Fractures + Joint Disorders Flashcards
Common site of stress fractures
Tibia
Fibula
Navicular
Femoral Neck
Pars Interarticularis
Talus
Sesamoids
Metatarsals (2nd/3rd)
Medial Malleolus
Ix for stress fractures
CT
MRI
Bone scan
FU XR 3 mo
RF for stress fractures
Female
Repetitive Activities (sports, running, walking, marching, gymnastics)
Obesity
Osteoporosis
Post-Menopausal
Rheumatoid Arthritis
Corticosteroids Use
Poor Footwear
Previous Inactivity
Previous Stress Fracture
Management of elderly w/ acute mobility change
investigate with bone scans + CT before excluding fracture
What are fragility fractures?
Fracture that is sustained from a fall from standing height
How to describe a fracture
Closed v open
Location
Orientation
Ways of describing location of fracture
Epiphyseal: end of bone
Metaphyseal: flared portion of bone at end of shaft
Diaphyseal: shaft of long bone
Physis: growth plate
Ways of describing orientation of fracture
Transverse
Oblique (angular)
Spiral (complex, multiplanar, rotation force)
Comminuted (more than 2 fracture fragments)
Intraarticular
Green-stick (incomplete fracture of one cortex)
Early complications of fractures
Compartment syndrome
Neurological/ vascular injury
Infection
Fracture blister
Late complications of fractures
Mal/ non-union
Avascular necrosis
Osteomyelitis
Heterotrophic ossification
Arthritis
Which fractures may not show up on XR and should be treated anyway?
Scaphoid
Elbow
Growth plate
Stress
When do you use a forearm volar slab splint
soft tissue injury of hand/ wrist, carpal bone fracture (excluding scaphoid), childhood buckle fracture distal radius)
How to apply a forearm volar slab splint
Landmark: distal palmar crease + proximal third of forearm
Stockinette should go 10cm beyond landmarks
Make splint with 10 layers of plaster between landmarks
What is a Toddler’s fracture - mechanism, age, presentation, XR + management
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
When are C spine rules applicable
stable pt, GCS 15, injury <48hrs ago, >16y/o, no vertebral dz, no penetrating injury, not pregnant
C spine rules
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
Ottawa knee rules
Age > 55
Isolated patellar tenderness
Tenderness head of fibula
Inability to flex 90
Inability to wt bear immediately AND in ED
Classification, ix and management of clavicle fractures
Allman classification
Ix: anteroposterior + serendipity views
Management: sling for 2-6w, may need surgery for displaced fracture
Mechanism of shoulder dislocation (ant + post)
Anterior = abduction, extension, external rotation
Posterior = posterior directed force, electric shock or sz injury
shoulder dislocation - physical findings, ix and management
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
Features on hx of scaphoid fracture + sx
FOOSH w/ wrist dorsiflexion + radially deviated, swollen, swelling + pain in anatomical snuffbox. Pain w/ axial pressure on 1st metacarpal bone
Sx of late presentation of scaphoid fracture
painful wrist extension, loss of grip
XR - what to order + management of scaphoid fracture
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
Causes of volar plate injury + place of maximal tenderness. What should you also test when examining?
Hyperextension of finger joint, usually PIP
maximum tenderness volar aspect of joint. Test collateral ligaments
Complications + management of volar plate injury
Complications: joint instability can lead to gradual hyperextension
Management: splint w/ progressive extension for 2-4wks followed buddy taping
Median nerve distribution
1st (thumb), 2nd (index), 3rd (long), and radial 4th (ring) fingers
Signs of carpal tunnel
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
Ulnar nerve distribution
5th (pinky), and ulnar half of 4th (ring) finger
Ix for carpal tunnel
EMG
Rx for carpal tunnel
NSAIDs (oral, topical)
Modified Duties (avoid repetitive strain)
Wrist Splinting
Corticosteroid injection
Oral Steroids
Open Carpal Tunnel Release
What is a claw hand?
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.
What is the benediction sign?
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.
Features of dupuytrens contracture
Idiopathic
Autosomal Dominant (incomplete penetrance)
Palmar Fibromatosis (progressive fibrosis of palmar fascia)
Flexion Deformaties
Loss of Grip Function
Nodules → Cords → MCP Joint Contracture
RF for dupuytrens contracture
Male
Increased Age
Family History
Northern European Ancestry
Smoking
Alcohol Use
Diabetes Mellitus
Chronic Vibration Exposures
Epilepsy
Management of dupuytrens contracture
Corticosteroid Injections
Collagenase Injections
Percutaneous and Needle Fasciotomy
Open Fasciotomy
Sx Trigger Finger
Locking, clicking or snapping of an extending digit in flexion
Palpable Nodule (over A1 pulley at MCP joints)
Crepitus
Tenderness
Rx for trigger finger
Splinting
Physiotherapy
Corticosteroid Injection
Surgical Release (A1 pulley)
Mallet finger
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
Rx mallet finger
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)
Adhesive capsulitis stages
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
Rx for adhesive capsulitis
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
Tests to perform on joint aspirate
Cell Count
Culture and Sensitivity
Gram Stain
Crystals
Sx thoracic outlet syndrome + positive tests
Numbness and tingling in arms + fingers
Weakness in hand grip strength
Pain in neck, shoulder and arm
Adson Test
Roos Test
Morley Test
Rx thoracic outlet syndrome
PT
Types of thoracic outlet syndrome
Neurogenic (compression of brachial plexus)
Vascular
Rotator cuff external rotation
Teres minor
Infraspinatus
Knee jerk reflex
L2-L3-L4 (Mainly L4)
Achilles’ tendon reflex
S1-S2 (Mainly S1)
Name 2 different nerves that could be responsible for a foot drop.
L5 nerve
Peroneal Nerve
XR findings with ACL rupture
Segond fracture
Sx radial head # and sign on XR
Reduced flex/ ex at elbow
Pain with pronation/ supination
Anterior/Posterior Fat Pad or “Sail Sign
Femoroacetabular Impingement features, sx
young person, anterolateral hip pain, worse with flexion adduction and internal rotation
Pes anserine bursa - where is it?
medial aspect of knee
Lateral ankle ligaments
ATF (anterior talofibular)
PTF (posterior talofibular)
CFL (calcaneofibular)
Infectious tenosynovitis sx
Pain with Passive Extension
Uniform Swelling
Flexion Posture
Percussion Tenderness
Causes of anterior elbow pain
Bicep tendinopathy
OA/ RA/ gout
pronator syndrome
Biceps tendinopathy mechanism, sx, ix and management
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
Causes of posterior elbow pain
olecranon bursitis
triceps tendinopathy
posterior impingement
Causes of medial elbow pain
medial epicondylitis (Golfer’s elbow)
cubital tunnel syndrome
ulnar collateral ligament
Causes of lateral elbow pain
lateral epicondylitis (Tennis elbow)
radial tunnel syndrome
olecranon bursitis causes + rx
Causes: trauma, anticoagulation, chronic repetitive leaning on elbows
Management: activity modification, consider aspiration, steroids if persistent
Sx + management of lateral epicondylitis (Tennis elbow)
Sx: pain + reduced grip strength, maximal pain 1cm distal to epicondyle, pain w/ resisted supination
Management: NSAIDs, bracing, PT, steroid inj
Cause, sx + rx of medial epicondylitis (Golfer’s elbow)
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
Causes of shoulder pain
AC joint sprain/ separation
Rotator cuff tendinopathy/ tear
Adhesive capsulitis
Shoulder impingement
Mechanism, sx, Ix + management of AC joint sprain/ separation
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
Sx, physical signs, Ix + Rx of Rotator cuff tendinopathy/ tear
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
Sx + Rx of Adhesive capsulitis
Sx: gradual onset pain, stiffness, reduced ROM in all direction, pain at extremes
Management: tylenol, PT, steroids
Sx + Rx of Shoulder impingement
Sx: pain anterolateral aspect of shoulder, worsened with overhead activities, worse at night
Management: rest, ice, NSAIDs, PT, steroids
Ottawa ankle rules
Pain in malleolar zone AND 1 of:
Bone tenderness lateral malleolus
Bone tenderness medial malleolus
Inability to wt bear immediately + in ER
Ottawa foot rules
Pain in midfoot AND 1 of:
Bone tenderness base of 5th
Bone tenderness navicular bone
Inability to wt bear immediately + in ER
Ligaments, mechanism + sx of Lateral ankle sprain
Ligaments: anterior talofibular + calcaneofibular
Mechanism: inversion of ankle
Sx: tenderness, swelling, ecchymosis over ligaments
Ligaments, mechanism + sx of High (syndesmotic) ankle sprain
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
Sx + rx of Posterior tibialis tendinopathy
Pain/ swelling posterior to medial malleous, pain worse w/ wt bearing
Management: orthotic to reduce pronation, consider short cast immobilisation x2w
Sx + rx of Achilles tendinopathy
Pain/ swelling/ crepitus above calcaneal insertion
Management: PT
RF, Sx + rx of Plantar fasciitis
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
Description, sx, Ix + management of Morton’s neuroma
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
Causes, sx, ix + rx of Metatarsalgia
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
Description, when it occurs, sx + rx of Calcaneal apophysitis (Sever’s disease)
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
Sx + rx of Sesamoiditis
Sx: gradual onset, isolated to 1st MTP joint, pain w/ palpation of sesamoid or passive ROM of joint
Management: offloading, PT, orthotics, steroid inj
Description, mechanism, sx + rx of Mallet finger
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
Description, mechanism, sx + rx of Jersey finger
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
Mechanism, sx + rx of Collateral ligament injuries (aka jammed fingers)
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
De Quervain tenosynovitis of wrist - description, RF, causes, sx and special tests
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
De Quervain tenosynovitis of wrist - Rx
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
Description, RF, Sx, special tests, Ix + rx of Carpal tunnel syndrome
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
Description, cause + sx of Ulnar neuropathy
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
What is the Modified trendelenburg + what does it show
Drop in iliac crest, indicating weakness on contralateral side = hip labral tear, transient synovitis, Legg-Calve-Perthes disease, SCFE
What is the FABER test
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
What does the Log roll test show?
(restricted movement, pain) = piriformis syndrome
What is the Straight leg raise against resistance test
(weakness, pain) = sports hernia, SCFE, femoral acetabular impingement
What is the Ober test
(cannot do passive adduction past midline) = external snapping hip, greater trochanteric pain syndrome
Causes of anterolateral hip/ groin pain
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)
Demographic, sx, positive tests, Ix + Rx of Femoroacetabular impingement
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
Sx, Ix + Rx of Labral tear
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
Causes of lateral hip pain
External snapping hip
Greater trochanteric pain syndrome
Greater trochanteric bursitis
Causes, sx, ix + rx of Greater trochanteric bursitis
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
Causes of posterolateral hip pain
Gluteal muscle tear/ avulsion
Iliac crest apophysis avulsion
Causes of posterior hip pain
Hamstring muscle strain
Ischial apophysis avulsion
Ischiofemoral impingement
Piriformis syndrome
Sacroiliac joint dysfunction
What is piriformis syndrome + what are the sx + rx
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
Causes, sx, positive signs, complications, management + sx of ruptured Popliteal synovial cyst (Baker’s cyst)
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
RF, sx, positive signs + rx of Pateollofemoral syndrome
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
RF, mechanism, sx, positive sign + rx of Patellar tendonitis
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
Mechanism, RF, sx + rx of Iliotibial band syndrome
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
Cause + name of prepatellar bursitis
Housemaid’s knee
Causes: kneeling/ crawling (carpet layers, housemaids, plumbers, roofers)
Cause + name of infrapatellar bursitis
Clergyman’s knee
Cause: kneeling in upright position
RF + sx of Pes anserine bursitis
RF: valgus knees
Sx: pain on upper medial tibia, 5cm distal to medial knee joint
Cause, RF, complications, sx, Ix + management of Meniscal tear
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
Mechanism, RF, sx + rx of Medial tibial stress syndrome (shin splints)
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
Description, sx + rx of Osgood Schlatter disease
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
OA of knee XR
JOSS - has bad knees
Joint Space Narrowing
Osteophyte Formation
Subchondral Cyst Formation
Subchondral Sclerosis
Causes of mechanical LBP
Slipped disc, SLE
Ankylosing spondylitis
Degenerative
Strain, scoliosis
Injury
RA
Red flag sx + causes for back pain + what investigation to order for that red flag
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
Yellow flags for back pain
(RF for chronic pain)
ABCDEFW
Attitudes + beliefs
Behaviours
Compensation issues
Diagnostic + treatment issues
Emotions
Family - overprotective or lack of support
Work, poor job satisfaction
Physical exam for back pain
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
L4 motor weakness, exam test + reflex
Extension of quad
Squat + rise
Knee
L5 motor weakness + exam test
Dorsiflexion of great toe + foot, hip abductor
Heel walk
S1 motor weakness, exam + reflex
Plantar flexion of great toe + foot, glute maximus
Toe walk
Ankle/ achilles
Back pain patterns
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
Ix for
?fracture
?infection
?inflammation
?aneurysm
?fracture: XR (AP + lateral)
?infection: CBC, ESR, CRP, MRI, joint aspiration
?inflammation: CRP, bone scan
?aneurysm: carotid MRA, abdo aortic US
Management of mechanical LBP
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
Causes of neck pain
whiplash, idiopathic, fractures, torticollis, spinal tumor, infection, epidural hematoma, aneurysm, retropharyngeal tendonitis, RA, spondyloarthropathy, Reiter’s syndrome, psoriatic arthritis, polymyalgia
Whiplash recovery stats
56% within 3mo, 80% within 1-2yrs, 5% severely affected
RF for chronic neck pain
old age, females, not employed
Red flags for neck pain
Kernig sign, avoiding rotation (atlanto-axial instability), HA
Demographic + sx of Ankylosing spondylitis
Young men, insidious onset >3mo
Pain + stiffness in AM >30mins
Decreased pain w/ exercise, worse w/ rest
Decreased flexion on exam
RF for OA
Obesity
Muscle weakness
Heavy physical activity
Inactivity
Prev trauma
Fam hx
Sx of OA
Gradual onset
Morning stiffness <30 mins
Stiffness after inactivity
Joint
Bony enlargement
Crepitus
Reduced ROM
Muscle wasting
Pain w/ ROM
Ix + Rx of OA
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
Test for ankylosing spondylitis
Schober Test
Ix for ankylosing spondylitis inc XR views + findings
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)
RF for gout
Hyperuricemia
Male
CKD
HTN
Obesity
CAD
DM
Dyslipidemia
Diuretics, cyclosporine, ASA
Meat, fish, alcohol, sugar
Sx + rx of gout (Acute, chronic, lifestyle) - when to test for HLA-B5801
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
Sx, Ix + Rx of wegener’s granulomatosis
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
Lupus sx, Ix + rx
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
Dx criteria for polymyalgia rheumatica
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
Ix for giant cell arteritis
Increased ESR >40
Increased CRP
Temporal artery biopsy
Angiography
MRI Angiogram
Doppler Ultrasound
RF for RA
Female
Older age
Smoking
Sx of RA
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)
Ix for RA + what to order prior to DMARD
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
Indicators for poor prognosis for RA
+RF
High # affected joints
Early erosion
Extraarticular features
High ESR + CRP
Complications of RA
Anemia
Scleritis
Deformities
Pericarditis
Infections
rx for RA + what tool do you use to determine which treatment
DAS28 tool for treatment
NSAIDs
DMARDs
Biologics
Steroids
Advice, SE + monitoring for methotrexate
Methotrexate - folate supplement + avoid alcohol
SE: GI, raised LFTs, pneumonitis
Monitoring: CBC, LFTs, albumin
SE + monitoring for sulfasalazine
SE: GI, mucositis, CNS
Monitoring: CBC, LFTs
SE + monitoring for Leflunomide
SE: GI, HA, weakness, rash, hair loss, hepatitis
Monitoring: CBC, LFTs, albumin
SE + monitoring for Hydroxychloroquine
SE: retinal damage
Monitoring: fundoscopy
SE + monitoring for Cyclosporine
SE: hyperplasia, HTN, hirsutism
Monitoring: Cr, CBC, BP
SE + monitoring for Azathioprine
SE: GI, rash, pancreatitis
Monitoring: CBC, LFTs
SE + monitoring for Infliximab
SE: hypotension, chills, chest tightness
Monitoring: CBC, LFTs, albumin
SE + monitoring for Etanercept
SE: redness, pain
Monitoring: CBC, LFTs, albumin
SE + monitoring for Anakinra
SE: redness, swelling, bruising, itching
Monitoring: CBC, LFTs, albumin
What are the features of a dangerous mechanism in relation to C spine rules?
fall >3ft
axial load
MCV >100km
ped or bike being hit by car
Reasons to refer to ortho for fractures
unstable, open, deformed, nerve/ tendon injury
Management of radial subluxation
no need for XR, hyperpronation manoever
DDx for concussion
migraine, cervical spine injury, vestibular dz, anxiety, depression
Which pts to give tetanus immunoglobulin?
Dirty wound + underimmunised or imms status unknown
2nd line for compartment syndrome rx
hyperbaric oxygen therapy
Hip fracture analgesia
US femoral nerve block
Salter-Harris classification
Straight through (1), Above (2), Lower (3), Transverse (4), Rammed (5)
What to order in kids for fractures
comparison film
Splints for 5th + 2nd metacarpal fracture
ulnar gutter splint, radial gutter splint
Complications of casts
compartment syndrome, ischemia, neurological injury, pressure sores, dermatitis, joint stiffness
Physical exam manouvre to assess scaphoid
axial load to thumb
Nerve supply for:
hip flexion
knee extension
bices
triceps
knees to first toe
middle toes
little toe
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
2nd line for gout
febuxostat
Spurling test
neck in extension, lateral flexion, axial compression - if it reproduces sx in extremities = degenerative cervical myelopathy
Myelopathy vs radiculopathy
myelopathy nerves are compressed, radiculopathy nerves are damaged
Cervical radiculopathy
pain in one or both upper extremities + motor/ sensory/ reflex deficits
Is imaging required for ?cervical radiculopathy?
No unless: hx of trauma, persistent sx >4-6wks, RF sx (malignancy, myelopathy, abscess)
What Ix for myelopathy?
MRI neck
What are the sx of primary sclerosing cholangitis and what is it associated with?
Fatigue, pruritus, RUQ pain. Associated w/ UC
How to differentiate between primary sclerosing cholangitis and primary biliary cirrhosis?
Antimitochondrial antibodies + in PBC
MRCP
