociation Tx
- splinting
- may req surg, referral
Colles Fracture Dx
x-ray
Colles Fracture Tx
Stable frax (< 20 degrees angulation, not displaced, not intraarticular)–> tx w/ immobilization
- Unstable frax (angulated, intraarticular, or displaced)–> req immediate reduction/immobilization & poss surg
Smith Fracture Dx
x-ray
Smith Fracture Tx
Stable frax (< 20 degrees angulation, not displaced, not intraarticular)–> tx w/ immobilization
- Unstable frax (angulated, intraarticular, or displaced)–> req immediate reduction/immobilization & poss surg
Mallet finger Dx
X-ray
Mallet finger Tx
- Finger splint- full extension 6-8 wks
- Surgery if significant displacement
Boutonniere Deformity Tx
- Finger splint- full extension 6-8 wks
- Surgery if displaced
Gamekeepers Thumb Dx
Imaging not usually indicated, but MRI may be used if conservative treatment fails
Gamekeepers Thumb Tx
- Immobilization in cast or splint
- Surgery if joint very unstable
Boxer’s Fracture Dx
X-ray
Boxer’s Fracture Tx
- minimal angulation–> immobilization
- mod angulation–> closed reduction & splinting
- severe angulation–>ORIF
Thumb Fractures Dx
x-ray
Thumb Fractures Tx
- depends on severity and intraarticular involvement
Thumb spica splint/cast
Surgery
Phalangeal Fractures
x- ray
Phalangeal Fractures Tx
- Depends on angulation, articular involvement
- Splinting (finger splint w/ buddy taping)
- Surgery
–> Closed reduction/pinning
–> ORIF
Phalangeal Dislocation Dx
x-ray
Phalangeal Dislocation Tx
reduce & splint
Metacarpal Fractures Dx
x-ray
Metacarpal Fractures Tx
- Tx depends on angle, rotation
–> Splinting
–> Closed reduction then splint
–> Surgery (ORIF, pinning)
Flexor Tendon Injuries Dx
- X-ray: assess for assoc. fracture/FB
- Actual tendon injury is diagnosed based on exam
Flexor Tendon Injuries Tx
- tendon > 60% lacerated = surg req
- < 60%, splint
- These ALWAYS require referral to hand surgery
Trigger Finger Dx
based on S/S & exam
Trigger Finger Tx
- Splint first
- Then steroid injection
- Then surgical release of A1 pulley
Flexor Tenosynovitis Dx
X-rays
can help rule out FB, but of flexor tenosynovitis is clinical
Flexor Tenosynovitis Tx
- Surgery: I&D
- IV antibiotics
- Hand immobilization
NOTE
any hand laceration requires prophylactics ABx
What is Dupuytren’s Contracture often associated with?
Peyronie’s Dz
Dupuytren’s Contracture Tx
Can try ROM exercises but will often require surgery
Felon Tx
bedside I&D, antibiotics
Costochondritis Dx
- Clinical dx of exclusion
- Be sure to rule out other causes of chest pain
–> EKG
–> CXR
Costochondritis Tx
- reassure pt that costochondritis is a benign condition w/ a SL course that may req wks - mos for resolution
- conservative tx is typically recommended & initial options include
–> analgesics
–> local heat or ice compresses
–> limiting or avoiding aggravating activities
Rib Fractures Dx
- CXR, be sure to look for pneumothorax
Rib Fractures Tx
- pain management (NSAIDS, opiates, lidocaine patches, ice)
