MSK Precision and Pearls #2 Flashcards
Patellofemoral pain syndrome (chondromalacia) is pain behind the kneecap due to abnormal patellar tracking. This is MC in ___________. What are some symptoms of this condition? What is the treatment?
Cyclists and runners
-Anterior knee pain around or behind the patella worse with hyperflexion
-Worse with jumping, sitting, climbing
-Apprehension sign with compression of patella
NSAIDs, rest, rehab, knee sleeve for stability
Which type of meniscus tear is more common? What is the MOI of this type of tear?
Name some symptoms of a meniscus tear
Medial meniscus
MOI: blow to out of the knee; also due to axial loading and rotation
Popping, giving away. Effusion after activities. Locking. Joint line tenderness.
What are some tests that can be done to test for a meniscus tear?
-McMurray
-Apley: prone, push down on knee
-Thessaly: stand, flex knee, twist
What is the best diagnostic for a meniscus tear?
Treatment for meniscus tear
MRI
Ice, NSAIDs, PT or arthroscopy if severe
What is osteoporosis? What are some risks of osteoporosis? What are some symptoms of this condition?
Loss of bone density due to resorption > formation
Caucasians, low BMI, CKD, ETOH, inactivity, smoking
Pathologic fractures (vertebrae MC), spine compression, decreased height, increased kyphosis, back pain
What diagnostic is done for osteoporosis and what are the values that are positive for it?
DEXA scan (Use the T score):
–Normal: 1.0 or greater
–Osteopenia: -1.0 to -2.5
–Osteoporosis: -2.5 or less
Who should be screened for osteoporosis?
Anyone 65 or older, younger if they have risk factors
Treatment for osteoporosis
-Lifestyle modification: Vitamin D + Calcium supplement (initial), weight bearing exercise, smoking cessation
-Bisphosphonates (inhibit osteoclast activity)
-SERM (Raloxifene) = inhibit bone resorption and decrease risk of fractures
-Denosumab: RANKL inhibitor
Explain what each of these do:
Osteoclasts
Osteoblasts
Clasts: crack down bone
Blasts: build up bone
What is Legg-Calve Perthes Disease?
Name some symptoms of this condition
Idiopathic AVN of the femoral head in kids, usually unilateral
-Painless limping worse at end of the day, decreased abduction and IR
-Atrophy of the thigh muscles
Who is Legg-Calve Perthes disease MC in (what are the risk factors)?
-Children 4-10 years old
-Boys
-Obesity
-Coagulation problems (Factor V Leiden)
What is the best view of radiographs to assess for LCP disease and what is seen?
AP pelvis and frog leg lateral views: Positive Crescent sign (micro fractures, collapse of the bone, flat femoral head)
SCFE, on the other hand, usually occurs bilaterally. What is this condition? What are the risk factors?
Displacement of femoral epiphysis from femoral neck through growth plate
-10-16 years old, obese males, AA, adolescents in growth spurt
If SCFE is seen BEFORE puberty, what conditions should you be concerned about?
Hypothyroidism or hypopituitarism
Symptoms of SCFE
What view of radiographs is recommended for SCFE?
Dull ache in the hip, groin, thigh pain with a painful limp (worse with activity)
-ER leg on affected side
-Altered gait
-Decreased IR and abduction
AP pelvis and frog leg lateral view: posterior displacement of epiphysis (ice cream slipping off cone)
Treatment for SCFE
Non-weightbearing with crutches –> ORIF due to increased risk of AVN
Compartment syndrome, which is muscle and nerve ischemia when _____________ > ___________, has etiologies such as _____, _____, and _______.
Name the symptoms of this condition.
compartment pressure > perfusion pressure
Trauma (MC after fractures of long bones), burns, and tight casts/splints/circumferential burns
Pain out of proportion to injury, paresthesias, pulselessness, pallor, pain with passive stretching, firm/wood like feeling
What is the best diagnostic for acute compartment syndrome and what is the treatment?
Increased intracompartmental pressure > 30mmHg
emergent fasciotomy. Place limb at the level of the heart while awaiting fasciotomy
Osteoarthritis, degenerative change in articular cartilage an joint degeneration, is MC in what kind of joints? Risk factors for this condition?
What are the symptoms?
MC in weightbearing joints
obesity, age, trauma, female gender
Joint pain worse in evening, worsens throughout the day, morning stiffness resolves < 60 minutes, hard bony joint, crepitus, decreased ROM, stiffness
What are two hand symptoms of OA and explain them.
Heberden nodes (DIP)
Bouchard nodes (PIP)
What kind of radiographs are the best for evaluating OA? What do they show?
Weightbearing X-rays: asymmetric joint narrowing, osteophytes, subchondral bone sclerosis
Treatment for OA
-Lifestyle modifications
-Acetominophen (1st line)
-NSAIDs
-Topical Capsaicin
-Joint replacement if severe
What is a hallux valgus and what are the risk factors?
Treatment?
Deformity of the first MTP joint with lateral deviation of the phalanx
History of poorly fitted, tight, or pointed shoes. Flat feet, RA, Women
Conservative vs surgery if refractory
Acute Osteomyelitis is infection of the bone due to open fracture or infected hardware. What bones are MC in children? Adults?
What are the common sources of this condition?
Children: Femur and tibia
Adults: vertebrae
Acute hematogenous spread, direct inoculation
Name the MCC of osteomyelitis in the following cases:
-MCC overall
-prosthetic joints, neonates, children with catheters
-sickle cell disease
-neonates
-puncture wounds
-Staph A
-Staph Epidermidis
-Salmonella
-Group B. Strep
-Pseudo Aeruginosa
Symptoms of osteomyelitis
Constitutional symptoms (fever, chills, etc.)
Bone pain
Decreased ROM
Warmth, swelling, tenderness
Sinus tract drainage (DM foot ulcer for example)
What is seen on radiographs of osteomyelitis (think old and new)?
What is the best diagnostic for this condition?
Sequestrum (necrotic bone separated from normal bone) and involucrum (new bone that surrounds the necrotic bone)
Bone Aspiration (Biopsy)
What are risk factors for osteomyelitis?
< 20 and > 50 years old
URI in kids
Sickle Cell
DM, Immunocompromised
What joint is MC affected with osteomyelitis in kids and when should you suspect this?
Hip joint
When they refuse to bear weight or use the extremity
Treatment for acute osteomyelitis (there’s lots of categories)
-Birth to 3 months (Group B Strep): Cefotaxime + Vanco/Naf/Oxacillin
-> 3 months to adults (MSSA): Naf/Cefazolin/Oxacillin
-> 3 mos to adults (MRSA): Vanco/Linezolid/Clinda
Sickle Cell (Salmonella): Cipro or 3rd gen Ceph
Pseudomonas from puncture wound: Cipro or Ceftazidime
Treatment for chronic osteomyelitis
Surgical debridement + cultures
ABX based on organism as well
Achilles tendon rupture MC occurs due to forced __________ in those people such as _____, ______. Furthermore, there are increased risks for this condition with what two things?
What are some symptoms?
plantarflexion
Weekend warriors, basketball players, etc.
Fluoroquinolone use (-oxacin) and steroid injections
Sudden heel pain after push off
“Pop”, sharp calf pain
Inability to weightbear
What test is positive in those with an achilles tendon rupture?
Thompson Test: positive if weak/absent plantar flexion with squeezing the gastrocnemius
What diagnostic is best for achilles tendon rupture? What is the treatment?
MRI
Nonoperative: serial splinting in mild plantar flexion with gradual dorsiflexion toward neutral
Operative: reattachment allows for early ROM
Explain the pain with plantar fasciitis
Gradual onset of inferior heel pain with first few steps in the morning and at night.
Local point tenderness on plantar side of foot near the insertion at calcaneus.
Pain increases with dorsiflexion of toes.
What are risk factors for plantar fasciitis?
Flat feet, high arches, females, obese, 40 years old
What is the recommended clinical intervention for complication of an orthopedic device?
Removal of hardware
What type of ankle sprain is MC? What ligament is injured in this type and what is the main motion of this ligament?
The other, less common type, has what ligament affected?
Lateral: ATFL (inversion stabilizer)
Medial: Deltoid (eversion stabilizer)
What exam tests can be done for an ankle sprain and which ligaments do they test for?
Anterior Drawer Test for ATFL
Talar Tilt test for CFL
Do we need imaging for ankle sprains (What rules do we use, what are they?
Ottawa Ankle Rules
Ankle Films
-Lateral malleolus pain
-Medial malleolus pain
-Can’t walk > 4 steps
Foot Films
-Navicular Pain
-5th metatarsal pain
-Can’t walk more than 4 steps
Spiral Fracture of proximal third of the fibula associated with distal medial malleolar fracture or rupture of deep deltoid ligament
What should you check for with this injury and why?
Maisonneuve Fracture
Foot drop, peroneal nerve is near here
Need operative intervention
Where is the LisFranc joint and what does it do?
At the base of the first 3 metatarsal heads and their respective cuneiforms.
Holds the mid foot to the forefoot.
Symptoms of a LisFranc Injury and what diagnostics do you get?
Midfoot pain, unable to weightier, swelling, bruising.
Weightbearing XR = fleck sign (fracture at the base of the second metatarsal)
Treatment for a LisFranc Injury
ORIF followed by NWB cast for 12 weeks
Regarding cervical vertebrae injury, what is the name of the C1 fracture? What view XR’s do you get? What is the treatment?
Burst of Atlas (Jefferson Fracture)
AP, lateral, odontoid view (open mouth) = increase in space between C1 and odontoid
External immobilization for 6-12 weeks. Fusion if unstable.
What is the name of the C2 fracture? What views do you get and what is the treatment?
Hangman’s Fracture (C2 pars interarticularis fx)
AP, lateral, odontoid
collar for 4-6 weeks if nondisplaced, closed reduction/immobilization if displaced
What is the MOI of a Jefferson Fracture vs a Hangman’s Fracture?
Jefferson: vertical compression
Hangman: hyperextension then flexion
Rhabdomyolysis is…..
What are some common etiologies of this condition?
Acute breakdown and necrosis of skeletal muscle
Trauma, prolonged immobility, statin therapy, seizures, cocaine, snake bikes, viral infections
What is the pathophysiology of rhabdomyolysis?
Myoglobin from breakdown is VERY toxic to the kidneys leading to acute tubular necrosis (acute kidney injury)
Symptoms of rhabdomyolysis
Muscle pain + muscle weakness or swelling + dark (tea-colored) urine
What does the workup look like for rhabdomyolysis?
ECG: most important initial test to look for hyperkalemia
UA and dipstick: positive for heme but negative for RBCs (which indicates myoglobin in the urine). Urine myoglobin most specific test.
Increased Creatinine phosphokinase (muscle enzymes)
Hyperkalemia, hyperuricemia, hypocalcemia, hypophosphatemia
What is the treatment for rhabdomyolysis?
IV fluids!
Mannitol or sodium bicarbonate may be added to alkalize the urine
calcium glutinate to stabilize cardiac membranes
Explain what cervical spondylosis is and what the MC locations of this condition are.
What is the unique test that goes with this condition and explain it.
Chronic disc and facet degeneration (DJD)
C5-C6, C6-C7
Spurling Test: extend neck, lateral bend, axial compression to provocate the pain
Treatment for spondylosis
Rest, NSAIDs, PT, muscle relaxants, surgery only if neuro deficits
What is one other thing to remember about cervical spondylosis that can occur and what does it cause?
Cervical nerve root compression –> radiculopathy, pain, or motor weakness
Explain the pain associated with a lumbosacral sprain or strain.
MCC of lower back pain
back pain or spasms that is activity related and doesn’t radiate down the leg. NO NEURO SYMPTOMS
A lumbar disc herniation MC occurs at what location and why?
Symptoms of this condition?
L5-S1 because it is the junction of mobile and nonmobile spine
Radicular back pain, unilateral
May radiate down the leg
Numbness in a dermatomal pattern
Increased pain with sitting, decrease with standing
Positive Straight Leg Raise
Explain the following nerve levels and the associated findings L4, L5, S1
Sensory Loss:
Pain Location:
Weak in Motion:
DTR:
L4: Sensory loss to medial malleolus, anterior thigh pain, weak ankle dorsiflexion, loss of knee jerk DTR
L5: Sensory loss to dorsum of foot, lateral thigh/hip pain, weak big toe extension/dorsiflexion, reflexes normal
S1: Sensory loss to plantar foot, posterior leg pain, weak plantarflexion, loss of ankle jerk DTR
Best test for lumbar disc herniation?
MRI
What is the treatment for lumbar disc herniation?
Conservative: NSAIDs, normal activity, PT, short periods of rest, muscle relaxants
What are the red flag symptoms associated with lumbar disc herniation in which you should get an MRI?
Bladder dysfunction
Prev history of cancer
Age > 50
Fever
Unremitting pain
Weight loss
Constant night pain
What is the MCC of Cauda Equina Syndrome?
What are the symptoms of this neurosurgical emergency?
Lumbar disc herniation
Low back pain, bilateral leg radiculopathy (pain), bowel or bladder dysfunction, saddle anesthesia (S2-S4 involvement), decreased anal sphincter tone, sexual dysfunction (ED)
Diagnostics and treatment for cauda equina syndrome
MRI
Emergent decompression
