Musculoskeletal Flashcards
Osteoporosis
- Characterized by low bone mass, structure disruption and increased skeletal fragility
Risk factors:
- Elderly, history of fracture, Caucasian and Asian patients, long term use of steroids, cigarette smoking, excessive alcohol use, low body weight
Diagnosis: Clinical diagnosis of osteoporosis can be made in the presence of:
- A fragility fracture
- A fragility fracture is a fracture that occurs either spontaneously or from minor trauma
- Most common sites for fragility fracture: spine, hip, wrist, humerus, pelvis and sometimes rib
- T-Score < -2.5
- A Dual energy X-Ray calculates a T-Score.
- T-Score: Measures a person’s bone density and compares it to a healthy adults bone density of the same gender
- T-Score < -2.5: Osteoporosis
- T-Score -1.0 to -2.5: Osteopenia
- T-Score > -1.0: Normal Bone density
- FRAX 10 year probability of major fracture is > 20%
- FRAX 10 year probability of hip fracture is > 3%
Treatment:
- Lifestyle measures: Adequate intake of calories, sufficient intake of calcium and vitamin D, regular exercise/muscle strengthening, smoking cessation, fall prevention and avoidance of heavy alcohol use.
- Calcium: Approximately 1200 mg/day (either through diet or supplementation)
- Vitamin D: 8000 to 1000 IU/Day
- First line pharmacotherapy: Bisphosphonates (alendronate, Risedronate)
- Contraindicated in patients with esophageal disorders, unable to sit upright for at least 30 minutes or sever kidney dysfunction.
Osteoarthritis
- most common form of arthritis
Presentation:
- Joint pain, stiffness and locomotor restriction
- Common joints involved: Knees, hips, interphalangeal joints, first CMC joints, first MTP joints and joints of the lower cervical and lower lumbar spine
- Heberden and Bouchard nodes (Bouchards are BELOW Heberdens)
- May involve a single joint or multiple joints (Generalized OA)
Diagnosis:
- Clinical diagnosis can be made if the following are present:
- Persistent usage related joint pain in one or few points
- Age 45 years or older
- Morning stiffness for 30 minutes or less
- Other signs that support diagnosis: Absence of constitutional symptoms, deformity, swelling, absence of warmth, crepitus, reduced ROM
- Radiography indicated: Diagnosis unclear, rule out alternative diagnoses, younger person with symptoms of OA, atypical symptoms, presence of unintentional weight loss or other systemic symptoms and also those patients that are experiencing “true locking” of the knee
Treatment:
- Non-pharmacological: weight management, exercise, braces and assistive devices when needed.
- Pharmacological: oral and topical NSAIDs, topical capsaicin, duloxetine and glucocorticoid injections
Rheumatoid Arthritis
- Chronic, systemic, autoimmune, inflammatory disorder that primarily affects the synovial joints
Presentation:
- Gradual onset of symptoms
- Pain
- Stiffness (generally worse in the morning or after staying in one place for too long, “Gelling phenomenon”)
- Swelling of the joints
- Most common sites: Metacarpophalangeal (MCP), and proximal interphalangeal (PIP) joints of the fingers, the interphalangeal joints of the thumbs, the wrists, and the metatarsophalangeal (MTP) joints of the toes.
- Chronic RA can cause deformities: MCP subluxation, ulnar deviation, swan neck deformity.
Diagnosis:
- RA should be suspected if previous symptoms present
Treatment:
- Refer to rheumatology
- Disease modifying anti rheumatic drug therapy is generally the preferred treatment.
REMEMBER: OA = on the go pain
RA = Rest pain
Ottawa Ankle & Foot Rules (for when to X-Ray)
Ankle: Pain and tenderness in the malleolar zone, or are unable to bear weight both immediately after the injury and for four steps on exam.
Foot: Pain in the mid-foot zone and have tenderness at the base of the fifth metatarsal or at the navicular or if they are unable to bear weight both immediately after the injury and for four steps on exam.
Sprains (Ligament Injury)
Grade 1: Results from mild stretching of a ligament with microscopic tears
- Presentation: Mild swelling and tenderness, NO JOINT INSTABILITY
- TREATMENT: ACE bandage, RICE
Grade 2: More severe injury involving an incomplete tear of a ligament.
- Presentation: Moderate pain, swelling, ecchymosis, MILD JOINT INSTABILITY, ambulation is painful.
- TREATMENT: Join immobilization, RICE, non-weight bearing until follow up with orthopedic.
Grade 3: Complete tear of a ligament
- Presentation: Severe pain, swelling, ecchymosis, JOINT INSTABILITY, unable to bear weight/ambulate
- TREATMENT: Join immobilization (aircast), RICE, non-weight bearing until follow up with orthopedic.
Carpal Tunnel Syndrome (CTS)
- Caused by compression of the median nerve
Presentation:
- Pain (often worse at night)
- Paresthesia in hand
- Weakness in the distribution of the median nerve
- Exacerbated with use of
Diagnosis:
- Tinea and Phalen signs support diagnosis
- Atypical symptoms or moderate to severe CTS symptoms, electrodiagnostic testing is indicated
- Moderate to severe CTS: Sensory loss, if symptoms interfere with hand function or one or more ADLs, if symptoms disrupt sleep, or if the patient experiences weakness in distribution of the median nerve.
Treatment:
- Wrist splint, glucocorticoid injections and surgery.
Scaphoid Fracture
Presentation:
- “Snuff Box Tenderness”
- Radial Side pain
Diagnosis:
- Clinical exam
- Radiography
Treatment:
- Thumb spica splint
- Surgery is indicated if the fracture is displaced, or if it is the proximal 5th of the scaphoid fracture
FOOSH Injury (falling on outstretched hand)
- common cause for injury
Volar sided pain
- Hook of hamate fracture
- Pisiform fracture
Dorsal sided pain
- Wrist sprain
- Distal radius fracture
- Carpal fracture
Radial sided pain
- Trapezium fracture
- Scaphoid fracture
De Quervain Tendinopathy
- Entrapment tendonitis
- Thickening of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons and the sheath they pass through
Presentation:
- Non-traumatic radial side wrist pain
- Pain worse with movement of thumb and wrist
- Possibly enlarged/swelling at the radial styloid
Diagnosis:
- Clinical diagnosis
- Positive Finkelstein Maneuver support diagnosis
- Patient folds their fingers over their thumb and the examiner gently rotates the patients wrist towards the ulnar aspect
Treatment:
- Often self limiting
- If pain persists options include: Thumb Spica splint, NSAIDs, glucocorticoid injections
- Last resort is surgical repair
Lateral Epicondylitis & Medial Epudoncylitis
“Tennis Elbow”
- Localized tenderness over the lateral epicondyle
Diagnosis:
- With the elbow fully extended:
- May have pain with resisted wrist extension
- May have pain with passive wrist flexion
“Golfer’s Elbow”
- Localized tenderness at the medial epicondyle
Diagnosis:
- With the elbow fully extended:
- May have pain with resisted wrist extension
- May have pain with passive wrist flexion
Treatment:
- Activity modification, bracing, analgesics, physical therapy and icing.
Anterior Cruciate Ligament Tear
Presentation:
- Pain and swelling
- Effusion
- Join instability
- Possible audible “pop”
Diagnosis:
- MRI is preferred
- Ultrasound can detect complete tears
- Positive Lachman and Anterior Drawer test can support diagnosis
Treatment:
- Refer to ortho
- RICE and non-weight bearing until follow up with ortho
Meniscus Tear
Presentation:
- Pain and swelling
- Substantial effusion
- Patient may loose the ability to fully extend or flex knee
Diagnosis:
- MRI is preferred
- Ultrasound can detect complete tears
- Positive McMurray test can support diagnosis
Treatment:
- Refer to Ortho
- RICE and non-weight bearing until follow up with ortho
Back pain
- < 1% having sever causes or etiologies
Indications for imaging on initial evaluation
- suspicion for spinal infection, risk factors for metastatic cancer, and suspected vertebral compression fracture
- patients without improvement after 4 to 6 weeks of conservative management after require imaging
- conservative management: heat, massage, acupuncture, spinal manipulation, short term, NSAIDs
- bedrest is not advised
Cauda Equina Syndrome
- rare complication of lumber, spinal stenosis affecting the nerve roots from L1 to L5 and S1 to S5
Presentation:
- bladder incontinence or retention
- fecal incontinence
- saddle paresthesia
- weakness or bilateral leg numbness
Diagnosis:
- requires emergent MRI
