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MSK Flashcards

1
Q

AC Separation

A

Sx: pain over AC joint

  • shoulder weakness
  • Kiss Test: pain w/cross-body adduction

Dx:
- Xray (AP, chest, clavicle)

Tx:

  • Type 1, 2: nonsurgical = immobilize, Codmans
  • Type 3: usually non-operative; sx for manual laborer/athlete
  • Type 4-6: surgery
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2
Q

AC Dislocation

A

D/t: direct fall on shoulder

Sx: deformity, swelling

Tx:

  • Grade 1, 2: sling w/ortho f/u
  • Grade 3: surgery
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3
Q

Clavicle Fracture

A

MC: middle 1/3

Dx: AP chest, clavicle views

Tx: most non-operative + Codmans

Surgery:

  • open fracture
  • fracture w/scapula-thoracic dislocation
  • relative indications: multiple trauma, skin tenting, competitive athlete
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4
Q

GH Joint (Shoulder) Dislocation

A

MC dislocation in the ED

Anterior (85%): direct blow; abduction, extension, external rotation

  • severe pain worse w/mvmt
  • squared off shoulder appearance
  • complications: recurrence; nerve injury; rotator cuff; Hill-Sachs or Bankart fracture

Posterior: seizure, electric shock; adduction, internal rotation
- flat appearance of anterior shoulder

Inferior: humerus fully abducted, elbow flexed, humeral head palpable on lateral chest wall
- a/w prox humerus fracture and rotator cuff injury

Dx: Xray pre/post reduction

Tx: ice, muscle relaxation, pain control

  • usually requires conscious sedation
  • shoulder immobilizer/sling in IR after reduction
  • re-assess neurovascular status
  • OP ortho f/u
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5
Q

Shoulder instability

A

Load shift test: posterior instability

Sulcus sign: inferior laxity

Apprehension test: anterior instability

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6
Q

Proximal humerus fracture

A

RF: osteoporosis, age; d/t FOOSH injury

Complications: adhesive capsulitis (MC)

  • neurovascular injury
  • avascular necrosis of femoral head

Sxs:
- pain, tenderness, deformity, dec mobility

Neer Classification of XR (based on displacement of fragments >1cm or angulation <45deg):

  1. anatomical neck
  2. surgical neck
  3. lesser tubercle
  4. greater tubercle

Mgmt
Nondisplaced (80%)
- sling or shoulder immobilizer
- opioids; ortho referral

Neer 2, 3, 4

  • immobilize, emergent ortho consult
  • may require surgical repair
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7
Q

Humeral shaft fracture

A

Direct blows to upper arm

  • MVC
  • FOOSH

Dx
- check radial nerve function

Mgmt
majority = nonoperative
- brace/coaptation splint + Codmans
- hanging arm cast for shortened fracture

Surgery:

  • open fracture
  • pathologic fracture
  • poorly controlled by closed ttechnique
  • concomitant ipsilateral forearm fracture; multiple fractures
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8
Q

Rotator Cuff injury

A

H/o falls or lifting in middle-aged men

MC: supraspinatous (abduction)

  • subscab (IR)
  • infraspinatous (Add)
  • teres minor (Abd, ER)

Sxs: pain, dec ROM

  • Positive drop arm test

Dx: Xray r/o fracture; will require MRI

Tx:

  • sling
  • PO analgesics: NSAIDs, opioids
  • Ortho f/u for MRI
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9
Q

Bankart Tear

A

Detachment of anterior-inferior labrum & capsule from anterior glenoid rim

Disruption of the anterior band of the IGHL

Sxs:

  • anterior shoulder instability
  • Apprehension test with ER +

Mgmt: Bankart repair to prevent dislocation

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10
Q

SLAP Tear

A

Superior labrum anterior to posterior tear

Sxs: pain and mechanical symptoms w/overhead and throwing activities

Labrum: seal around glenoid, provides stability, deepens glenoid

SGHL: primary restraint to anterior translation, 0-45deg abduction, can be absent

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11
Q

Radial nerve injury

A

A/w humeral shaft fracture

Sxs: inability to extend wrist/fingers and absent sensation on the back of hand

Dx: f/u for EMG if no improvement

Tx: observed, unless it occurs after reduction

  • most regain function in 6mo w/wrist splint and finger exercises
  • surgical exploration if no improvement after 6mo
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12
Q

Shoulder impingement

A

Mechanical:
- bone spur prevents greater tuberosity from clearing the coracoacromial arch = painful arc of motion

AC Joint Arthrosis:
- common in overhead workers (electricians) and athletes

Sxs:

  • Neers: forward flexion while resisting scapular rotation
  • Hawkins: IR w/arm abducted and External rotation 90deg while resisting scapular rotation

Dx: outlet view Xray for subacromial bone spurs

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13
Q

Long head of biceps rupture

A

MC in older pt w/long standing h/o impingement OR wt lifter, throwing sport

Sxs:

  • present w/lump in arm
    • Ludington’s Test (lump w/flexion of biceps)
  • sudden pain in upper arm w/audible snap
  • pain w/palpation of bicipital groove

Dx: Xray, eventual MRI

Tx: usually non-operative; outpatient ortho f/u

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14
Q

Adhesive capsulitis

A

“Frozen shoulder” d/t DM (MC)
- other cause: prolonged hospitalization, surgery, immobilization

Sxs: loss of active and passive ROM

Tx:

  • conservative PT, intra-articular corticosteroid injections
  • may take 1yr to “unfreeze”
  • analgesics
  • surgery
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15
Q

Nursemaid’s elbow

A

MC 1-3yo; MC elbow injury in children

Radial head subluxation

  • longitudinal traction on extended/pronated arm w/sudden traction on distal radius
  • annular ligament slips over head of radius and slides into radiohumeral joint where it becomes trapped

Sxs:

  • “pull” injury but can be more traumatic (fall/twist)
  • child will not move arm
  • mild tenderness over anterolateral aspect of radial head
  • pain w/even mild supination

Dx: post-reduction neurovascular evaluation
- typically don’t need Xray

Tx:

  • reduction
  • supination with flexion** = moderate pressure on radial head; distal forearm pull w/gentle traction and supinate and flex
  • hyperpronation may work also
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16
Q

Supracondylar Elbow Fracture

A

MC elbow fracture in kids d/t FOOSH
- usually posterior displacement

Complications:

  • Volkmann’s ischemic contracture: compartment syndrome d/t brachial artery disruption
  • other UE nerve injury

Dx: Xray

Mgmt:

  • splint if posterior fat pad + significant tenderness
  • ophtho consult

nondisplaced w/intact neurovascular:

  • long arm splint
  • sling
  • close ortho f/u

displaced:
- admit for ortho surgical reduction, fixation

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17
Q

Elbow dislocation

A

Perform neurovascular checks pre/post reduction

Mgmt:

  • reduced in ED w/sedation
  • initial immobilization in posterior mold splint
  • transition to hinged elbow brace for early motion
  • surgery for failed outpatient reduction or in certain fracture dislocation patterns
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18
Q

Olecranon bursitis

A

A/w olecranon bone spur
- suppurtive vs. non-suppurtive

If not inflamed, warm, no signs of infection can do compression wrap, will reabsorb on its own

Dx: synovial analysis

Mgmt:

  • compressive wraps, padded elbow sleeve, aspiration; avoid resting on elbow
  • may require IV abx (suppurtive)
  • surgery for bursectomy
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19
Q

Lateral epicondylitis

A

Tennis elbow

Sxs:

  • pain, fullness of lateral elbow
  • pain with resisted wrist extension
  • chronic tendinosis of extensor origin

Tx:

  • avoid using extensors
  • therapy: stretching, eccentric loading, NSAIDs, ice, counterforce brace, wrist splint, cortisone injection
  • failed conservative tx: surgery
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20
Q

Medial epicondylitis

A

Golfers elbow

Sxs:

  • pain, fullness of medial elbow
  • pain with resisted wrist flexion

Tx:

  • therapy for stretching, eccentric loading, NSAIDs, ice, wrist splint, cortisone injection
  • surgery for failed conservative management
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21
Q

Radial head fractures

A

FOOSH injury

Sxs:
- medial bruising of elbow

R/o medial collateral injury of elbow

Dx:
- Sail sign* : displaces fat pat d/t effusion in joint (presumed fracture)

Mgmt:

  • minimally displaced: conservative w/sling, edema control, early ROM
  • a/w medial injury to MCL w/pain and ecchymosis requiring limits in valgus to protect MCL
  • displacement or comminution = surgery
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22
Q

Distal biceps rupture

A

D/t forceful lifting

Sxs:

  • feel a pop, bruising in AC fossa
  • weakness w/resisted supination

Mgmt:

  • limited time to fix, otherwise biceps tendon can retract away
  • surgery
  • control extension, INC by 10deg/wk
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23
Q

Cubital tunnel syndrome

A

Compression of ulnar nerve at medial elbow

R/o diabetic polyneuropathy, drugs (amiodarone), neck compressive neuropathy

Sxs:

  • pain, numbness, tingling in ulnar nerve distribution
  • Positive Tinnel’s and elbow flexion testing
  • extreme cases: “clawing” d/t prolonged ulnar neuropathy

Motor

    • Froments: pinch paper between thumb, first finger
  • Wartenberg’s: ulnar drift of pinky

Dx: confirm w/EMG/NCS

Tx:

  • nerve glides, splinting at night
  • surgery for failed conservative treatment (anterior transposition for gliding a better pathway)
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24
Q

Carpal tunnel syndrome

A

D/t flexion/extension

  • use of vibratory tools (jackhammer)
  • acutely = trauma (distal radius fracture)

Sxs:

  • numbness, tingling, pain in median distribution
  • reduced grip strength

Positive Tinel, Phalens, carpal compression testing

Motor involvement can include weak extensor pollicis brevis

Mgmt:

  • night splints, nerve glides, cortisone injection, modification of activity
  • failed = surgery
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25
Q

Osteoarthritis of 1st CMC Joint

A

d/t overuse

Sxs:
- pain, fullness, limited function

Complication: thumb in palm deformity, hyperextension at MCP joint

Dx: Xray
Tx:
- splinting, APAP, NSAIDs, cortisone

Surgery:
- remove trapezium +/_ ligament reconstruction, tendon interposition (anchovy procedure),cast for months, splint, therapy

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26
Q

DeQuervain’s stenosing tenosynovitis

A

Inflammation of 1st doral compartment (APL, EPB)

Sx: pain, swelling of radial aspect of wrist

Dx: + Finkelstein test

Tx:

  • rest
  • tendon glides
  • splinting
  • NSAIDs, cortisone injection
  • surgery: release 1st dorsal compartment
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27
Q

Ganglion cyst

A

MC soft tissue tumor of wrist and hand

  • joint = mucus cyst
  • tendon sheath = retinacular cyst
  • may be dorsal or volar

D/t insult to joint, often don’t remember initiating injury

Tx:

  • avoid aspiration of volar ganglion to avoid injury to radial artery
  • recurrence up to 30% with or without surgery
  • can scar after surgery
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28
Q

Distal radius fracture

A

Need plain lidocaine w/out epinephrine

R/o EPL rupture w/the injury +/- surgery (can’t lift thumb off table)

Dx: Xray

Tx:

  • nondisplaced: short arm cast
  • displaced: reduce using hematoma block (w/lidocaine) and traction w/finger traps w/application of Sugar Tong Splint** (prevents forearm rotation)

surgery: failed conservative mgmt, open fracture, younger age, significant displacement

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29
Q

Scaphoid fracture

A

MC fracture wrist bone d/t FOOSH
- commonly results in nonunion if displaced, d/t poor blood supply to proximal aspect

Sxs: anatomical snuffbox pain

Dx: may not be evident on initial film

Tx:

  • thumb spica cast* - hand in position like you’re going to shake their hand
  • surgery
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30
Q

Osteoarthritis (hand joints)

A

DJD; irreversible loss of articular cartilage

RF: Fhx, obesity, age, trauma

Sxs:

  • stiffness, pain
  • Herberden’s = DIP nodes
  • Bouchard = PIP nodes
  • Osteophytes (bone spurs) = can wear on the extensors
  • Mucous cysts = DIP, ganglion cyst

Dx: Xray to r/o other pathology

Mgmt:

  • exercise in pain free range to maintain motion/strength
  • wt loss
  • pain mgmt: APAP, NSAIDs, topicals, intraarticular injections
  • surgery
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31
Q

Rheumatoid arthritis

A

Systemic, disabling polyarthritis resulting in chronic synovitis w/erosive articular changes

Sxs:
- ulnar deviation at MCP, caput ulnar

Dx: RF, CBC

Mgmt:

  • Salicylates, NSAIDs, corticosteroids
  • DMARDs: methotrexate, hydroxychloroquine
  • splinting, assistive devices
  • surgery
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32
Q

Trigger finger

A

D/t

  • congenital d/t widened FPL
  • acquired: age>40, diabetes, RA

Sxs:

  • inflammation of flexor tendon sheath
  • form nodule along flexor, does not glide
  • pain, locking, catching
  • tenderness at A1 pulley, can lock in flexion or can hear clicking*

Mgmt:

  • A1 pulley release: NSAIDs, cortisone injections, surgery
  • splint to keep pt from going all the way into flexion (+ cortisone injection)
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33
Q

Mallet finger

A

A/w avulsion of base of distal phalanx
- injury of distal extensor mechanism

Sxs: cannot extend DIP

Mgmt:

  • reduce into extension; if not, pin
  • splint or serial casting in slight hyperextension for 6wk followed by prn splinting until week 8 vs. surgical pinning
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34
Q

Jersey Finger

A

common athletic injury (football, wrestling)

Rupture of distal flexor digitorum profundus (FDP)

Mgmt: surgical repair to reattach FDP to distal phalanx

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35
Q

Gamekeepers Injury

A

A/w ski pole injury (forceful radial deviation)

Rupture of ulnar collateral ligament (UCL) of thumb +/- avulsion injury
[main stabilizer of MCP joint]

Dx: confirm w/clinical exam and stress views under fluoroscopy of the thumb - valgus stress and see if it opens up

Complication: long term instability may lead to arthritis

Mgmt:

  • nonsurgical: cast, splint
  • surgical: required for large avulsion fracture
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36
Q

Dupuytren’s disease

A

Scandinavian >50 a/w DM, alcohol, epilepsy, pulmonary disease

Sxs:

  • thickening and contraction of palmar fascia
  • painless palmar nodule and progress to flexion deformity
  • 4th or 5th digit

Dx:
- >30deg = intervention

Mgmt:

  • invasive fasciectomy
  • CCH or PNF
  • high risk of recurrence
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37
Q

Finger dislocation

A

D/t sporting injury

Document neurovascular pre/post

Dx: Xray to r/o fracture

Mgmt:

  • reduce by applying longitudinal traction distally, and gentle pressure over dorsal deformity to guide reduction
  • if unable to reduce with or without digital block, may require open reduction
  • immobilize w/splinting or casting
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38
Q

Finger fractures

A

Mgmt:

  • ice, elevation, pain mgmt, mobilization of unaffected joints
  • immobilization w/splinting or casting
  • closed reduction +/- percutaneous pinning
  • open reduction internal fixation w/pin, screw, plate
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39
Q

Boxer’s fracture

A

Punching w/fist

Sxs:
- fracture of metacarpal neck

Complication: may end up with a little palmar deformity

Mgmt:
- non surgical treatment unless severe

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40
Q

Finger tip injuries

A

E.g. industrial, snow blower, nail bed crush

common in children

Sxs:
- bleed a lot

Consider open fracture if nail bed involved and must cover w/abx

Tuft fracture: injury to distal pharynx, swollen, tender, nail involvement, splint

Mgmt:

  • remove nail and inspect nail bed
  • use nail or foil to split eponychial fold = best chance for nail regrowth
  • might require revision amputation
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41
Q

Lateral Femoral Cutaneous Nerve Syndrome (Meralgia Paresthetica)

A

Compression/entrapment of LFCN
- compression where it exits pelvis medial to ASIS under inguinal ligament

Et: thin female w/heavy workmans belt
- other RF: obesity, tight clothing, scar tissue from previou surgery/trauma

Sxs: SENSORY only

  • pain, burning, hypoesthesia; anterolateral or lateral thigh
  • joggers: “electrical jab” w/hip extension
  • strength/DTR unaffected

Dx: clinical

  • abd/pelvic exam to r/o intraabdominal pathology
  • AP pelvis, AP/lateral hip; r/o bony pathology
  • CT/MRI if intrapelvic mass suspected

Mgmt:

  • remove compression
  • wt loss
  • cortison injection
  • surgical release rarely required

Red flags:
- intolerable sxs failing conservative treatment warrant referral for further eval

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42
Q

Osteonecrosis of the Hip (AVN)

A

Bone death in femoral head d/t disruption of vascular supply to femoral head from trauma

  • progresses to bone structure fragment, collapse resulting in articular surface collapse and progressive arthritis
  • MC 3-5th decades; often bilaterally
  • RF: trauma, corticosteroids, ETOH, SCD, RA, SLE, HIV

Sxs: gradual dull ache or throbbing in groin* or lateral hip*

  • severe pain w/bone death
  • limited ROM, antalgic limp

PE:

  • pain w/active SLR
  • pain w/active/passive ROM of hip

Dx: AP pelvis, AP/frog-lateral

  • *crescent sign: well-defined sclerotic area just beneath articular surface representing a subchondral fracture
  • MRI if indicated

Mgmt:

  • limit weight bearing
  • intraarticular corticosteroid injection
  • surgical: refer to ortho [core decompression, vascularized fibular grafting, osteochondral allografting, total hip arthroplasty]
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43
Q

IT Band Syndrome (Snapping Hip)

A

Snapping/popping sensation occurring as tendons move over bony prominences
- MC: IT band snapping over greater trochanter

Sxs:

  • pain if trochanteric bursitis (often coexist)
  • iliopsoas tendon involved: felt in groin as hip extends from flexed position (rising from chair)

Limitation in IR, a limp, or shortening of limb suggests problems w/in joint and not IT band

Dx: clinical

  • AP pelvis, lateral hip Xray
  • MRI r/o acetabular labrum tear

Mgmt: PT, NSAIDs, corticosteroid injection
- surgery (rare)

Refer:

  • unclear diagnosis
  • intraarticular pathology
  • failure of conservative measures
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44
Q

Trochanteric bursitis

A

Inflammation/hypertrophy of greater trochanteric bursa
- may be secondary to lumbar spine disease, intraarticular hip pathology, leg length discrepancy, inflammatory arthritis, prior hip surgery

Sxs:

  • pain/tenderness over greater trochanter; pain w/hip abduction; worse rising from seated position
  • night pain
  • may radiate distally to knee or proximally into butt
  • Trendelenburg sign*

Dx: clinical
- AP pelvis, lateral hip Xray

Refer: failure of tx, uncertain dx, suspected fracture

Mgmt:

  • PT
  • corticosteroid/local injection into greater trochanteric bursitis
  • NSAIDs, ice/heat
  • activity modification - use of cane
  • surgery rare
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45
Q

Osteoarthritis of Hip (DJD)

A

Loss of articular cartilage of hip joint
- idiopathic; secondary to hip problems

Sxs: gradual onset groin/anterior thigh pain

  • butt or lateral thigh pain; may be referred to knee
  • initially pain w/activity but progress to pain at rest/night
  • antalgic gait
  • loss of ROM
  • abductor lurch (sway trunk over affected hip) to compensate for pain and abductor weakness
  • pain w/active SLR

Dx: AP pelvis/hip, lateral

  • joint space narrowing
  • osteophyte formation
  • subchondral cyst formation
  • subchondral sclerosis

Mgmt: NSAIDs/APAP, activity mod, PT, corticosteroid injection (fluoroscopic or US guided)
- surgery: THA (replace femoral neck, head, acetabulum)

Referral/Red Flag:

  • persistent pain despite conservative treatments
  • all young patients
46
Q

Pelvic Fractures

A

Pelvic Ring: different fracture patterns that occur based off applied forces to the pelvis

Pubic symphysis = surgery

Rami fracture can be managed with protected wt bearing and not surgery

Dx:

  • pelvic ring: AP (standard) & inlet/outlet views
  • acetabular: AP (standard) & Judet (45deg oblique)
  • CT scan

Mgmt:

  • protected weight bearing (6-12wk)
  • certain patterns are stable and patients can wt bear as tolerated

Surgical stabilization:

  • widened pubic symphysis
  • SI joint widening or dislocation
  • extended sacral fractures

Refer ALL to ortho

47
Q

Acetabulum fractures

A

Fracture pattern depends on position of femoral head at time of injury, magnitude of force, and age

MC: trauma when femoral head takes out superior part of acetabulum

Dx: Xray

  • check pulse/sensation after traction
  • if you lose pulse, get vascular surgeon involved

Tx:

  • distal femoral traction: preserve soft tissue, maintain length, maintain femoral head reduction if dislocated
  • non-op tx: minimally displaced, joint maintained, no intraarticular fragments, poor surgical candidate
  • surgical tx: min posttraumatic arthritis, repair acetabulum, toe-touch weight bearing up to 3mo postop

Complications:

  • posttraumatic arthritis
  • neurovascular injury
  • heterotopic ossification
  • avascular necrosis
48
Q

Femoral head fracture

A

Almost all a/w hip dislocation

Look for intraarticular fragments a/w fracture

Dx: Xray

Mgmt:
<1mm step off = closed treatment
>1mm step off = surgery (ORIF)

49
Q

Femoral neck fracture

A

MC older women r/t osteopenia/osteoporosis
- other: falls in elderly, high energy trauma in younger pt

Sxs: affected leg is shorted and ER**

Garden Classification system

  1. impacted - femoral neck shortened
  2. non-displaced
  3. partially displaced
  4. completely displaced w/vertical fx line

Dx: xray
- intraoperative imaging

Mgmt:

  • nondisplaced: pinning; usually younger pt
  • displaced: hemi or total hip arthroplasty

Percutaneous pinning: restricted weight bearing

Hemi arthroplasty: WBAT

50
Q

Intertrochanteric fractures

A

Area between greater/lesser trochanter

  • F 60-70yo, r/t osteopenia/osteoporosis
  • h/o fall, direct trauma to greater trochanter

Sxs: leg shortened, ER**

Mgmt:

  • most need surgical stabilization (sliding/dynamic hip screw; intramedullary nail)
  • non-op: high-risk pt or demented nonambulator
51
Q

Trochanteric fracture

A

Greater: obtain MRI
- operative mgmt

Lesser: elderly, look for evidence of pathologic process (tumor, osteoporosis)
- tx sxs

52
Q

Subtrochanteric Fractures

A

Point between lesser trochanter and point 5cm distal

  • high energy (GSW in young pt)
  • falls in elderly

Dx: xray

Mgmt:

  • placed initially into bucks traction if going to OR w/in 24hr
  • non-op mgmt for very poor surgical candidate only
  • surgical stabilization**
  • restricted WB 6-10wk, PT, short-term nursing home
53
Q

Femoral Shaft Fracture

A

Good healing rate d/t large blood supply

Mgmt:

  • typically placed in some type of traction prior to proceeding to the OR
  • intramedullary nailing
54
Q

Distal Femur Fractures

A
  • any fracture involving the distal 9cm of the femur
  • usually d/t high energy trauma; elderly may be d/t osteoporosis and low-energy injury

A: supracondylar
B: condylar
C: combination

Mgmt:

  • non-op: nondisplaced or incomplete fracture
  • operative [intramedullary nailing or ORI w/surgical plating]: intraarticular, displacement, ipsilateral LE fracture

MC Complication*
- loss of knee motion, results if you don’t maintain articular surface of the knee

55
Q

ACL Tears

A

MC knee tear

  • d/t twisting of hyperextension injury
  • MCL/meniscus may be involved

Sxs:

  • sudden onset pain; unable to return to activity following injury
  • audible pop
  • development of hemarthrosis in the following 24hr
  • chronic instability if not treated

PE:
+ Lachman
+ Anterior Drawer

Dx:

  • AP, lateral, tunnel views of the knee: usually only positive for effusion, possibly avulsion fracture of lateral capsular margin of tibia
  • fall injury = Xray to r/o other fracture
  • Knee MRI: if ACL suspected but not confirmed w/PE

Mgmt: Refer all to ortho*

  • RICE, crutches, WB if tolerated in knee immobilizer
  • PT

Surgical options

  • young, active pt: ACL reconstruction
  • older, less active pt: PT +/- ACL functional bracing
56
Q

PCL Tears

A

Isolated injury is less common than combination injury w/ACL

Cause: dashboard injury*, fall onto flexed knee, pure hyperflexion injury (usually ACL/PCL)

Sxs:

  • pain, joint effusion w/in 24hr; limited ROM
  • instability w/weight bearing
  • may not have tenderness to palpation

PE:
+ posterior drawer
+ sulcus sign (hold tibia up)

Dx: MRI**
- AP, lateral Xray to identify bony pathology

Mgmt: RICE, knee immobilizer

  • PT, early ROM; functional bracing
  • surgery: less common to repair
57
Q

MCL Tears

A

D/t valgus force w/out rotation

Sxs:

  • usually able to ambulate after injury
  • localized swelling (less than ACL/PCL)
  • limited motion
  • mechanical symptoms or instability infrequent
  • ecchymosis/effusion 24-48hr

PE:

  • tenderness along MCL
  • Valgus stress test

Dx: MRI*
- AP, lateral Xray may show avulsion fracture

Mgmt:

  • RICE, crutches, NSAIDs, PT
  • Grade II: refer, protective bracing, WBAT [5-10mm laxity]
  • Grade III: refer, 3-4mo protective bracing w/gradual return to WBAT over 4-6wk [>10mm laxity]
58
Q

LCL Tears

A

D/t varus force w/out rotation
- less common than MCL

Sxs:

  • usually able to ambulate following injury
  • localized swelling
  • mechanical sxs or instability infrequent
  • ecchymosis/effusion after 24-48hr
  • limited motion

PE

  • tenderness along LCL
  • varus stress test

Dx: MRI**
- AP, lateral Xray may show avulsion fracture

Mgmt:

  • RICE, crutches, NSAIDs, PT
  • Grade II: refer, protective bracing, WBAT [5-10mm laxity]
  • Grade III: refer, 3-4mo protective bracing w/gradual return to WBAT over 4-6wk [>10mm laxity]
59
Q

Meniscal tear general

A

Acute injury - traumatic twisting of knee
Older pt - degenerative

May be a/w injury of another knee ligament

Sxs:

  • sudden onset pain, swelling, stiffness over 2-3d
  • joint effusion w/acute injury
  • mechanical sxs** : locking, catching, popping
  • large fragment, knee may become “locked”
  • medial or lateral pain, with twisting or squatting
  • pain waxes and wanes

PE:

  • tenderness over medial/lateral joint line
  • limited ROM
    • McMurray test
    • Apley’s test

Red Flags:

  • traumatic effusion
  • mechanical symptoms
  • ligamentous instability
  • no response to conservative treatment
  • persistent joint line tenderness or effusion
60
Q

Meniscal tears Dx/Tx

A

Dx:

  • AP, lateral, sunrise Xray if trauma or effusion
  • chronic: AP, lateral should be weight-bearing
  • MRI if not responding to conservative treatment or if ligament injury suspected
  • Aspiration if crystal disease or joint infection suspected

Mgmt:
Conservative: no mechanical sxs; degenerative
- RICE, PT, NSAIDs, APAP

Surgery: acute injury, locking or catching*, younger pt

  • meniscectomy vs. repair
  • red: vascular
  • white: non-vascular
61
Q

Bursitis of the Knee

A

Sxs:

  • pain w/activity or direct pressure
  • often worse if sedentary for long period, limp
  • localized swelling and tenderness
  • numbness below patella if saphenous nerve and infrapatellar branch compressed by pes and anserine bursa

Dx:

  • aspiration of prepatellar bursa for fluid analysis to r/o infection
  • purulent or seropurulent material
  • gram stain, culture, crystal analysis, synovial fluid analysis
  • AP, lateral Xray of knee

Mgmt:

  • NSAIDs, ice, activity modification, PT
  • aspiration, corticosteroid injection
  • IV/PO abx if infection
  • surgery to resect bursa (rare)

Red Flags:

  • symptoms not responding to conservative tx
  • signs of ligament or tendon problems
  • infected bursa not responding to conservative treatment
62
Q

Prepatellar bursitis

A
  • bursa lies between skin and patella to anterior aspect of knee
  • MC caused by direct trauma* or chronic kneeling*
  • may be infected w/Staph aureus or streptococcus
63
Q

Pes anserine bursitis

A
  • bursa lies under sartorius, gracilis, semitendinosus on medial aspect of tibia just below tibia plateau
  • MC cause by OA of medial compartment
64
Q

Osteochondritis dissecans

A

Osteonecrosis of subchondral bone

  • MC medial femoral condyle
  • d/t repetitive small stresses to subchondral bone that disrupt blood supply
  • osteonecrotic bone becomes separated from surrounding bone, weakens, and gradual fracture of articular cartilage surface occurs becoming loose bodies in joint

Sxs:

  • gradual onset of knee pain, knee effusions, catching or locking
  • walking w/foot externally rotated may relieve pain
  • tenderness to palpation

PE: + Wilson Test
- supine, flex hip and knee to 90deg, internally rotate tibia and slowly extend knee
+ = pain at 20-30deg and pain relieved w/ER of tibia

Dx: AP, lateral, tunnel Xray - necrotic area of bone or FB in joint
- MRI assess overlying articular cartilage and stage lesion

Mgmt: goal is heal lesion
Nonsurgical:
- child prior to skeletal maturation (overlying cartilage still intact)
- activity modification, crutch use

Surgical:

  • adults, articular cartilage that has been separated from bone
  • intact lesion - drill to promote vascular growth
  • unstable lesion - temporary internal fixation
  • remove loose fragment, debride articular surface defect
65
Q

Patellar/Quadriceps Tendonitis [“Jumpers Knee”]

A

D/t overuse or overload syndrome; common in younger pt (<40y) but may occur in older pt after lifting strain

Sxs: anterior knee

  • pain following exercise or w/prolonged sitting, squatting, kneeling
  • increased pain w/stairs, running, jumping, squatting
  • tenderness over tendon or attachments
  • warmth, swelling, soft-tissue crepitus
  • normal ROM but pain w/resisted knee extension or hyperflexion

Dx: AP, lateral Xray (-) but may see osteophyte or heterotopic ossification
- MRI for surgical cases or when partial rupture suspected

Mgmt: rest (days-wks) + NSAIDs, analgesics, ice after/heat before activity

  • avoid corticosteroid injection into tendon (may increase r/o tendon rupture)
  • PT, knee sleeve

Red Flags:

  • possible or confirmed rupture of the extensor mechanism
  • failure of conservative treatment
66
Q

Patellofemoral Pain Syndrome

A

Diffuse anterior knee pain increased w/activity

  • usually r/t overuse or overloading of patellofemoral joint
  • chondromalacia not always present

Sxs:

  • sense of instability or catching; no swelling or prior trauma
  • worse after prolonged sitting, stairs, jumping, squatting
  • knee angulation; increased Q angle
  • J sign: active knee flexion then extension - patella moves laterally >1cm
  • pain w/patellar compression
  • crepitus w/knee flexion –> extension
  • patellar apprehension sign* (instability)

Dx: AP, lateral, sunrise view

Mgmt: activity modification, PT, NSAIDs, APAP, wt loss
- surgery

Red flag:

  • persistent symptoms, recurrent effusions
  • findings of patellar instability
67
Q

OA (Knee)

A

MC >55yo; gradual onset pain especially w/weight-bearing activity

Sxs:

  • may have mechanical symptoms of buckling or giving away
  • stiffness, intermittent swelling
  • progresses to pain at rest or w/sleeping
  • tenderness to joint lines
  • valgus or varus deformity
  • mild effusion
  • crepitus to patellofemoral joint
  • decreased ROM w/progressive disease

Dx:

  • weight-bearing* AP Xray, lateral, sunrise
  • joint space narrowing, osteophyte formation, sclerosis, periarticular cysts
Mgmt: 
Conservative
- NSAIDs/APAP; PT; intraarticular corticosteroid injection
- Ice, heat, topical analgesics
- ambulatory device

Surgical: indicated when pt cannot stand the pain anymore
- TKA

Red flags:

  • failure of conservative tx
  • pain at rest, decreased ROM, significant functional limitations
68
Q

Baker’s cyst [Popliteal cyst]

A

MC synovial cyst/bursa in the knee

  • communicates w/knee joint and becomes more prominent when trauma creates excess joint fluid
  • a/w degenerative meniscal tears or systemic inflammatory conditions (RA)**

Sxs

  • swelling or fullness to popliteal fossa w/pain and tenderness; mechanical symptoms
  • severe pain and swelling in calf if rupture occurs
  • mass seen and/or palpated at popliteal fossa
  • effusion and mechanical symptoms usually indicate intraarticular irritation

Dx:
(-) Xray, but may show DJD or calcification of cyst
- U/S to differentiate cyst/vascular*
- do NOT aspirate pulsatile mass

Mgmt:

  • RICE
  • aspiration only transient and fluid often reaccumulates
  • treat cause of increased fluid and cyst usually resolves spontaneously [meniscectomy, TKA]
  • cyst excision
69
Q

Shin Splints

A

Gradual onset pain to posteromedial aspect of distal third of leg

  • develops w/exercise; a/w prolonged walking or running
  • may be inflammation of tibial periosteum secondary to repetitive muscle contraction

Sxs: gradual onset; pain to distal third of medial tibia, site of origin of posterior tibialis

  • tenderness to distal third of medial tibia
  • pes planus, overpronation

Dx: AP, lateral views of tibia to r/o stress fracture

Mgmt:
- activity modification, NSAIDs, ice massage, analgesic, shoe inserts

Red flags:
- r/o stress fracture and exertional compartment syndrome w/neurovascular checks, pain out of proportion to injury

70
Q

Patella Fracture

A

Mechanism: direct or indirect
- quad tendon attaches superiorly, patellar tendon attaches distally

Dx:

  • important to assess active knee extension: ability to perform active extension must be assessed w/SLR*
  • Xray

Complications:

  • loss of knee motion
  • loss of extensor strength
  • posttraumatic arthritis

Mgmt:
Nonoperative:
- <3mm displacement, minimal articular disruption, intact extensor mechanism
- WBAT in knee immobilizer
- Knee ROM 4-6wk once callus begins to form

Operative:

  • 3mm of displacement, >2mm articular disruption, disrupted extensor mechanism
  • WBAT in knee immobolizer postop
  • repair tendon
  • patellectomy vs. ORIF
71
Q

Tibial plateau fracture

A

Mechanism: forceful varus/valgus stress

  • elderly: fall
  • involves articular surface; more serious when involving joint
  • MC = lateral plateau
  • may be a/w ligament injury

Dx: CT

Mgmt:
Initial: long leg cast
Nonop: nondisplaced, comorbid conditions, preexisting arthritis
Op: perform when soft tissue swelling improved (10-14d s/p injury)
- ORIF + NWB x 3mo

72
Q

Achilles tendon tear

A

Usually occurs 5-7cm proximal to calcaneus
Med: ciprofloxacin

Sxs: sudden, severe calf pain, rapidily achy

  • partial: calf strain or pull w/maintainence of function
  • complete: weakness, loss of function

PE: + thompson test
- check palpable deficit, tenderness, achilles swelling

Dx: MRI

Mgmt:
Nonsurgical: partial tear or poor surgical candidate
- splint in plantarflexion, then subsequent casting is less and less flexion

Surgical: complete tear

  • treatment must not be delayed as deficit widens as muscle belly retracts end of tendon*
  • refer all suspected partial or complete tears
73
Q

Achilles tendonitis

A

Posterior heel “start up” pain
Tenderness w/palpation of Achilles

Dx: imaging not requires; may show calcification if chronic

Mgmt: PT, NSAIDs

  • refer if conservative failure after 1wk
  • NO steroid injections
74
Q

Ankle sprain

A

MC: ATFL
MC inversion injury
High ankle sprain: tibiofibular syndesmosis injury

Sxs:

  • pain over anterolateral ankle; swelling and loss of function common
  • inability to walk
  • ecchymosis and swelling
  • tenderness over affected ligament

PE:

  • anterior drawer: laxity suggesting higher grade ligament tear
  • squeeze test: high ankle sprain

Dx: AP, lateral Xray IF [Ottawa rules]

  • tenderness at tip of malleolus
  • inability to weight bear immediately after injury or take four steps in the ER
  • pain at the base of 5th metatarsal (may pull off part of the bone)

MRI rarely indicated; if you think it is required = refer

Mgmt:
Goal - prevent chronic instability and pain
- RICE, NSAIDs, PT
- severe: 2-3wk NWB boot

Refer:

  • high ankle sprain, fracture
  • significant instability
  • failure of conservative measures
75
Q

Foot and ankle arthritis

A

Cause: idiopathic, inflammatory, posttraumatic
90% of ankle DJD = prior injury*

Sxs: pain w/activity, swelling, stiffness, rest pain

  • decreased ROM
  • pain w/palpation, creptius
  • swelling, fullness, warmth

Dx: Xray

Mgmt:
- NSAIDs, immobilization, bracing, shoe modification; temporary steroid injections

Refer:

  • pain and ambulation problems
  • worsening sxs
  • failure of conservative treatment

Surgical:

  • fusion = remove arthritis
  • fix w/plate, screw
76
Q

Tarsal tunnel syndrome

A

Entrapment of tibial nerve in tarsal tunnel

Sxs: pain, swelling in posterior medial ankle w/associated radiating neuritis sxs in the tibial nerve distribution

PE: + tinel

Dx: EMG
- MRI preop, r/o tarsal tunnel mass

Mgmt:

  • immobilization for acute inflammation
  • PT for nerve glide exercises
  • Gabapentin (Neurontin) or Pregabalin (Lyrica) for neuropathic pain

Surgical: fail conservative; tarsal tunnel mass

77
Q

Plantar fasciitis

A

H/o increased physical activity or obesity

Sxs: start-up pain
- pain over plantar fascia origin or throughout fascia
+/- Baxter’s nerve

Dx: radiograph may show heel spur

Mgmt:

  • 1yr of conservative treatment: NSAIDs, heel cord stretches, night splint, PT
  • cortisone injection from medial aspect (NOT plantar)

Surgical: plantar fasciotomy + stretching

78
Q

Haglund Deformity

A

Females
Symptomatic in shoes

“Pump bump” - posterior lateral prominence
- soft tissue changes first, then bony

Dx: Xray

Mgmt: gel sleeve, heel lift, surgery

79
Q

Central fat pad atrophy

A

+/- h/o trauma
Worse in barefoot or hard floor; only w/weight bearing activity
Comparable to plantar fasciitis - but NO startup pain

Sxs: pain over central heel on exam
+/- palpable bone indicating fat pad atrophy
- adequate fat pad but + pain w/palpation = maybe bruised fat pad

Dx: Xray r/o stress fracture

Mgmt:

  • orthotic pads help cushion
  • no injections, no replacement therapy
80
Q

Calcaneal stress fracture

A

Military recruit, marathon runner

PE: provocative test = + pain w/squeezing of calcaneal body

Dx: Xray; but MRI confirms*

Mgmt:

  • NWB boot x 4-6wk, then PT to stretch area that tightened up in boot
  • gradual return to activity
81
Q

Lisfranc injury

A

D/t forced plantar flexion; easily missed as ankle or foot sprain

Sxs: pain over dorsal midfoot, usually mild to significant swelling

  • swelling, pain over tarsal-metatarsal joint
  • stabilization of ankle and hindfoot w/sagittal stress of the midfoot will create pain and occasionally instability is felt

Dx:

  • Fleck sign: metatarsals and bones of foot don’t line up
  • Xray

Mgmt:

  • immobilization
  • urgent surgery* to stabilize medial column
  • posterior splint at 90deg from base of foot to base of knee
82
Q

Metatarsal fracture

A

D/t trauma or fatigue (stress)

Sxs: swelling, pain w/weight bearing
- new or INC training regimen is common for stress fracture

Dx: Xray

Mgmt:

  • NWB x 4-6wk then WBAT
  • refer to Ortho

Surgery:

  • significant shortening, displacement, angulation, subluxation
  • painful non-union at 8wk
83
Q

Jones Fracture

A

5th metatarsal fracture

  • classic: zone 2 [NWB cast 6-8wk, surgery In athlete or sxs non union at 3mo]
  • pseudo jones: zone 1 [NWB cast x 4-6wk]
  • zone 3: stress induced [usually need surgery as delayed union is common]

Dx: Xray

84
Q

Metatarsal stress fracture

A

Sxs: pain, swelling, erythema
Dx: Xray often negative
Mgmt: NWB in post op shoe
- followed by gradual increase in WB, activity

85
Q

Hallux valgus (bunion)

A

Lateral deviation of hallux d/t hereditary, acquired, traumatic
- more common in females d/t shoe wear

Sxs: prominent medial eminence, pain w/activity, problems in shoe wear

Mgmt: shoe modification
- surgery: deformities w/sxs on regular basis

86
Q

Lesser toe deformity

A

Cause: shoe, trauma, high arches, pressure from bunion

Hammer toe: flexion at PIP, extension DIP
Claw toe: flexion at both PIP, DIP
Mallet toe: neutral PIP, flexion DIP

pain over deformity prominence can cause corns or distal tip of toe rubbing

Dx: Xray
Mgmt: reduce w/pencil, buddy tape
- reassure that it may be tender for a while
- surgery: percutaneous fixation for significant angulation fracture or cannot be reduced

87
Q

Toe fractures

A

Direct trauma - stubbed toe, kicked something
Permanent deformity is uncommon unless significantly displaced

Sxs: swelling, pain, ecchymosis

Dx: Xray
Mgmt: reduce w/pencil, buddy tape
- reassure that it may be tender for a while
- surgery: percutaneous fixation for significant angulation fracture or cannot be reduced

88
Q

Metatarsalgia

A

Common in walkers or d/t overuse, poor shoes

Sxs:

  • pain in ball of foot: worse in barefoot or hard floors (“walking on stones”)
  • pain with palpation of metatarsal heads: callous, fat pad atrophy, hammer toe, bunion

Dx: normal Xray

Mgmt: orthotics w/metatarsal pad
- refer if no improvement in a few weeks

89
Q

Morton’s neuroma

A

Hard to differentiate w/metatarsalgia

Pain worse in tight shoes* and better barefoot
Neuritic symptoms radiate into affected toes
Pain w/compression in web space (2nd, 3rd, webspace)

Dx:

  • negative radiograph
  • U/S
  • diagnostic lidocaine* : dec pain in Morton’s but not metatarsalgia

Mgmt:

  • orthotics w/MT pad
  • Neurontin
  • sclerosing agent?
  • Surgical excision if conservative measures fail
90
Q

Sesamoiditis

A

Anatomy

  • 2 sesamoid bones surround by FHB and plantar plate fibers
  • tibial (medial) and fibular (lateral)

Causes: inflammation from overuse/direct trauma; fracture; AVN

Sxs: pain under 1st MT head
+/- h/o forced DF injury (Turf Toe)
- may fracture sesamoids

Dx: best visualized on AP Xrary
- presence of sesamoids alone not indicative

Mgmt:

  • if overuse, orthotics w/sesamoid protection
  • refer to ortho if fail orthotic treatment or if fracture or AVN are present
91
Q

Charcot Marie Tooth (CMT)

A

Hereditary neuromuscular disorder w/multiple variants

Sxs: weakness of tibialis anterior and peroneal

  • neuropathy symptoms
  • Cavovarus deformity: ankle instability; 5th MT stress fractures

Mgmt:

  • bracing for weak tibialis anterior (foot drop)
  • reconstructive surgery (refer to ortho)
92
Q

Charcot Neuropathy

A

DM pt d/t breakdown of bone from trauma or DM neuropathy

Sxs: acute erythema, warmth, edema

  • improves w/elevation and off-loading*
  • chronic: bone destruction leaves a rocker bottom deformity - at risk of ulcer, infection, or loss of limb

Dx: initial Xray may be negative
- classic sign: fragmentation of bone and subsequent collapse

Tx: manage DM

93
Q

Pilon Fracture

A

D/t high energy trauma (fall)
- fracture of distal tibia w/extension into ankle joint

Sxs: pain, severe swelling quickly*

Dx: CT
Weber class (based on fibular involvement)

Weber A: below tibial plafond = stable; NWB cast 4-6wk

Weber B: at tibial plafond

  • w/out displacement, tx nonop
    • deltoid tenderness of medial clear space widening: ORIF
  • stress test if unclear
  • may have syndesmotic injury

Weber C: above tibial plafold

  • indicates syndesmotic injury
  • requires ORIF

Mgmt: call ortho immediately
- external fixation until definitive fixation can be performed

94
Q

Medial malleolus fracture

A

Isolated
Check proximal fibula
Xray if malleolus tender

Mgmt:

  • nondisplaced: cast
  • displaced: ORIF
95
Q

Bimalleolar fracture

A

Lateral + medial
Xray

Mgmt:

  • unstable: ORIF surgery
  • no displacement and multiple comorbidities: consider casting
96
Q

Trimalleolar fracture

A

high rate of associated dislocation
Lateral + medial + posterior
Xray

Mgmt:

  • very unstable and requires ORIF
  • usually 7-10d after injury to allow soft tissue to settle down
  • initially splint in stirrup + posterior rigid splint - call ortho*
97
Q

Maisonneuve fracture

A

External rotation injury
- medial deltoid ligament tear + syndesmotic tear + proximal fibular fracture

Xray

Unstable = ORIF

98
Q

Hindfoot fracture

A

Talus, calcaneus d/t very high energy trauma
- MVA, fall from height

Dx: check spine for concomitant injury**

  • Hawkins classification
  • Xray
99
Q

Talar neck fracture

A

Nondisplaced: cast immobilization 6-8wk
Displaced: ORIF

100
Q

Talar fracture

A

Mgmt:

  • immediate reduction & fixation
  • complications: AVN
101
Q

Talar AVN

A

MC complication from fracture

Hawkins sign: subchondral lucency of talar body; occurs 6-8wk postop
- confirm w/MRI

Mgmt:

  • NWB in boot w/bone stimulator
  • more diffuse alteration in blood supply compared to OLT
102
Q

Calcaneus fracture

A

D/t high impact trauma

Sxs: pain/swelling around heel

Dx: Xray, CT if needed

Complications:

  • high rate of posttraumatic subtalar DJD
  • chronic heel pain d/t fat pad injury - treat w/orthotics

Mgmt:

  • refer all to ortho*
  • short leg splint ASAP
  • 10d NWB for both surgical and nonop pt

Woudn dehiscence MC postsurgical complication

103
Q

Ankylosing spondylitis

A

Inflammatory back pain (lumbar, SI, hip)

Manifestations:

  • acute anterior uveitis (MC)
  • bowel disease
  • enthesitis
  • peripheral arthritis
  • psoriasis

Dx:

  • Schober test <4cm
  • Occiput to wall - cervical mobility
  • Labs: HLA-B27*, inc ESR/CRP

Imaging - lags behind presentation 7-10y

  • Bamboo spine** - bone building disease, dec ROM
  • Sacroilitis = radiograph hallmark**

Mgmt: tx current manifestations of dz

  • NSAIDs for pain, stiffness
  • pt ed, exercise, PT
  • NO DMARDs
  • corticosteroid injections may be helpful
  • may consider surgery
104
Q

Back strain/sprain general

A

Strain: paravertebral muscles
Sprain: facet joints, disc, spinal ligament

Most injuries thought to be a combo of both*

PE: neck, back, PV

Red flags:

  • h/o CA
  • unexplained weight loss
  • urinary retention, incontinence
  • progressive motor or sensory loss
  • loss of anal sphincter tone
  • saddle anesthesia*
  • trauma, fever, UTI, infection
105
Q

Back strain/sprain dx/tx

A
  • imaging does NOT improve outcomes in pt w/o sxs of serious underlying condition, therefore not indicated for most

significant trauma: plain film*, may need CT or MRI
- concern for serious neurologic cause = MRI (r/o cauda equina syndrome)

  • even w/minor red flags, 4-6wk of conservative treatment reasonable prior to imaging

Mgmt:

  • pt ed; avoid bedrest; NSAIDs/APAP; muscle relaxants; warm compress; PT
  • oral steroids; lumbar supports; massage; spinal manipulation
106
Q

Kyphosis

A

Anterior compression (>5deg) in at least three adjacent vertebral bodies, as measured on lateral spine radiograph

  • MC in tall boys; a/w w/back pain in adulthood
  • affects thoracic or thoracolumbar spine

Sxs: subacute pain w/out precipitant

  • pain worse after activity and at end of day
  • pain improved w/rest and age

PE: curvature does not flatten w/forward bending, extension, or lying supine*

Dx:

  • standing lateral spine radiograph**
    criteria:
  • anterior wedging >5deg in three adjacent vertebral bodies

Mgmt:

  • conservative: strengthening, stretching, analgesics, avoidance of precipitants
  • bracing or surgery may be warranted w/persistent pain or kyphosis >60deg
107
Q

Scoliosis

A

Lateral curvature of spine

Sxs: generally painless* MC R thoracic curvature

  • asymmetry of shoulder heights, scapular prominence or position
  • waistline or pelvic height discrepancy
  • rib hump when pt bends over and comes back up slowly

Dx:

  • females screened twice at ages 10/12 and boys once at 13 or 14
  • standing AP spine radiograph*
  • location of curve defined by apical vertebrae; direction of curvature defined by direction of convexity
  • Cobbs Angle* = degree of curvature; > 15 is abnormal

Mgmt:

  • ortho referral
  • curve 20-25: monitor
  • curve 25-45: no bracing in skeletally mature; Milwaukee brace in growing children
  • curve >45: may require surgery regardless of skeletal maturity; refer regardless of age
108
Q

Osteoarthritis general

A

Non-inflammatory DJD, MC arthritis in adults

  • leading cause of hip/knee replacement
  • progressive erosion of articular cartilage* leading to sclerosis and osteophyte formation
  • synovitis (cool effusions) and synovial hypertrophy
  • ligamentous laxity and disruption of joint capsule w/out injury

Causes:
- aging
- congenital, obesity*, injury
RF: age, female, AA, genetic, obesity, joint stress

Sxs:

  • joint pain INC w/activity, relieved w/rest; worse in evening
  • stiffness <30min, restricted ROM
  • asymmetric sxs
  • weakness, atrophy
  • no systemic sxs
  • Herberden’s, Bouchard’s nodes
109
Q

OA dx/tx

A

Dx:

  • normal ESR/CRP
  • neg rheum tests
  • noninflammatory synovial fluid (WBC <2k)

xray: joint space narrowing, osteophytes, sclerosis, subchondral cysts, nodes

Mgmt:

  • limited to sx control; wt loss!!
  • joint protection
  • APAP
  • NSAIDs + PPI
  • can’t tolerate NSAIDs: capsaicin cream, methylsalicylate cream, diclonfenac sodium gel
  • intraarticular steroid injection (or hyaluronic acid)

Surgical indications:
- pain affecting work, sleep, walking, leisure

110
Q

Osteoporosis general

A

Skeletal fragility w/compromised bone strength predisposing to an INC r/o fracture

  • primary: reduced bone mass/fractures in postmenopausal women or older men d/t age related factors
  • secondary: bone loss from clinical disorder

bone mass peaks by 18-25yo

RF: female, white, petite, Fhx, early menopause, immobilization, ETOH, cigarette, Ca/Vit D def, meds, gastrectomy, intestinal surgery
- meds: steroids, heparin, AEDs

Sxs:

  • fractures, complications
  • MC: vertebral, proximal femur, distal forearm
  • no pain prior to fracture
  • fracture can result in chronic pain and disability

Osteopenia Pt

  • T-score -1 to -2.5
  • FRAX: calculate 10y risk of hip and major osteoporotic fracture (based on femoral neck BMD + RFs) - only applies before treatment
111
Q

Osteoporosis dx/tx

A

Dx: BMD, hp/vertebral fx w/o trauma
- all postmenopausal women, men >50yo eval for need of BMD

BMD testing

  • women >65
  • men >70
  • adult w/fracture over age 50
  • adult w/condition (RA) or taking medication (glucocorticoid) associated w/low bone mass or bone loss

Osteoporosis: T-score at or below -2.5

Mgmt:

  • Calcium [men 1000mg/d female 1200mg/d]: Ca carbonate take w/food; citrate for pt on PPIs or if they have constipation
  • Vit D 600-800 IU/day
  • PT/OT, smoking cessation, dec ETOH

Prevention:

  • estrogen
  • raloxifene
  • alendronate, risedronate, ibandronate

Treatment:

  • raloxifene (SERM)
  • bisphosphonates**
  • calcitonin, teriparatide, IV zoledronic acid, denosunab

Treat 4-5y w/bisphosphonates then drug holiday 1-2y
R/o osteonecrosis of jaw, atypical fremur fracture

Family Medicine (17 decks)

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