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Ambulatory Medicine > Musculoskeletal Problems > Flashcards

Musculoskeletal Problems Flashcards

0
Q

Factors that exacerbate pain in disc herniation

A
  • maneuvers that increase intraspinal pressure (coughing, sneezing)
  • forward flexion: sitting, driving, lifting; worsens leg pain
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1
Q

Most common causes low back pain

A
  • musculoligamentous strain
  • degenerative disc disease
  • facet arthritis
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2
Q

Low back pain

A

2nd most common reason for med office visits in US

acute: sx 12wks

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3
Q

Radicular leg pain…

A

nerve compression likely;

lumbar spine MRI if: leg symptoms severe, objective weakness present (but unnecessary in most patients who present with acute episode of pain)

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4
Q

Patients with spinal stenosis…

A

have leg pain on back extension; pain worsens with standing or walking ; relief when bending or sitting

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5
Q

Cauda equina syndrome

A
  • caused by severe stenosis in lumbar spine, most commonly due to acute disc herniation
  • patients present with severe back pain or leg pain (uni or bilateral) with or without weakness in legs.
    key findings: bladder dysfunction (retention incontinence) and saddle anesthesia (numbness in perineal or buttock region)
  • symptoms can have acute onset, or start with leg pain initially and over ensuing days progress to weakness and bladder dysfunction
  • surgical emergency! obtain MRI immediately
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6
Q

Lumbar disc herniation

A

majority of patients with lumbar disc herniation and sciatica improve with conservative care.
only about 10% will require surgical intervention

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7
Q

Imaging findings and back pain

A

imaging findings do not necessarily correlate with symptoms!

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8
Q

sciatica is aka

A

radicular leg pain

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9
Q

Pathology in other organ systems cause back pain and should be ruled out…

A
  1. vascular disease: aortic aneurysm, aortic dissection
  2. pancreatic disease
  3. urologic disease: prostate infection, renal calculi (“kidney stones”)
  4. gynecologic/obstetric disease: endometriosis, ectopic pregnancy, pelvic inflammatory disease)
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10
Q

Chronic lower back pain

A

imaging findings on MRI dont nec correlate w presence or severity of pain; psychosocial variables much stronger predictors of pain + disability

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11
Q

Neoplasms in spine

A

most common spinal tumor is metastasis: breast, lung, prostate, kidney, thyroid

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12
Q

vertebral compression fracture

A
  1. minor stress in elderly pts
  2. long term steroid treatment
    pain at level of fracture w local radiation across back and around trunk
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13
Q

INfection: discitis or osteomyelitis

A

suspect in pts with hx IV drug use, dialysis, indwelling catheter

labs to order: CBC w differential, ESR, CRP
MRI if suspicion high

epidural abscess in cervical and thoracic spine can –> rapid neuro deterioration and in most cases need sx decompression

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14
Q

Major segmental innervation of lower limb

A 
hip flexion: L2
knee extension: L3
ankle dorsiflexion: L4, L5
great toe dorsiflexion: L5
ankle plantar flexion: S1
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15
Q

RAdiologic imaging and lower back pain

A

generally unnecessary in evaluation of low back pain

image appropriate if: sx dont resolve within 1 month or if there are neuro signs and symptoms

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16
Q

Differentiate patients w predominantly low back pain from those with predominantly leg pain

A

when conservative treatment fails sx often effective for leg pain but results for low back pain less predictable

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17
Q

Management lower back pain

A

avoid pronged inactivity (leads to deconditioning)

in 1st wk: attempt walking routine (20 mins, 3x/day, interspersed with bed rest)

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18
Q

chronic axial neck pain

A

without radiating arm pain: common, hard to treat

with radiculopathy: arm pain, numbness, tingling, weakness; unilateral neck pain radiating to arm in dermatomal pattern most common

most common cause = cervical spondylosis (osteoarthritis) and disc herniation

ddx: shoulder pathology (impingement syndrome, rotator cuff dz), peripheral nerve entrapment (carpal tunnel or cubital tunnel syndrome), thoracic outlet syndrome, zoster, Pancoast tumor (can present with brachial plexus symptoms)
best test to dx nerve root compression: MRI cervical spine

rare for pt w cervical radiculopathy to progress to myelopathy; appears these are 2 distinct entities

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19
Q

shoulder impingement syndrome

A
  • often confused w cervical radiculopathy involving C5 nerve root
  • in in doubt: inject shoulder (subacromial space) w cortisone to see if sx resolve
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20
Q

Gait unsteadiness in elderly pts

A

often not investigated and attributed to “Old age”; whenever elderly pt begins to rely more on assistive devices for walking, consider cervical stenosis and order MRI

refer for surgical consult if stenosis present

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21
Q

cervical myelopathy

A

neurologic dysfunction 2/2 spinal cord compression (cervical stenosis) in cervical spine
dx: MRI of cervical spine

earliest symtpom: gait disturbance! (unsteady while ambulating)
other: loss of hand dexterity (clumsiness, difficult buttoning shirts, change in handwriting), bowel and bladder dysfunction* are late findings

pain not common finding so pts may go undiagnosed until myelopathy severe

conservative measures dont help with cervical stenosis w myelopathy need surgery to prevent further neuro worsening

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22
Q

Clinical pearl: causes of arthritis

A

-osteoarthritis (most common cause)
- systemic immune dz: rheumatoid arthritis, SLE, IBD, seronegative spondyloarthropathies
- crystal disease: gout, pseudogout (cppd)
- infectious: septic arthritis, Lyme disease
- trauma
- charcot joint (diabetes)
- pediatric orthopedic conditions: congenital hip dysplasia, legg-calve-perthes disease, slipped capital femoral epiphysis
- hematologic: sickle cell disease (avascular necrosis of femoral head), hemophilia (recurrent hemarthrosis)
- deposition diseases: Wilson’s disease, hemochromatosis
s

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23
Q

Patellofemoral pain

A

common cause of anterior knee pain

send these pts to physical therapy to strengthen/stretch quadriceps and hamstrings

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24
Q

Degeneration or tear of meniscus

A
  • may be due to specific injury or degenerative process (old ppl)
  • key features: recurrent knee effusions, tenderness along medial or lateral joint lines, positive mcmurray test
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25
Q

Recurrent knee effusion

A

sign of intra-articular pathology and further investigation warranted

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26
Q

Baker’s cyst

A

intra articular pathology (eg meniscus tear)

rupture can –> pain,swelling if extends to calf may mimic thrombophelbitis or acute dvt
majority resolve spontaneously

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27
Q

Clinical pearl: physical exam for knee pain

A
  • assess distortion of normal knee contours, irregular bony prominences at joint margin
  • determine presence of effusion
  • check for muscle atrophy
  • assess meniscal injury by mcmurray (supine) and apley (prone) tests
  • determine range of motion
  • test stability of collateral ligaments
  • assess anterior cruciate ligament stability via lachman test or anterior drawer test
  • assess joint tenderness (medial or lateral)-meniscus tear or osteoarthritis
  • patellar grind test-Push down on patella and ask patient to raise leg
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28
Q

Ottawa ankle rules

A
  1. patient able to walk four steps at time of injury and at time of evaluation
  2. there is no bony tenderness over distal 6 cm of either malleolus

avoid unnecessary radiographs of ankle
clinically significant fractures not missed

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29
Q

most commonly injured lateral ligament of ankle

A

anterior talofibular ligament (ATFL)

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30
Q

pain due to ankle sprain

A

usually tender directly over injured ligament

31
Q

Treatment of all acute ankle sprains

A

–> even severe sprains

RICE: rest, ice, compression, elevation
+
physical therapy

sx rarely if ever needed acutely
recurrent ankle sprains require evaluations for possible surgery

32
Q

Impingement syndrome

A
  1. common cause of shoulder pain
  2. due to impingement of greater tuberosity on acromion
  3. pain with overhead activity
  4. may lead to rotator cuff pathology over time
  5. steroid injections give temporary relief
  6. surgery (acromioplasty) v effective
33
Q

Most common cause of shoulder pain

A

tendinitis (esp supraspinatus (rotator cuff) tendinitis-impingement syndrome)

pain poorly localized, difficult for pt to pinpoint, insidious onset, generally over lat delt, pain w arm abduction

34
Q

Best test for diagnosing rotator cuff tear

A

MRI

35
Q

Tennis elbow

A

lateral epicondylitis at elbow

inflammation/degeneration of extensor tendons of forearm (originate from lat epicondyle)
excessive/repetitive supination/pronation

splint forearm, not elbow itself

36
Q

Golfer’s elbow

A

medial epicondylitis

pain distal to medial epicondyle
exacerbated by wrist flexion; caused by overuse of flexor pronator muscle group;

37
Q

De Quervain’s disease

A

pain at radial aspect of wrist (esp w pinch gripping)
common for pain to radiate to elbow or thumb

inflammation abductor pollicus longus and extensor pollicis brevis

positive finkelsteins test: pt clench thumb under other fingers when make fist, ulnar deviate wrist –> pain reproduced if +

38
Q

Osteoarthritis dx quick hit

A

hip osteoarthritis: presents with groin pain
lateral hip pain (over greater trochanter) or in buttock not due to osteoarthritis

before dx osteoarthritis of hip as source of pain: make certain patient’s symtpoms are primarily in groin

39
Q

Ddx hand numbness (as seen in carpal tunnel syndrome)

A
  • cervical radiculopathy (nerve root compression in cervical spine)
  • peripheral neuropathy (diabetes)
  • median nerve compression in forearm
40
Q

Phalen’s sign and Tinel test

A

do not exclude carpal tunnel syndrome if negative

41
Q

carpal tunnel syndrome

A

median nerve compression in carpal tunnel –> numbness and pain in median nerve distribution ; if long standing and severe –> atrophy of thenar muscles

sx usually worse at night; sometimes pain or nubmness along entire arm

42
Q

conditions assoc w carpal tunnel

A

hyperthyroidism, diabetes, repetiive use of hands in both activities, pregnancy, recent trauma or fracture of wrist

43
Q

TEsts for carpal tunnel

A

tinel’s sign: tap over median n at wriste crease –> paresthesias in median nerve dist

phalen’s test: palmar flexion of wrist for 1 min –> paresthesias in median n dist

EMG and nerve conduction velocity studies definitive dx

44
Q

The following can contribute to or exacerbate forces to cartilage

A
  • compromised pain sensation or proprioception
  • ligamental laxity
  • falls of very short distance (not enough time for compesatory mvmts to decrease impact load)
45
Q

If spine involved in osteoarthritis…

A

nerve roots may become compressed and –> radicular pain

46
Q

Hip osteoarthritis

A

causes pain in groin (not lateral hip or buttock);

if pt is tender over lateral aspect of hip, suspect greater trochanteric bursitis

47
Q

Osteoarthritis clinical features

A

often monoarticular; insidious destruction of cartilage over time; deep dull ache relieved with rest, worsened with activity; stiffness in morning or after period of inactivity; limited range of motion late stages; no systemic sx (erythema, warmth); swelling may be present (inflammation)

48
Q

Radiographic findings in osteoarthritis

A

initial tests; ideally obtained in standing position for lower extremities

  • joint space narrowing
  • osteophytes
  • subchondral sclerosis
  • subchondral cysts
49
Q

Common “pimp” info

A

Bouchard’s nodes: bony overgrowth and significant osteoarthritis changes (ie, osteophytes) at PIP joints

Heberden’s nodes: bony overgrowth and significant osteoarthritis changes (ie, osteophytes) at DIP joints

50
Q

PHarmacologic treatment osteoarthritis

A

1st line: acetaminophen

NSAIDs just as effective but concern w GI bleeding long-term

51
Q

Osteoarthritis of hips

A

pain is in groin region and sometimes radiates to anterior thigh

52
Q

quick hit: for left knee or hip pain…

A

…can should be held in right hand!

53
Q

Xray findings and OA

A

although xrays not diagnostic of OA, not all patients with xray findings of OA have symptoms; there is no consistent correlation bw sx and severity of xray findings

54
Q

Osteoporosis: primary vs secondary

A

OFten difficult to distinguish primary vs secondary osteoporosis and the 2 may coexist.

best: attempt to Id any predisposing conditions and eliminate them if possible

55
Q

Primary osteoporosis

2 types that are impractical clinically…?

A

type I: postmenopausal women 51-75 years; excess loss of trabecular bone; vertebral compression fractures and Colles fractures common

type II: men and women 70+; equal loss of both cortical and trabecular bone; fractures of femoral neck, proximal humerus, and pelvis = most common

56
Q

Secondary osteoporosis

A

obvious cause is present, such as excess steroid therapy/Cushing’s syndrome, immobilization, hyperthyroidism, long-term heparin, hypogonadism in men, vitamin D deficiency

57
Q

elderly patients and kyphosis

A

some elderly patients have progressive kyphosis (hunch-back deformity) bc they have multiple vertebral compression fractures

58
Q

osteoporosis is a silent dz

A

asymptomatic until a fracture occurs

59
Q

risk factors for osteoporosis

A
  1. estrogen depletion (postmenopausal : estrogen deficient state but not all postmenopausal women get osteoporosis; hx of athletic amenorrhea, eating disorders, oligomenorrhea; early menopause)
  2. female gender: women have lower peak bone mass and smaller vertebral end plates
  3. calcium deficiency/vit d deficiency
  4. decreased peak bone mass
  5. heritable risk factors: fam hx, european or asian ancestry, thinness/slight build
  6. decreased physical activity (prolonged immobility)
  7. endocrine: hypogonadism in men (with low testosterone), hyperthyroidism, vit d deficiency
  8. smoking and alcohol abuse
  9. medications: corticosteroids, prolonged heparin use
60
Q

mainstay of therapy for prevention and treatment of osteoprosis

A

exercise program w calcium and vit d supplements

61
Q

PROOF trial and calcitonin

A
  • no effect at hip
  • shown to decrease risk of vertebral fractures by as much as 40%
  • slight increase in bone density at lumbar vertebrae
62
Q

Clinical pearl: osteoporotic fracture risk assessment

A

validated risk factors for osteoporotic fracture risk that are independent of bone mineral density:

  • advanced age
  • previous osteoporotic fracture
  • long term steroid therapy
  • cigarette smoking
  • low body weight (< 58 kg)
  • fam hx hip fracture
  • excess alcohol intake
  • rheumatoid arthritis
  • secondary osteoporosis
63
Q

Highest morbidity and mortality among fragility fractures

A

hip fractures

64
Q

colles fracture

A

distal radius fracture usually due to fall on outstretched hand

65
Q

REcommend the following to all patients with osteoporosis

A

daily calcium
daily vitamin d
weight bearing exercise
smoking cessation

66
Q

Bone mineral density T-score criteria for osteopenia and osteoporosis

A

normal: >=1.0
osteopenia: bw -1 and -2.5
osteoporosis: <= -2.5 and fragility fracture

67
Q

DEXA (dual-energy x-ray absorptiometry)

A

if DEXA scan normal and no risk factors, repeat DEXA in 3-5 years

gold standard for precise measurements of bone density

68
Q

Indications for bone mineral density measurement

A

all woman >=65
postmenopausal women < 65 w 1 or more risk factors for fracture
men w risk factors for fracture

69
Q

Rule out secondary causes of osteoporosis before making dx

A

check calcium, phosphorous, alkaline phosphatase, TSH, vitamin D, free PTH, creatinine, CBC

70
Q

pts with fragility fractures receiving osteoporosis therapy?

A

most pts w fragility fractures dont subsequently receive osteoporosis therapy, despite data showing benefit in reducing risk of 2nd fracture

71
Q

smoking role in osteoporisis

A

accelerates bone loss

72
Q

1st line treatment osteoporosis

A

bisphosphonates

inhibit bone resorption
decrease osteoclastic activity (bind to hydroxyapatite) and decrease risk of fractures

oral bisphosphonates: alendronate, risedronate preferred

side efx: reflux, esophageal irritation, IV bisphosphonates

73
Q

PTH therapy (or human recombinant pth therapy)

A

pth is an effective drug that increases bone mineral density and reduces fracture risk but not 1st line (cost, subcutaneous admin, long term safety concerns)

max duration of treatment: 24 months (concern for osteosarcomas)

74
Q

Estrogen-progestin therapy to treat osteoporosis in postmenopausal women

A

no longer 1st line bc of increased risk of breast cancer, stroke, venous thromboembolism, and perhaps coronary artery disease

Ambulatory Medicine (19 decks)

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