Musculoskeletal Flashcards
Navicular Fracture: Overview
Scaphoid Bone Fracture
- Wrist pain on palpation of anatomic snuffbox
- Pain on axial loading of thumb
- hx of falling forward w/ outstretched hand (hyperextension of wrist) to break the fall
Imaging: Initial x-ray of wrist may be normal, but a repeat x-ray in 2 weeks will show the scaphoid fracture (d/t callous bone formation)
* high risk of avascular necrosis and nonunion
Tx:
- Splint wrist (thumb spica splint)
- Refer to hand surgeon
- Name of cast for fractures of wrist is “thumb spica cast” (also available as a splint)
Colles Fracture: Overview
Fracture of distal radius (w/ or w/out ulnar fracture) of forearm along w/ dorsal displacement of wrist
- AKA “dinner fork” fracture d/t appearance of arm and wrist after fracture
- most common type of wrist fracture
hx of falling forward w/ outstretched hand (as in navicular fracture)
Acute Osteomyelitis: Overview
An acute infection of the bone → causing inflammation and destruction
- caused by bacteria, mycobacteria, and fungi
- most cases are d/t contiguous spread from a nearby infected wound to the bone (ex: infected pressure sore on heel → osteomylitis of heel bone or calcaneus [nonhematogenous spread])
- Direct trauma to bone can also cause infection
Most common pathogen: staphylococcus aureus
S/Sx
- localized bone pain
- swelling
- redness
- tenderness of affected area and fever
Imaging: MRI (shows changes to bone and bone marrow) before plain X-ray or radiograph
Labs:
- WBC ↑
- ESR ↑
- CRP ↑
- BC may be positive
Tx:
- Antibiotics are based on C&S results
- May need surgical debridement, amputation, and bone grafts
Hematogenous spread
seeding of the bone from an infection in the bloodstream (bacteremia)
Ex: patient w/ bacteremia complains of refractory vertebral pain and tenderness (hematogenous osteomyelitis)
Hip Fracture: Overview
PMHx: hx of slipping or falling
- more common in elderly; have a 1-year mortality from 12-37% r/t complications of immobility (e.,g., pneumonia and DVT)
S/Sx
- sudden onset of one-sided hip pain
- unable to walk/bear weight on affected hip
- if mild fracture, may bear weight on affected hip
- if displaced fracture, presence of severe hip pain w/ external rotation of hip/leg (abduction) and leg shortening
Pelvic Fracture: Overview
PMHx: - hx of sign or high-energy trauma (e.g., motor vehicle or motorcycle accident)
S/Sx - depends on degree of injury to pelvic bones and other pelvic structures (e.g., nerves, blood vessels, & pelvic organs)
- ecchymosis and swelling in lower abdomen, hips, groin, and/or scrotum
- may have bladder and/or fecal incontinence
- vaginal/rectal bleeding
- hematuria
- numbness
- may cause internal hemorrhage (life-threatening!)
Tx: Check ABC!!
Cauda Equina Syndrome: Overview
pressure (most common cause is a bulging disc) on sacral nerve root → inflammatory and ischemic changes to nerves
S/Sx
- sudden onset of saddle anesthesia
- bladder incontinence (or urine retention)
- fecal incontinence
- accompanied by bilateral leg numbness & weakness
Tx: MEDICAL EMERGENCY!
A surgical emergency! Needs spinal decompression! → Refer to ED!
Low-Back Pain (From a Dissecting Abdominal Aneurysm): Overview
S/Sx:
- acute and sudden onset of “tearing,” severe low-back/abdominal pain
- presence of abdominal bruit w/ abdominal pulsation
- s/s of shock
- more common in elderly males, atherosclerosis, white race, and smokers
Bone Metastases
Bone is one of the most common sites of distant metastases
- Cancers of prostate, breast, lung, thyroid, and kidney = up to 80% of bone metastases
S/Sx
- achy, sharp, and/or well localized or feel like neuropathic pain (burning, shooting pain)
- can be severe w/ night pain and/or pain w/ weight bearing
- may be accompanied by night sweats, malaise, fever, and weight loss
- can be constant or intermittent
- can get exacerbated w/ movement of joint or bone
* Pathologic fractures can occur
Labs
- ↑ alkaline phosphatase
- ↑ serum calcium (hypercalcemia)
Imaging:
- Radiograph (x-ray) has poor sensitivity (44-50%) but can show boney lesions and early lesions
- MRI* is most sensitive and specific imaging test
Normal Findings
Joint Anatomy: Synovial fluid
Thick, serous, clear fluid (sterile) that provides lubrication for the joint
- Cloudy synovial fluid can be indicative of infection; order C&S
Normal Findings
Joint Anatomy: Synovial space
Space between 2 bones (the joint) filled with synovial fluid
Normal Findings
Joint Anatomy: Articular cartilage
the cartilage lining the open surfaces of bones in a join
Normal Findings
Joint Anatomy: Meniscus or menisci (plural)
Crescent-shaped cartilage located in each knee
- two menisci in each knee
- Damage to menisci may cause locking of the knees and knee instability
Normal Findings
Joint Anatomy: Tendon
connects muscle to the bone
- partial or complete tear of tendon or muscle is a strain
What is a MSK strain?
partial or complete tear of tendon or muscle
OR
partial or complete tear of a ligament is a sprain
Normal Findings
Joint Anatomy: Ligament
connects bone to bone
Normal Findings
Joint Anatomy: Bursae
saclike structures located on the anterior and posterior areas of a join that act as padding; filled with synovial fluid when inflamed (bursitis)
- Cloudy fluid is abnormal and is indicative of infection
Joint Anatomy
Benign Variants: Genu recurvatum
Hyperextension or backward curvature of the knees
Joint Anatomy
Benign Variants: Genu valgum
knock-knees
- To remember valgum, think of “gum stuck between the knees” (knock-knees); the opposite if varus, or bow legs
Joint Anatomy
Benign Variants: Genu varum
Bowlegs
- To remember valgum, think of “gum stuck between the knees” (knock-knees); the opposite if varus, or bow legs
General rules: Exercise and Injuries
- What is the time frame to protect joint after injury?
- What should you NOT do with injuries regarding activity/exercising?
- Within the first 48 hours, protect joint, and acutely inflamed joints should NOT:
- be exercised in any form (not even isometric exercises)
- engage in any active ROM exercises; if done too early, they will cause more inflammation and damage to affected joints
- Undergo exacerbating activities
RICE Mnemonic
Within first 48 hours after musculoskeletal trauma, follow these rules: RICE
Rest → avoid using injured joint/limb
Ice → Apply cold packs on injured area (e.g., 20 mins on, 10 mins off) for first 25-48 hours
Compression → Use elastic bandage wrap over joints to ↓ swelling and provide support; joints usually compressed are ankles and knees
Elevation → This prevents or ↓ swelling; avoid bearing weight on affected joint
Exercise:
1. Adults
2. Children and teens (6-17 years)
3. HTN adults
- 150-300 mins weekly of mod-intensity aerobic activity (or 75-150 mins of vigorous aerobic activity) + muscle strengthening exercise at least 2 days/wk
- 60 mins daily of mod-vigorous physical activity + including muscle-strengthening & bone strengthening activity 3 x/week
- aerobic exercise has been found to lower resting clinic systolic/diastolic BP
Exercise:
4. Non-weight-bearing exercise
5. Weight-bearing exercise
- Isometric exercises - performed in fixed state where muscles are flexed against stationary object
Ex: pushing one fist against the palm of the other, which is stationary
- Biking and swimming are aerobic exercises, which are non-weight bearing (do not strengthen bones) - Here bones/muscles are forced against gravity
- recommended for treating osteopenia and osteoporosis to strengthen bone durability
Ex: - walking
- skiing
- yoga
- tai chi
- lifting weights
- other sports
Orthopedic Maneuvers:
1. General rule
2. Drawer Sign: Anterior vs Posterior
- Test BOTH extremities
- Use normal limb as “baseline” for comparison - Test for knee stability
- Excessive laxity of affected knee is suggestive of torn ligament
Anterior Drawer Sign
Pt lies on exam table supine → Hip flexed 45º knee is bent to 90º → Examiner sits on forefoot/toes to stabilize knee joint → then grasp lower leg by joint line and pulls the tibia anteriorly (like opening a drawer)
* Positive: indicative of a damaged or torn anterior cruciate ligament (ACL)
Posterior Drawer Sign
Pt lies supine → Hip flexed 45º → Hip bent 90º → examiner sits on forefoot/toes to stabilize knee joint → grasp lower leg by joint line and pushes posteriorly (like closing a drawer)
* Positive: indicative of damaged or torn posterior cruciate ligament (PCL)
Sensitivity: 90%
Specificity: 99%
Orthopedic Maneuvers: Finkelstein’s Test
De Quervain’s tenosynovitis (or tendinosis) → caused by inflammation of tendon sheath, located at base of thumb
* Positive if there is pain and tenderness on wrist on thumb side (abductor pollicis longus and extensor pollicis brevis tendons)
Procedure: Pt flex thumb toward palm, them make a fist by folding remaining fingers over thumb → tell pt to ulnarly deviate wrist
* Positive if pt complains tendon (on thumb side) hurts w/ ulnar deviation
Orthopedic Maneuvers: McMurray’s Test
Knee and a “click” sound upon manipulation of knee are POSITIVE
- Positive test → injury to medial meniscus of knee
** GOLD STANDARD test for joint damage is MRI!
Orthopedic Maneuvers: Lachman’s Sign
Positive result is suggestive of ACL damage of knee
Orthopedic Maneuvers: Collateral Ligaments (Knees) - MCL vs LCL
Positive finding is an ↑ laxity of damaged knee (ligament tear)
Valgus stress test of knee: Test for MCL
Varus stress test of knee: Test for LCL
Joint Injections
1. Definition/Indications
2. Procedure
3. Complication
4. Contraindications
- Administering intra-articular/periarticular joint injections w/ steroids (e.g., triamcinolone) is a controversial tx for inflamed joints
- ~4 injections per joint (e.g., knee) in a lifetime - If high resistance if felt when pushing syringe, do NOT force
- Withdraw needle slightly (do not remove from joint) and redirect - tendon rupture
- nerve damage
- infection
- bleeding
- hypothalamic-pituitary-adrenal (HPA) suppression
- tendon rupture
- patients on anticoagulation d/t risk of hemarthrosis
Radiography: What does it show?
Plain x-ray files (radiographs)
* Best for bone injuries (fractures)
Shows:
- bone fractures
- osteoarthritis (OA; joint space narrowing, osteophyte formation)
- damaged bone (osteomyelitis, metastases)
- metal and other dense objects
NOT recommended for soft tissue structures such as menisci, tendons, and ligaments
- usually initial imaging modality
- Some bone fractures may not be visible (e.g., stress fractures)
CT Scans: Definition + What does it show?
combines x-rays (gamma radiation) that are rotating in continunous circle around patient w/ computer software to show slices of 3D images
- can be done w/ or w/out contraste
Detects:
- bleeding
- aneurysms
- masses
- pelvic and bone trauma
- fractures
MRI Scans: Definition + What does it show? + Contraindications
uses magnetic field and radio waves, not radiation (compared w/ x-rays and CT scans)
- can be done w/ or w/out contrasts
- best for soft tissue, joints, occult fractures, and soft tissue
GOLD STANDARD for injuries of:
- cartilage
- menisci
- tendons
- ligaments
- or any joints of the body
Contraindications:
- metal implants
- pacemakers
- aneurysm clips
- insulin pumps
- metallic foreign body in the eye
- “triggerfish” contact lens
- cochlear implant
- electrodes for deep brain stimulation
- metallic joints
Orthopedic Terminology
1. Abduction
2. Adduction
- varus - movement going away from body
- valgum - movement going toward the body
Orthopedic Terminology: Hands & Feet
1. Metacarpals
2. Carpals
3. Phalanges
4. Metatarsals
5. Talus
6. Calcaneus
- bones of the hands
- bones of the wrist; there are 8
- finger sand toes; singular form: phalanx
- bones of the feet
- ankle bone
- heel bone
Orthopedic Terminology
1. Proximal
2. Distal
- Body part located close to the body (compared w/ distal)
- Body part farther away from center of the body
Medial Tibia Stress Syndrome ( Shin Splints) & Medial Tibial Stress Fracture
1. Definition/Etiology
2. Clinical Presntation
- LE injury caused by overuse → microtears and inflammation of muscles, tendons, and bone tissue of tibia
- AKA “shin splints”
- more common in runners
- higher incidence in females & flat-feet people
- If severe → progress to stress fracture → female at higher risk of stress fracture, esp those with “female athlete triad” (amenorrhea, eating disorder, and osteoporosis)
- Onset precipitated or worsened w/ intensification of activity (increased milage and/or frequency of training) - recent onset of pain on inner edge of tibia
- can be sharp and stabbling
OR dull and throbbing
- aggravated during and after exercise
- c/o sore spot on inside of lower leg or shin (tibia)
- some may have pain on anterior aspect of shin
- focal area is tender when touches
- some may develop stress fracture on tibia
- recent onset of pain on inner edge of tibia
Medial Tibia Stress Syndrome ( Shin Splints) & Medial Tibial Stress Fracture
3. Treatment Plan
- RICE + several weeks of rest recommended
- Cold packs uring acute exacerbation for 20 min at a time, several times a day for first 24-48 hrs and then PRN
- Take NSAIDs PRN
- Compression bandage or sleeve may help ↓ swelling
- using cushioned shoes (sneakers) for daily activity helps ↓ tibial stress
- when pain is gone, wait ~2 weeks before resuming exercise
- avoid hells and very hard surfaces until shin splints have resolved
- If aerobic exercise is desired → recommend lower impact exercises (e.g., swimming, stationary bike, elliptical trainer)
- if stress fracture is suspected, advise pt to avoid exercising
- Stretch before exercise & start at lower intensity
- wear supportive sneakers
- RICE + several weeks of rest recommended
Imaging test: If suspect stress fracture, bone scan and/or MRI
* Radiograph (x-ray) does not show stress fractures
- Refer to orthopedic specialist
Plantar Fasciitis
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan
- Acute or recurrent pain on bottom of feet, aggravated by walking
- caused by microtears in plantar fascia d/t/ tightness of Achilles tendon
- higher risk w/ obesity (BMI ≥30), DM, aerobic exercise, flat feet, prolonged standing - plantar foot pain (either on one or both feet)
- worsened by walking and weight bearing
- pain is worse during first few steps in the morning and continues to worsen w/ prolonged walking
- plantar foot pain (either on one or both feet)
- NSAIDs: Naproxen (Aleve) PO BID, iburpofen PO Q4-6 hrs
- Topical NSAID: Diclofenac gel (Voltaren Gel) applied to soles of feet BID
- Use orthotic foot appliance at night for a few weeks; will help to stretch Achilles tendon
- Stretching and massaging of foot: Rolla a golf ball with sole of foot several times a day
- lose weight (if overweight)
- use shoes w/ well-padded soles and/or use a heel cup on affected foot
- Consider x-ray to r/o fracture, heel spurs, complicated case → Refer to podiatrist PRN
- NSAIDs: Naproxen (Aleve) PO BID, iburpofen PO Q4-6 hrs
Mortons’ Neuroma
1. Definition/Etiology
2. Clinical Presentation
3. Labs/Diagnostics
4. Treatment Plan
- Inflammation of digital nerve of foot b/w 3rd and 4th metatarsals
- ↑ risk w/ high-heeled shoes, tight shoes, obesity, dancers, runners - many weeks of plantar foot pain, worsened by walking esp. while wearing high heels or tight narrow shoes
- pain is described as burning and/or numbness
- located on space between 3rd and 4th toes (metatarsals) on forefoot
- PE may reveal small nodules on space b/w 3rd and 4th metatarsals
- some pts may palpate same nodules and report it as “pebble-like”
- many weeks of plantar foot pain, worsened by walking esp. while wearing high heels or tight narrow shoes
- Mulder Test
- Avoid wearing tight narrow shoes and high heels
- use forefoot pad
- wear well-padded shoes
- Diagnosed by clinical presentation and hx
- Refer to podiatrist
- Avoid wearing tight narrow shoes and high heels
Mulder Test
Test for Morton’s neuroma
- Done by grasping 1st and 5th metatarsals and squeezing forefoort
* Positive: hearing a click along w/ a pt report of pain during compression; pain is relieved when compression is stopped
Degenerative Joint Disease (DJD)
1. Definition/Etiology
2. Goal of Treatment
3. Clinical Presentation
Aka Osteoarthritis (OA)
1. Occurs when cartilage covering articular surface of joints becomes damaged from overuse and w/ age
- large weight-bearing joints (hips and knees) and the hands (HBouchard’s and Heberden’s nodes) are most commonly affected
- can affect one side or bilaterally
- RF: older age, overuse of joints, positive fam hx
- Relieve pain
- Preserve joint mobility and function
- Minimize disability and protect joint
- Relieve pain
- Gradual onset (over years
- early morning joint stiffness w/ inactivity
- shorter duration of joint stiffness (<15 mins) compared w/ RA
- pain aggravated by overuse of joint
- during exacerbations, involved joint may be swollen and tender to palpation
- may be one-sided (e.g., right hip only)
- absence of systemic sx (not a systemic inflammatory illness like RA)
- Heberden’s and/or Bouchard’s nodes may be noted
- Gradual onset (over years
DJD: Heberden’s nodes & Bouchard’s nodes
H: Bony nodules on distal interphalangeal (DIP) joints
B: Bone nodules on proximal interphalangeal (PIP) joints
H: -den ending is D for DIP joint
Remember: B comes before H; therefore, Bouchard’s node comes before Herberden’s nodes
Degenerative Joint Disease (DJD)
4. Nonpharmacologic Management
5. Treatment Plan
- Exercise w/ care at least TID
- lose weight
- stop smoking
- Do isometric exercises to strengthen quadriceps muscles (knee OA)
- Engage in weight-bearing exercise (walking, lifting weights), resistance-band exercises
- avoid aggravating activities
- use cold or warm packs and ultrasound treatment
- use walking aids; patellar taping by PT will ↓ load on knees
- Alternative medicine: use glucosamine supplements, SAM-e, tai chi exercises, acupuncture
- Exercise w/ care at least TID
- First line: acetaminophen 325-650 mg Q4-6 hrs (max 4 g/daily) PRN OR Tylenol 325-1000 mg Q4-6 mg (max 4g per 24 hrs) PRN; Dehydration ↑ risk of hepatic adverse effects; drink a lot of water
- if no relief w/ acetaminophen → short-acting NSAID
- Start w/ ibuprofen (Advil) 1-2 tabs Q4-6 hrs or naproxen (Aleve) BID or Anaprox DS 1 tab Q12hr PRN
- For added GI protection (if long-term), add PPI; omeprazole or misoprostol (Cytotec)
- If pt is at high risk for both GI and CV side effects, avoid NSAIDS
► GI bleed RF: Hx of uncomplicated ulcer, aspirin, warfarin (Coumadin), PUD, platelet disorder
► Opioid analgesics: avoid if possible (esp if pt is a recovering narcotic addict)
- Age >75 years: Use topical (vs oral) NSAIDs for treatment
- R/O osteoporosis and order bone mineral density test (postmenopausal females, chronic steroid treatment males/females)
- First line: acetaminophen 325-650 mg Q4-6 hrs (max 4 g/daily) PRN OR Tylenol 325-1000 mg Q4-6 mg (max 4g per 24 hrs) PRN; Dehydration ↑ risk of hepatic adverse effects; drink a lot of water
Other treatments:
- analgesics & NSAIDs (PO or topical)
- steroid injection on inflamed joints (NO systemic/oral steroids)
- surgery (e.g., joint replacement)
** Do NOT confuse treatment options for OA w/ those for RA
Topical Medicine: NSAID vs Capsaicin cream
NSAID
- Diclofenac gel (Voltaren Gel) → apply to painful area nad massage well into skin QID
Capsaicin cream: Apply to painful area QID
- Avoid contact w/ eyes/mucous membranes
- comes from chili peppers
- also used to treat neuropathic pain (e.g., post shingles)
- Do NOT use on wounds/abraded skin
- avoid bathing/showering afterward (so that it is not washed off)
NSAID Drug Risk
1. Highest risk of GI bleeding
2. Lower risk of GI bleeding
3. Highest risk of CV events
4. Lowest risk of CV events
- Ketorolac (Toradol) and piroxicam (Feldene)
* Ketorolac (Toradol) is limited to 5 days use; first dose is given IM or IV - Ibuprofen and celecoxib (Celebrex)
- Diclofenac and celecoxib at higher doses
- Naproxen
NSAIDs injure the GI tract by blocking cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2) → lower levels of systemic prostaglandins
* Aspirin (acetylsalicylic acid) is a type of NSAID → affects platelets and clotting permanently, but will resolve once affected platelets (life span ~10 days) resolve (if not on chronic NSAIDs)
Systemic Lupus Erythematosus (SLE)
1. Definition/Etiology
2. Clinical Presentation
3. Treatment Plan
4. Patient Education
- Multisystem autoimmune ds
- more common in women - 9:1
- characterized by remissions and exacerbations
- more common in African American & hispanic women
- Milder form of lupus: cutaneous lupus erythematosus
Organ systems affected:
- skin
- kidneys
- heart
- blood vessels
- women between 20-35 years
- classic rash: maculopapular butterfly-shaped rash on middle of face (malar rash)
- nonpruritic thick scaly red rashes on sun-exposed areas (discoid rash)
- UA+ for proteinuria
- women between 20-35 years
- Refer to rheumatologist
Meds:
- N SAIDs
- analgesics
- steroids
- antimalarial (Plaquenil)
- immune modulators (methotrexate, biologics)
- monoclonal antibodies
- Refer to rheumatologist
- Avoid sun b/w 10am and 4pm (causes rashes to break out)
- Cover skin w/ high sun protection factor (SPF; UVA and UVB sunblock)
- Wear sun-protective clothing (hats w/ wide brims, long-sleeved shirts)
- use nonfluorescent light bulbs (more sensitive to indoor fluorescent lighting)
- Avoid sun b/w 10am and 4pm (causes rashes to break out)
Rheumatoid Arthritis (RA)
1. Definition/Etiology
2. Clinical Presentation
3. Physical/Objective Findings
- Systemic autoimmune ds
- more common in women - 8:1
- mainly manifested through systemic inflammation of multiple joints and other parts (skin, heart, blood vessels, kidneys, GI, brain/nerves, eyes)
Goal of treatment: prevent joint and organ damage
- Pts at higher risk for other autoimmune ds, including Graves’ disease and pernicious anemia
- Adult, commonly middle-aged woman
- gradual onset of sx over months w/ daily fatigue
- low-grade fever
- generalized body aches
- myalgia
- generalized join pain, usually multiple joints bilaterally
- starts in fingers/hands (PIP and metacarpophalangeal [MCP] joints) and wrists
- early morning stiffness/pain
- warm, tender, and swollen fingers in DIP/PIP joints (aka “sausage joints”)
- eventually involves majority of joints in body bilaterally
- Adult, commonly middle-aged woman
- Joint involvement is symmetric w/ more joints involved compared w/ DJD
- Most common joints affected: hands, wrist, elbows, ankles, feet, and shjoulders
- “sausage joints”
- morning stiffness occurs for at least 1 hr and has been present for >6 weeks
- Rheumatopid nodules present (chronic ds)
- Swan neck deformity (50%): flexion of the DIP joint w/ hyperextension of PIP joint
- Boutonniere deformity: hyperextension of DIP w/ flexion of PIP joint
- Joint involvement is symmetric w/ more joints involved compared w/ DJD
RA: Swan Neck deformity
flexion of the DIP joint w/ hyperextension of PIP joint
- Disruptuion in extensor tendon
- late and/or severe RA disease
RA: Boutonniere deformity
hyperextension of DIP w/ flexion of PIP joint
- central band disruption (induces the lateral band to slip)
- late and/or severe RA disease
RA
4. Labs/Diagnostics
5. Treatment Plan
- Sedimentation rate ↑
- CBC: Mild microcytic or normocytic anemic (common)
- Rheumatoid factor (RF): + in 70-80%
- Radiographs: Bony erosions, joint space narrowing, subluxations (or dislocations)
- Serology/antibodies: Anti-cyclic citrullinated peptide/protein (anti-CCP), others
- Sedimentation rate ↑
- Refer to rheumatologist for early aggressive management to minimize joint damage
- Surgery: joint replacement (hip, knees) ameliorates RA
- Careful assessment is necessary → NEVER prescribe a biologic or anti-tumor necrosis factor (anti-TNF) med if s/sx of infection (e.g., fever, sore throat) are present
- TB testing should be ordered prior to start of anti-TNF therapy
- Refer to rheumatologist for early aggressive management to minimize joint damage
RA
6. Medications
7. Complications
- NSAIDs (e.g., ibuprofen, naproxen Na) to relieve inflammation and pain
- Steroids: systemic oral doses
- Steroid joint injections (synovial space)
- Disease-modifying antirheumatic drugs (DMARDs) such as methotrexate, sulfasalazine, cyclosporine, and hydroxychloroquine (an antimalarial drug)
* Methotrexate is contraindicated during pregnancy! If prescribed to childbearing women, contraception MUST be prescribed and adhered to while on med
- NSAIDs (e.g., ibuprofen, naproxen Na) to relieve inflammation and pain
- If poor response to nonbiologic DMARMs, use other options → biologic agents, TNF, and alpha inhibitors
- Anti-TNF biologics: Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade) → WARNING: can ↑ risk of infections, squamous cell skin cancer, lymphoma
- Uveitis (eyes) → inflammation of uvea (middle layer eyeball); sudden onset of eye redness, pain, blurred vision; can cause vision loss → Refer to ophthalmologist stat
- RA ↑ risk of anterior uveitis, scleritis, vasculitis, pericarditis
- ↑ risk of certain malignancies (lymphoma)
- When prescribing Plaquenil, all pts MUST have an eye exam prior to start; frequent eye-exam monitoring should be performed Q6 months or as recommended by ophthalmologists to assess and prevent retinal damage (can lead to blindness)
- Uveitis (eyes) → inflammation of uvea (middle layer eyeball); sudden onset of eye redness, pain, blurred vision; can cause vision loss → Refer to ophthalmologist stat
How to distinguish between RA and OA using classic presentation
- Bouchard’s nodes vs Heberden’s nodes
RA
- joint stiffness lasts long
- involves multiple joints and has symmetric distribution
- accompanied by systemic sx such as fatigue, fever, normocytic anemia
Bouchard’s nodes can occur in both OA/DJD and RA (PIP)
Heberden’s nodes only seen in OA/DJD (DIP)
What is uveitis with inflammatory diseases like RA
- Swelling of the uvea; middle layer of eye that supplies blood to retina → Refer to opthalmologist stat
- Treated w/ high-dose steroids for several weeks
- higher risk of uveitis w/ inflammatory diseases (e.g., ankylosing spondylitis, sarcoidosis, IBS)
Gout
1. Definition/Etiology
2. Clinical Presentation
3. Labs/Diagnostics
- Deposits of uric acid crystals (monosodium urate) inside joints and tendons d/t genetic excess production or low excretion of purine crystals (by-product of protein metabolism)
- high levels of uric acid can crystallize in peripheral joints (e.g., first joint of large toe; metatarsophalangeal [MTP], ankles, hands, and wrists
- most common in middle-aged males >30 years
- recurrent flares, accompanied by ↑ serum uric acid <6.8 mg/dL (most common way to diagnose gout) - painful, hot, red, and swollen MTP joint of great toe (podagra)
- limping d/t severe pain from weight bearing on affected toe
- hx of previous attacks at same site
- precipitated by ingestion of alcohol, meats, or seafood
- chronic gout has tophi (small white nodules full of urates on ears and joints)
- hx of recurrent inflammatory arthritis (gout flare)
- painful, hot, red, and swollen MTP joint of great toe (podagra)
- GOLD STANDARD: joint aspiration of synovial fluid of joint → Microscopy exam using polarized light is used to identify uric acid crystals in synovial fluid to diagnose gout
- Uric acid level: ↑ >6.8 mg/dL; tx target <6 mg/dL
► During acute phase, uric acid level is normal; uric acid level does not begin to ruse until after acute phase
► Test uric acid level 2 weeks after acute attack
► Consider other conditions/meds that ↑ serum uric acid
- CBC: ↑ WBC
- ESR ↑
- CRP ↑
Gout: Other conditions that ↑ serum uric acid
- chemotherapy
- radiation therapy
Gout: Medications that ↑ uric acid
- hydrochlorothiazide
- furosemide
Gout
4. Treatment Plan: Acute Phase
First goal: Pain relief w/ oral steroids, NSAIDs, or colchicine
- Tx should star ASAP for best results
- During flares, if pt is taking daily urate-lowering therapy (e.g., allopurinol, probenecid, febuxostat, lesinurad, pegloticase) do NOT discontinue it; can continue taking meds w/ gout flare meds
- Prednisone or prednisolone 30-40 mg daily or divided in BID dosing; taper the dose over 7-10 days; shorter duration (5 days) or tapered packs (Medrol Dosepak) are also effective
- NSAIDs if pt refuses steroids (and does NOT have renal or active GI ds)
- Indomethacin BID, naproxen Na BID, diclofenac BID, celecoxib BID, or ibuprofen (800 mg TID); do NOT use narcotics (not effective of gout pain)
- Can discontinue NSAIDs after 2-3 days of complete resolution
Colchicine:
- 2 tablets (1.2 mg) at onset of pain and then 1 tablet (0.6 mg) in 1 hr
- Do NOT take more than 3 tablets per gout flare episode
- Avoid eating grapefruit or drinking grapefruit juice w/ colchicine
- Common SE: diarrhea, abdominal pain, cramps, N/V
- Drug interactions: Macrolides, azole antifungals, some antivirals, CCBs, cyclosporine, tacrolimus, others
- Contraindications: any degree of renal or hepatic impairment
- Serious and life-threatening effects: blood cytopenias, rhabdomyolysis, liver failure, neuropathy
Gout: Urate-Lowering Medications - Xanthine oxidase inhibitors (XOI)
- Meds example
- BBW
- Uricosoric agents?
- Uricase?
Xanthine oxidase inhibitors (XOI):
- Allopurinol (Zyloprim)
- febuxostat (Uloric)
BBW for febuxostat (Uloric): Gout pts w/ heart ds have ↑ rate of CV death compared with CV pts w/ gout tx w/ allopurinol
Uricosoric agents:
- Probenecid
- lesinurad (Zurampic)
Uricase: Pegloticase IV
- can cause anaphylaxis and infusion reactions
- premedicate w/ antihistamines and corticosteroids
Gout: Urate-Lowering Therapy (ULT)
1. How long should you wait after an acute gout flare before starting ULT?
2. Indicates for ULT?
3. Allopurinol dose? Considerations to increase?
- Wait for several weeks after acute gout flare before starting on ULT
- Tophus or tophi
- frequent attacks (≥2 per year)
- Tophus or tophi
- Allopurinol (Zyloprim) initial dose
100 mg daily
- increase dose until serum uric level is <6 mg/dL
- Check CBC (affects bone marrow), renal fx, LFTs, then periodically
- Preferred urate-lowering agent and generally well tolerated
Gout: Allopurinol Hypersensitivity
1. Who is at higher risk for hypersensitivity?
2. Alternative meds?
3. Lifestyle changes? Dietary education?
4. Alternative medicine?
- Renal disease
Manifests as: fever, rash (toxic epidermal necrolysis [TEN]), & hepatitis
- STOP allopurinol immediately if occurs and refer! - febuxostat (Uloric) if allergic to allopurinol
Alternative med is probenecid - Important part of treatment
- Avoid/minimize alcohol (<2 servings for males; <1 servings for females)
- Lose weight if overweight or obese
- avoid fructose- or corn syrup-sweetened beverages (↑ uric acid)
- remain well hydrated
- ↓ high protein/dietary purine intake (red meat, shellfish, protein shakes, high dairy, organ means) - cherries or red cherry juice
- vitamin C
- cherries or red cherry juice
Gout: Complications
- Joint destruction
- joint deformity
- tophi
Ankylosing Spondylitis
1. Definition/Etiology
2. Clinical Presentation
3. Objective Findings
- Chronic inflammatory disorder (seronegative arthritis) affecting mainly the spine (axial skeleton) and sacroiliac joints (axial spondylarthritis)
- Other joints affect: shoulders, hips, knees, and sternoclavicular joints
- some develop diffuse swelling of fingers (dactylitis)
- pain is diminished w/ exercise and NOT relieved by rest
- More common in Males (2/3x)
- HLA-B27 positive
- avg age of onset: 20-40 years - chronic case of back pain (>3 months); started in neck and progressed down to spine
- neck pain is early sx
- pain gradually progressed from neck to upper back (thoracic spine) then lower back
- impaired spinal mobility
- joint pain keeps pt awake at night
- associated w/ generalized sx: low-grade fever and fatigue
- may have chest pain w/ respiration (costochondritis) and costo=vertebral tenderness
- long-term stiffness improves w/ activity
- some have mid-buttock pain (sciatica indicates sacroiliac spine involved)
- chronic case of back pain (>3 months); started in neck and progressed down to spine
- marked loss of ROM of spine such as forward bending, rotation, and lateral bending
- ↓ respiratory excursion down to <2.5 cm (normal 5 cm); some have lordosis
hyperkyphosis (hunchback) occurs after >10 yrs w/ ds
- Uveitis (up to 40%) → eye irritation, photosensitivity, eye pain + scleral injection and blurred vision; unilateral eye involvement is common (25-35%) → Refer to ophthalmologist ASAP (tx w/ steroids)
- marked loss of ROM of spine such as forward bending, rotation, and lateral bending
Ankylosing Spondylitis
4. Labs/Diagnostics
5. Treatment Plan
6. Complication
- ESR and CRP: slightly ↑; RF is negative
- Spinal radiograph: Classic “bamboo spine” (resembles bamboo)
** Know s/sx so you are able to diagnose on exam; Bamboo spine is pathognomonic of ankylosing spondylitis!
- Refer to rhematologist
- If smoker, smoking cessation
- screen for anxiety and depression
- Refer to PT for initial evaluation and training, including postural training, ROM, stretching
- Exercise therapy combined w/ hydrotherapy is more effective than exercise alone
- Advise pt to buy mattress w/ good support
- First-line treatment: NSAIDs (naproxen BID, celecoxib BID, ibuprofen 800 mg TID); usually max dose to control pain
- If high risk of bleeding, prescribe PPI w/ NSAIDs or COX-2 inhibitor (celecoxib BID)
- For severe cases, tx options are TNF inhibitors, biologics (e.g., etanercept), DMARDs (methotrexate), spinal fusion)
- Refer to rhematologist
- anterior uveitis
- aortitis (inflammation of the aorta)
- fusing of spine w/ significant loss of ROM
- Spinal stenosis, hyperkyphosis
- anterior uveitis
Low-Back Pain
1. Definition/Etiology/Risk Factors
What is? Timeline?
- Acute back pain
- Subacute back pain
- Chronic back pain
- Usually d/t soft-tissue inflammation, sciatica, sprains, muscle spasms, or herniated discs (usually L5-S1)
- majority of pts have nonspecific low-back pain (usually self-limited)
- R/O fracture and other serious etiology
- Very common disorder w/ lifetime incidence of 85%
Acute back pain → up to 4 weeks
Subacute back pain → 4-12 weeks
Chronic back pain → Persists for ≥12 weeks
Risk Factors:
- Obesity
- age
- female
- smoking
- anxiety
- depression
- psychologically strenuous work
- physically strenuous or sedentary work
- workers’ compensation insurance
- job dissatisfaction
Low-back Pain: Recommended Further Evaluation/History
- Hx of significant trauma
- suspect cancer metastases
- suspect infection (osteomyelitis)
suspect spinal/vertebral fracture (elderly w/ osteopenia/osteoporosis, chronic steroid use) - pt >50 w/ new onset of back pain (R/O cancer) or pain that wakes pt from sleep
- suspect spinal stenosis (R/O ankylosing spondylitis)
- suspect cauda equina or spinal compression
- suspect radiculopathy (spinal nerve root inflammation such as sciatica)
- suspect ankylosing spondylitis
- fevers, night sweats, weight loss, or signs of systemic illness
- symptoms worsening despite usual treatment
- Herniated disc w/ sx: common site is L5-S1 (buttock/leg pain)
Low-back Pain
2. Lab/Diagnostics
3. Treatment
4. Complications
- MRI: BEST method for diagnosing a herniated disc
- Bone scan may be helpful in identifying occult, lytic lesions
- Imaging for low-back pain w/out other sx ↑ risk for additional or invasive procedures
- MRI: BEST method for diagnosing a herniated disc
- Treatment depends on etiology*
- For uncomplicated back pain → NSAIDs (naproxen Na)
- apply warm packs if muscle spasms
- Muscle relaxants if associated w/ muscle spasms (causes drowsiness; warn pt)
- abdominal and core-strengthening exercises after acute phase
- Consider chiropractor for uncomplicated low-back pain
- Treatment depends on etiology*
** Back rest is not recommended except in severe cases of low-back pain, because it will cause deconditioning (loss of muscle tone and endurance) and ↑ risk of pneumonia
- Cauda Equina Syndrome: Acute pressure on sacral nerve roots → inflammatory and ischemic changes to nerve; sacral nerves innervate pelvic structures such as sphincters (anal and bladder)
- Consider surgical emergency!
- needs spinal and/or nerve root decompression
- REFER to ED!
- Cauda Equina Syndrome: Acute pressure on sacral nerve roots → inflammatory and ischemic changes to nerve; sacral nerves innervate pelvic structures such as sphincters (anal and bladder)
Signs of Cauda Equina Syndrome:
- bladder incontinence is more common than bowel incontinence
- saddle anesthesia
- bilateral sciatica sx such as paresthesias on mid-buttock radiating down back of leg
Piriformis Syndrome
1. Definition/Etiology
2. Clinical Presentation
3. Labs/Diagnostics
- Piriformis muscle is located in buttocks and can compress, irritate, and entrap sciatic nerve b/w its muscle layers
- responsible for 0.3-6% of all cases of low-back pain
- Obtain hx of injury - sciatica sx
- pain and numbness of buttocks, which may radiate down leg
- pain worsened by prolonged sitting, driving
- can be episodic
- hx running, lifting heavy objects, falls, or excessive stair climbing
* Perform PE of hip and groin, including inspection, palpation, ROM testing, pulses, DTR, and strength testing
* Maneuvers can be done to irritate piriformis muscle (such as FAIR (flexion, adduction, internal rotation) maneuvers
- sciatica sx
- Radiograph (x-rays): consider if limited hip ROM or chronic groin pain; can help diagnose osteoarthritis of hip
- Ultrasound: can diagnose tendon and soft-tissue injury around hip and groin
- MRI: can diagnose sciatic nerve compression, stress fracture of femoral neck, cartilage tears, tendon ruptures
- Radiograph (x-rays): consider if limited hip ROM or chronic groin pain; can help diagnose osteoarthritis of hip
Piriformis Syndrome
4. Treatment Plan
5. Muscle Relaxants
- Avoid positions that trigger pain
- RICE: Rest, Ice, Compression, Elevation
- Cold packs or heat can be used
- Warm up and stretch before sports or exercises
- Rest, cold packs, and heat may help sx
- Avoid positions that trigger pain
Medications (most common)
- NSAIDs
- Muscle relaxants
- Refer for PT for stretching and exercising
- centrally active skeletal muscle relaxant
- SE: drowsiness, dizziness, nervousness, reddish-purple urine, hypotension; do NOT mix muscle relaxants w/ sedating drugs or alcohol
- centrally active skeletal muscle relaxant
Examples:
- Cyclobenzaprine (Flexeril)
- Metaxalone (Skelaxin)
- Tizanidine (Zanaflex)
- Carisoprodol (Soma) can be addicting; it is a FDA schedule IV substance
Naproxen: Why is this preferred NSAID?
Has the fewest CV effects but has the same GI effects as other NSAIDs; can however, ↑ BP, so monitor!
Cauda Equina S/Sx and tx?
Innervation of bladder and sphincter comes from sacral nerves and w/ cauda equina
sx:
- new-onset incontinence of urine and/or bowel
- saddle-pattern paresthesia
- sciatica
*** Medical emergency! Refer to ED!
Acute Musculoskeletal Injuries: Overall Treatment - RICE
Rest, Ice, Compression, Elevation
Ice is best during first 48 hours post-injury
- 15-20 mins/hour several times/day (frequency varies)
Rest and elevate affected joint to help ↓ swelling
Compress joints as needed; use elastic bandage wrap
- joints most commonly compressed are knees and ankles
- helps with swelling and provides stability
Administer NSAIDs (naproxen BID, ibuprofen QID) for pain and swelling PRN
Tendinitis (All cases)
What is it? Onset? Treatment?
Microtears on a tendon(s) → inflammation → pain
- usually d/t repetitive microtrauma, overuse, or strain
- gradual onset
- follow RICE mnemonic for acute injuries
Rotator Cuff Disease (Supraspinatus Tendinitis)
1. Definition/Etiology
2. Clinical Presentation
3. Labs/Diagnostics
- usually involves damage to supraspinatus muscle, which helps move the shoulder during abduction and external rotation
- caused by microtears, causing inflammation of supraspinatus tendon
- jobs or sports w/ repetitive overhead activity (e.g., swimming, tennis, golf, weightlifting, gymnastics, and volleyball) ↑ risk for rotator cuff disease
- usually involves damage to supraspinatus muscle, which helps move the shoulder during abduction and external rotation
- hx of repetitive overhead activity (sport or job)
- c/o shoulder pain /w overhead movements (brushing hair or putting on a shirt)
- local point tenderness over tendon located on anterior area of shoulder
- may have pain at night when sleeping on side of affected shoulder
- hx of repetitive overhead activity (sport or job)
- Maneuvers (painful arc test, jobe’s test)
- Musculoskeletal US, useful for initial evaluation of tendon tears
- MRI can identify rotator cuff tear(s)
- Maneuvers (painful arc test, jobe’s test)
Rotator Cuff Disease (Supraspinatus Tendinitis) Maneuvers: Arc test
Painful arc test
- pain w/ shoulder ROM
- >90º of adduction or pain w/ internal rotation is suggestive of rotator cuff tendinopathy
POSITIVE:
- shoulder pain occurring b/w 60 and 120 degrees of active abduction
Rotator Cuff Disease (Supraspinatus Tendinitis) Maneuvers: Jobe’s test
Empty can test
- test for strength of supraspinatus muscle
- instruct pt to straighten arm at 90º of abduction w/ 30º of forward flexion, then internally rotate shoulder
- tell pt to resist when examiner attempts to adduct the arm
POSITIVE:
- shoulder pain w/out weakness (tendinopathy)
- shoulder pain w/ weakness (suggests tendon tear)
Rotator Cuff Disease (Supraspinatus Tendinitis)
4. Treatment
- Initial Treatment: rest affected shoulder and apply cold packs (15 mins cold pack, repeated about 2-4x /daily) esp during acute phase for 24-48 hrs
- NSAIDs for pain PRN
- PT for rehabilitating shoulder
- Refer to orthopedic specialist if inadequate or poor response to conservative management
- Initial Treatment: rest affected shoulder and apply cold packs (15 mins cold pack, repeated about 2-4x /daily) esp during acute phase for 24-48 hrs
Epicondylitis
1. Definition/Etiology
2. Lateral Epicondylitis vs Medial Epicondylitis
3. Complications
- Common cause of elbow pain
- lateral epicondyle tendon pain (tennis elbow) or medial epicondyle tendon pain (golfer’s elbow)
- usually caused by overuse injury
- most causes not d/t sports
Lateral Epicondylitis (Tennis Elbow)
- Gradual onset of pain on outside of elbow
- sometimes radiates to forearms
- pain worse w/ twisting or grasping movements (opening jars, shaking hands)
- PE will show local tenderness over lateral epicondyle
Medial Epicondylitis (Golfer’s Elbow)
- Gradual onset of aching pain on medial area of elbow (side of elbow that is touching body)
- can last a few weeks to months
- pain can be mild-severe
- more common in women 45-64 years
- occurs in part of elbow also called “funny bone” (ulnar nerve)
- PE will show localized tenderness over medial epicondyle
- Ulnar nerve neuropathy and/or palsy (long-term pressure/damage)
- complain of numbness/tingling on little finger and lateral side of ring finger and weakness of hand
- worse-case scenario is development of a permanent deformity called “claw hand”
- Refer to neurologist if suspect ulnar nerve palsy
- Ulnar nerve neuropathy and/or palsy (long-term pressure/damage)
Hamstring Muscle Injury
1. Definition/Etiology
2. Clinical Presentation
3. Labs/Diagnostics/Imaging
4. Treamtent
- Hamstring composed of 3 muscles; located in posterior tight; used for knee flexion and hip extension
- may occur while performing activities (e.g., running at fast pace or sprinting) - most are acute
- pt will report hearing popping noise accompanied by sudden onset of posterior thigh pain while performing activities
- most are acute
PE → welling, bruising, tenderness on posterior thight
- muscular mass may be palpable
- Musculoskeletal US and MRI - best methods of assessing hamstring injuries
- Refer to orthopedic specialist
Sprains
1. Definition/Etiology/Types
2. Ottawa Rules (of the Ankles)
3. General tx (mod-severe) + pain/swelling
- Overstretching or tearing of a ligament
- Ankle sprains usually d/t sports
- Most common sport causing ankle injuries: basketball, indoor volleyball, track & field, climbing
Ankle sprains → caused by overstretching of joint, partial rupture, or complete rupture of ligament
- Lateral ankle sprains are most common type
Types:
- Lateral ankle sprain: most common cause is inversion of plantar-flexed foot
- Medial ankle sprain: most common cause is forced eversion of ankle; can cause avulsion fracture of medial malleolus d/t pulling by ruptured deltoid ligament
- Used to determine whether pt needs radiographs of injured ankle in ED
- highly sensitive (96-99.6%) for excluding ankle fracture - Mild-mod sprains during acute phase → RICE and elastic bandage wrap
- For pain and swelling → NSAIDs for pain PRN
- Mild-mod sprains during acute phase → RICE and elastic bandage wrap
Grading of Sprains (Grade I-III)
Grade:
I → mild sprain (slight stretching & some damage to ligament fibers
- Pt able to bear weight and ambulate
- no joint instability present during ankle evaluation
II → Moderate sprain (partial tearing of ligament)
- ecchymosis, mod swelling, pain
- joint tender to palpation
- ambulation and weight bearing are painful
- mild-mod joint instability
- Consider xray, referral
III → Severe pain, swelling, tenderness, and ecchymosis
- sign. mechanical ankle instability and significant loss of function and motion
- unable to bear weight or ambulate
- refer to ED for ankle fracture
Criteria for Ankle X-ray series consideration
Required if there is pain in malleolar zone AND
- Inability to bear weight immediately after injury
OR
- inability to ambulate at least four steps
OR
- bone tenderness over posterior edge or tip of medial malleolus
OR
- bone tenderness over posterior edge/tip of lateral malleolus
Sprains
4. Physical Exam
- Ask about injury w/ sx
- look for swelling and ecchymosis
- palpate entire ankle (lateral side and medial side), Achilles tendon, and foot
- check for weight bearing, ROM, ability to ambulate
- check pedal and posterior tibial pulses
- Grade sprain
Sprains
5. Treatment
- Grade sprain and determine if xray series is needed or refer to orthopedics
- NSAIDs (oral) and topical (e.g., voltaren gel, diclofenac patches) → pain and swelling; can use combination
- RICE
- Grade sprain and determine if xray series is needed or refer to orthopedics
Grade I (mild sprains)
- do not require immobilization
- use elastic wrap (ACE bandage) for a few days
Grade II (mod sprain)
- may need more suppose
- ACE and an Aircast or similar splint for a few weeks
Grade II
- managed by orthopedic or sports specialist
- Early rehabilitation important
- Refer to PT after initial swelling and pain have decreased so pt can tolerate simple exercises
Meniscus Tear (Knees)
1. Definition/Etiology
2. Clinical Presentation
3. Physical Exam Considerations
- Meniscus is cartilaginous lining b/w certain joints, shaped like a crescent
- tears result from trauma and/or overuse
- sports w/ higher risk are soccer, basketball, and football - click, locking, or buckling of knee(s)
- some pts are unable to fully extend affected knee
- may limp
- c/o knee pain and difficulty walking and bending knee
- some c/o joint line pain
- ↓ ROM
- certain movements aggravate sx
- click, locking, or buckling of knee(s)
- Assess for joint line tenderness and knee ROM
- look for locking or inability to fully extend or straighten leg
- will be unable to squat or kneel
- knee may be swollen (joint effusion)
- observe pt’s gait
- Assess for joint line tenderness and knee ROM
Meniscus Tear: McMurray’s Test
Pt in supine. Examiner holds knee and palpates joint line w/ one hand. Other hand holds sole of feet. Perform internal rotation of tibia and apply varus stress, then return knee to maximal flexion, then extend knee w/ external rotation of tibia and apply valgus stress
POSITIVE: Pain, clicking, or if knees locks
Meniscus Tear: Apley’s Test
Pt is proned w/ affected knee flexed at 90º. Stabilize pt’s thought (with examiner’s knee or hand). Press pt’s heels downward (push heel toward the floor) while foot is internally and externally rotated. Examiner is compressing the meniscus b/w tibia and femur while twisting foot
POSITIVE: pain is elicited w/ compression of knee
Meniscus Tear
4. Treatment Plan
- Best test for assessment? Referral?
4.- RICE
- Rest knee
- Avoid or minimize positions that overstress knees, such as squatting, kneeling, climbing stairs
- Apple ice/cold pack for 15 mins Q4-6 hrs, elevate limb, may need crutches
- When pain/swelling are resolved, start quadriceps-strengthening exercises (largest muscles of the body; they will help to stabilize the knees)
- Swimming, water aerobics, and light jogging are possible exercises
- NSAIDs or acetaminophen for pain PRN
- Locking or unstable knees need to be referred to orthopedist; many need arthroscopy to repair menisci
BEST Test: MRI → Refer to orthopedic specialist for repair
Ruptured Baker’s Cyst (Popliteal Cyst)
1. Definition/Etiology
2. Clinical Presentation
- Baker’s cyst → type of bursitis, located behind knee (popliteal fossa); bursae are protective, fluid-filled synovial sacs located on joints, acting as cushion and protect bones, tendons, joints, and muscles
- sometimes when joint is damaged and/or inflamed, synovial fluid production increases, causing bursa to enlarge - Physically active pt (jogs or runs) or older pt /s whx of knee pain from DJD c/o ball-like mass behind one knee, soft and smooth
- mass will soften when knee is bent at 45º (Foucher’s sign) d/t less tension
- Asymptomatic or will have sx such as pressure sensation, posterior knee pain, and stiffness
- Physically active pt (jogs or runs) or older pt /s whx of knee pain from DJD c/o ball-like mass behind one knee, soft and smooth
If cyst ruptures, will c/o severe pain, erythema, and calf tenderness d/t inflammatory reaction resembling cellulitis, DVT, popliteal artery aneurysm, ganglion cyst, tumors
Ruptured Baker’s Cyst: Foucher’s sign
When ball-like mass behind one knee soften and smooth when knee is bent at 45º d/t less tension
Ruptured Baker’s Cyst
3. Labs/Diagnostics/Imaging
4. Treatment Plan
- Clinical diagnosis w/ hx
- If suspect DVT or uncertain of diagnosis, initial testing is US, which can show ruptured cyst or venous compression
- MRI is diagnosis if uncertain
- R/O plain bursitis from bursitis w/ infection (“septic joint”)
- If imaging desired or diagnosis in question:
INITIAL: US
- Plain radiography of knee and calf - RICE; gentle compression w/ elastic bandage wrap
- NSAIDs PRN
- Large bursa can be drained w/ syringe using 18-g if painful; synovial fluid is a clear, golden color
- if cloudy synovial fluid and joint is red, swollen, and hot → order C&S to R/O septic joint infection
- after drainage, an intraarticular injection of a glucocorticoid (triamcinolone acetonide) can ↓ inflammation
- Warn pt that cyst can recur in future; most popliteal cysts are asymptomatic and do not require intervention
- RICE; gentle compression w/ elastic bandage wrap
Gold standard test for any joint damage and stress fractures
MRI
Plain radiograph of a joint will show what and not what?
Will show bony changes or narrowing of joint spaces (OA), but not soft tissue such as meniscus or ligaments.
Best imaging for cartilage, meniscus, or tendon damage is MRI
