Orhtopaedics/MSK Medicine Flashcards
Osteoarthritis radiological features (4)
- Joint space narrowing
- Subchondral sclerosis
- Osteophytes
- Subchondral cysts
- ?Joint erosions
?Diagnosis
Pain/swelling at posteromedial aspect of ankle
Seen in ballet dancers/jumping sports
pain w/ resistive flexion of great toe
Flexor hallicus longus tendinopathy
?Diagnosis
Pain/swelling posterior to medial malleolus
Worse w/ weight bearing, inversion against resistance/plantarflexion against resistance
Posterior tibial tendinopathy
?Which conditions (2)
Too many toes sign
-Medial ankle tendinopathy (posterior tib, flex. hal. longus)
-Posterior tib tendon rupture
?Diagnosis
Pain worse at night
Relieved by NSAIDs
Small radiolucent nidus (high prostaglandin production)
Prox. Femur most common, also tibia
Boys >girls
Osteoid osteoma
benign bone tumour
?Diagnosis
Pain worse at night
Relieved by NSAIDs
Small radiolucent nidus (high prostaglandin production)
Prox. Femur most common, also tibia
Boys >girls
Osteoid osteoma
benign bone tumour
Rheumatoid arthritis radiological features (4)
Loss of joint space
Erosions of joint margins
Subluxation
Subchondral cysts
Gout = punched out erosions
Ottawa Ankle rules
Need inability to weight-bear immediately + in ED
+ bone tenderness at posterior aspect of lat/med. malleolus, navicular/5th metatarsal base
How to differentiate between:
Tibia stress fractures vs. shin splints (medial tibial stress syndrome)
Stress # - pinpoint pain
Shin splints - wider area of pain
Muscle strain/tear Rx principles (4)
RICE initially + panadol
NO nsaids after 48 hrs (?inhibits muscle repair)
Exercise
Recover 5-8 weeks
Ligament sprain –> NSAIDs okay
Gastroc. tear Rx principles (4)
Firm elastic bandage
RICE (48 hrs)
Heel raise
–> passive stretching, strength training
?Diagnosis
-Middle age 40-60 y.o. ?Overload from lifestyle, exercise
-RFs - overweight/obesity, poor biomechanics, barefoot walking, abnormal foot arches
* History
○ Severe heel pain in morning/after rest
○ –> Subsides w/ movement but worsens again after prolonged weight-bearing
* Exam
○ Tenderness over medial calcaneal tubercle
○ Pain w/ dorsiflexion 1st toe
Plantar fasciitis
Osteoarthritis Pharm. Mx options (5)
- Topical NSAID QID
- Topical capsaicin 0.025% QID
- Panadol/panadol osteo/NSAIDs
- Intra-articular steroid injections
- Duloxetine 30mg –> 60mg daily
Opioids - limited role
Osteoarthritis examination findings (5)
○ Bony enlargement, weakness/wasting of muscles around joint
○ Crepitus
○ No redness/warmth/swelling
○ Joint line/peri-articular tenderness
○ Reduced ROM
- Minimal trauma # of hip/vertebra ->?next steps
- Minimal trauma # any other site ->?next steps
- DEXA for baseline bmd BUT straight to Rx (denosumab, bisphos, oestrogen replacement)
- DEXA scan -> if T score <-1.5 –> start Rx, if T score >-1.5 - refer for specialist r/v
Osteoporosis non-pharm Rx (5), pharm Rx options (3)
Non-pharm
-Falls reduction strategies
-Weight-bearing/strengthening exercise
-Diet (calcium >1g daily)/smoking/eTOH
-Healthy BMI
-Sun exposure
Pharm
-Bisphosphonates (e.g alendronate 70mg weekly)
–A/e myalgias, upper GI side effects, hypocalcaemia
–Rare risk osteonecrosis of jaw, atypical femoral shaft #
-Denosumab
–Compliance essential -↑risk vertebral fractures if suddenly stopped
–Rare risk osteonecrosis of jaw, atypical femoral shaft #
-Teriparitide - specialist, need >2 min trauma #s and T score < -3.0
When to recheck DEXA for osteoporosis (monitoring)
-Consider 2 years after starting Rx
-1-2 years after significant change to Rx
-If stable - recheck interval 2-5 years
—If worsening - check adherence, consider switching therapy
Bisphosphonate duration of therapy 5-10 years
?Diagnosis
consistent shoulder pain
Nocturnal pain + weakness
older age >65 y.o
Rorator cuff tendinopathy
or gleonhumeral/shoulder osteoarthritis
Rotator cuff tendinopathy Rx aspects (4)
-Complete rest contraindicated
-Reduced load - modified work/activity plan
-Physio - strengthening/ROM exercises
-NSAIDs/paracetamol
-short-term steroid injection benefit - ?detrimental med-long term?
?Limited evidence for subacromial decompression surgery
Carpal tunnel Rx options (4)
-Oral NSAID
-Local steroid injection (preferred for pregnant women)
-Overnight wrist splint
-Elevate hand overnight
Lateral epicondylitis clin. features (6)
○ Reduced grip strength
○ Pain w/ gripping
○ Pain w/ resisted extension
○ Pain w/ resisted supination
○ Pain w/ passive stretching of common extensor origin
○ Tenderness over distal/anterior lateral epicondyle/lateral supracondylar ridge
Lat/medial epicondylitis Rx options
- NSAIDs (oral OR topical up to QID)
- Steroid injections (6-12 week, short term benefit only)
- Physio/exercise - progressive loading program
4.
Imaging not that helpful
Lat/medial epicondylitis Rx options (4)
- NSAIDs (oral OR topical up to QID)
- Steroid injections (6-12 week, short term benefit only)
- Physio/exercise - progressive loading program
- ?brace ?enlarge grip surface of tools/rackets
Greater trochanteric pain syndrome - examination features (4)
○ Focal tenderness over greater trochanter
○ Passive external rotation w/ hip flexed 90 deg –> pain
○ Resisted de-rotation of externally rotated hip –> pain
○ Resisted hip abduction –> pain
De Quervain’s tenosynovitis clin. feautres (4)
Any Ix?
○ Pain + swelling over radial styloid, agg. by thumb motion/wrist deviation
○ Difficulties w/ lifting/grasping/twisting
○ Finkelstein’s test
○ Eichoff’s test - similar, but pt holds thumb in flexion using own fingers
-**USS** may be helpful (per eTG)
De Quervain tenosynovitis Rx aspects (3)
○ NSAIDs, steroid injections
○ OT/hand therapy for splint
§ 4-6 weeks for splint
○ Activity modification
○?Soft tissue massage ○ ?Taping ○ ?Graded pain-free exercises
?Diagnosis
Back pain insidious onset age <45
Worse in AM w/ morning stiffness
HLA-B27 +ve
Sacro-iliac joints + lower spine affected
Ankylosing spondylitis
Back pain red flags (4 main conditions)
Tumour:
-Hx. of cancer
-LOW
-Night pain
-Age >40 or <15 y.o
Fracture:
-History of trauma, or RFs for fragility #
Infection:
-Fever >38
-Night sweats/chills
-Immunosuppression
-IV drug use
Cauda equina:
-Urinary retention
-Saddle anaesthesia
-Progressive neuro - flaccid paralysis
Chronic back pain non-pharm Rx options (7)
-Education
-Cold/hot packs
-Weight loss (>5% of body weight)
-Early return to activity
-Exercise (low stress/light)
-Physiotherapy - strengthening, posture control, core exercises
-Pyschology - CBT, progressive relaxation
Chronic back pain pharm Rx options (5)
-Paracetamol
-NSAIDs
-Antidepressants
-?tapentadol
-Intra-articular facet joint injections
Acute low back pain DDx (many - think broad categories)
-Compression #
-Herniated disc nucleus pulposus (leg pain > back pain, worse w/ sitting)
-Lumbar strain/sprain
-Spondylolysis
-Spondylolisthesis (similar to spinal stenosis)
-Spinal stenosis (leg pain > back pain, worse w/ standing/waling, better w/ spine flexed, uni or bilat)
-Inflammatory spondyloarthropathy
-Malignancy
-Vertebral discitis/OM
-AAA
-GI conditions - pancreatitis, peptic ulcer disease, cholecystitis
-Herpes zoster
-Pelvic conditions - PID, endometriosis, prostatitis
-Retroperitoneal conditions - renal colic, pyelonephritis
Ottawa Knee Rules (after acute knee injury) (5)
○ Age >55
○ Tenderness over head of fibula
○ Isolated patellar tenderness
○ Inability to flex knee 90 deg
○ Inability to weight-bear
1 age, 2 palpate, 2 ROM
Osteoarthritis DDx (7)
- Crystal arthropathy
- Spondyloarthropathies
- Inflammatory arthritis
- Septic arthritis
- Fibromyalgia
- Tendinopathy
Osteonecrosis
Osteoporosis risk factors (many)
-Lifestyle
-Diseases
-Medications
See pic
JIA examination aspects (general) (6)
○ Joint exam
○ Lymphadenopathy
○ Hepatosplenomegaly
○ Fever/rash
○ Nail changes
○ Bruising/bleeding
JIA Ix (5) - when to order?
- Ix (if symptoms >4 weeks)
○ FBE
-ESR
-CRP
○ Xray
○ ?Autoimmune panel (discuss w/ paeds rheum) - do not use to screen as can be +ve in healthy kids
JIA Initial Rx (5)
○ NSAIDs, paracetamol (no evidence for topical NSAIDS)
○ Exercise
○ Diet - Calcium/Vit D supp
○ Heat/ice packs
○ Splints/foot orthotics
JIA DDx (8)
- Septic arthritis - acute painful monoarticular arthritis w/ fever
- Post-infectious/reactive (Ross River, mumps, Dengue)
- Rheumatic fever
- Trauma/NIA
* Inflammatory (IBD/sarcoidosis)
* Infection - OM/Lyme disease
* SLE, HSP
* Acute lymphocytic leukaemia
AC subluxation/seperation: return to sport timeframe?
2-6 weeks
Rx: RICE, broad arm sling
Osgood Schlatter Rx aspects (4)
○ Modification of sporting activities (avoid complete rest)
○ Quads strengthening/stretching exercises
○ Cold/ice packs post-activity
○ Knee-brace/strap during activity
?Diagnosis
○ Common in adolescents
○ Anterior knee pain - behind kneecap
○ Exac by running/jumping, or prolonged sitting (movie theatre sign)
○ +/- popping/catching sensation
○ Exam: +ve patellar grind test, audible/palpable crepitus
Patellofemoral pain syndrome
?Diagnosis
○ Irritation/impingement of infrapatellar fat –> burning/aching pain below kneecap
Infrapatellar fat pad (Hoffa’s) syndrome
?MRI
Achille’s tendinopathy examination aspects (2)
Management (5)
○ ?Pain exac by dorsiflexion - Achilles tendon irritation
-Squeeze test - test tendon integrity
Rx: - ○ Avoid exacerbating activity ○ NSAID short course ○ Heel raise/pad in shoe ○ Physio - calf strengthening exercises ○ Topical Rxs - ?NSAID + neuropathic cream medication
Acute haemarthrosis DDx (3)
Intra-articular fracture
ACL rupture
Patella dislocation
Inability to straighten knee DDx (5)
- Injury to quad tendon
- Injury to patella tendon
- Patella fracture
- Loose chondral/osteochondral defect
- ACL/meniscal tear
Areas to optimise pre-operatively for TKR (7)
Diabetes
Smoking
Weight - Aim BMI <40
Opioid use
Anaemia
Malnutrition
Vit D deficiency
