MSK Quiz 2: Part 2 Flashcards
What does diarthroses mean?
freely movable
Where is the synovial fluid secreted from?
synoviocytes
what’s the job of the synovial fluid?
nourishes the articular cartilage, shock absorber
What’s the most common of all joint diseases?
osteoarthritis
What is osteoarthritis?
progressive, irreversible loss of joint cartilage
Most commonly affected joints by osteoarthritis?
cervical and lumbosacral spine, hip, knee, 1st MTP joint, hands (DIP, PIP, 1st CMC joint)
Risk factors for osteoarthritis
joint vulnerability (systemic factors, intrinsic joint factors) and joint loading
Systemic risk factors for OA
increased age, female gender, racial/ethnic factors, genetics, nutrition
Intrinsic joint risk factors for OA
previous damage, muscle weakness, increasing bone density, malalignment, proprioceptive deficiencies
Does OA impact extra-articular organs?
No
Does OA impact men or women more?
women
Presentation of OA
pain (bone pain, aching to severe, localized to radiating, affects sleeping), stiffness lasting <30 minutes (worse with inactivity), swelling, joint instability, decreased ROM, locking and grinding
PE OA
TTP, joint effusion, possible deformity, crepitus, antalgic gait, decreased ROM, muscle atrophy
What are OA deformities you can see in the knees?
genu varum, genu valgum
what are OA deformities you can see in teh hands?
Heberden nodes (DIP) and Bouchard nodes (PIP)
Films for OA
Plain films (joint space narrowing, osteophytes, subchondral bone sclerosis/cysts), MRI (r/o if needed), US (not routinely used)
What labs are used for OA?
nothing specific, just r/o other causes
Treatment for OA?
RICE, unloader brace, injections, NSAIDS/tramadol/glcuosamine and chondroitin sulfate, physical therapy/aquatic therapy, patient education, CAM
Surgical options for OA?
arthroscopy is NOT indicated for OA, joint replacement
What’s the most common form of autoimmune arthritis?
Rheumatoid arthritis
What types of joints does RA typically impact?
synovial joints
What’s the cause of RA?
unknown triggers for immune response in synovial tissue
Which genetic marker determines both risk and severity of RA?
HLA-DR4
What are possible triggers of RA?
bacterial antigens (mycobacteria, strep, mycoplasma, e. coli, h. pylori), viral agents (EBV, rubella, parvovirus), smoking, hormonal changes
Risk factors for RA?
female sex, positive family history, older age, smoking, coffee consumption (>3 cups daily)
Who is impacted by RA more, men or women?
women
When does RA occur?
Any age; men <45 is uncommon, women it increases with age until 60 yo
Presentation of RA
insidious to sudden onset pain (affecting distal joints first), stiffness, swelling, possible systemic symptoms (Fatigue, low-grade fever, weight loss); symmetric polyarthritis, morning stiffness (gel phenomenon, lasting more than 1 hour, decreases with physical activity), swelling and tenderness, nodules
PE findings of OA
painful/loss of ROM, possible muscle pain, swelling, deformity, rheumatoid nodules
Affected joints for RA
MCP, PIP (flexor tendon tenosynovitis), MTP, wrist, knees, elbows, ankles, hips, shoulder, C1-C2 articulation, TMJ
When is the DIP joint involved in RA?
almost never
Hand/feet symptoms of RA?
MCP ulnar deviation, swan-neck deformity, boutonniere deformity, nodules, hammer toes
Exta-articular manifestations of RA
rheumatoid nodulosis, pulmonary nodules and fibrosis, vasculitis, pericarditis, musculoskeletal nodules, tenosynovitis, k. sicca, scleritis
Skin symptoms you may see in RA
subcutaenous nodules
Pulmonary symptoms you may see in RA
pleurisy, effusion
cardiovascular symptoms you may see in RA
digital infarcts, ischemic mononeuropathy
Musculoskeletal symptoms you may see in RA
carpal tunnel syndrome, tarsal tunne syndrome, trigger finger
Ocular symptoms you may see in RA
dry eyes, corneal ulcer, scleral injection
Felty’s syndrome is a combination of?
RA, splenomegaly, and neutropenia
Associated complication of Felty’s syndrome
hepatomegaly, thrombocytopenia, lymphandenopathy, fever
Diagnostic tests for RA
RF, ANA, CBC with diff (anemia, thrombocytosis, neutropenia), CRP, ESR, Anti-CCP
Imaging for RA
x-rays (joint erosions)
4 categories for RA criteria
joint involvement, serology, duration of synovitis, acute phase reactants
How many points do you need for criteria for RA?
6/10
Joint Involvement criteria (RA)
1 med/large joint (0), 2-10 med/large joints (1), 1-3 small joints (2), 4-10 small joints (3), >10 joints with at least one small (5)
Serology criteria (RA)
neither RF nor ACPA positive (0), at least one test low positive titre (2), at least one test high positive titre (3)
Duration of synovitis criteria (RA)
<6 weeks (0); >6 weeks (1)
Acute phase reactants criteria RA
neither CRP nor ESR abnormal (O), abnormal CRP or abnormal ESR (1)
Treatment of RA?
lifelong disease without cure; patient education, referral to rheumatologst, braces, splints, orthoses, medications
What’s the goal of RA treatment?
remission
Drug treatment options for RA?
NSAIDS or low-dose prednisolone, intra-articular steroid injection, disease modifying antirheumatic drugs (DMARDs), anti-TNF drugs
What do antirheumatic drugs (DMARDs) do?
target cytokines or receptors in inflammatory cascade, decrease monocolonal antibodies
Examples of antirheumatic drugs?
sulfasalazine, hydroxychloroquine, methotrexate, leflunomide, cyclophosphamide
Anti-TNF drug examples?
infliximab, etanercept, adalimumab, golimumab
RA surgical options?
joint replacement
Describe three components of RA?
inflamed joint capsule and synovial membrane; loss of space in synovial cavity; cartilage destruction
Describe three components of OA?
loose cartilage particles; bone spur; severe cartilage destruction
Fracture presentation
history of an injury with pain and edema, worse over first 1-3 days, TTP
4 phses of fracture healing
1) cellular callus–mesenchymoid cell proliferation, 2) mineralized callus–collagen to cartilage 3) bony callus-lamellar bone replaces mineralized callus 4) remodeling
Fracture complication
ARDS (fat embolism syndrome), atelectasis (early post-op fevers and hypoxemia), DVT, PE, compartment syndrome, nerve or blood vessel injury, failure of normal healing
Five Ps of compartment syndrome
pain out of proportion, paresthesia, pallor, paralysis, pulselessness
Malunion:
incomplete or faulty healing
Delayed union:
slower than normal healing
Non-union:
lack of bony reconstruction
How do you describe position on bone?
proximal, mid, distal
Closed fracture:
no break in the skin
Open fracture:
part of bone protrudes through skin
Complete fracture:
all cortical surfaces are disrupted
What are two types of incomplete fractures?
greenstick, buckle
What’s a greenstick fracture?
one side of bone breaks, the other side is still intact
What’s a buckle fracture?
crunches on one side of the bone
Simple fracture:
single fracture line in 2 bone fragments
Comminuted fracture:
2 or more fracture fragments
Butterfly fracture:
esults from two oblique fracture lines meeting to create a large triangular or wedge-shaped fragment located between the proximal and distal fracture fragments, and resembles a butterfly.
Give examples of fracture line direction
transverse, spiral, oblique
Term for a fracture that disrupts the joint?
intra-articular
Distraction:
a fracture resulting in increased overall bone length (bone fragments are pulled apart)
Impaction:
If there is shortening of bone without loss of alignment, the fracture is impacted. “over riding”
How to describe displacement?
anterior, posterior, lateral, medial (need 2-3 views!)
Angulation:
direction apex is pointing; location of distal fragment
Change in anatomic position in a circular motion is called?
rotation
Partial disruption/displacement of joint:
subluxation
Clavicle fracture MOI
direct blow, fall on outstretched arm
Presentation of clavicle fracture
pain, deformity, grinding at fracture site, sagging shoulder
Treatment of clavicle fracture
based on displacement; conservative (immobilize in sling figure-8 brace for 4-6 weeks) vs. surgery (open reduction internal fixation or intramedullary nail)
Proximal humerus MOI
high energy injury (Fall, MVA)
What classification system do you use for proximal humerus fracture?
Neer Classification
Treatment for proximal humerus fractures?
sling up to 6 weeks, passive ROM after 3 weeks vs. surgery (ORIF vs hemiarthroplasty)
With proximal humerus fractures, which nerve do we worry about?
Axillary
Humeral shaft fracture MOI
trauma, fall
What’s a common negative outcome with humeral shaft fractures?
mal-union
What nerve do we worry about with humeral shaft fracture?
Radial (wrist drop)
Elbow x-ray analysis
joint effusion, ossification centers, alignment, subtle fractures
Fat pad sign
When there is a joint effusion, the anterior fat pad becomes elevated, likely intraarticular fracture.
What’s the most common elbow fracture in kids?
supracondylar fractures
supracondylar fractures MOI
fall with elbow extended
Treatment of supracondylar fracture
typically surgery
Complications of supracondylar fractures
brachial artery injury
Epicondyle/condylar fracture MOI
FOOSH, valgus or varus force
treatment of epicondyle/condylar fracture MOI
conservative (rest, splint, delayed ROM) vs surgical (percutaenous pinning vs ORIF)
What’s the most common elbow fracture in adults?
radial head/neck fractures
radial head/neck fracture MOI
fall with elbow extended
treatment of radial head/neck fracture
long arm splint for 2-3 weeks (must go beyond wrist); rarely surgery; do not immobilize too long (need early PT)
Olecranon fracture MOI
fall on posterior elbow or active triceps avulsion
treatment of olecranon fracture
displacement and triceps guide treatment
Describe the Monteggia fracture
ulnar fracture (proximal 1/3), radial head dislocation
Describe the Galeazzi fracture
radial fracture, distal radioulnar joint dislocation
Monteggia fracture MOI
FOOSH
Monteggia fracture demographics
peds patients ages 4-10
Monteggia fracture treatmetn
usually surgery
Galeazzi fracture MOI
fall on outstretched hand with elbow flexed
Galeazzi fracture demographics
adult males
Galeazzi treatment
surgical fixation
Radial shaft fracture usually occurs with?
ulnar shaft fractures or dislocation
radial shaft fracture MOI
high energy injury (MVA)
treatment of radial shaft fracture
often surgery
ulnar shaft fracture AKA
nighstick
ulnar shaft fracture MOI
usually a direct blow
presentation of ulnar shaft fracture
medial forearm pain
treatment of ulnar shaft fracture
splint, rarely needs surgery
What’s the most common fracture of upper extremity?
distal radius fracture
who commonly experiences distal radial fractures?
elderly (low energy FOOSH), younger patients (higher energy falls)
presentation of distal radial fractures
deformity, swelling, ecchymosis, tenderness over fracture site
Colles fracture MOI
FOOSH
colles fracture (3 components)
dorsal angulation (apex volar), dorsal displacement, impaction/shortening
Smith fracture AKA
reverse colles
Which is more common colles or smith?
colles
Smith fracture MOI
falling onto flexed wrist
What’s the common anecdote for the smith fracture?
“i drank too much and fell down”
Treatment of distal radius fracture (buckle or minimal displacement)
immobilize
Treatment of distal radius fracture (other than buckle or minimal displacement)
colles, smith, or any angulation/displacment require referral
treatment for adults with distal radius fracture (immobilization)
6 weeks immobilization (2 in splint, 4 in cast)
treatment for adolescents with distal radius fracture (immobilization)
6 weeks immobilization
Wrist reduction and splint procedure
analgesia to area or patient, hang in traps with counter-weight typically ten pounds, wait ten minutes, reduce and sugartong splint
Chauffer fracture
radial styloid fracture
chauffeur fracture MOI
direct blow to back of wrist, forced ulnar deviation and supination
treatment of chauffeur fracture
surgery
Most common carpal fracture?
scaphoid fracture
presentation of scaphoid fracture
snuff box pain
scaphoid fracture MOI
FOOSH
scaphoid fractures are commonly diagnosed as?
sprains
Scaphoid fractures have a % nonunion rate?
8-10
Scaphoid fractures can result in?
AVN
Treatment for scaphoid fracture
splint, cast for total of 12 weeks vs. surgery
Are metacarpal fractures more common in men or women?
men
Metacarpal fractures MOI
hitting an object with closed fist
common metacarpal fracture locations
5th metacarpal (especially neck AKA boxer’s fracture)
PE metacarpal fracture
pain, swelling, deformity, rotational deformity, depression knuckle; look for open wounds
What do you need to assess with metacarpal fracture?
assess for rotational deformity
What’s the most common metacarpal fracture?
boxers fracture
Bennet fracture
intra-articular avulsion fracture at CMC joint
Bennet fracture MOI
sublux/dislocation
Rolando Fracture
Y or T shaped comminuted, intra articular fracture
Rolando Fracture MOI
sublx/dislocation
Metacarpal fracture treatment
treated by fracture type: angulation (10-20-30-40 rule) and rotational deformity (not accepted); conservative (ulnar gutter splint/cast–recheck in 1 week, 4-6 weeks immobilization); referral for unstable or rotational deformity fractures
What’s the 10-20-30-40 rule
It’s how much angulation is acceptable in index through little metacarpal
Complications of metacarpal fractures?
loss of grip strength, residual dorsal deformity, loss of knuckle prominence
What’s the most common skeletal system injuries?
phalange fracures
Which fragment phalange is most often fractured?
distal > middle and proximal
PE for phalange fractures
pain, swelling, deformity, look for open wounds, nail bed injuries
Phalange fractures treatment
buddy taping (except mallet finger…need extension splint); surgical if angulation or displacement or open
complications of phalange fractures
loss of motion, malunion, nonunion
Low energy pelvic fractures are common iN?
elderly after a fall
PE for low energy pevlic fracture
pain in groin, lateral hip or buttock with ambulation
tx of low energy pelvic fracture
conservative, PT/OT, possible rehab or SNF (skilled nursing facility)
High energy pelvic fracture MOI
MVA–side impact and motorcycle account for most
For high energy pelvic fracture you need to assess…
GU injuries (check bladder and prostate)
treatment of high energy pelvic fracture
stabilize, most need surgical repair
Hip fracture presentation
fall, unable to bear weight, leg is shortened and externally rotated
Considerations with treatment of femoral neck fractures
displacement, patient activity level, patient/family wishes
Treatment of femoral neck fracture with no/minimal displacement:
femoral neck with no/minimal displacement: hip pinning = cannulated screw fixation
Treatment of femoral neck fracture with displacement
hip arthroplasty
Intertrochanteric fracture surgical treatment
intramedullary nail gamma nail, dynamic hip screw
Femur fractures (shaft) MOI
high energy, typically MVA; in elderly patients it could be fall with poor bone quality
Femur fracture (shaft) treatment
non-displaced and patients with multiple co-morbidities = non-surgical; surgical if displaced/unstable
Supracondylar fracture MOI
load to flexed knee (younger patients MVA), older patients (low energy fall)
Associated injuries of supracondylar fracture
popliteal artery, ACL
What else do you need to order with supracondylar fracture
arteriogram
presentation of supracondylar fractures
pain, swelling, inability to flex/extend knee, posible deformity
Supracondylar fracture tx
conservative vs. surgical
Tibial plateau fracture MOI
extreme load or fall
Where are tibial plateau fractures commonly located?
60% are lateral, often accompanying cartilage/ ligament injury
Treatment of tibial plateau fracture
depends on displacement. Non-operative must be NWB with close follow-up; surgical is cannulated screen fixation or plate/screw with NWB
Patella fracture MOI
direct trauma or forceful quadriceps contraction
patella fracture presentation
deformity, swelling, can’t SLR
treatment for patella fracture
surgery if displacement is >3 mm; non-operative is NWB for 6 weeks, gradually increase PROM
What’s the most common long bone fractures?
tibial shaft fractures
tibial shaft fractures MOI
high energy–associated with open fractures; twisting mechanism–spiral/oblique
tibial fracture presentation
pain, deformity, wounds, fracture blisters, compartmetn syndrome
tibia shaft fracture
conservative (LLC with progressive weight bearing) vs surgical for unstable, open fracture (IM nail)
Fibula fracture MOI
direct blow, inversion or eversion injury
Fibular fracture presentation
limping or unable to bear weight (due to pain), edema, ecchymosis
Treatment of fibular fracture
dependent on severity of fracture and location
Maisonneuve Fracture
Eversion injury; mortise widening and proximal 1/3 fibula fracture
What do you worry about with a maisonneuve fracture?
superficial peroneal nerve palsy
Treatment of maisonneuve fracture
surgery
What’s the most common bone and join injury?
ankle fractures
contributing factors to ankle fracture?
smoking and body habitus
MOI of ankle fractures
twisting–inversion/eversion; MVA
presentation of ankle fractures
pain, swelling, deformity, inability to ambulate
Conservative treatment of ankle fractures
avulsion is treated like a severe ankle sprain, minimally or non-displaced fractures get posterior splint x 1 week; recheck (walking cast vs. walking boot for 4-5 weeks)
Surgical treatment of ankle fractures if?
any mortise widening/suspicion of syndesmotic injury
Medial malleolus fracture MOI
usually high-impact
Considrations of medial malleolus fracture
displacement (<2 mm in joint is acceptable), joint involvement (<25% joint surface involvement), tenderness elsewhere
Medial malleolus fracture treatmetn
surgery if ankle mortise widening and displacement; non-operative = NWB short leg splint x 1 week (recheck in 1 week); NWB vs. WBAT short leg cast x 6-7 weeks (recechk every 1-2 weeks)
Bi-malleolar fracture tx
need referral, sx (ORIF)
Tri-malleolar fracture tx
referral for surgery
3 main types of fifth metatarsal fracture
stress, jones, avulsion
Fifth metatarsal fracture: stress tx
NWB cast for 6-8 weeks
Fifth metatarsal fracture: jones tx
surgery vs. short-leg walking cast vs. NWB cast for 6-8 weeks
Fifth metatarsal fracture: avulsion tx
most common, short-leg walking cast/boot for 4-6 weeks
What’s a common MOI for firth metatarsal fracture?
inversion ankle sprain
What causes a stress fracture?
result of bone being exposed to repeated tensile or compressive stresses
Where is the most likely place for stress fractures?
spine (pars interarticularis in lumbar spine), hip (femoral neck), lower leg (tibia), ankle and foot (talus and metacarpals)
Stress fracture presentation
onset of insidious pain that progressively gets worse
imaging for stress fracture
plain films, bone scan, MRI SCAN (looking for fluid/inflammatory response), Ct scan
Treatment of stress fracture
Initial: eliminated stress; NWB 6-12 weeks; possible immobilization; activity modification; PT; pain control
Risk factors for stress fractures
prior stress fracture, low fitness, sudden increase in exercise, female gender/menstrual irregularity, lower BMI, eating disorders, poor diet, poor bone health, poor biomechanics, workout environment
What’s the assessment of physeal fractures called?
Salter-Harris classification
SALTER:
straight across; above; lower and below; two or through; erasure of growth plate or crush
Type I: S
fracture of the cartilage of the physis
Type II: A
the fracture lies above the physis
Type III: L
the fracture is below the physis in the epiphysis
Type IV: T
through the metaphysis, physis, and epiphysis
Type V: R
physis has been crushed
