MSK Flashcards
1
Q
Most frequent sports injury?
A
Ankle sprains
Can lead to chronic pain, swelling, and functional instability (tend to reinjury the same ankle)
2
Q
Common treatments for ankle sprain
A
- Ankle bracing
- Rehab
- Multifaceted prevention program
- Surgery
3
Q
MOA of Ankle bracing?
A
The brace physiologically restricts ankle motion
Rigid braces more effective than taping
Recommend use for at least 6 months, but little to prevent future injury
4
Q
Benefits of rehab for ankle sprain?
A
Preferable to bracing and surgery for acute ankle injury
Proprioceptive exercises may be protective from future injury
Resistance exercises only begin when pt has FROM and can bear full weight
Focus is on strengthening muscles
5
Q
Benefits of multifaceted prevention program for ankle sprain?
A
Incorporates a variety of strategies to injury reduction/sprain prevention
Education on the importance of disciplined play (ie warm up/cool down, correct gear
Needs more research
6
Q
Benefits of surgery for ankle sprain?
A
Reserved for patients that fail non-operative treatment.
Highly successful in treating chronic instability
7
Q
Most common pharmacologica approach in sprains?
A
NSAIDs
8
Q
Initial treatment of choice for an acute ankle sprain?
A
Functional rehabilitation
9
Q
How many adults have low back pain?
A
Approx 2/3
10
Q
Spondylolysis is a defect in?
A
the pars interarticularis of the vertebra
Can be congenital or due to stress fx
11
Q
Spndylolistesis refers to?
A
Anterior displacement of vertebra
Occurs as a result of spodylolysis or degenerative disk dz
Process can contribute to narrowing of spinal canal -> spinal stenosis
12
Q
Foot dorisflexion tests?
A
L5
13
Q
Plantar strength, ankle reflex tests?
A
S1, L4
14
Q
Therapy for nonspecific low back pain
A
Scheduled NSAIDs
Ciro, PT if pain persists > 3 wks
Rapid return to normal activities
15
Q
Treatment for herniated intervertebral disks (w/o neurologic deficit)
A
NSAIDs, Chiro, PT x 1 month. Narcotics can be used for a short amount of time.
Epidural corticosteroids
CT or MRI if syx are persistant
Benefit of dikectomy is unclear for long term tx
16
Q
Treatment for spinal stenosis
A
Avoid alcohol and sedatives to reduce the risk of falls
Encourage walking/cycling
NSAIDs, PT, epidural corticosteroids
Laminectomy in persistant pain
Spinal fusion if they also have degenerative spondylolithesis
17
Q
Treatment for chronic low back pain w/o radiuclopathy
A
Intensive exercise
TCA, SSRI’s for those w/ depression (chronic pain causes neuronal hyperactivity)
Refer to multidisciplinary pain center
18
Q
Best way to prevent back pain
A
Aerobic conditioning with back and leg strengthening
19
Q
When is surgery a good option for back pain?
A
Pts with sciatica or other neurological process
20
Q
Which nerve is affected in carpal tunnel syndrome?
A
Median n.
21
Q
Pt demonstrats a “painful arc” on shoulder exam. Dx
A
Supraspinatus tendinitis
22
Q
What is the most appropriate first line management for a small ganglion?
A
Reassure and review if not improving or enlarging
23
Q
What are some red flags for back pain?
A
Pain that does not go away with rest
Pain w/ neurological syx
Hx of cancer
Fevers and chills
24
Q
What type of limp is characterized by shortening of stance?
A
Antalgic
25
12 year old male is brought into the office for evaluation of hip pain and a limp. On Physical exam he is obese and limping. Xray shows narrowing of femoral joint. Dx?
Slipped capital femoral epiphysis
26
Your female patient is referred for evaluation after recent diagnosis with Graves disease. She has a large goiter and compressive symptoms. Management?
Radioiodine therapy
27
Most common compressive neuropathy of the upper extremity?
Carpal Tunnel syndrome
28
What is the most superficial structure in the carpal tunnel?
Meadian n.
Enters the space in the midline or just radial to the midline
nerve can divide in the forearm or in the tunnel
29
Why is the median n. susceptible to compression within the carpal canal?
Unyeilding fibrosseous borders of the canal
| With edema/inflammation the pressure increases -> nerve irritation
30
Precipitating factors for acute CTS?
Wrist trauma
Infection
High pressure injection
Hemorrhage
31
Precipitating factors for chronic CTS
```
More common than acute
Idiopathic
Anatomic
Systemic
Exertional
```
32
What causes anatomic chronic CTS?
```
Persistent median a.
Infection
Ganglion cyst or Tumor
Trauma (edema, hemorrhage, scaring)
w/in carpal canal increases interstitial fluid pressure
```
33
What causes systemic chronic CTS?
```
Obesity
Drug toxicity
Alcoholism
Diabetes
Pregnancy (3rd trimester)
Hypothyroidism
RA
Primary amyloidosis
Renal failure
```
34
What causes exertional chronic cTW?
Repetitive use of wrist and digits, repeat impact to the palm, and operation of vibrating tools
35
How do you dx CTS?
History - nocturnal pain, numbness, tingling of thumb and 1st two fingers. Improves with shaking
B/l common
Tinel's sign, Phalen's test
ABN EMG
36
How do you treat CTS?
Splinting, corticosteroids, diuretics, NSAIDS - idiopathic cases
Surgery - Trauma or infection, or chronic cases with denervation of abductor pollicis brevis m. (thenar atrophy) or pronounced sensory loss
37
Most common method to decompress CTS?
Open surgical release
| Palmar fascia and TCL are incised
38
Most common complication of CTS surgery?
Incomplete release of TCL -> recurrent CTS symptoms
More common in endoscopic
Endoscopic and open surgery overall equivalent
39
What Xrays should be ordered for a shoulder injury?
AP and axillary lateral
40
Most common causes of shoulder pain?
1. Impingement syndrom - rotator cuff is compressed against the acromion
2. Rotator cuff tears
3. Adhesive capsulitis
4. Arthritis of glenohumoral and AC joint
41
Pain when pt elevates the arm in the scapular plane as high as possible
Painful arc sign
| Rotator cuff tear
42
Pain when pt elevates arm in the plane of the scapula fully and return to their sides slowly. Or passive elevation of arm and pt quickly drops arm back to their side
Drop arm sign
| Rotator cuff
43
Examiner passively elevates arm above the patients head and elicits pain in the front of the shoulder
Neer impingement
| Impingement syndrome or rotator cuff tear
44
Pain when Pt's arm is abducted 90 degrees and then rotate between neutral and internal rotation.
Hawkins impingement sign
| Impingement syndrome
45
External rotation strength is tested b/l with pts arms and side and elbows flexed 90 degrees. Instruct pt to push against the examiner
Rotator cuff strength
Use to dx full-thickness or large rotator cuff tears
Partial thickness or small tears are unlikely to cause weakness on examin
46
Best test for bursitis or partial rotator cuff tear?
Neer impingement
47
+ Painful arc sign, drop-arm test, and external rotation strength test have high probability for?
Rotator cuff tear (91%)
48
What test should be ordered to confirm Rotator cuff tear?
MRI
49
How do you treat impingement syndrome?
PT
Can also offer a subacromial steroid injection
If no response x3 months consider decompression
50
If a pt has a rotator cuff tear that is repairable can they receive subacromial steroid injections?
Yes, but no more than two as this can weaken the remaining tendon and have poorer outcome after repair
51
When is a rotator cuff irreparable?
If MRI demonstrates fevere fatty atrophy of the muscles or if the humeral head has migrated up to the acromion.
This migration occurs several months after a tear.
52
Why do rotator cuff tears have an option to try PT for 3 months prior to surgery?
Approx half the time PT can make the tear painless
Reasonable option for those that really want to avoid surgery
Only offered to those with partial or small tears. PT makes large tears worse
53
What are the risks of steroid injections?
```
Infection
Anaphylaxis
Vagal response
Hyper glycemia in DM
Long term: tendon rupture
```
54
What surgery is recommended for impingement syndrome?
Outpt arthroscopy
Recovery 3-4 months
Better outcomes if they participate in PT post surgery
55
What are the benefits of rotator cuff surgery?
90% have excellent results
Result directly correlates with size of tear and amount of atrophy
Recovery takes 4-6 months + PT
56
When does a adhesive capsulitis pt become a candidate for surgery?
If they do not respond to 12 months of PT
| Capsular release
57
Most common impingement syndrome of the shoulder?
Subacromial impingement syndrome
Painful arc of motion when pt reaches overhead
Can advance to a rotator cuff tear/tendonitis
58
What are the 3 categories of subacromial impingment syndrome?
Primary external - outlet, rotator cuff obstruction dysfunction
Secondary external - instability, rotator cuff dysfuntion
Internal - repCetitive, rotator cuff microtrauma dysfunction =/- instability (posterior pain)
59
What is a SLAP injury?
Superior labrum tear with anterior and posterior extension
60
What is a HAGLE injury?
Humeral Avulsion of the Inferior Glenohumeral Ligament
61
What is an ALPSA injury?
Anterior Labroligamentous periosteal sleeve avulsion
62
Chronic labral tears can often cause?
Paralabral synovial cysts
63
What are two risk factors for elbow injury?
1. Asymmetic loss of shoulder internal rotation
2. Weak scapular stabilizers
Looking for strain or tear to the ulnar collateral ligament (UCL)
64
Two causes of thumb pain
1. DeQuervain tenosynovitis - abductor pollicis longus and extensor pollicis brevis
2. First metacarpophalangeal (MCP) joint UCL laxity
65
How do you grade ligament injuries?
Grade 1 - Tenderness no laxity
Grade 2 - tenderness, mild laxity
Grade 3 - tenderness, significant laxity
66
Steroid injections are considered definitive (curative) treatment for?
```
De Quervain tenosynovitis and
Trochanteric bursitis (hip pain)
```
67
Definitive tx for rotator cuff pain?
PT
+ injection of not responsive
Arthroscopy if failed conservative therapy
68
Most common indication for intra-articular injection?
Arthritis
69
Recommended time interval between injections?
3 months
70
When is a soft tissue injection concerning?
When pt is a diabetic - close glycemic control for 5-21 days
71
What are the contras for injection?
```
Broken skin at the injection site
Known hypersensitivity to intra-articular agent
Osteochondral/intra-articular fx
Protestic joint
Severe joint destruction
Skin infection at site of infection
Unstable coagulopathy
```
72
If a steroid has low solubility it will have?
Longer duration of action, but more cutaneous side effects
73
Causes of bone pain
```
Trauma
Cancer
Infection
Metabolic dz
Repetitive stress
```
74
Most common cancers that cause bone metastasis?
Lung
Breast
Prostate
75
Leading cause of mobility problems in the elderly?
OA
76
What is the pathophys of OA?
Wear increases lysosomes and matrix proteins that break down cartilage and decreases rate in synthesis of new proteoglycans
Often follows changed biomechanics of the joint
77
Tendinosis is the new preferred term for tendonitis because?
Bx do not reveal inflammatory cells
78
Most commonly injured ligament in the ankle sprain?
Anterior talofibular ligament
| + ankle anterior drawer = torn ligament
79
Which canal shape is predisoposed to lateral recess spinal stenosis?
Trefoil-shaped
| Aging, disc herniation, facet joint hypertrophy, ligamentum flavum thickening and disc space narrowing also contribute
80
What else can cause a narrowed spinal conal?
Aging, disc herniation, facet joint hypertrophy, ligamentum flavum thickening and disc space narrowing also contribute
81
Why are nerve roots sensitive to injury?
Lack of protectic perineurium
82
What is the pathophys of nerve injury in spinal stenosis?
Nerve root ischemia
83
spinal stenosis should be considered to be caused by a combination of?
1. Narrowing of the spinal canal
2. Ischemia of the roots (venous HTN/engorgement, arterial insufficiency, biomechanics)
May also have a inflammatory or instability (stretch) component
84
How many levels of stenosis do you need to produce symptoms?
More than 1
85
If L4 herniates, what nerve root will be affected?
L5-S1
| Responds well to decompression
86
Narrowing + ischemia means that spinal stenosis will respond to?
Decompression as well as vasodilators (calcitonin)
| CVD drugs may be useful on this "back angina"
87
Tendons connect?
muscle to bone
88
3 theories for tendinosis?
1. Mechanical - accumulation of micrtraumas, degeneration
2. Vascular - hypovascularity of the tendon
3. Neural - intradentous nerves lying close to the mast cells -> degranulation -> release substance P
89
What is the main tx for tendonopathy?
Exercise as soon as tolerable- maintain fitness, flexibility, strength
Bracing, NSAIDs, injections, sclerosing agets (polidocanol), and PRP can be considered
90
DDx for hip snapping in a young healthy athlete
Intra-articular - loose bodies, labral tears, synovial condromatosis, osteochondral fx, femoral acetabular impingement
extra-art = IT and glutues tendon snapping, ilipsoas tendon
91
What causes femoral acetabluar impingement?
ABN contact between the femoral neck and the acetabulum
92
How do you treat a snapping hip?
3 months of NSAIDs, rest, stretching
Add injections
Hip arthroscopy
93
Which pts are most prone to ACL tears?
15-25 y/o females
| Usually via noncontact
94
Why are women more prone to ACL tears?
They have less knee and hip flexion during movement, increased valgus and internal rotation. Quadriceps domiant
95
Athlete describing retropatellar and occasional medial or lateral pattellar aching
Patellofemoral pain
Usually exacerbated by hills, stairs, squatting, or prolonged sitting
Pay attention to lower limb alignment on exam
Also consider ITB tightness and meniscal tears
96
How do you manage patellofemoral pain?
Bracing, activity modification
97
which ligaments are injured in ankle sprains?
Anterior talogibuular ligment
| Calcaneofibular ligament
98
Ddx for a marathon runner with lower leg pain?
Muscle/tendon overload, bone overload, chronic exertional compartment syndrome, vascular causes
99
Runners with a hypertrophied medial gastrocnemius m. are at risk for?
popliteal a. entrapment syndrome
100
Most mobile joint in the body?
Shoulder
101
Whcih two bones compose the shoulder girdle?
Clavicle scapula
102
Which muscles attach to the scapula?
The rotator cuff
| Supraspinatus, infra, teres minor, sub scap
103
The clavicle provides protection to?
subclavian a. v.
| brachial plexus
104
What is a shoulder speration?
sprain or dislocation of the AC joint
105
Who is at risk of a labral tear?
Folks with overhead activity like swimmers or pitchers
106
Repetitive stress to the patellar tendinous insertion at the proximal tibia
Osgood-Schlatter dz (traction apophysistis)
107
Young adults are more prone to? Vs elderly?
Young - septic arthritis, ligament injuries
| Elderly - crystal depostition dz's
108
What type of joint is the knee?
Hinge
109
Largest sesamoid bone in the body?
Patella
| Encapsulated within the quadriceps tendon
110
What lies under the patellar tendon?
Infrapatellar bursa
| Hoffa fat pad
111
which lower leg bone is medial?
Tibial
112
Common insertion of the semitendinosis gracilis, sartoious tendons
Pes anserinus
| Insert anteromedially just distal to the medial tibial plateau
113
Inabillity to fully extend knee during exam?
Effusion, obstruction
114
Securing the patella w/ inferior pressure and pt tightens quads producing pain
Patellofemoral syndrome
115
Valgus stress tests the?
LCL (push on medial side of kee)
116
Varus stress tests the?
MCL (push on lateral side of knee)
117
Lachman tests the integrit of?
ACL tear
118
The pivot-sift test - cradle lower leg in extension and flexing the knee with valgus stress
Pivot-shift, MacIntosh test
| See laxity with ACL deficient knee
119
Test of meniscal injury
McMurray
Pain or click = positive
external = lateral
internal = medial
120
IF McMurray isn't tolerable,what can you try?
Apley compression test - apply downward pressure on the foot and alternate external and internal rotation
Not as accurate as McMurray so consider MRI
121
Pt lies on side to test ITB legnth
Ober
122
What Xrays views should be ordered?
Anteroposterior (AP), lateral, oblique
123
Patellar tilt can be imaged with?
Merchant or sunrise views
124
What are the 3 functional parts of the vertebrae?
1. Vertebral body - bears weight
2. Vetebral (neural) arch - protects the neural elements
3. Bony processes (spinous and transverse) - increase efficiency of the muscles
125
How are lumbar vertebral bodies different from thoracic?
Lumbar do not have rub facets
126
If ossification of the pars interarticularis fails to occur?
Spondylolysis
127
3 layers of the meninges?
pia
arachnoid
dura mater - strongest
128
Fibrosing disorders with slowly progressive thickening and shortening of the plamar facia -> debilitating digital contractures
Dupuytren disease
Especially affects smaller fingers
More likely in males, FHx
PAINLESS
