Musculoskeletal problems Flashcards
Ortho assessment tips
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
Gout Risk factors
- Obesity, DM, family Hx
- medications: thiazides, niacin, aspirin
- alcohol, purine-rich diet ( organ meats, sardines, anchovies, spinach, oatmeal)
- chronic kidney disease/renal failure
Gout presentation and cause
- 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
Treatmetn for acute gouty arthritis attack
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
Prevention of gout attack
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
McMurray test
- 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
Talar tilt
- assessment for ankle instability
Tinel’s sign
Phalen’s sign
- identifies carpel tunnel syndrome
- tinel’s - tap on the medial nerve of the wrist elicits pain, tingling
Lachman test
- similat to drawer test but knee is slightly bent
- identifies ACL tear
Straight -Leg raising test
- Identifies lumbar nerve root compression
- positive when it evokes radiating pain along the lower libm along L5, S1
Supurling Test
- 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.
Drop arm test
rotator cuff evaluation
Finkelstein test
- 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
Lumbar -sacral Strain
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
Lumbar radiculopathy
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
L4
motor: foot dorsiflexion
reflex: Knee jerk
Sensory area: medial calf
L5
Motor: great toe dorsiflexion
No reflex test
Sensory are: medial foot
S1
Motor: Foot eversion
Reflex: Ankle jerk
Sensory area: lateral foot
Diagnostic imaging for low back pain
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
Lumbar Spinal stenosis
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
Osteoporosis
- 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
Scaphoid Fracture
- 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
Ankle sprain
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
Ankle sprain intervention
- 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
Polymyalgia Rheumatica
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
Rheumatoid arthritis
- 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
Systemic Lupus Erythematous
- 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
meniscal tear
- 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
reactive arthritis
- 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
BMD testing
- 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
who should be treated for osteoporosis
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
Osteoporosis Treatment
- 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
