Musculoskeletal Flashcards
Shoulder dislocation (anterior vs posterior)
Ant: axillary N injury; arm abduct + ext rotat*
Post: rare; seiz/electroc; arm adduct + int rotat*
ttt: reduction then sling/swathe
If recurr, surg
Humerus fracture
Radial N palsy → wrist drop + loss thumb extens*
ttt: cast vs sling; functional bracing
“Nightstick fracture”
Ulnar shaft fx (trauma in self-defense ag blunt obj)
ttt: ORIF
Monteggia fracture
Diaphys fx of prox ulna + subluxat* radial head
Fall on pronated + outstretch arm
ttt: ORIF of fx + reduct* of radius
Galeazzi fracture
Diaphys fx of radius + disloc of distal radioulnar joint
Direct blow to radius
ttt: ORIF of radius + cast in supination
Colles fracture
Distal radius; dorsally displaced
Fall to outstretched hand
Esp child or elder (osteop)
ttt: closed reduct* + long-arm cast; open reduct if intraartic
Scaphoid fracture
1 fractured carpal bone
Fall to outstretch hand
Tendern in anatom snuffbox w/ axial loading
Xray: 2wks to appear
ttt: thumb spica cast +/- open reduct*
!! AVN if disrupt* of bld flow
Boxer’s fracture
5th metacarpal neck
Forward trauma to closed fist
ttt: closed reduct*, ulnar gutter splint; +/- pinning
Hip dislocation (anterior vs posterior)
Post: >90%; post force on an internally rotated flexed adducted hip; sciatic N injury + AVN
Ant: obturator N
ttt: closed reduct* then abduct* pillow/bracing then CT
Hip fracture
Short + ext rotat leg
If Xray⊖ and clinic ⊕, do CT/MRI
-Displaced femor neck fx: ↑R AVN
Ass w/ DVTs
ttt: ORIF; if displaced fem neck fx in elder, arthroplasty
+ Anticoag
Femoral fracture
!! fat emboli: fev, chang ment status, dyspn, hypox, petech, ↓plts
ttt: intramedull nailing
ACL vs PCL knee injuries
ACL: noncontact twist, forced hyperextens* or impact to extended knee
⊕ ant drawer
R/o meniscal or MCL injury
PCL: post force on flexed knee
⊕ post drawer
Meniscal tears of knee
Acute twist or degenerative tear in elder
Click/lock
Joint line tendern; ⊕McMurray
Knee injuries (ttt)
MRI (#1)
MCL/LCL/Meniscal tears: conserv ttt
ACL: surg
PCL: surg if highly competitive athlete
Meniscal: surg: if young or old refractory to conserv ttt
Tibial fracture
!! compartment sd
ttt: casting vs intramedull nailing vs ORIF
Achilles tendon rupture
Sudden “pop” w/ ↓activ (plantar flex*)
⊕ Thompson test
ttt: surg then long-leg cast x6wks
Radial nerve injury
Motor def: wrist extens*
Sens def: dorsal forearm + first 3 fingers
Cause: hum fx, prolong compr of hum
Clinic: wrist drop
Median nerve injury
Motor def: forearm pronat* + thumb oppos
Sens def: palmar first 3 fingers
Cause: carpal tunnel
Clinic: weak wrist flex* + flat thenar eminence
Ulnar nerve injury
Motor def: finger abduct*
Sens def: palmar + dorsal (last 2 fingers)
Cause: elbow dislocat*
Clinic: claw hand
Axillary nerve injury
Motor def: arm abduct*
Sens def: over deltoid
Cause: ant should dislocat*
Peroneal nerve injury
Motor def: dorsiflex, evers
Sens def: dorsal foot + lateral leg
Cause: knee dislocat*, trauma to fibula
Clinic: foot drop
Compartment syndrome (etiologies, PE)
↑pressure in confined space; compromise N/M/perfus*
Ant comp of lower leg; forearm
After fx, muscl injury, surg
Pain out of prop; pain w/ passive mot* of fing/toe; paresthesia; pallor; poikiloth; pulseless; paralysis
Compartment syndrome (dg, ttt)
Dg: Hx, clinic, ⊕ delta pressure (≤30)
Delta P* = DBP - compartment P*
ttt: immediate fasciotomy
Carpal tunnel syndrome (RF, PE)
Entrapment of median N at wrist
By overuse of wrist flex*; ass w/ DM, thyroid dysf
Pgnt and middle-aged W
Pain in thenar area + prox forearm; paresth in palmar of first 3 fingers; worse at night
Phalen/Tinel ⊕
Carpal tunnel syndrome (dg, complications, ttt)
Dg: clinic; EMG to confirm
Complic: permanent loss sensat*/strength/fine motor
ttt: splint wrist in neutral (night + day); CS inject*
Surg if refract or advanced
Bursitis
Infl by repetitive use/trauma/inf/system infl ds/microcristall
Esp subacromial, olecranon, trochanteric, pre/infrapatellar
Local tendern, ↓motion, edema, eryth
Dg: if septic or crystal suspic, needle aspir
ttt: rest, heat+ice, elevat, NSAIDs
Intrabursal CS inj (but CI in septic); Septic ttt w/ 7-10d AB
Tendinitis (PE)
From overuse
Esp supraspinatus, biceps, wrist extensor, patellar, iliotibial band, post tibial, Achilles
Pain at tendon insert, swell, impair fct; worse w/ repetiive stress + resist strength
Lat epicondyl ↑w/ resist extens of wrist vs Med w/ resist flex*
Tendinitis (dg, ttt)
Dg: clinic; radio if trauma; MRI/US in tendon tear
ttt: rest + NSAIDs + ice first 24-48h
Splint, brace, immobil
Once pain stops, strengthen exo
If all fail, CS inject (CI in Achilles)
Herniated disk (PE)
Degen, trauma, strain/sprain Esp lumbar (L5-S1; L4-L5); middle-aged+older men
Sudden severe (w/ valsalva), electr-like LBP, preceded by months of pain
Ass w/ sciatica, paresth, weakness, atrophy, contract*
Passive straight-leg raise ↑pain
If midline, cauda equina sd
Herniated disk (dg, ttt)
Dg: ESR/Xray (if susp of inf, trauma, fx)
Stat MRI: cauda equina sd or sev progress neuro def
MRI: if sympt refract to conservative ttt
ttt: NSAIDs + physical therapy + local heat: resolut* 4wks
No bed rest; +/- inject* or nerve block
Sev or rapid progr and cauda equina: surg
Spinal stenosis (PE)
Narrow lumbar or cervical spinal canal
Compr of sp cord and nerv roots
Esp degen joint ds; middle-aged or elder
Neck/back pain radiates to arms/buttocks/legs
Leg numb/weak; leg cramp worse w/ stand/walk
Improv w/ flex* of hip + bend forw/
Spinal stenosis (dg, ttt)
Dg: radio (degen, narrow); MRI/CT (spinal stenos)
ttt: mild to mod: NSAIDs + abdo muscl strength
Adv: epidural CS inj
Refract: surg laminectomy (!recurr)
Osteosarcoma (PE)
Child/ado: #1 bone malign
Adult: benign (Paget) transfo to malign
Metaph of distal femur, prox tibia, prox hum
Progr intractable pain, worse at night
+/- fev, ↓weight, night swt, eryth, enlarg
Osteosarcoma (dg, ttt)
Dg: radio (Codman triangle, sunburst); biopsy
(# onion skin of Ewing sarc; #soap bubble of giant cell tumor)
MRI/CT of chest (stage + plan surg)
ttt: limb-sparing surg, pre and post chemoth; amputation
Septic arthritis
After open injury or bacteremia
RF: prosthetic joint; RA; osteoarthritis; bacteremia; IVDA
Warm, red, immobile joint, effus*, fev/chill
Dg: joint aspir (WBCs>80K, ⊕ Gram/Cx)
Esp staph/strep/GNRs
ttt: empir cetriax + vanco then change; surg debrid or several aspir
Osteoarthritis (RF, PE)
Chronic, noninfl arthritis of synov joint
RF: ⊕fam Hx, obes, Hx of joint trauma
Crepitus, ↓ROM, pain ↑w/ activ + weight and ↓rest
Morning stiffness <30min
Osteoarthritis (dg, ttt)
Dg: radio (joint spac narrow; osteophyte; subchond scler + bone cyst); fluid (yellow, Nl viscos, WBC<2K); labs Nl
ttt: physical therapy, ↓weight, NSAIDs; intra-art CS
Joint replac if adv
Causes of hyperuricemia
↑cell turnover (hemolys, blast crisis, tumor crisis, pso, myelodyspl) Cyclosporine Dehydration Diabetes insipidus Diet (red meat, alcoh) Diuretics Lead poisoning Lesch-Nyhan sd Salicylates (low dose) Starvation
Gout (RF, PE)
Recurr attac; acute monoart arthritis
Monosod urate cryst
RF: male, obes, postmenop, binge drink
Excruc sudden pain; 1st MTP (podagra), other joints
Erythem, swoll, tender; +/- tophi and kidn stones if chron
Gout (dg, ttt)
Dg: fluid aspir (needle cryst, ⊖ birefr); ↑/Nl serum uric ac
Acute: high-dose NSAIDs (#1); steroids (if 1 is ineff/CI); colchicine
Mainten: allopurin (over-producer; CI to proben; refract); probenecid (under-secret)
↓weight; avoid trigg (alcoh, …)
Rheumatoid arthritis (RF, PE)
Autoimm ds; chron destruct symmetr infl arthritis
Synov hypertr; pannus; eros* of cartil/bone/tendon
RF: female, 35-50yo, HLA-DR4
Morning stiff >1h, pain, warm, swell, multi symm joints
Esp wrist, MCP, …; ulnar deviat*
Tendon deform; vasculitis; atlantoaxial sublux
Rheumatoid arthritis (dg, ttt)
Dg: ↑RF (IgM ag Fc IgG) or anti-CCP Ab; ↑ESR/CRP ≥3 joints for >6wks; exclude acute/cryst cause Fluid aspir (turbid, ↓viscos, ↑WBCs 3K-50K) Radio: joint space narrow + eros*
ttt: NSAIDs (↓ or d/c after success ttt w/ DMARDs)
DMARDs: start early w/ methotrexate; or hydroxychlor, sulfasalazine; #2 TNF inh, rituximab, leflunomide
Ankylosing spondylitis (RF, PE, dg)
Chron infl of spine + pelvis
RF: male, early 20s, ⊕fam Hx
Fatig, interm hip pain, LBP worse w/ rest+morning
⊕ Schober, no lumbar lordosis
Ant uveitis, heart block, enthesitis of heel
Dg: ⊕HLA-B27; radio (fused sacroiliac j, bamboo spine); ↑ESR/CRP; ⊖RF; ⊖ANA
Ankylosing spondylitis (r/o, ttt)
R/o other sero⊖ spondylarth:
- Reactive arthritis (Reiter; arthr/uveit/urethr aft campylo/shigel/salmo/chlam/ureapl)
- Psoriatic arthritis (oligoarth, also DIP, dactylitis)
- Enteropathic spondylitis (sacroiliitis asymm, IBD)
ttt: NSAIDs + exo (improve posture + breath)
TNF inh or sulfasalazine (if refract)
Polymyositis and dermatomyositis (PE)
50-70yo; W>M; bla>whi
Progr syst connect T. ds; immune-med infl of striated M.
Polym: symm progr prox M. weak/pain
Dermatom: same + rash; heliotr (violac periorb); Shawl sign (should/chest/back); Gottron papul (dors hands)
+/- diff breath/swall; myocarditis; card conduc def
Ass w/ malign (lung/breast)
Polymyositis and dermatomyositis (dg, ttt)
Dg: clinic+lab; ↑CK; ↑anti-Jo-1 Ab
ttt: high-dose CS x4-6wks then taper
Azathioprine +/- methotrexate if no CS
Systemic sclerosis / Scleroderma (RF, PE)
Infl → progr T. fibrosis by excess depos collag I+III
RF: female, 35-50yo
Symm thick skin: limited (head, neck, dist upp extrem); diffuse (chest, abdo, prox upp extrem)
CREST: Calcinosis, Raynaud, Esoph dysmot, Sclerodact, Telangiect
Diff: GI dysmot, pulm fibros, cor pulm, acute renal fail, malign HTN (Morta from pulm/card/renal complic)
Systemic sclerosis / Scleroderma (dg, ttt)
Dg: Anticentrom Ab in CREST; Anti-Scl-70 Ab (antitopoiso 1) in diffuse (poor pg)
May have: eosino; RF/ANA ⊕
ttt: organ-based; CS (acute flares); penicilliamine (skin chang); CCB (Raynaud); ACEIs (renal + prevent ren crisis)
Systemic lupus erythematosus (RF, PE)
Autoimm; Ab-mediat cellular attack + deposit Ab-Ag compl
RF: black women; child-bear age
Fev, anorex, ↓weight, symm joint pain
≥4 criteria of DOPAMINE RASH (Discoid rash; Oral ulc; Photosens; Arthritis; Malar rash; Immuno (dsDNA, Sm, anti-phospholi); Neuro (seiz, cerebritis); ↑ESR; Renal; ANA⊕; Serositis (pleur/peric eff); Hemato abNl)
Systemic lupus erythematosus (dg, ttt)
Dg: ⊕ANA; anti-dsDNA Ab; anti-Sm Ab
+/- antiphosph Ab; An; leukop; thrombocytop; proteinur/casts
⊕antihistone Ab (drug-ind); ⊕anti-Ro Ab (neonat)
ttt: NSAIDs (mild joint); CS (acute exac)
Progr/Refrac: CS, hydroxychlo, cycloph, azathiop
Hydroxychl (only skin/joint ds); Cycloph (sev nephritis)
Giant cell arteritis / Temporal arteritis (RF, PE)
Subacute granulom infl of large Vx (Ao, caroti, verteb)
RF: polym rheum, >50yo, female
New headac (uni/bil), tempor tendern, jaw claudic Fev, monoc blind, ↓weight, myalg/arthralg (should/hip)
Giant cell arteritis / Temporal arteritis (dg, ttt, complications)
Dg: tempor art biops (defin; thromb, media necros, lymphoc, plasma C, giant C); ↑ESR, ophth eval
ttt: high-dose prednisone immed; ophth follow-up
Complic: blindness (by occl of central retin art)
Complex regional pain syndrome (PE)
3 phases: acute/traum → dystrophic → atrophic
No true nerve injury
Diffuse pain out of prop; non-anatom distrib
Loss of fct of limb
Sympathetic (autonom) dysfct: changes of skin (temp, hair, nail growth), tiss, bld flow
Complex regional pain syndrome (dg, ttt)
Dg: clinical
ttt: NSAIDs, CS, low-dose TCA, gabapentin, pregabalin
Physical therapy; chemical sympathetic blockade
Fibromyalgia (PE)
Chron soft T and axial skeletal pain
No joint pain; No infl
Women 30-50yo; ass w/ depress, anxiet, sleep disord, IBS, cognit disord
Fibromyalgia (dg, ttt)
Dg: ≥11 of 18 painful areas over all body
If <11 then myofascial pain syndrome
ttt: antidepress (SSRI+TCA or 2 SNRIs), gabapentin, pregabalin, muscle relax, physical therapy
Multidisciplinary
Polymyalgia rheumatica
Inflamm; ass w/ temporal arteritis
RF: female, >50yo
Pain+stiff in should/hip/neck; diffic standing or lifting arms
Fev, mal, ↓weight
Dg: ↑ESR, anemia
ttt: low-dose prednisone (10-20mg/d)
