musculoskeletal deck 1 Flashcards by Brittany Blackston

What is the definition of NEXUS criteria

a set of validated criteria used to decide which trauma patients do not require cervical spine imaging.

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What is the NEXUS (National Emergency X-Radiography Utilization Study) criterion?

alert and stable
no focal neurologic deficit
no altered level of consciousness
not intoxicated
no midline spinal tenderness
no distracting injury

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What is the Canadian C-spine rules definitition

a set of guidelines that help a clinician decide if cervical spine imaging is not appropriate for a trauma patient in the emergency department. The patient must be alert and stable.

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What are the 3 Canadian C-spine rules

There are three rules:

is there any high-risk factor present that requires cervical spine imaging?
≥65 years
a dangerous mechanism
fall from elevation >3 ft (or 5 stairs)
axial load to the head
high-speed motor vehicle collision (e.g. >100 km/hr or ~60 mph, rollover, ejection)
motorized recreational vehicles
bicycle collision
paresthesias in extremities
If any high-risk factor is present, then cervical spine imaging is warranted.

is there any low-risk factor present?
simple rear-end motor vehicle collision
excludes being hit by a high-speed vehicle, a large vehicle (e.g. bus), or rollover
sitting position in emergency department
ambulatory at any time since the injury
delayed onset of neck pain
absence of midline C-spine tenderness
If the patient does not meet the criteria of a low-risk injury, then cervical spine imaging is warranted.

If the patient meets the criteria of a low-risk injury, then one should assess on physical exam whether the patient can rotate the neck 45°.

if low-risk injury and the patient can rotate the neck 45°
no cervical spine imaging required
if low-risk injury and the patient cannot rotate the neck 45°
then cervical spine imaging is warranted

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Shoulder pain- acute time line

< 2 weeks

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acute shoulder pain, what should you consider?

trauma, fractures, dislocations, falls

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common causes of chronic shoulder pain

-Rotator Cuff Injury
•Impingement syndrome
•Adhesive capsulitis
•Osteoarthritis

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Common causes of chronic referred shoulder pain

Neural impingement
–(at the level of the cervical spine)
•Peripheral nerve entrapment
–(distally to the spinal column)
• Diaphragmatic irritation
–(spleen laceration, perforated viscous, infection
ruptured ectopic pregnancy)

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Positive Kehrs sign

L shoulder pain indicative of a splenic lac

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articular surface commonly associated with arthritis

glenohumeral

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4 muscles that make up the rotator cuff

-Anterior: Supraspinatus, Subscapularis

–Posterior: Infraspinatus, Tres minor

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test for subacromial impingement or a supraspinatus tendon lesion

Jobes test aka empty can test

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Diagnostic imaging for Shoulder pain

• Lidocaine injection test (in office)- checks for
possible response to steroids. Can also be a
treatment.
•Plain X/rays- 2 views minimum
• MRI with or without-
–Can visualize better, but not definitive.
• U/S- Can be equal to MRI if done well.

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Lab Diagnostics for shoulder pain

CBC- look for infection

* Sed rate- Inflammation

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Hawkins Kennedy test

pain is a positive test is most likely indicative of damage to the tendon of the supraspinatus muscle and greater tuberosity impingement

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How is the hawkins kennedy test performed

Flexing the shoulder and elbow to 90 degrees and forcibly internally rotating the shoulder

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Positive (Painful) arc sign

have the patient elevate the arm in the scapular plane and then reverse the motion. pain is produced between 60 and 120 degrees - means either supraspinatus tendonitis or a partial tear of the tendon

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Neer Test

tests for subacromial impindgement.

Take arm up bast head and forcefully moves the arm through the full range of forward flexion or until reports of pain.

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lag sign is indicative of

a muscle tear (rotator cuff)

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Chronic shoulder pain generally is caused by the

Rotator cuff

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What is impingement syndrome

used to describe symptoms that occur from the compression of the rotator cuff tendons and the subacromial bursa between the greater tubercle of the humeral head and the lateral edge of the acromion process

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older adults tend to present with what in regard to shoulder pain

frozen shoulder ( adhesive capsulitis) and symptomatic osteoarthritis

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What is adhesive capsulitis

also known as frozen shoulder….a stiffened glenohumeral joint that has lost significant range of motion (ROM)

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Osteoarthritis

usually the glenohumeral joint….represents wear and tear of the articular cartilage. occurs due to trauma years earlier

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Special tests used for rotator cuff problems

empty can test | Neers test

special tests looking for acromioclavicular joint disease

Cross arm test

special test for glenohumeral joint stability

apprehension test

Special test for maneuvers to test ROM

Scratch test | Painful Arc Test

Degenerative arthritis

Osteoarthritis (OA)

Inflammatory arthritis

``` Rheumatoid Psoriatic systemic lupus gout undifferentiated arthritis ```

Joint infection

parvovirus B19 Lyme disease septic joint

Morning stiffness lasting more than 60 minutes indicates a

inflammatory process

The metacarpal joints (MCP) and wrists are painful in

Rheumatoid arthritis

Distal interphalangeal (DIP) and proximal interphalangeal joints (PIP) are painful in

``` fever weight loss fatigue Hair loss mouth sores shortness of breath pleuritic pain chest pain palpitations abd pain n/v diarrhea personality change headaches numbness/tingling seizures malar rash photosensitive rashes ```

symptoms of Systemic Lupus Erythematosus

``` fever weigh loss fatigue hair loss chest pain palpitation ```

symptoms of Rheumatoid arthritis

symptoms of psoriatic arthritis

psoriatic plaque | nail pitting

pain is symmetrical - RA or OA?

pain is usually not symmetrical - RA or OA?

slapped cheek rash

Human parvovirus B19

"I'm allergic to the sun" rashes on hands when in sun

Systemic lupus

RA can occur in any joint but most commonly found in

``` wrists hands feet spine knees jaw ```

Hand pain conjunctivitis urethral discharge urethritis

Reiter's syndrome symptoms

Neuro issues hand pain Annular Red plaque

Lyme Disease symptoms

hand pain | Plaque on hands

Psoriatic Arthritis

eye pain vision loss hand pain

Uveitis or temporal arteritis

Dry mouth | Hand pain

Sjrogens disease

mild rash usually in children can cause swollen joints "slapped cheek rash"

Parvovirus B19 (fifths disease)

test not specific to RA

Rheumatoid factor

what test is specific to RA

Anti-citrullinated protein antibody test

diagnostic test used in autoimmune disorders and is present in RA and SLE

ANA (antinuclear antibodies)

lab markers for inflammation - not specific

CRP | sed rate

presence of protein and red cell cast in urinalysis may indicate

SLE

Lyme tyter western blot

Lyme disease

Parvovirus B19 antibodies Igm

acute infection (remember Igm - m for miserable)

Parvovirus B19 antibodies Igg

they are not currently sick but have had it before

CBC

looks for infection, anemia

CMP

looks for renal and liver problems

American college of rheumatology classification for RA

>6 points - pt has RA

Carpal tunnel diagnostics

• H&P and physical exam most important –Hx. Of paresthesia, repetitive motions +, weakness, clumsiness of hand and s/s worsen at night. –Tinel or Phalen tests positive • Conservative treatment initially • Brace • Steroid injection • Electro-diagnostic studies only IF conservative treatment not working and the patient is considering surgery

Paget's Disease

Disrupts bodys normal bone recycling process Old bone tissue is gradually replaced with new bone tissue Over time the affected bones become fragile and can cause pain and tenderness

Rotation and shortening of the leg is classic for what?

Hip fracture

* Any recent procedures? * Any recent needle sticks? * Any recent illnesses? Viral or bacterial.

can all lead to infection in the hip

Hip pain diagnostics

•Plain X-Ray- 3 views- look for joint problems, fractures, structures of the hip • CT scan for better definition. Use contrast to look at vessels and blood flow. • MRI with or without contrast. • Compartment pressure measurement- –Insert a needle into the area while attached to a pressure monitor.

Hip pain labs

* CBC: infection, inflammation * Sed Rate: Inflammation * CRP: Inflammation, infection

Arthrocentesis (Joint aspiration)-

–Never through cellulitis –Artificial joints need to be done by Ortho –Large joints may benefit from Arthroscopy –Ultrasound to determine size and location of effusion –Spinal joints done with fluroscopy

Lab diagnostics for the arthrocentesis

– cell count, WBC’s with differentials, –Gm. Stain, C&S (aerobic and anerobic), –Crystals (diagnostic for gout) –Fungal cultures?

Knee pain in pediatrics

–Osgood-Schlatters disease –Patellar tendinitis (jumper’s knee) –Osteochondritis dissecans –Patellofemoral syndrome

what causes anterior knee pain

``` Osgood-Schlatters disease •Patellar tendinitis (jumper’s knee) •Patellofemoral syndrome (PFS) •Prepatellar bursitis •Osteoarthritis ```

Osgood-Schlatter disease

tibial tuberosity from overuse/sports refer to ortho

Patellar tendinitis diagnostics

US | if cant find anything you can use MRI

Patella femoral syndrome

Pain behind or around the patella generally aggravated by weight-bearing activities such as squatting, running, and stair climbing. • Most common cause of anterior knee pain • 16-25% of injuries in runners • classic presentation is pain in anterior knee worsened with activities such as squatting or descending stairs. • J-sign- Patella jumps laterally when leg fully extended.

Prepatellar Bursitis causes

chronic use - anyone who is on their knees alot Can be Aseptic (chronic or acute) • Can be Septic • Can be crystal-induced (Gout)

Prepatellar Bursitis diagnostics

Plain Xrays to r/o other causes • MRI / U/S • Joint aspiration- refer to ortho if infection suspected

Posterior knee pain causes

Baker’s cyst (most common) | •PCL tear

Medial knee pain causes

* Medial meniscus injury * MCL injury * Bursitis

Lateral knee pain causes

* LCL injury * Lateral meniscus injury * Iliotibial band syndrome

Drawer test - tests for

ACL and PCL

Mcmurray test - tests for

meniscus

Lachman test - tests for

ACL

General diagnostics for Knee pain

``` •Plain X-Ray- look for joint problems, fractures, structures of the knee • CT scan for better definition. Use contrast to look at vessels and blood flow. • MRI with or without contrast. Arthrocentesis ```

Labs for knee pain

* CBC: infection, inflammation * Sed Rate: Inflammation * CRP: Inflammation, infection

Radiating pain into the leg along a dermatome | indicates

ruptured disc

Back pain with a history of Cancer needs to rule | out

metastatic disease

Loss of bowel or bladder indicates an

emergency (Cauda Equina syndrome)

•Straight Leg Raise (SLR) – –Elevate leg- if pain noted between 30-60 degrees, test is positive

(poss. Herniated disc)

• Rectal exam- for bleeding

for possible | Cancer

Diagnostics- Lab and X-rays for back pain

Plain film with oblique views for trauma • MRI- • CT skan if unable to do MRI • CBC, Sed rate, CRP if infection suspected

Diagnostics for Nurse Maids

Physical exam with history. Pulling mechanism without other injury

rule out septic joint

any fever? Been using elbow until pulling mechanism no swelling no redness