MSK Treatments Flashcards
Spinal stenosis?
Pain control, PT, steroid injections, decompression laminectomy.
Ankylosing spondylitis?
NSAIDs, PT, TNF inhibitors.
Herniated disc?
NSAIDs, PT, muscle relaxers/oral steroids.
If fails conservative tx, corticosteroid injection.
If pain for >6 wks, laminectomy & discectomy.
Compression fracture?
Orthopedic/neuro consult.
Spondylolysis?
Low grade or symptomatic: Observe
Symptomatic: PT & activity restriction
Acute or failed PT: Bracing
Spondylothisthesis?
Mild: PT and activity restriction.
Severe: Surgery.
Cauda equina?
Call ortho/spine/neuro immediate.
RA?
Exercise, NSAIDs for pain. Corticosteroids if NSAIDs don’t work.
What is the best initial DMARD?
Methotrexate.
Side effects of methotrexate?
GI upset, oral ulcers, mild alopecia, bone marrow suppression (must give WITH folic acid), hepatocellular injury.
Leflunomide?
Alternative to methotrexate or can be used as an adjunct to therapy with a DMARD.
Hydroxychloroquine?
Alternative first line DMARD, but usually not as effective as methotrexate and used in less severe cases
What do pts require of they are on hydroxychloroquine?
Eye exam every 6 months because of risk of visual loss due to retinopathy.
Sulfasalazine?
Alternate first line agent, but less effective than methotrexate.
What do you prescribe if first line agents do not work for RA?
Antitumor necrosis factor (anti-TNF) inhibiting agents (etanercept, infliximab).
Reactive arthritis/Reiter Syndrome?
NSAIDs. If no response, sulfasalazine and immunosuppressive agents like Imuran. NO ABX.
Polyarteritis nodosa?
Glucocorticoids.
Refractory: add cyclophosphamide.
Polymyalgia rheumatica?
Corticosteroids to suppress inflammation.
Polymyositis and Dermatomyositis?
First line: High dose corticosteroid.
If refractory: immunosuppressive agents like methotrexate.
Hydroxychloroquine useful for skin lesions.
Fibromyalgia?
Low intensity exercise.
First Line: Amitriptyline.
For trigger points: Local anesthesia.Also Milnacipran and Pregabalin.
CBT.
Sjorgen Syndrome?
Increase mucosal secretions: Artificial tears to prevent corneal ulcers; Increase fluid intake; sugar free gum; artificial saliva and fluoride treatments.
Cholinergic drugs: Pilocarpine or Cevimeline -> increased secretions
Adverse effects = diaphoresis, flushing, sweating, bradycardia, diarrhea, nausea, vomiting.
Scleroderma?
Treatment is organ-specific: GERD = PPIs Raynaud = vasodilators (CCBs) Severe disease = DMARDS Pulmonary fibrosis: Cyclophosphamide Pulmonary hypertension: Bosentan, Sildenafil
Lupus?
AVOID SUN!
Mild: Hydroxychloroquine w/ or w/o NSAIDS and/or short-term low dose glucocorticoids.
Mod: Hydroxychloroquine plus short-term glucocorticoid therapy. Belimumab (Benlysta)- Usually reserved for active cutaneous or MSK disease unresponsive to glucocorticoids or other immunosuppressive agents.
Severe: High dose glucocorticoids or intermittent IV “pulses” of methylprednisolone with other immunosuppressive agents (Cyclophosphamide, Mycophenolate, Rituximab).
Antiphospholipid syndrome?
Asymptomatic = no treatment
Recurrent thrombosis may require lifelong Warfarin or other type of anticoagulant.
Juvenile (Idiopathic) RA?
First line: NSAIDs
If NSAIDs not effective, Steroids.
PT.
Severe/2nd line: Anakinra, methotrexate, leflunomide.
If ANA positive, routine eye exam every 3 months (b/c uveitis).
Hip dislocation?
Closed reduction over conscious sedation or ORIF surgery.
Hip fracture?
Prophylactic antithrombotic therapy for DVT.
Surgical- ORIF.
Trochanteric bursitis?
Rest & NSAIDs.
Steroid injections.
Surgery as last resort with resection of bursa.
Slipped capital femoral epiphysis (SCFE)?
Non weight bearing w/ crutches followed by internal fixation.
Legg-Calve-Perthes Disease?
Activity restriction (non bearing first) w/ ortho follow up. Revascularization within 2 years. PT. Brace/cast. Surgery in advanced cases.
Femoral Shaft fracture?
Surgery within 24-48 hours with ORIF.
Tibial and fibular fractures?
Nondisplaced and closed: Full leg cast for 4-6 wks then below knee walking cast for another 4-6 wks.
Comminuted or displaced: ORIF.
Popliteal (Baker’s) Cyst?
Ice & NSAIDs.
Intraarticular corticosteroid injection for knee pain and swelling.
If cyst gets large, needle drainage.
Surgical excision for refractory.
LCL and MCL?
Sprained or incompletely torn (Grades 1 or 2): Pain control, PT, RICE, NSAIDs, knee immobilizer. Complete tear (Grade 3): Surgery
ACL?
Surgery in younger athletes.
Conservative vs. surgery.
PCL?
Conservative unless other injuries then surgery.
Meniscal tear?
Conservative and PT. Surgery (arthroscopic repair or partial mensicectomy if refractory.
Patellofemoral syndrome (Chondromalacia)?
Conservative + PT.
Elastic knee sleeve for patellar stabilization.
Patellar dislocation?
Closed reduction- Push anteromedially on patella while gently extending leg.
Post reduction films, knee immobilizer (full extension), quads strengthening.
Patellar fracture?
Non displaced: knee immobilizer, leg cast.
Displaced: surgery.
Femoral condyle fracture?
Immediate ortho consult (needs surgery bc of perineal nerve and popliteal artery); ORIF.
Tibial plateau fracture?
Conservative: Non weight bearing, hinged knee brace, ortho follow up.
If displaced: Surgery.
Tibial Femoral dislocation?
Immediate ortho consult for prompt reduction. Emergent surgical intervention. Check pulses.
Osgood-Schlatter Disease?
Conservative: RICE, NSAIDs, knee immobilization (resolve in 12-24 months).
Refractory: Surgery after growth plate closes.
Ankle sprain?
RICE, NSAIDS, crutches for the first few days, ACE wrap for support.
Achilles Tendon Rupture?
Conservative: Splint/Cast
Surgery.
What DRUG has a BLACK BOX WARNING about Achilles Tendon Rupture?
Fluoroquinolones.
Ankle fracture?
Stable w/ no displacement: Splint/cast w/ or w/o crutches.
Unstable and displaced: Surgery.
Stress/March Fracture?
Rest, avoidance of high impact activities, ice, splint, analgesia.
Surgery if high risk area.
Plantar fasciitis?
Rest, ice, NSAIDs, heel/arch support in shoes (orthotics), PT (plantar stretching exercises.
If no relief: Steroid injection. Can take up to one year to fully heal. If not better after one year, surgery.`
Tarsal Tunnel Syndrome?
First: Conservative (rest, NSAIDs, properly fitted shoes & orthotics).
Refractory: Corticosteroids.
Severe: Surgical tunnel release.
Hallux Valgus (Bunion)?
First: Wide toed shoes.
Refractory: Surgery.
Charcot Joint/ Neuropathic arthropathy?
Conservative: rest, non weight bearing, accommodative footwear.
Morton’s Neuroma?
First: Metatarsal support or pad, broad toes shows w/ firm soles.
If fails: Steroid Injection.
Refractory: Surgery.
Jones Fracture?
Non weight bearing in short leg cast for 6-8 weeks.
Often complicated by nonunion or malunion, which frequently requires surgical repair.
Lisfranc Injury?
ORIF, then non-weight bearing cast for 12 weeks.
Anterior glenohumeral dislocation?
Reduction and immobilization
MUST check axillary nerve for injury before AND after reduction.
Posterior glenohumeral dislocation?
Reduction and immobilization.
Acromioclavicular joint dislocation/seperation?
Type 1, 2, 3: Conservative (ice, brief, sling immobilization, rest). Early rehab for ROM preservation.
Type 4, 5, 6: Surgical Reattachment of ligaments.
Impingement Syndrome?
Conservative w/ PT.
Adhesive capsulitis?
MC in?
Shoulder stiffness due to inflammation.
40-60 y/o, DM, hypothyroidism.
Adhesive capsulitis?
Rehab ROM therapy = mainstay
Anti-inflammatories; intraarticular steroid injection & heat.
Rotator Cuff Injury?
Nonoperative: PT, NSAIDs, steroid injections if pt fails NSAIDs.
Operative: If fail conservative within 6 months or complete tears.
Humeral Head Fracture?
Sling Immobilizations, analgesics, PT.
Humeral Shaft Fracture?
Coaptation splint/sling w/ prompt ortho follow up.
If open fx or vascular/brachial plexus injuries, surgery.
Thoracic Outlet Syndrome?
Caused by?
MC in men or women of what age?
Secondary to?
Positional, intermittent compression of the brachial plexus and/or subclavian artery and vein.
Hypertrophied scalene muscles compress the vessels and nerves against the clavicle and between the 1st rib.
Women 20-50 y/o.
Neck trauma, sagging of shoulder girdle (from aging, obesity, or pendulous breasts). Also occupation, faulty posture, or thoracic muscle hypertrophy from activities like weightlifting, baseball pitching.
Thoracic Outlet Syndrome?
Conservative for 95% of cases: PT, pain relief, avoid activities that compress neuromuscular bundle.
Refractory: Surgery decompression.
Olecranon bursitis?
Olecranon bursitis = padding to area; NSAIDs; ACE wrap for compression.
Septic bursitis = drainage and ABX (Dicloxacillin or Clindamycin).
Olecranon fracture?
Nondisplaced: Reduction and posterior long arm splint (90 degrees flexion).
Displaced: ORIF.
Elbow dislocation?
Stable: Emergent reduction w/ long arm splint at 90 degrees w/ ortho follow up.
Unstable: ORIF.
Radial Head Fracture?
Nondisplaced: immobilization (sling, long arm splint 90 degrees).
Displaced: surgical (ORIF).
Ulnar Shaft (Nightstick) Fracture?
Nondisplaced distal 1/3: short arm cast.
Nondisplaced mid-proximal 1/3: long arm cast.
Displaced (>50%): ORIF.
Monteggia Fracture?
Unstable fractures require ORIF.
Galeazzi Fracture?
ORIF.
Long arm/sugar tong splint temporarily.
Lateral epicondylitis (tennis elbow) and Medial epicondylitis (Golfer’s elbow)?
Conservative: activity modification, RICE, NSAIDS, counterbalance braces; intraarticular steroid injections for short-term relief. Can take up to 6 months to fully heal.
Surgery if refractory to conservative management.
Cubital Tunnel Syndrome?
Wrist immobilization especially with sleep, NSAIDS.
If chronic, intraarticular steroids.
Scaphoid (navicular) fracture?
Nondisplaced fracture or snuffbox tenderness: thumb spica splint.
Displaced > 1mm: ORIF or pin placement.
Scapholunate Dissociation?
Initial: radial gutter splint.
Surgical repair of the scapholunate ligament usually required to prevent degenerative arthritis.
Colles Fracture?
Stable: closed reduction followed by sugar tong splint/cast.
ORIF if comminuted or unstable.
Lunate Dislocation?
Emergent closed reduction & splint followed by ORIF - ORTHO EMERGENCY.
Lunate Fracture?
Immobilization with orthopedic referral / follow up.
Mallet (baseball) Finger?
Nonoperative: uninterrupted extension splint of the DIP for 6-8 weeks.
Closed reduction & percutaneous pinning if needed.
Boutonniere Deformity?
Splint PIP in extension for 4-6 weeks with hand surgeon follow-up.
[name: French for “button hole” – head of proximal phalanx pops through gap like a finger through a button hole]
Swan Neck Deformity?
Surgery.
De Quervain Syndrome?
Thumb spica splint initial management, NSAID, PT.
Corticosteroid injection if initial treatment is unsuccessful.
Carpal Tunnel Syndrome?
Initial/Conservative: volar splint, NSAIDS/
Corticosteroid injections
Surgery in refractory cases.
Dupuytren Contracture?
Intralesional collagenase and/or corticosteroid injection.
Surgical correction for advanced or refractory cases.
Boxer’s Fracture?
Initial:ulnar gutter splint.
ORIF.
Check for bite wounds (punched in the teeth) and give ABX Augmentin.
Radial Head Subluxation?
Closed reduction – pressure on radial head with supination of elbow, followed by flexion of elbow.
Clavicular Fracture?
Group 1 – sling immobilization (with sling or figure 8 splint)
If lateral or proximal, get an ortho consult.
Surgery is typically indicated for any open fractures, displaced fractures, etc.
