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CCFP Version 1 > Fractures + Joint Disorders > Flashcards

Fractures + Joint Disorders Flashcards

1
Q

Common site of stress fractures

A

Tibia
Fibula
Navicular
Femoral Neck
Pars Interarticularis
Talus
Sesamoids
Metatarsals (2nd/3rd)
Medial Malleolus

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2
Q

Ix for stress fractures

A

CT
MRI
Bone scan
FU XR 3 mo

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3
Q

RF for stress fractures

A

Female
Repetitive Activities (sports, running, walking, marching, gymnastics)
Obesity
Osteoporosis
Post-Menopausal
Rheumatoid Arthritis
Corticosteroids Use
Poor Footwear
Previous Inactivity
Previous Stress Fracture

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4
Q

Management of elderly w/ acute mobility change

A

investigate with bone scans + CT before excluding fracture

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5
Q

What are fragility fractures?

A

Fracture that is sustained from a fall from standing height

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6
Q

How to describe a fracture

A

Closed v open
Location
Orientation

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7
Q

Ways of describing location of fracture

A

Epiphyseal: end of bone
Metaphyseal: flared portion of bone at end of shaft
Diaphyseal: shaft of long bone
Physis: growth plate

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8
Q

Ways of describing orientation of fracture

A

Transverse
Oblique (angular)
Spiral (complex, multiplanar, rotation force)
Comminuted (more than 2 fracture fragments)
Intraarticular
Green-stick (incomplete fracture of one cortex)

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9
Q

Early complications of fractures

A

Compartment syndrome
Neurological/ vascular injury
Infection
Fracture blister

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10
Q

Late complications of fractures

A

Mal/ non-union
Avascular necrosis
Osteomyelitis
Heterotrophic ossification
Arthritis

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11
Q

Which fractures may not show up on XR and should be treated anyway?

A

Scaphoid
Elbow
Growth plate
Stress

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12
Q

When do you use a forearm volar slab splint

A

soft tissue injury of hand/ wrist, carpal bone fracture (excluding scaphoid), childhood buckle fracture distal radius)

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13
Q

How to apply a forearm volar slab splint

A

Landmark: distal palmar crease + proximal third of forearm
Stockinette should go 10cm beyond landmarks
Make splint with 10 layers of plaster between landmarks

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14
Q

What is a Toddler’s fracture - mechanism, age, presentation, XR + management

A

Spiral tibial fracture
Mechanism: twisting injury while tripping
Age: 9mo-3y/o
Presentation: limping, inability to wt bear, tenderness at site
XR: repeat in 2 wks as hard to see fracture line, 2 view antero-posterior and lateral and consider internal oblique
Management: immobilisation with short leg back slab - not cast. Remove in 4 wks

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15
Q

When are C spine rules applicable

A

stable pt, GCS 15, injury <48hrs ago, >16y/o, no vertebral dz, no penetrating injury, not pregnant

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16
Q

C spine rules

A

Any high risk factors:

-Age >65
-Dangerous mechanism
- Paraesthesia in extremity

If YES to any = XR

Any helpful factors?
Ambulatory at any time
In a sitting position in ED
Delayed onset of pain
No midline C spine tenderness
Simple rear end collision

If any of these factors present, can assess neck movement.
If none of these factors present, need XR.

Assessing neck: can they actively rotate neck left and right by 45? No = XR
Yes = cleared

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17
Q

Ottawa knee rules

A

Age > 55
Isolated patellar tenderness
Tenderness head of fibula
Inability to flex 90
Inability to wt bear immediately AND in ED

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18
Q

Classification, ix and management of clavicle fractures

A

Allman classification
Ix: anteroposterior + serendipity views
Management: sling for 2-6w, may need surgery for displaced fracture

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19
Q

Mechanism of shoulder dislocation (ant + post)

A

Anterior = abduction, extension, external rotation
Posterior = posterior directed force, electric shock or sz injury

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20
Q

shoulder dislocation - physical findings, ix and management

A

Physical: palpable humeral head in axilla, dimple inferior to acromion laterally, assess for axillary nerve injury
Ix: anteroposterior, scapular Y, axillary XR
Management: XR before and after reduction, sling 1w, PT after 2w

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21
Q

Features on hx of scaphoid fracture + sx

A

FOOSH w/ wrist dorsiflexion + radially deviated, swollen, swelling + pain in anatomical snuffbox. Pain w/ axial pressure on 1st metacarpal bone

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22
Q

Sx of late presentation of scaphoid fracture

A

painful wrist extension, loss of grip

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23
Q

XR - what to order + management of scaphoid fracture

A

XR: anteroposterior, lateral, oblique views)
Management: immobilize wrist in spica short arm cast and re-image
If high clinical suspicion but not confirmed on XR, splint w/ spica cast and repeat XR in 10-14d or bone scan 1-2d after injury

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24
Q

Causes of volar plate injury + place of maximal tenderness. What should you also test when examining?

A

Hyperextension of finger joint, usually PIP
maximum tenderness volar aspect of joint. Test collateral ligaments

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25
Q

Complications + management of volar plate injury

A

Complications: joint instability can lead to gradual hyperextension
Management: splint w/ progressive extension for 2-4wks followed buddy taping

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26
Q

Median nerve distribution

A

1st (thumb), 2nd (index), 3rd (long), and radial 4th (ring) fingers

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27
Q

Signs of carpal tunnel

A

Paresthesia (median nerve distribution)
Nocturnal awakening
Positive Flick Sign
Positive Tinel Sign (over flexor retinaculum)
Positive Phalen Sign
Positive Durkan Compression Test
Decreased Sensation (1st, 2nd, 3rd fingertips)
Decreased Grip Strength
Decreased Opposition Strength
APB Weakness (abductor pollicis brevis)
Thenar Eminence Wasting

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28
Q

Ulnar nerve distribution

A

5th (pinky), and ulnar half of 4th (ring) finger

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29
Q

Ix for carpal tunnel

A

EMG

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30
Q

Rx for carpal tunnel

A

NSAIDs (oral, topical)
Modified Duties (avoid repetitive strain)
Wrist Splinting
Corticosteroid injection
Oral Steroids
Open Carpal Tunnel Release

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31
Q

What is a claw hand?

A

Flexion of the DIPs and PIPs of the 4th and 5th digits with extension of all the MCPs or inability to extend the 4th and 5th digits at the DIPs and PIPs. When asked to open their hand, the patient will present this “Claw Hand” but the patient is able to make a full fist. This is present in ulnar nerve injuries.

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32
Q

What is the benediction sign?

A

Flexion of the DIPs and PIPs of the 4th and 5th digits with extension of all the MCPs or inability to flex the 2nd and 3rd digits at the PIP. When asked to close their hand, the patient will present this “Benediction Sign” and when asked to open their hand, the patient will not be able to extend them either. This is present in median nerve injuries.

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33
Q

Features of dupuytrens contracture

A

Idiopathic
Autosomal Dominant (incomplete penetrance)
Palmar Fibromatosis (progressive fibrosis of palmar fascia)
Flexion Deformaties
Loss of Grip Function
Nodules → Cords → MCP Joint Contracture

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34
Q

RF for dupuytrens contracture

A

Male
Increased Age
Family History
Northern European Ancestry
Smoking
Alcohol Use
Diabetes Mellitus
Chronic Vibration Exposures
Epilepsy

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35
Q

Management of dupuytrens contracture

A

Corticosteroid Injections
Collagenase Injections
Percutaneous and Needle Fasciotomy
Open Fasciotomy

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36
Q

Sx Trigger Finger

A

Locking, clicking or snapping of an extending digit in flexion
Palpable Nodule (over A1 pulley at MCP joints)
Crepitus
Tenderness

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37
Q

Rx for trigger finger

A

Splinting
Physiotherapy
Corticosteroid Injection
Surgical Release (A1 pulley)

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38
Q

Mallet finger

A

Extensor Tendon Injury at DIP joint
Hyperflexion Injury of an Extended DIP (eg: ball strike)
Avulsion Fracture of the Distal Phalanx (can be present)
Finger held in passive DIP flexion
Absent DIP extension
Normal DIP and PIP flexion, normal PIP extension

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39
Q

Rx mallet finger

A

Finger splint in DIP hyperextension x 6 weeks (if patient flexes their finger during any point of this 6 week period, they need to restart treatment period, if not, it can result in a permanent deformity)

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40
Q

Adhesive capsulitis stages

A

Freezing (0-9 months); significant increasing pain with gradual decreased range of motion
Frozen (4-12 months); pain gradually subsides with peaked limitation of range of motion
Thawing (5-24 months); both pain and range of motion gradually return to baseline

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41
Q

Rx for adhesive capsulitis

A

Physiotherapy (it is important that only gentle pain-free range of motion exercises be implemented during the “freezing” stage so that it does not worsen the condition)
Corticosteroid Injections (intra-articular glenohumeral)
Analgesics
Relative Rest and Reassurance
Orthopaedic Referral (Capsular Release)
Distention Arthrogram

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42
Q

Tests to perform on joint aspirate

A

Cell Count
Culture and Sensitivity
Gram Stain
Crystals

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43
Q

Sx thoracic outlet syndrome + positive tests

A

Numbness and tingling in arms + fingers
Weakness in hand grip strength
Pain in neck, shoulder and arm
Adson Test
Roos Test
Morley Test

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44
Q

Rx thoracic outlet syndrome

A

PT
Types of thoracic outlet syndrome
Neurogenic (compression of brachial plexus)
Vascular

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45
Q

Rotator cuff external rotation

A

Teres minor
Infraspinatus

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46
Q

Knee jerk reflex

A

L2-L3-L4 (Mainly L4)

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47
Q

Achilles’ tendon reflex

A

S1-S2 (Mainly S1)

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48
Q

Name 2 different nerves that could be responsible for a foot drop.

A

L5 nerve
Peroneal Nerve

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49
Q

XR findings with ACL rupture

A

Segond fracture

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50
Q

Sx radial head # and sign on XR

A

Reduced flex/ ex at elbow
Pain with pronation/ supination
Anterior/Posterior Fat Pad or “Sail Sign

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51
Q

Femoroacetabular Impingement features, sx

A

young person, anterolateral hip pain, worse with flexion adduction and internal rotation

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52
Q

Pes anserine bursa - where is it?

A

medial aspect of knee

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53
Q

Lateral ankle ligaments

A

ATF (anterior talofibular)
PTF (posterior talofibular)
CFL (calcaneofibular)

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54
Q

Infectious tenosynovitis sx

A

Pain with Passive Extension
Uniform Swelling
Flexion Posture
Percussion Tenderness

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55
Q

Causes of anterior elbow pain

A

Bicep tendinopathy
OA/ RA/ gout
pronator syndrome

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56
Q

Biceps tendinopathy mechanism, sx, ix and management

A

Mechanism: repeated elbow flexion w/ forearm in supination or pronation, overhead activities, pulling + lifting
Sx: ant elbow/ shoulder pain, hook test
Ix: US
Management: NSAIDs, rest, ice, PT

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57
Q

Causes of posterior elbow pain

A

olecranon bursitis
triceps tendinopathy
posterior impingement

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58
Q

Causes of medial elbow pain

A

medial epicondylitis (Golfer’s elbow)
cubital tunnel syndrome
ulnar collateral ligament

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59
Q

Causes of lateral elbow pain

A

lateral epicondylitis (Tennis elbow)
radial tunnel syndrome

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60
Q

olecranon bursitis causes + rx

A

Causes: trauma, anticoagulation, chronic repetitive leaning on elbows
Management: activity modification, consider aspiration, steroids if persistent

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61
Q

Sx + management of lateral epicondylitis (Tennis elbow)

A

Sx: pain + reduced grip strength, maximal pain 1cm distal to epicondyle, pain w/ resisted supination
Management: NSAIDs, bracing, PT, steroid inj

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62
Q

Cause, sx + rx of medial epicondylitis (Golfer’s elbow)

A

Cause: repetitive valgus stress + flexion at elbow
Sx: gradual onset medial elbow pain + grip weakness, maximal tenderness at flexor-pronator insertion (10cm ant/ distal to medial epicondyle). Pain w/ resisted pronation
Management: rest, brace (wrist extension), PT, steroid injection

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63
Q

Causes of shoulder pain

A

AC joint sprain/ separation
Rotator cuff tendinopathy/ tear
Adhesive capsulitis
Shoulder impingement

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64
Q

Mechanism, sx, Ix + management of AC joint sprain/ separation

A

Mechanism: fall onto superior aspect of shoulder w/ arm adducted
Sx: AC tenderness, swelling of displaced clavicle, active compression test
Ix: anteroposterior XR + Tauber protocol (Zanca, axillary + dynamic lateral views)
Management: sling 2w, PT, possible surgery

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65
Q

Sx, physical signs, Ix + Rx of Rotator cuff tendinopathy/ tear

A

Sx: pain w/ overhead activities
Physical:
Infraspinatus + teres minor: external rotation against resistance
Subscapularis: Gerber’s lift off
Supraspinatus: empty can test, painful arc
Ix: US then MRI for further assessment
Management: surgery ASAP for young pts with full thickness tear. Small or chronic tears: PT, NSAIDs, steroid inj

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66
Q

Sx + Rx of Adhesive capsulitis

A

Sx: gradual onset pain, stiffness, reduced ROM in all direction, pain at extremes
Management: tylenol, PT, steroids

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67
Q

Sx + Rx of Shoulder impingement

A

Sx: pain anterolateral aspect of shoulder, worsened with overhead activities, worse at night
Management: rest, ice, NSAIDs, PT, steroids

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68
Q

Ottawa ankle rules

A

Pain in malleolar zone AND 1 of:
Bone tenderness lateral malleolus
Bone tenderness medial malleolus
Inability to wt bear immediately + in ER

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69
Q

Ottawa foot rules

A

Pain in midfoot AND 1 of:
Bone tenderness base of 5th
Bone tenderness navicular bone
Inability to wt bear immediately + in ER

70
Q

Ligaments, mechanism + sx of Lateral ankle sprain

A

Ligaments: anterior talofibular + calcaneofibular
Mechanism: inversion of ankle
Sx: tenderness, swelling, ecchymosis over ligaments

71
Q

Ligaments, mechanism + sx of High (syndesmotic) ankle sprain

A

Ligaments: posterior superficial + deep tibiofibular ligaments, interosseous membrane
Sx: + squeeze test (squeezing lower leg at mid calf)
Management (both types of sprain): ice, compression, bracing

72
Q

Sx + rx of Posterior tibialis tendinopathy

A

Pain/ swelling posterior to medial malleous, pain worse w/ wt bearing
Management: orthotic to reduce pronation, consider short cast immobilisation x2w

73
Q

Sx + rx of Achilles tendinopathy

A

Pain/ swelling/ crepitus above calcaneal insertion
Management: PT

74
Q

RF, Sx + rx of Plantar fasciitis

A

RF: pes planus, pes cavus, excess running, obesity, prolonged standing, tightness of achilles
Sx: heel pain + tightness, worse in AM when standing, improves with ambulation
Management: activity modification, wt loss, PT, steroid inj, night splints

75
Q

Description, sx, Ix + management of Morton’s neuroma

A

Compression neuropathy of common digital nerve
Sx: numbness, tingling, burning on plantar aspect of foot, usually 3rd intermetatarsal space
Ix: XR + US
Management: metatarsal pads, footwear alteration, steroids

76
Q

Causes, sx, ix + rx of Metatarsalgia

A

Causes: capsulitis, metatarsal stress fracture, avascular necrosis
Sx: gradual onset plantar forefoot pain, swelling, stiffness, hyprekeratosis of plantar skin
Ix: consider XR
Management: metatarsal pad, footwear alterations

77
Q

Description, when it occurs, sx + rx of Calcaneal apophysitis (Sever’s disease)

A

Overuse due to repetitive strain frain achilles tendon causing irritation and avulsion of calcaneal apophysis
Occurs during rapid growth
Sx: active adolescent w/ heel pain, worse after physical activity, improves w/ rest, tender at achilles insertion, pain w/ passive dorsiflexion
Management: rest, orthotics, achilles tendon stretches

78
Q

Sx + rx of Sesamoiditis

A

Sx: gradual onset, isolated to 1st MTP joint, pain w/ palpation of sesamoid or passive ROM of joint
Management: offloading, PT, orthotics, steroid inj

79
Q

Description, mechanism, sx + rx of Mallet finger

A

Extensor tendon injury at DIP joint
Mechanism: object striking finger (e.g. ball)
Sx: can be stretched, torn or fully ruptured. Pain at dorsal DIP, unable to extend joint
Management: splint DIP in neutral / slightly hyperextended position for 6w. PIP should remain mobile

80
Q

Description, mechanism, sx + rx of Jersey finger

A

Flexor digitorum profundus tendon injury
Mechanism: forced extension of the DIP joint during active flexion (getting caught in another player’s jersey)
Sx: pain/ swelling at volar aspect of DIP joint, tendon fullness if retracted. Isolate tendon by holding MCP/PIP in extension while other fingers are flexed and have pt flex DIP
Management: refer to ortho

81
Q

Mechanism, sx + rx of Collateral ligament injuries (aka jammed fingers)

A

Mechnism: force ulnar/ radial deviation of any ITP joint
Sx: pain only at affected ligaments. Flex MCP 90, flex involved joint 30 then apply valgus/ varus stress and compare laxity to other joints
Management: buddy taping

82
Q

De Quervain tenosynovitis of wrist - description, RF, causes, sx and special tests

A

Stenosing of the 1st dorsal compartment of the wrist
RF: middle age women, dominant hand
Causes: repetitive tension (household chores, typing, lifting, manipulations)
Sx: gradual onset pain, worse when grasping, thumb abduction, ulnar deviation of wrist. Pain localised on radial side of wrist, pain radiation up and down, improves with rest
Special tests:
Finkelstein test - grasp pt’s thumb + quickly deviate the hand + wrist ulnarly. Positive = pain
Eichoff maneuver: pt clench thumb in fist, following by brisk deviation of wrist ulnarly
Ix: no imaging needed

83
Q

De Quervain tenosynovitis of wrist - Rx

A

Management: rest (avoid thumb flexion and ulnar deviation), splinting (radial thumb spica extension holding wrist in neutral + thumb in 30 flex / abduction), NSAID, steroid inj (repeat 4-8w later), severe pain + refractory to rx = surgery

84
Q

Description, RF, Sx, special tests, Ix + rx of Carpal tunnel syndrome

A

Compression of median nerve within carpal tunnel
RF: lesions, pregnancy, hypothyroid, infection, DM, familial, repetitive activity
Sx: numbness, tingling, burning or pain in 2 of 3 digits supplies by median nerve (palmar aspect of thumb, index, middle finger), difficulty holding objects, opening jars, buttoning shirt. Weakness of thumb abduction + opposition
Special tists:
Flick sign: awaken w/ sx and shake hands out to get relief
Phalen + Tinels
Ix: EMG (must be done prior to surgery)
Management: splinting, steroid inj, PT, sx

85
Q

Description, cause + sx of Ulnar neuropathy

A

Originates from C8 + T1, innervates muscle of forearm + hand, sensation to hypothenar eminence
Cause: ganglion cyst, repetitive trauma (cycling, karate, baseball)
Sx: wrist discomfort with sensory changes in 4th + 5th digit, grip weakness. Examine C spine, shoulder, elbow. Compression ulnar nerve at Guyon canal = hypothenar weakness + sensory disturbance in 5th digit

86
Q

What is the Modified trendelenburg + what does it show

A

Drop in iliac crest, indicating weakness on contralateral side = hip labral tear, transient synovitis, Legg-Calve-Perthes disease, SCFE

87
Q

What is the FABER test

A

flexion, abduction, external rotation) posterior pain localised to SI joint, Lspine or post hip indicates intraarticular pathology = hip labral tear, loose bodies, femoral acetabular impingement, OA, SI joint dysfunction, iliopsoas bursitis

88
Q

What does the Log roll test show?

A

(restricted movement, pain) = piriformis syndrome

89
Q

What is the Straight leg raise against resistance test

A

(weakness, pain) = sports hernia, SCFE, femoral acetabular impingement

90
Q

What is the Ober test

A

(cannot do passive adduction past midline) = external snapping hip, greater trochanteric pain syndrome

91
Q

Causes of anterolateral hip/ groin pain

A

Stress fracture
Femoroacetabular impingement
Labral tear
Iliopsoas bursitis
Hip OA
Osteonecrosis
Septic arthritis
Transient synovitis (age 3-8)
Slipped capital femoral epiphysis (age 11-14)

92
Q

Demographic, sx, positive tests, Ix + Rx of Femoroacetabular impingement

A

Usually young + active pts
Sx: gradual onset, deep, referred pain, worse w/ sitting, rising from seat, getting in + out of car, leaning forward, pivoting towards affected side, pain in groin w/ radiation to lat/ ant hip/ thigh
FABER + FADIR + Log roll +
Ix: XR: anteroposterior, lateral, Dunn
Management: arthroscopy if refractory to conservative tx

93
Q

Sx, Ix + Rx of Labral tear

A

Sx: gradual onset, dull pain in groin, radiates to lat hip/ ant thigh. Worse w/ wt bearing/ walking/ pivoting/ prolonged standing. 50% have catching/ clicking/ popping

Antalgic gait, loss of internal rotation, FADIR +, FABER +

Ix: MRA but can start with XR/ MRI

Management: treat underlying cause, sx if no improvement w/ conservative measures

94
Q

Causes of lateral hip pain

A

External snapping hip
Greater trochanteric pain syndrome
Greater trochanteric bursitis

95
Q

Causes, sx, ix + rx of Greater trochanteric bursitis

A

Causes: repetitive stress, hip injury, spine dz, leg length discrepancy, RA, bone spurs, ITB contracture, lumbar spondylosis
Sx: lateral hip pain (sharp), can radiate down to lateral aspect of thigh, worse at night when laying on effected side, when getting up from a chair. Exacerbated by walking, stair climbing, squats
Ix: US if unsure
Management: activity modification, NSAID, PT, steroid inj

96
Q

Causes of posterolateral hip pain

A

Gluteal muscle tear/ avulsion
Iliac crest apophysis avulsion

97
Q

Causes of posterior hip pain

A

Hamstring muscle strain
Ischial apophysis avulsion
Ischiofemoral impingement
Piriformis syndrome
Sacroiliac joint dysfunction

98
Q

What is piriformis syndrome + what are the sx + rx

A

Deep gluteal syndrome / pelvic outlet syndrome
Excessive contraction of piriformis muscle
Sx: buttock pain with posterior thigh radiation aggravated by sitting / squats or walking w/ ipsilateral radiation to posterior thigh from sciatic nerve compression. Positive log roll test, tenderness over sciatic notch
Management: PT, NSAID, neuropathic pain meds, US guided steroid inj

99
Q

Causes, sx, positive signs, complications, management + sx of ruptured Popliteal synovial cyst (Baker’s cyst)

A

Causes: injury, meniscal tear, arthritis, OA, hydrops, inflammatory arthritis, ACL tear
Sx: small + symptomless bulge, may cause tightness, restricts flexion.
Foucher sign = softens w/ knee flexed - differentiates from other masses
Complications: infection, rupture, neurovascular compression
Management: no action needed, cold pack, NSAIDs, US guided aspiration/ steroid, sx
Ruptured: swelling of calf + pain - similar to DVT. Dx w/ US

100
Q

RF, sx, positive signs + rx of Pateollofemoral syndrome

A

RF: 20-30y/o, females, IT band tightness, abnormal patellar mobility, quad muscle weakness
Sx: gradual onset, ill-defined ache to anterior knee behind patellar, pain worsened w/ compression e.g. up/ down stairs, knee flexion, squatting
Q angle, pain to palpation patellar retinular, pain w/ movement of patellar, patellar tracking test
Management: activity modification, PT, McConnell taping, brace

101
Q

RF, mechanism, sx, positive sign + rx of Patellar tendonitis

A

RF: 15-30y/o, males
Mechansim: jumping, landing, cutting, pivoting (volleyball)
Sx: gradual onset pain inferior pole of patellar, worsened w/ wtbearing + knee extension, pain w/ sitting/ squatting/ stairs
Basset’s sign
Management: activity modification, PT

102
Q

Mechanism, RF, sx + rx of Iliotibial band syndrome

A

Pain b/c repetitive friction of iliotibial band over lateral femoral epicondyle
RF: running, cycling, males
Sx: sharp, burning pain 2cm sup to lateral joint line, worsened by activity/ knee flexion, relieved by rest
Management: activity modification, PT, steroid inj

103
Q

Cause + name of prepatellar bursitis

A

Housemaid’s knee
Causes: kneeling/ crawling (carpet layers, housemaids, plumbers, roofers)

104
Q

Cause + name of infrapatellar bursitis

A

Clergyman’s knee
Cause: kneeling in upright position

105
Q

RF + sx of Pes anserine bursitis

A

RF: valgus knees
Sx: pain on upper medial tibia, 5cm distal to medial knee joint

106
Q

Cause, RF, complications, sx, Ix + management of Meniscal tear

A

Cause: traumatic twisting injury, OA
RF: joint stress, malalignment, prev ligament inj
Complications: arthritis
Frequently occur with ACL tears
Sx: swelling, catching,locking, instability, buckling
Ix: MRI, arthroscopy
Management: rest, elevation, PT or if >1cm, arthroscopy

107
Q

Mechanism, RF, sx + rx of Medial tibial stress syndrome (shin splints)

A

Mechanism: microdamage to tibia d/t strain/ impact loading of lower limb resulting in bony reabsorption and marrow edema
RF: female, fewer years of running, orthotics, high BMI
Sx: vague diffuse lower extremity pain along mid-distal tibia, associated w/ activity. Pain to palpation of tibia
Management: rest, ice, PT, activity modification, footwear, orthotics

108
Q

Description, sx + rx of Osgood Schlatter disease

A

Pediatric overuse syndrome affecting young athletes during growth spurt
Sx: pain at tibial tubercle, worsened w/ activity, relieved w/ rest
Management: rest, ice, NSAID + PT, brace

109
Q

OA of knee XR

A

JOSS - has bad knees
Joint Space Narrowing
Osteophyte Formation
Subchondral Cyst Formation
Subchondral Sclerosis

110
Q

Causes of mechanical LBP

A

Slipped disc, SLE
Ankylosing spondylitis
Degenerative

Strain, scoliosis
Injury
RA

111
Q

Red flag sx + causes for back pain + what investigation to order for that red flag

A

Ask: BACKPAIN
bladder, bowels
anesthesia (saddle)
constitutional sx

paraesthesia
age >50
infection
neuro deficit

Neuro deficit (tumor, neuro dz, cauda equina): urgent MRI

Infection (fever, IVDU, immunosuppressed, DM, HIV): XR + MRI

Fracture (trauma, osteoporosis, female, low BMI, steroids): XR

Tumor (wt loss, night sweats, night pain, fever, >50y/o): XR + MRI

Inflammation (chronic, morning stiffness >30 mins, improves w/ exercise): refer to rheum

112
Q

Yellow flags for back pain

A

(RF for chronic pain)
ABCDEFW
Attitudes + beliefs
Behaviours
Compensation issues
Diagnostic + treatment issues
Emotions
Family - overprotective or lack of support
Work, poor job satisfaction

113
Q

Physical exam for back pain

A

Palpation
Gait: heel walking (L4-5) and toe walking (S1)
Standing: pain w/ lumbar extension (facet arthropathy), pain w/ flexion (discogenic)
Sitting: patellar reflex (L3-4), ankle dorsiflexion (L4-5)
Lying supines: straight leg raise (sciatic)
FABER

114
Q

L4 motor weakness, exam test + reflex

A

Extension of quad
Squat + rise
Knee

115
Q

L5 motor weakness + exam test

A

Dorsiflexion of great toe + foot, hip abductor
Heel walk

116
Q

S1 motor weakness, exam + reflex

A

Plantar flexion of great toe + foot, glute maximus
Toe walk
Ankle/ achilles

117
Q

Back pain patterns

A

Discogenic (pattern 1): back pain dominant, worse w/ flexion, normal neuro
Facet joint (pattern 2): back pain dominant, worse w/ extension, never worsened w/ flexion
Compressed nerve (pattern 3): leg dominant, positive straight leg raise
Spinal stenosis (pattern 4): leg dominant, intermittent, bilateral, worse w/ walking

118
Q

Ix for
?fracture
?infection
?inflammation
?aneurysm

A

?fracture: XR (AP + lateral)
?infection: CBC, ESR, CRP, MRI, joint aspiration
?inflammation: CRP, bone scan
?aneurysm: carotid MRA, abdo aortic US

119
Q

Management of mechanical LBP

A

Stay active, heat packs, patient education, early return to work, PT, MDT, CBT, SNRI (duloxetine)
NSAIDs, muscle relaxants (cyclobenzaprine 10-30mg once daily up to 1 wk), epidural steroid inj
FU 1 wk if pain severe, 6wks if not recovered
Pattern 1: repeated prone lying, passive extension, short walks, reduce sitting
Pattern 2: sitting in chair, bend forward and stretch
Pattern 3: rest, Z lie

120
Q

Causes of neck pain

A

whiplash, idiopathic, fractures, torticollis, spinal tumor, infection, epidural hematoma, aneurysm, retropharyngeal tendonitis, RA, spondyloarthropathy, Reiter’s syndrome, psoriatic arthritis, polymyalgia

121
Q

Whiplash recovery stats

A

56% within 3mo, 80% within 1-2yrs, 5% severely affected

122
Q

RF for chronic neck pain

A

old age, females, not employed

123
Q

Red flags for neck pain

A

Kernig sign, avoiding rotation (atlanto-axial instability), HA

124
Q

Demographic + sx of Ankylosing spondylitis

A

Young men, insidious onset >3mo
Pain + stiffness in AM >30mins
Decreased pain w/ exercise, worse w/ rest
Decreased flexion on exam

125
Q

RF for OA

A

Obesity
Muscle weakness
Heavy physical activity
Inactivity
Prev trauma
Fam hx

126
Q

Sx of OA

A

Gradual onset
Morning stiffness <30 mins
Stiffness after inactivity
Joint
Bony enlargement
Crepitus
Reduced ROM
Muscle wasting
Pain w/ ROM

127
Q

Ix + Rx of OA

A

Ix:
Wt bearing XR
Knee: standing, AP, lateral
Hip: lateral
Management
Lifestyle: exercise, strengthening, PT, supportive footwear, assistive devices, wt loss
Tylenol
NSAIDs - consider gastroprotection
Topicals - capsaicin, NSAIDs
Joint inj
Refer:
Inadequate pain control
Night pain
Functional restriction

128
Q

Test for ankylosing spondylitis

A

Schober Test

129
Q

Ix for ankylosing spondylitis inc XR views + findings

A

Hemoglobin
ESR
CRP
RF
ANA
HLA-B27

Xray
SI Joints (oblique view) - sacroilitis, sclerosis and erosions can be a late finding in disease
Spine (lateral view); - squaring, erosions, bamboo spine can be a late finding in disease
MRI (can show sacroilitis earlier)

130
Q

RF for gout

A

Hyperuricemia
Male
CKD
HTN
Obesity
CAD
DM
Dyslipidemia
Diuretics, cyclosporine, ASA
Meat, fish, alcohol, sugar

131
Q

Sx + rx of gout (Acute, chronic, lifestyle) - when to test for HLA-B5801

A

Sx:
Acute pain, swelling, erythema
Tophi - urate deposit in cartilage/ tendon/ bursa
Ix:
Only if unsure of dx
Management
Diet: limit purine, alcohol, meat, shellfish
Wt loss
Avoid thiazides
Acute:
NSAIDs e.g. naproxen 500mg BID x1-3d
Colchicine 0.6mg BID x1-3d
Corticosteroids if NSAIDs or colchicine CI, methylprednisone 40-80mg IM x1 or prednisone 25-50mg x3-5d
Chronic:
Allopurinol 50-100mg
Give if:
>1 tophi
Radiographic damage from gout
>2 flares/ yr
Test for HLA-B5801 prior to starting in:
Chinese
Korean
Thai
African American

132
Q

Sx, Ix + Rx of wegener’s granulomatosis

A

Sx:
Malaise, fever, weakness, wt loss
Sinusitis, hearing loss, cough, hemoptysis
Ix:
Low Hb, high WBC, high Cr, high ESR
C-ANCA positive
Protein + blood on UA
Rx:
Prednisone 1mg/kg x3-6mo
Cyclophosphamide 2mg/kg x3-6mo

133
Q

Lupus sx, Ix + rx

A

Sx:
Rash, ulcers, photosenstivity, wt loss
Alopecia
Purpura
Ix:
Low Hb, high WBC, low platelets
ANA positive
Protein + cellular casts in UA
Rx:
Sunscreen, topical steroids
Prednisone

134
Q

Dx criteria for polymyalgia rheumatica

A

Age >50
Bilateral proximal muscle aching
Morning stiffness lasting >45 mins
ESR >40
Rapid/successful response to corticosteroids
Hip Pain or Limited Range of Motion
Absence of RF or Anti-CCP
Absence of other joint involvement

135
Q

Ix for giant cell arteritis

A

Increased ESR >40
Increased CRP
Temporal artery biopsy
Angiography
MRI Angiogram
Doppler Ultrasound

136
Q

RF for RA

A

Female
Older age
Smoking

137
Q

Sx of RA

A

Morning stiffness >1hr, improves w/ use, worsens w/ rest
Symmetric joints
Constitutional sx
Vasculitis e.g. scleritis, cutaneous ulcers, purpura, peripheral neuropathy
Lymphocytic infiltrates e.g. rheumatoid nodules, pulmonary fibrosis, pericarditis, Hashimoto’s thyroiditis
Joint deformities (Boutonniere, Swan neck, hammer toe, mallet toe, claw toe)

138
Q

Ix for RA + what to order prior to DMARD

A

Rheumatoid Factor
Antinuclear antibody (ANA)
Anti- CCP (Cyclic Citrullinated Polypeptide)
Anti-MCV (mutated and citrullinated vimentim)
Erythrocyte sedimentation rate (ESR)
CBC (high platelets)
Prior to DMARD: CBC, LFTs, Cr, lytes, CXR, hep B + C, HIV

139
Q

Indicators for poor prognosis for RA

A

+RF
High # affected joints
Early erosion
Extraarticular features
High ESR + CRP

140
Q

Complications of RA

A

Anemia
Scleritis
Deformities
Pericarditis
Infections

141
Q

rx for RA + what tool do you use to determine which treatment

A

DAS28 tool for treatment
NSAIDs
DMARDs
Biologics
Steroids

142
Q

Advice, SE + monitoring for methotrexate

A

Methotrexate - folate supplement + avoid alcohol
SE: GI, raised LFTs, pneumonitis
Monitoring: CBC, LFTs, albumin

143
Q

SE + monitoring for sulfasalazine

A

SE: GI, mucositis, CNS
Monitoring: CBC, LFTs

144
Q

SE + monitoring for Leflunomide

A

SE: GI, HA, weakness, rash, hair loss, hepatitis
Monitoring: CBC, LFTs, albumin

145
Q

SE + monitoring for Hydroxychloroquine

A

SE: retinal damage
Monitoring: fundoscopy

146
Q

SE + monitoring for Cyclosporine

A

SE: hyperplasia, HTN, hirsutism
Monitoring: Cr, CBC, BP

147
Q

SE + monitoring for Azathioprine

A

SE: GI, rash, pancreatitis
Monitoring: CBC, LFTs

148
Q

SE + monitoring for Infliximab

A

SE: hypotension, chills, chest tightness
Monitoring: CBC, LFTs, albumin

149
Q

SE + monitoring for Etanercept

A

SE: redness, pain
Monitoring: CBC, LFTs, albumin

150
Q

SE + monitoring for Anakinra

A

SE: redness, swelling, bruising, itching
Monitoring: CBC, LFTs, albumin

151
Q

What are the features of a dangerous mechanism in relation to C spine rules?

A

fall >3ft
axial load
MCV >100km
ped or bike being hit by car

152
Q

Reasons to refer to ortho for fractures

A

unstable, open, deformed, nerve/ tendon injury

153
Q

Management of radial subluxation

A

no need for XR, hyperpronation manoever

154
Q

DDx for concussion

A

migraine, cervical spine injury, vestibular dz, anxiety, depression

155
Q

Which pts to give tetanus immunoglobulin?

A

Dirty wound + underimmunised or imms status unknown

156
Q

2nd line for compartment syndrome rx

A

hyperbaric oxygen therapy

157
Q

Hip fracture analgesia

A

US femoral nerve block

158
Q

Salter-Harris classification

A

Straight through (1), Above (2), Lower (3), Transverse (4), Rammed (5)

159
Q

What to order in kids for fractures

A

comparison film

160
Q

Splints for 5th + 2nd metacarpal fracture

A

ulnar gutter splint, radial gutter splint

161
Q

Complications of casts

A

compartment syndrome, ischemia, neurological injury, pressure sores, dermatitis, joint stiffness

162
Q

Physical exam manouvre to assess scaphoid

A

axial load to thumb

163
Q

Nerve supply for:
hip flexion
knee extension
bices
triceps
knees to first toe
middle toes
little toe

A

L1/L2 = hip flexion
L3/L4 = knee extension
C5/C6 = bices
C7/C8 = triceps
L4 = knees to first toe
L5 = middle toes
S1 = little toe

164
Q

2nd line for gout

A

febuxostat

165
Q

Spurling test

A

neck in extension, lateral flexion, axial compression - if it reproduces sx in extremities = degenerative cervical myelopathy

166
Q

Myelopathy vs radiculopathy

A

myelopathy nerves are compressed, radiculopathy nerves are damaged

167
Q

Cervical radiculopathy

A

pain in one or both upper extremities + motor/ sensory/ reflex deficits

168
Q

Is imaging required for ?cervical radiculopathy?

A

No unless: hx of trauma, persistent sx >4-6wks, RF sx (malignancy, myelopathy, abscess)

169
Q

What Ix for myelopathy?

A

MRI neck

170
Q

What are the sx of primary sclerosing cholangitis and what is it associated with?

A

Fatigue, pruritus, RUQ pain. Associated w/ UC

171
Q

How to differentiate between primary sclerosing cholangitis and primary biliary cirrhosis?

A

Antimitochondrial antibodies + in PBC
MRCP

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