Exam 2 - Ortho (need to know) Flashcards
Causes of lower back pain
- Cumulative trauma disorders
- Repetitive strain injuries
- Repetitive motion injuries
Lower back pain: physical exam components
- Mechanical pain aggravated by activity
- Pain relieved with lying down
- Pain may radiate to one or both buttocks
- Lumbar or sacroiliac tenderness
- ROM tenderness with turning or bending
Lower back pain: diagnostic testing
- Straight leg test
- Axial stimulation
- MRI
- Labs
What is the straight leg raise test?
Passive test - assesses damage from L5 to S1
- Raise straight leg to 70-90 degrees of hip flexion
- If pain produced at any point when the leg is in 20-70 degrees, the test is positive
Lower back pain: treatment
If patient has stable pain -
- Rest
- Ice to affected area 3-4 times/day
- Compression (back brace)
- Heat after 2-3 days, 3-4 times/day
- PT
- NSAIDs (naproxen, ibuprofen), muscle relaxers
Lower back pain: treatment when pain is due to trauma or has associated neurological changes
Referral to ER for evaluation
Lower back pain: treatment when pain is chronic, disabling, or shows no improvement
- Refer to pain management
- Refer to orthopedics
Criteria suggesting need for imaging of back pain
- Bowel/bladder dysfunction
- New onset of erectile dysfunction
- Fevers or night sweats (suggestive of infection or malignancy)
- Unintentional weight loss
- Night pain
- Personal history of cancer
- Saddle anesthesia
- History of recent trauma (fall or direct blow)
- NOT twisting or lifting
- Age >50 or <18
- Patient with current or recent use of steroids
- Any suspicion of an infectious or neoplastic cause
- Pain for >6 weeks
What does a positive straight leg raise test indicate?
Nerve root impingement from herniated disk (e.g. sciatica)
What does the empty can test assess for?
Shoulder function
Empty can test technique
- Have patient hold out affected arm as if offering examiner a can of soda (abduction to 90 degrees)
- Have patient turn arm to empty the contents (internal rotation)
What indications would the provider suspect if there is pain with the empty can test? Weakness?
Pain = rotator cuff tendinitis
Weakness = tear
What is epicondylitis? What causes it?
Inflammation at the tendon origin
Cause:
- Repetitive strain injury
- Repetitive motion injury
- Heavy lifting, hammering, screwing, gripping
Epicondylitis: physical exam findings
- Lateral and medial
Lateral - pain reproduced by resistive wrist extension
Medial - pain reproduced by resistive wrist flexion
Medial versus lateral epicondylitis
Lateral: “tennis elbow”, radial tunnel and posterior nerve syndrome
Medial: “golfers elbow”, ulnar collateral ligament injury
Epicondylitis: diagnostic testing
- Lateral elbow pain with passive wrist flexion and active wrist extension = lateral
- Pain with resisted wrist flexion, forearm pronation, and passive wrist extension = medial
Epicondylitis: treatment/management
- Oral or topical NSAIDs
- Tennis elbow splint
- Exercises - “palms up”, toning of wrist extensors
- Cortisone injections if conservative measures fail
- Ortho referral if treatment continues to fail
What is ulnar neuritis?
Cubital tunnel syndrome - compression of ulnar nerve causing numbness or tingling in nerve’s distribution
Patient presentation: ulnar neuritis (cubital tunnel syndrome)
- Tenderness of ulnar groove
- Sensory loss of fifth digit
- Diminished motor strength of fourth and fifth digits
- Positive Tinel sign
- If severe, forearm motor weakness and muscle atrophy
Ulnar neuritis: diagnostic studies
EMG
Ulnar neuritis: management
- PRICE
- Elbow pads, wrist-elbow splint, support in neutral position
- Oral or topical NSAIDs
- PT
- Referral to orthopedics (conservative measures rarely effective)
What factors has been associated with the development of septic olecranon bursitis?
- Male gender
- Manual labor
- Certain sports
- Military population
Presentation of septic olecranon bursitis
- Tenderness
- Erythema
- Warmth
Risk factors for developing septic olecranon bursitis
- Diabetes
- Immunocompromised
- Alcoholism
- Psoriasis
- Crystalline disease (e.g. gout and pseudogout)
- RA
Septic olecranon bursitis management
- Fluid for culture
- Start antibiotics to cover s. aureus
What are ganglion cysts of the wrist?
Fluid filled sacs that appear, disappear, or change in size
- Occur around joints, tendon sheaths
- Most commonly in dorsal carpal area and volar surface of wrist
Wrist ganglion cyst: symptoms
- Pain with activity or pressure
- Weakness
- Bone changes
- Interfering with joint function
Ganglion cyst: physical exam findings
- Smooth and rubbery
- Translluminate with light
- Pain may or may not be present with palpation
Imaging for ganglion cysts
- X-ray (to r/o fracture, dislocation, bony abnormality)
- Ultrasound
- MRI
Ganglion splint: treatment/management
- Splinting/immobilization
- Aspiration
- Surgical excision
What is de quervain tenosynovitis?
Painful inflammation of abductor pollicis longus and extensor pollicis brevis tendons along dorsal aspect of wrist
De quervain tenosynovitis: risk factors
- Women aged 30-40 (especially postpartum r/t care of newborn)
- Motions: pinching, lifting, wringing, grasping, activities such as gardening and knitting
De quervain tenosynovitis: diagnostic testing
History and physical exam
- Finkelstein test
De quervain tenosynovitis: treatment/management
- Rest, ice
- Immobilization (splints or braces)
- NSAIDs
- PT
- Cortisone injections
- Surgery
What is carpal tunnel syndrome?
Caused by compressive neuropathy of median nerve
Carpal tunnel syndrome: symptoms
- Burning, tingling, numbness of palm, thumb or index and middle fingers
- Hand weakness
- Shock-like sensation
Carpal tunnel syndrome: risk factors
- Repetitive maneuvers
- Obesity
- Pregnancy
- Female gender
- Systemic disease (DM, hypothyroidism)
Carpal tunnel syndrome: diagnostic studies
Tinel sign, phalen test
- EMG
- X-ray
- Ultrasound
- MRI
Carpal tunnel syndrome: treatment/management
- Splinting in neutral position (esp at night) to prevent provocative maneuvers
- NSAIDs
What classification of medications can be given to patients if they have muscle spasms associated with neck pain?
Muscle relaxants
- Tizanidine
- Cyclobenzaprine
- Baclofen
What is trochanteric bursitis? What makes it worse?
Pain over the greater trochanter or ischial spines
- Worse with activities, lying on the affected side, hip rotation
- May have associated swelling, redness, warmth
Trochanteric bursitis: causes
- Injuries
- Overuse
- Incorrect posture
- Previous surgeries (total hip replacement)
- Other conditions: RA, OA, gout, runners
Trochanteric bursitis: components of physical exam
- Hip, back, knee, abdomen, vascular, neurological
- Gait analysis and stance assessment
- ROM
- Hip flexion and rotation can ilicit pain
Trochanteric bursitis: treatment/management
- NSAIDs
- PT
- Cortisone injections (limit to 3 times/year)
- Surgery for OA, joint infection, avascular necrosis, progressive loss of function or refactory pain
What is Osgood-Schlatter disease?
Microtrauma in the deep fibers of the patellar tendon at its insertion on the tibial tuberosity
- Often seen in adolescents after patient has undergone growth spurt
- Tendon pulling on growth place of the shinbone (tibia)
Osgood-Schlatter disease: symptoms
- Recent physical activity (soccer, football, running)
- Pain increases during and immediately after activity
- Running, jumping, kneeling, squatting, going up/down stairs makes pain worse
Osgood-Schlatter disease: physical exam findings
- Pain reproduced by extending knee against resistance, stressing quads, squatting with knees in full flexion
- Focal swelling, heat, point tenderness at tibial tuberosity
- Full ROM of knee
Osgood-Schlatter disease: diagnostic studies
History and physical exam
Osgood-Schlatter disease: treatment/management
Self-limiting, symptom management
- Rest, avoid activities that cause pain
- Ice
- Knee brace and NSAIDs or acetaminophen
- PT
What is slipped capital femoral epiphysis (SCFE)?
Salter-Harris type I fracture through proximal femoral physis
- Stress around hip causes sheer force to be applied to growth plate
- Intrinsic weakness in physeal cartilage
SCFE: risk factors
- Onset of puberty (adolesence)
- Overweight/obese
- Male gender (skeletally immature)
- African American, Pacific Islander, latinos
- History of radiation therapy or trauma
SCFE: physical exam findings
- Pain in groin or diffusely over knee or anterior thigh
- Pain and decreased internal rotation
- Limp with short leg component, externally rotated while walking
- Unstable SCFE, unable to bear weight
SCFE: diagnostic studies
X-ray
SCFE: treatment/management
Aimed to prevent further slippage by stabilizing epiphysis and avoiding complications
- Immediate referral to orthopedic surgeon
- Non weight bearing, bed rest
ACL injuries: history, mechanism of injury
Most commonly injured in sports during rapid deceleration or quickly changing directions
- Twisting or hyperextension while foot is planted and knee extended
- Report of a “popping”, knee shifting, pulling apart
ACL injuries: clinical findings
- Swelling/effusion and pain
- Instability with lateral movement
- Autonomic symptoms (dizziness, sweating, faint)
ACL/PCL injuries: diagnostic studies
ACL - Lachman and anterior drawer test
PCL - posterior drawer test
ACL injuries: management
- Following injury, knee brace or immobilizer until swelling and pain subsides
- Rest, ice
- NSAIDs
How would the provider perform the Lachman test to assess ACL injuries?
- Knee flexed to about 15-30 degrees
- One hand below the knee on posterior and other on anterior aspect of femur
- Lift lower leg while pushing down on upper leg
- If ACL intact, after few mm of movement examiner should feel a “knock” or firm “stop” as ACL prevents tibia from sliding forward
How would the provider perform the anterior drawer test to assess for ACL injuries?
- Knee flexed to 90 degrees with foot kept flat
- Sit on patients foot and grasp lower leg
- Place fingers above popliteal space and thumbs on tibial tuberosity
- Pull on tibia attempting to slide it foward
- “Soft” or absent endpoint indicates tear
Meniscus injuries: symptoms
- Popping ‘sensation’
- Pain
- Swelling
- Stiffness
- Difficutly straightening the knee
- Knee locking or buckling
Meniscus injuries: causes
- Twisting or deep bending
- Sports
- Degenerative changes (wear and tear)
Meniscus injuries: diagnostic studies
- Thessaly test
- McMurray test
How would the provider perform the McMurray test to diagnose meniscus injuries?
- Patient lies supine with legs straight
- Place one hand on heel/ankle and the other on knee joint
- Flex knee while rotating tibia internally and externally on femur
- Apply valgus stress on lateral side of knee
- Hold valgus stress while extending leg and palpating medial joint line
- If click or pop heard/felt, medial meniscus torn
What is patellofemoral pain syndrome (runner or jumper’s knee)?
Most common overuse injury of the knee
- Knee pain that is localized to the anterior portion of the knee, around, and behind the patella
Which patient populations is patellofemoral pain syndrome most common?
- Women
- Young active athletes
- Runners
Patellofemoral pain syndrome: causes
- Abnormal tracking of the patella related to weak quadriceps
- Poor flexibility
- Patellar hypermobility
- Tight iliotibial band
- Anatomic malalignment
- Overuse
Patellofemoral pain syndrome: symptoms
- Bilateral knee pain that is limited to anterior portion of knee
- Pain worse with squatting, kneeling, climbing stairs, hill running
- Feeling like knees are “giving out”
- Cracking or popping sounds
Patellofemoral pain syndrome: physical exam components
- Gait observation
- Palpation while sitting
- Orthopedic tests: patellar compression-grind, patellar tilt, patellar glide (elicits pain)
- May have lateral tracking of patella when in seated position
Patellofemoral pain syndrome: management
- RICE
- Orthotics
- NSAIDs
- PT
What is a popliteal cyst?
Also known as a Baker cyst - inflammatory and degenerative disorder of the knee
- Cause of knee pain
What conditions are popliteal cysts (Baker cysts) associated with?
- RA
- OA
- Internal derangements of the knee
Are popliteal cysts (Baker cysts) dangerous?
Benign condition
- As cyst increases, possibility of rupture increases
- Ruptured cyst can drain into calf causing pain, erythema, swelling
- Mimics phlebitis
Popliteal cyst (Baker cyst): imaging
Ultrasound to determine location/extent of cyst
What is plantar fascitis?
Plantar fascia becomes irritated from overuse, trauma, shoes with poor arch support
- Individuals with flat or cavus feet are vulnerable
Plantar fascitis: symptoms
- Pain with weight bearing first thing in the morning or after rest periods
- Pain in bottom of foot, along arch, in heel
- Pain with standing for long periods, rising up on toes
Plantar fascitis: physical exam findings
Point tenderness at insertion of fascia to calcaneus
Plantar fascitis: treatment/management
- Rest from high-impact activities (first line)
- Supportive shoes/inserts (arch support)
- NSAIDs and ice massage
- Stretches
- Weight loss
If doesn’t respond to conservative therapy, refer to ortho or podiatry
What is morton neuroma?
Perineural fibrosis of plantar nerve at point where medial and lateral branches of plantar nerve converge
Morton neuroma: risk factors
- Middle aged women (wearing high heels)
- Trauma
- Ischemia
- Impingement
- Intermetatarsal bursitis
- Conditions such as claw toes and bunions
Morton neuroma: symptoms
- Severe pain and burning in third webspace (between 2nd and 3rd toes)
- Aggravated by foot elevation
- Relieved by going barefoot and undergoing foot massage
Morton neuroma: physical exam findings
- Point tenderness and edema over third webspace (between 3rd and 4th metatarsal)
-
Mulder sign
- Compression of medial and lateral side of foot with one hand and squeezing 3rd and 4th metatarsal bones with the other
- Will hear palpable or audible click
Morton neuroma: treatment/management
- Wear wider toed shoes, insole adjustments, separate toes with small pads
- NSAIDs
- Cortisone injections (short term)
