Musculoskeletal problems

Question 1

Ortho assessment tips

Answer 1

Pt otherwise well?
* likely condition is limited to bones and or joints
* osteoarthritis, osteoporosis

Systemic symptoms?
* fever involuntary weight loss, anemia of chronic disease, rash, joint swelling
* orthopedic manifestation of systemic disease
* RA, SLE, polymyalgia rheumatica

Risk factors/predisposition
* acute factors (trauma, sudden change in activity level), age, gender, weight, autoimmune disorder, profession, sports/repetative movements, medications

Question 2

Gout Risk factors

Answer 2

• Obesity, DM, family Hx
• medications: thiazides, niacin, aspirin
• alcohol, purine-rich diet ( organ meats, sardines, anchovies, spinach, oatmeal)
• chronic kidney disease/renal failure

Question 3

Gout presentation and cause

Answer 3

• Acute onset of severe joint pain, most common in the metacarpophalangeal joint of the great toe

Cause
* uric acid overproduction - 10% of cases
* Uric acid under-excretion - 90%, made worse with risk factors

Question 4

Treatmetn for acute gouty arthritis attack

Answer 4

Initiate Pharmacotherapy in 24 hrs
* NSAIDS
* oral corticosteroids
* oral colchicine
* if currently on urate lowering medications this should be continued but never initiate new therapy durring an attack

Question 5

Prevention of gout attack

Answer 5

First line Urate lowering therapy
* Xanthine oxidase inhibitor therapy: allopurinol (aloprim) or febuxostat (Uloric)
* to prevent triggering acute attack , start at least 6 months after start of NSAID/colchicine treatment

• serum urate levels should be lowered to improve s/s with a target of at a minimum <6mg/dl
• combination oral ULT with 1 XOI agent and 1 uricosuric agent is appropriate when serum urate target has not been met by XOI alone

Question 6

McMurray test

Answer 6

• identification of possible meniscal tear
• Pt is supine an drelaxed. Examiner grasps pt heel and the joint line of the knee. Knee is maximally flext with internal or external rotation
• due to twisting injury

Question 7

Talar tilt

Answer 7

• assessment for ankle instability

Question 8

Tinel’s sign
Phalen’s sign

Answer 8

• identifies carpel tunnel syndrome
• tinel’s - tap on the medial nerve of the wrist elicits pain, tingling

Question 9

Lachman test

Answer 9

• similat to drawer test but knee is slightly bent
• identifies ACL tear

Question 10

Straight -Leg raising test

Answer 10

• Identifies lumbar nerve root compression
• positive when it evokes radiating pain along the lower libm along L5, S1

Question 11

Supurling Test

Answer 11

• cervical nerve root compression at the foramovale

The test is considered positive when radicular pain is reproduced (pain radiates to the shoulder or upper extremity ipsilateral to the direction of head rotation).[6][7] The Spurling Test is designed to reproduce symptoms by compression of the affected nerve root.

Question 12

Drop arm test

Answer 12

rotator cuff evaluation

Question 13

Finkelstein test

Answer 13

• de quervain’s tenosynovitis
• sticking sensation when trying to move the tumb
• exminer grasps the thumb and ulnar deviates the hand sharply
• positive if elicits pain

Question 14

Lumbar -sacral Strain

Answer 14

Etilogy
* spasm , irritation of LS spine-supporting muscles
* most common reason for low back pain

Characteristics
* spasam ache stiffness
* position, activitym rest typically impacts pain

PE
* paraspinal muscle tenderness and spasm
* LS curve straightening
* Decreased LS flextion
* Nerulogic exam WNL (no loss of strength, DTR intact, no numbness)

Intervention
* Moderate pain/stiffness can last 1-2wks, most recover in 1 month
* Analgesia
* encourage physical conditioning
* heat or ice for comfort
* Skeletal muscle relaxer can be helful but all sedating, some with abuse potential

Question 15

Lumbar radiculopathy

Answer 15

Etiology
* irradiation or damage of neural structures,such as disks
* L4-L5, L5-S1 most common sites

Characteristics
* sharp, burning, electric-shock sensation
* worse when increased spinal fluid pressure on nerve root - sneeze, cough, strain, evokes sharp pain

PE
* Signs of LS strain + altered nero exam including abnormal straight leg raise, sensory loss, altered DTRs

Intervention
* up to 70% improve within 2 weeks
* conservative treatment: heat/ice, NSAID, muscle relaxer
* Specialty evaluation indicated for rapidly evolving defect, persistant neurological defect without resolution after 4-6 weeks of conservative therapy

Question 16

L4

Answer 16

motor: foot dorsiflexion
reflex: Knee jerk
Sensory area: medial calf

Question 17

L5

Answer 17

Motor: great toe dorsiflexion
No reflex test
Sensory are: medial foot

Question 18

S1

Answer 18

Motor: Foot eversion
Reflex: Ankle jerk
Sensory area: lateral foot

Question 19

Diagnostic imaging for low back pain

Answer 19

No Imaging
* no criteria for any imaging of any kind during 1-2 month trial of standard conservative back pain therapy, esp in the presence of normal neuro exam, abscence of acute significant trauma, and low risk for vetebral compression fracture

MRI
* for s/s of radiculopathy that persist after trial of standard conservative therapy in pts who are candidates for surgery or epidural corticosteroid injection
* risk factors for or symptoms of spinal stenosis in pts who are candidates for surgery

Question 20

Lumbar Spinal stenosis

Answer 20

Features
* older age >50, RA, ankylosing spondylitis
* standing discomfort with improvement in symptoms with bending forward nearly universal
* pseudoclaudication - leg pain that worsens with activity, improves with rest
* bilateral lower-extremity numbness, weakness in the majority

Dx
* initially, no diagnostics indicated
* for symptoms persisting >1 month, consider x-ray, CT, MRI

Intervention
* Conservative: PT, NSAIDS, epidural, corticosteroid injection
* Surgical - decompressive surgery

Question 21

Osteoporosis

Answer 21

• Normal: T score -1.0 and above
• Osteopenia: Tscore -1.0 to -2.5

Osteoporosis:
* T-score at or below -2.5 - pts in this group who have alreadt expirenced one or more fractures are deemed to have severe/established osteoporosis
* low trauma spine or hip fracture - reguardless of BMD
* T score between -1.0 and 2.5 and a fragility fracture of provimal humerus, pelvis, or distal forearm
* t-score between -1.0 and 2.5 and high Frax fracture probability

Question 22

Scaphoid Fracture

Answer 22

• FOOSH (fall on outstretched hand) in extension injury, palmar branch of radial artery supplies blood to scaphoid’ distal pole then proximal pole; blood supply can be disrupted by fracture with risk of nonunion and avascular necrosis

clicical presentation
* pain radial aspect of wrist, proximal to thumb (snuff box), decreased grip strength

dx
* standard x-ray (PA, lateral, oblique) plus scaphoid view may miss fracture
* consider repeat radiographs within 7-10 days: CT, MRI, and bone scan

Intervention
* Thumbspica splint, analgesia, orth referral - even if initial x-ray neg

Question 23

Ankle sprain

Answer 23

Grade 1
* mild stretching of ligament with micro tears
* no joint insatbility on exam, can bear weight with mild pain

Grade 2
* incomplete tear of a ligament
* mild-mod joint instability, decreased ROM
* weight bearing and ambulation are painful
* mild-mod pain, swelling, tenderness, and eccymosis

Grade 3
* Complete tear of ligament
* Pain swelling, tenderness, ecchymosis.
* Loss of function and motion
* Unable to bear weight and ambulate

Question 24

Ankle sprain intervention

Answer 24

• RICE - rest, ice, compression, elevation
• Crutches until able to walk with normal gait - grade 2
• analgesia
• PT
• Consider Ortho referral
• DD: fracture, dislocation, sublixation, syndesmosis injury, tendon rupture
• Grade 1 does not require immobilization
• Grade 2: immpbilization with walking boot or splint for few weeks
• Grade 3: cast, splint, boot - refer to ortho

Question 25

Polymyalgia Rheumatica

Answer 25

Etiology
* inflammation of unknown origin that affects muscles and joints
* generally > 50yrs, caucasian female

Presentation
* aches in the shoulder 1st then neck, upper arms, lower back, hips and thighs (large joints)
* symptoms come quickly (days-weeks), worse in am imrove during day
* PMR, CRP, ESR typically elevated
* MRI/US detects inflammation in affected joints
* CBC= mild anemia of chronic disease
* temproal artery Bx if giant cell arteritis present

Intervention
* low-dose corticosteroids until symptoms relieved 2-3 weeks then taper to find suppresive dose
* Tx continues up to 2-3 yrs
* Supplement with Vit D, calcium
* NSAIDS
* DMARDS and biologics not reccomended

Question 26

Rheumatoid arthritis

Answer 26

• chronc ssytemic inflamatory disease resulting in persistant symmetric polyarthritis

Risk factors:
* family hx, female, middle age, smoking, overweight

Presentation
* synovitis of hands and feet, progressive articular deterioration, joint swelling and stiffness, synovial proliferation, joint deformity
* Extra-articular manifestations can include fatigue, malase, subcut nodules, various organ system involvment

Dx
* combo of clinical, lab, and imaging
* labs ESR/CRP, RF, ANA, anti-CCP
* CBC= anemia of chronic disease

Intervention - 1st line DMARDS:
* nonbiologic: methotrexate, sulfasalazine, hydroxychloroquine
* biologic: TNF inhibitor, etanercept, infliximab, adalimumab
* corticosteroids and NSIADS for symptom relief

Question 27

Systemic Lupus Erythematous

Answer 27

• autoimmune disorder with production of antibodies to nuclear and cytoplasmic antigens resulting in multisystem inflammation

Risk factors:
* >90% are women, child bearing age

Presentation:
* fever, joint pain, and rash in wmn of child bearing age
* other signs include raynaud pleuritis, fatigue, weigt change, photosensitivity, GI upset, myocarditis

Dx
* combo of clinical and lab findings
* ESR/CRP, serum creatinine, complement levels, liver function, autoantibody tests
* CBC = anemia of chronic disease

Intervention
* based on severity
* hydroxuchloroquine, sort course of systemic corticosteroids, biologic and non biologic DMARDS, NSAIDS

Question 28

meniscal tear

Answer 28

• pivoting injury
  Presentation:
• effusion with knee tightness and stiffness
• limited ROM due to pain
• larger tears report knee locks, makes a popping sound, or gives out
• MRI can be usefull
• McMurray test and apley grind test specific for but not sensitive

Intervention
* RICE, analgesia initial treatment
* arthroscopy considered if no improvement in 4-6 weeks
* aspiration if no improvement in 2-4 weeks

Question 29

reactive arthritis

Answer 29

• most common in men 20-50
• painful inflammatory arthritis typically seen days-weeks after an episode of acute bacterial diarhhea or sexually transmitted infection

Presentation
* pain/swelling of the knees, ankles, toes, or fingers; persistant low back pain
* conjunctivitis and urinary problems
* Dx can involvelabs to check for infection and inflammation
* Genetic test for HLA-B27 gene
* x-rays
* test for chlamydia

Intervention
* NSAIDS, corticosteroids, or TNF blockers
* joint injection of corticosteroids
* abx not beneficial, though may shorted duration of symptoms when urtheritis is also present

Question 30

BMD testing

Answer 30

• women 65 and older and men 70 and older reguardless of risk factors
• younger postmenopausal women, perimenopausal, and men 50-69 with risk factors
• A women or man >50 who has broken a bone
• adults with a condition or taking a medication associated with low bone mass or bone loss

Question 31

who should be treated for osteoporosis

Answer 31

postmenopausal women and men aged >50 with the following
* DXA reveles T-score less than -2.5
* low bone mass or osteopenia and a 10-year hip racture probability of 3% or more or 20% or more based on FRAX
* Hx of hip or vertebral fracture

Question 32

Osteoporosis Treatment

Answer 32

• Bisphosphonates: alendronate (fosamax), ibandronate (Boniva), risedronate (actonel), zoleronic acid (Reclast)
• Calcitonin (miacalcin)
• SERM: raloxifene
• RANKL inhitor: denosumab (Prolia)

all should be given with vit D and Ca
Vit D: >800-1000
Ca men 1000, Wmn 1200