Musculoskeletal Flashcards
Shoulder inspection presents with: Arm adducted, internally rotated, ant. shoulder is flat, prominent Humeral had. what type of dislocation do you suspect?
Posterior Glenohumeral dislocation
Anterior Glenohumeral dislocation shoulder presentation includes?
Arm abducted, Externally rotated, inferior humeral head, deltoid contour loss.
Which shoulder dislocation is more common, Anterior or posterior?
Anterior is the MC type
a compression fracture of the humeral head groove.
impact against glenoid.
Hill-Sachs Lesion
A bank-Hart lesion is a fracture of the what?
Inferior Glenoid rim fracture
Posterior Glenohumeral shoulder dislocation is most common associated with what injury (s)?
Seizures, Electric shock, or trauma
What must you rule out with and Anterior shoulder dislocation?
Must rule out Axillary nerve injury (Sensation over deltoid)
Most helpful view to differentiate Posterior v.s Anterior dislocation?
Axillary and Y view
Anterior deltoid pain w decreased ROM w overhead activities, external rotation, or abduction.
Combing hair, wallet reach, can’t sleep on affected side.
(+) Drop arm test, Neer’s, Jobe’s Tx:
Rotator Cuff Injury (SITS)
Tx: NSAID, Rest, wall climbs (PT)
As a result of Direct blow to an adducted shoulder leads to ?
Acromioclavicular Joint Dislocation
Class of AC dislocation where there is significant widening of AC/CC space?
Class III AC separation with CC involved (both rupture)
Class of AC dislocation where there is slight widening@ AC space?
Class II Only AC rupture
Classes of AC/CC dislocations that require surgery?
Class III-V (Otherwise sling, Ice, analgesia)
Humeral fracture where patient may develop wrist drop?
Must R/O Radial Nerve injury
Humeral shaft fracture
Proximal or Humeral head fractures requires to R/O injuries to what area?
Brachial plexus and Axillary nerve injuries
What is the management for Humeral shaft fractures?
Sugar tong splint + Sling/Swathe Ortho w/I 24-48 hrs
MC commonly fractured bone in children /adolescent/ newborn?
Clavicle fracture
Which clavicle fracture requires orthopedic consult?
Proximal 1/3 of involvement of the clavicle
Stiffness/inflammation w Decreased ROM especially with external rotation, you think what disorder?
Tx:
Adhesive Capsulitis (Frozen shoulder)
Tx: NSAIDs, PT ROM, IACS injection
Pain or paresthesia’s to the forearm and or Ulnar side of hand: (+) Adson’s
Dx: Tx:
Thoracic Outlet syndrome
Dx: MRI Tx: PT, Ortho, +/- Surgery
On x-ray you see a displaced anterior fat pad and (+) posterior fat pad sign (hemarthrosis), you think what lesion? Tx:
Supracondylar humeral Fracture (Kid)
Radial Head fracture (Adult)
Tx: Non displaced= Posterior splint
Displaced= ORIF
Median nerve and Brachial Artery injury are consistent with ?
Volkmann Ischemic contracture (Claw-like deformity)
Supracondylar Humeral fractures are MC with what MOI and ages?
FOOSH MC in children 5-10 YOA
Lateral radial pain with inability to fully extend the elbow: (+) posterior fat pad or displaced A. fat pad?
Radial Head Fractures
What are the Kanavel’s signs?
FLEX Finger held in flexion Length of tendon sheath tenderness Enlarged finger Xtension of finger increased pain (Passive)
What specific lesion is Kanavel’s associated with?
Suppurative Flexor Tenosynovitis
MOI includes a fall on a flexed elbow with inability to extend elbow–> ______ _______ dysfunction?
Tx:
Olecranon Fractures
Tx: Displaced: ORIF Non-displaced=reduction
Splint 90 degree
Abrupt swelling, boggy, red elbow. Tender or painless. Limited ROM w flexion.
Tx:
Olecranon Bursitis
Tx: NSAIDs, Padding, ILCS injection, rest
Septic Bursitis Diagnosis
Needle aspiration with >2K WBC
Distal radial shaft fracture with dislocation of the DRUJ from FOOSH MOI?
Tx:
Galeazzi Fracture
Tx: Unstable! needs ORIF (Long arms splint
A Monteggia fracture involves what injuries?
Tx:
Proximal Ulnar fracture with Anterior Radial Head Dislocation
Tx: Unstable! need ORIF
A nursemaid’s Elbow injury patent will have what presentation?
Radial Head subluxation (MC 2-5 YOA)
Arm slightly flexed
Refuses to use arm
TTP of the Radial Head
A radial styloid fracture is known as?
Hutchinson’s fracture (Chauffer’s fracture)
Inflammation of the insertion Extensor Carpi Radialis Brevis (ECRB)?
Lateral Epicondylitis (Tennis)
Medial Epicondylitis (Golfer’s Elbow) is inflammation of the?
Pronator Teres-flexor Carpi Radialis (PTFCR)
Patient presents with prominent olecranon process and flexed elbow. MOI Hyperextension FOOSH
Must R/O what injury?
Elbow dislocation
R/O- Brachial artery and Median/Ulnar/Radial nerve injury
What elbow dislocation is MC?
Tx:
Posterior Dislocation is MC
Tx: Immediate reduction @ 90Degrees 7-10 days
unstable= ORIF
Paresthesias /Pain along the Ulnar Nerve that is worse with elbow flexion?
Tx:
Cubital Tunnel Syndrome (Ulnar Neuropathy)
Tx: Immobilize with sleep, NSAIDS, IACS Inj.
Physical exam tests for Cubital Tunnel Syndrome
(+) Tinel’s @ elbow and (+) Froment’s Sign (Pinch test)
Scaphoid Fracture is MC at what anatomic location?
Tx:
Waist of scaphoid (Vascular Distal to proximal)
Tx: 2 week Thumb Spica (repeat X-R)
Pain at dorsal radial side of wrist w click on wrist movement: (+) Terry Thomas sign (>3mm sep.)
Tx:
Scapholunate Dissociation
Tx: Radial Gutter Splint
Distal Radial fracture with Ventral angulation
Tx:
Smith Fracture
Tx: Sugar Tongue Splint cast
>20 degree Angulation/ Comminuted= ORIF
Distal radial Fracture with Dorsal Angulation:
“Dinner Fork Deformity”
Tx:
Colles Fracture (CD)
Tx: Sugar Tongue Splint cast
>20 degree Angulation/ Comminuted= ORIF
Spilled Tea Cup Lat view/Piece of pie AP sign is associated with?
Tx:
Lunate dislocation
Tx: Unstable- ORIF
Kienbock’s Disease is associated with what injury?
Lunate Fracture
Pain is out of proportion to injury with autonomic nervous system S/Sx: following bone/tissue injury
Post wrist fracture/surgery: Waxy or pale skin, hairloss, joint atrophy and contractures. Pain out of proportion
Complex Regional Pain syndrome
MOI: blow to extended finger forcing it to flex may–> avulsion Fx of distal phalanx. inability to extend@ DIP
Mallet finger
Mallet Finger may lead to ?
Swan Deformity
Boutonniere Deformity includes
Finger flexion @ PIP and hyperextension @ DIP
Swan Neck Deformity includes
Hyperextension @ PIP and flexion @ DIP
Mallet finger includes
Flexion @ DIP with inability to extend DIP
Sprain or tear of the Ulnar Collateral Ligament of thumb with instability of MCP joint? (Hyperabduction
Tx:
Gamekeeper’s (Skier Acute) Thumb
Tx: Thumb Spica and Hand Sx referral
Intraarticular fracture through the base of the 1st MCP with a large distal fragment dislocated by APL?
Tx
Bennet Fracture (Comminuted Bennet= Rolando)
Tx: Unstable-ORIF
Any Boxer fracture with > ____to____ angulation requires what treatment?
Tx:
> 25-30 Degrees angulation= Reduction (Unable=ORIF)
Tx: Ulnar Gutter w 60degree flexion
Bite wounds with hand fracture require what ABX
Amoxicillin with Clavunate (Eikenella Corrodens Human)
Growth Plate Fracture with involvement of Metaphysis/Epiphysis?
SALTER Harris fracture IV
Growth plate Fracture with involvement of Metaphysis only?
Salter Harris II fracture
Growth plate compression fracture?
Salter Harris V fracture
Pain along the radial aspect of the wrist radiating to forearm? (+) Finkelstein
Tx:
De Quervian Tenosynovitis
Tx: Thumb Spica splint X 3 weeks
De Quervian Tenosynovitis involves stenosing synovitis of the?
Abductor Pollicus Longus and Extensor pollicis Brevus
Carpal Tunnel syndrome involves entrapment of the_____ nerve with paresthesia and pain of palmar?
Tx:
Median Nerve
(Palmar 1st three and half of the 4th digits worse at night)
Tx: Volar splint + NSAIDS, IACS Inj., Sx
Dx: Of carpal tunnel syndrome includes
Electromyography and Nerve conduction velocity study
Dupuytren contracture presents how? and mostly affects what fingers?
painful Nodule over palm crease @ fixed MCP flexure.
Mostly Ring and little finger
Hip pain with leg shortened and internally rotated with hip/knee adduction you think what injury?
Posterior Hip Dislocation “MC” (External rotated=Ant. Dislocation)
Hip Pain with leg shortened and externally rotated with hip/knee abducted you think?
Tx:
Hip/ Femoral head/neck fractures
Tx: ORIF
MC in children 4-10 YOA (boys): presents with painless limping worse w activity and at end of the day.
Loss of abduction and internal rotation.
Dx: Tx:
Legg-Calve Perthes Disease
Dx: Crescent sign (Hip XR) Tx: Rest NWB (Ortho)
MC in children 7-16 (>10): Obese, AA males @ puberty.
Hip, thigh, or knee pain with “limp w external rotation”
Dx: Tx:
Slipped Capita femoral Epiphysis
Dx: Slipped ice cream cone XR Tx: NWB–> ORIF
Incomplete fracture w cortical disruption periosteal tear on convex w intact periosteum concave w bowing?
Greenstick fracture (Through 1 cortex)
Incomplete fracture with wrinkling or bump?
Throughout cortex of bone
Torus (Buckle fracture)
What grade is considered a complete MCL/LCL tear injury?
Grade III
What is the MC knee Ligament injury?
ACL Injury
Which Meniscal tear is MC because of more bony attachments?
Tx:
Medial Meniscal Tear is MC (3X MC)
Tx: Partial WB (arthroscopy)
Posterior Cruciate Ligament MC MOI leading to injury?
Direct blow or fall on to flexed knee (Dashboard Injury)
Avulsion of the lateral tibial condyle with Varus stress to the knee is pathognomonic with what other injury?
What is it called?
Segond Fracture (ACL Tear)
what is the Unhappy “O’Donoghue’s Triad
- ACL
- MCL
- Medial Meniscal injury
Locking, Popping, or giving way w effusion post-activities you think what injury?
Meniscal injury
MC > 40 yo males with systemic disease with a forceful quadriceps contraction MOI? Dx: what is best view?
Patellar and Quadriceps Tendon Rupture (Sunrise view)
(<40 yo= Patellar “Patella Alta”)
(>40= Quadricep “Patella Baja”)
What is a Baker’s Cyst? X3 highlights
- popliteal synovial effusion (2T meniscal Tear)
- Mimic DVT (US Dx and R/O DVT)
- Tx- ILCS or Sx
Patient presents w anterior knee pain or behind/around patella. Worse w knee hyperflexion (Prolonged sit/jump)
Dx: Tx:
Patellofemoral syndrome (Chondromalacia)
Dx: (+) Apprehension test Tx: NSAID, Rest, Rehab
MCC of knee pain in runners: (+) ____ test:
______ muscle Inserts at Tibial “Gerdy’s Tubercle?
Iliotibial Band Syndrome (Ober’s Test)
Tensor Fascia Late(TFL)
MC Ankle dislocation?
Tx:
Posterior dislocation
Tx: closed Reduction + Posterior splint (ORIF if severe)
MC ankle sprain Grade I and II are?
Anterior Talofibular Ligament (Main inversion stabilizer)
Grade I and II are incomplete tears
Achilles Tendon rupture Highlights X4
- Risk W fluoroquinolones
- (+) Thompson (Absent plantar flexion)
- Splint in mild plantar flexion
- Age 30-50
Fibular Fractures Weber Ankle fracture class A, B, C highlights
A: Below syndesmosis (Tibiofibular syndesmosis intact)
B: At syndesmosis (TF syndesmosis intact or mild tear)
C: Above Mortis (TFS torn + wide TF joint) Tx- ORIF
Maisonneuve Fracture is defined as
Spiral Proximal Fibular Fracture
2T Distal TF syndesmosis
2T Medial Malleolar Fracture or Deltoid
Fracture of the distal Tibia from impact with the Talus w axial load extending in to ankle joint?
Tx:
Pilon (Tibial Plafond) fracture
Tx: ORIF
MC foot Stress fracture is at what anatomic aspect?
3rd Metatarsal
Tarsal Tunnel manifests with what symptoms?
What nerve is involved?
Pain, numbness at the medial Malleolus/heel/sole
Posterior Tibial Nerve Compression (Mimics PF-itis)
Presents with flexion of PIP joint and hyperextension of the MPT and DIP?
Hammer toe
Joint damage/destruction as a result of peripheral neuropathy MC affecting the _______?
Charcot’s Joint (Diabetic Foot) “ Midfoot”
Morton’s Neuroma MC affects the ?
3rd Metatarsal
Jone’s Fracture is defined as a_____ fracture
Tx:
Transverse fracture through the diaphysis of the 5th MT
Tx: NWB X 6-8 weeks
Lisfranc Injury highlights
- 2nd MT and medial cuneiform Disarticulation
- Fleck sign
- Tx=ORIF–> NWBX 12 weeks
What is a Fleck Sign
Fracture of the base of the 2nd MT
Herniated Disc is MC at ?
L5-S1 (sciatica)
L4 involved Injury will cause what sensory, weakness and diminished reflex?
- Anterior Thigh Pain + loss of medial ankle
- Weak Ankle Dorsiflexion
- Patellar Reflex
L5 involved Injury will cause what sensory, weakness and diminished reflex?
-Lateral thigh/leg hip/groin pain/numbness
(Sensory- between 1st/2nd toes)
-Weak Big Toe extension
-Difficult walking on heels
S1 involved Injury will cause what sensory, weakness and diminished reflex?
- Posterior leg/calf gluteus (Sensory plantar foot)
- Weak Plantar Flexion
- Difficult walking on toes (No Achilles DTR)
Cauda Equina syndrome highlights X3
Tx:?
- New urinary/BM retention/incontinence
- Saddle anesthesia
- Decreased anal sphincter tone
Tx: Nuerosurgery ER (Corticosteroids)
Back pain that is worse with extension, prolonged walking/standing relieved w flexion/sitting walking uphill
“Shopping cart sign” Tx:
Spinal Stenosis (Pseudo-claudication)
Tx: Lumbar epidural CS injection
Scoliosis Highlights X3?
Tx: ?
- > 10 degree Lateral curvature
- MC in girls and FmHx
- Adam’s Forward bending test most sensitive
Tx: 20-40 degrees= Bracing >40 degrees Surgery
Pars interarticularis defect from failure of fusion or stress fracture?
Tx:
Spondylolysis (MC @ L5/S1
Tx: Bracing
Spondylolisthesis is defined as
Tx:
forward slipping of a vertebrae on another (MC 10-15 yo)
Tx: Surgical if high grade
Osteomyelitis Highlights X4
- S. Aureus MC (Salmonella-sickle cell)
- Acute Hematogenous MC in children
- MRI most sensitive (Bone aspiration GS DOC)
- Nafcillin or Oxacillin (Cefazolin > 4mos) x4-6 weeks
Single swollen warm painful joint Decreased ROM. Knee MC: _____ bacteria MC
Dx: Tx:
Septic Arthritis (S. Aureus MC [Sex active-Gonorrhea])
Dx: Aspirate >50K PMNs Tx: Nafcillin (Gono-Rocephin)
what is the earliest indicator of compartment syndrome?
Pain on passive stretching
What is the intra-compartmental pressures diagnosing compartment syndrome?
> 30-45 mmHg (Normal < 20-30mmHg)
MC bone Malignancy in adolescents < 20 yo: MC in femur–> Tibia, Humerus:
Palpable mass with pain/swelling
Dx: Tx:
Osteosarcoma
Dx: XR- Sunray burst- Hair on end mass Tx; Chemo
Cartilage cancer MC seen in adults 40-75 yo:
Dx: Tx:
Chondrosarcoma
Dx; Mineralized matrix/punctate arc Tx: Sx resection
Tumor MC in children males 5-25 yo: Femur/Pelvis MC: joint swelling +/- fever
Dx: Tx:
Ewing Sarcoma
Dx: Periosteal Rx “Onion Skin” Tx: Chemo/Rad/Sx
MC Benign bone tumor ages 10-20s: precedes chondrosarcomas. begins in childhood
Osteochondroma Tx: Observe
What is Paget’s disease?
Abnormal bone remodeling MC >40 yo: Larger weaker compact bones. Bone pain MC sx Dx: Lab Increased alkaline phosphate Tx: Bisphosphonates
Triad of Joint pain, fever, and malar “butterfly” rash.
Glomerulonephritis, retinitis, oral ulcers, alopecia.
Systemic Lupus Erythematous
SLE specific Diagnosis labs?
- (+) Anti double stranded DNA
- (+) Anti-smith
SLE best initial test non-specific?
ANA
SLE TX:
- sun protection
- Hydroxychloroquine
- NSAID
- Methotrexate
Systemic connective tissue disorder due to fibrous collagen build up?
Scleroderma
Scleroderma specific Lab Dx?
(+) Anti-centromere AB
+) Anti-SCL 70 (Diffuse disease
Scleroderma associated syndrome?
Calcinosis Raynaud's Esophageal Sclerodactyly Telangiectasias
Scleroderma Treatment?
- DMARDS
- Corticosteroids
- CCBs (Raynaud’s)
Chronic inflammatory disease –> joint destruction due to pannus (T-cell mediated): a.m stiffness> 60min.
S/sx: MCP, wrist and PIP Ulnar deviation: worse with rest: stiffness improves later on day.
Rheumatoid Arthritis
Rheumatoid Arthritis specific and initial lab Dx?
Anti-Cyclic citrullinated peptide ABs (specific)
RF (Initial test)
Rheumatoid Arthritis Tx that reduces permanent joint damage?
DMARDS (Biologic Adalimumab (Humira))
(Non-Biologic Methotrexate Leflunamide)
Rheumatoid Arthritis 1st Line Tx?
Methotrexate + NSAIDS/CS (NSAID 1st line Pain control)
Closely related to Giant cell arteritis: Increased ESR + anemia: S/Sx: a. stiffness over 30mins.
difficulty standing from chair/ putting on coat/ brushing hair: Tx:
Polymyalgia Rheumatica
Tx: LDCS, NSAID, methotrexate
Progressive symmetrical proximal muscle painless weakness. Increased Aldolase/ Creatine Kinase.
Blue/purple discoloration of upper eyelid: raised violaceous scaly knuckle eruptions. Tx:
Polymyositis / Dermatomyositis
Tx: High Dose cortico-steroids
Polymyositis / Dermatomyositis specific lab dx?
(+) Anti-Jo 1 Ab
(+)Anti-SRP Ab (PM)
(+) Anti-Mi2 Ab (DM)
Fibromyalgia highlights Dx/Tx?
- Diffuse pain in 11 out of 18 Trigger points
- > 3months
- Tx-exercise and Pregabalin
Autoimmune D/O that attacks exocrine glands (salivary, Parotid, lacrimal, thyroid gland): “Sicca Disorders”
Increased incidence of. non-Hodgkin Lymphoma:
Tx:
Sjogren’s Syndrome
Tx: Pilocarpine or Cevimeline
Sjogren’s Syndrome specific lab Dx?
ANA- Anti SS-A (RO)
Anti SS-B (La)
Schirmmer test
Gout treatment that reduces uric acid production by inhibiting xanthine oxidase?
Allopurinol
Gout treatment that promotes renal uric acid secretion?
Prebenecid/ Sulfynpyrazone
Only Gout treatment that can be used in acute chronic gout?
Colchicine
1st line treatment for pseudo-gout?
intraarticular CS
NSAIDS
Colchicine (Acute or prophylaxis)
Linear radiodensities seen in radiographs with pseudo-gout?
Chondrocalcinosis (Cartilage calcifications)
Gout attacks are MC due to underexcretion of uric acid caused by high intake of purine rich foods and what drugs?
Thiazides and Loops ACEi/ARBs Pyrazinamide Ethambutol Aspirin
Gout crystals specifics X2?
- Monosodium Urate
- Negative Birefringent
MCC: immobility, crush injuries, overexertion: Niacin/ fibrates (Seizure/burns).
Tx:
Rhabdomyolysis
Tx: IV saline 4-6 L/day, Mannitol, Sodium Bicarb (Urine)
Prevent ATN
Rhabdomyolysis Dx Labs?
- Creatine phosphokinase increase > 20K
- Hyperkalemia (Intracellular release)
- Hypercalcemia (Ca2+ bonds to damaged muscle)
Rhabdomyolysis UA
(+) for Heme but negative for blood
< 16 yo: Daily Arthritis, diurnal high fever, salmon color migratory rash?
Juvenile Idiopathic Arthritis (Still’s Disease)
< or > 5 joint involvement joint pain with iridocyclitis (Uveitis)
Juvenile Idiopathic Arthritis
Pauci-Articular (< 5)
Poly-Articular (>5)
Recurrent painful oral and genital ulcers
Tx: corticosteroids
Behcets Syndrome
Mostly affects cranial arteries of the carotid artery: fever
Jaw claudication, Temporal lancinating pain, vison dist.
Giant Cell arteritis
Giant Cell arteritis Tx:
HDCS- Prednisone 40-60 mg/day X 6 weeks
Vasculitis that affects the Aorta, Aortic Arch, and pulmonary arteries: 10-40 yo: –> stenosis, occlusion
Tx:
Takayasu’s Arteritis
Dx; Angiography Tx: HDCS60 mg/day x6 weeks
MC in children <5 yo medium-small vessel vasculitis: –> Coronary Artery aneurysm and MI: Echo/Angiography
Tx:
Kawasaki Syndrome
Tx: IVIg and High Dose Aspirin
Kawasaki Syndrome Clinical manifestation X5?
Conjunctivitis Rash (Polymorphous) Extremity desquamation Adenopathy Mucous membrane (Lip swelling/ Strawberry tongue)
systemic vasculitis small arteries ANCA (-)w Renal failure, myalgias, neuropathy, derm purpura/livido reticularis
Polyarteritis Nodosa (PAN)
Systemic small/medium vasculitis P-ANCA (+) w asthma, hyper eosinophilia, and chronic rhinosinusitis
Eosinophilic Granulomatosis w PAN (Churg-strauss)
small vessel vasculitis w inflammation/necrosis of nose, lungs, and kidney:
saddle nose, sinusitis w lung dz and hematuria
Granulomatosis with PAN (Wegener’s)
Glomerulonephritis + Pulmonary hemorrhage (Hemoptysis) think?
Good Pasture’s
Good pasture’s with purpura think?
Microscopic Polyangiitis
Henoch-schonlein Purpura highlights?
- MC 3-15 yo (HSPA)
- Hematuria
- Synovial pain (Arthritis/algias)
- Purpura palpable
- Abdominal Pain (2T vasculitis)
Asymmetric Arthritis: dactylitis (Sausage digits), sacroiliitis, uveitis, pitting of nails (Pencil in cup), +
HLAB27
Psoriatric Arthritis
Sacroiliac joint inflammation with progressive stiffness: 15-30 yo: chronic LBP: Increased ESR/HLAB27
Ankylosing Spondylitis (Bamboo Spine)
Autoimmune response inflammation caused by “chlamydia”, gonorrhea, salmonella, campy, shigella
Arthritis, conjunctivitis, and urethritis.
Reactive Arthritis ( Reiter’s Syndrome)
Felty’s syndrome includes
Rheumatoid Arthritis, splenomegaly and repeated infections (decreased WBCs)