1. Minimal trauma of hip/vertebra ->?next steps 2. Minimal trauma any other site ->?next steps

1. DEXA for baseline bmd BUT straight to Rx (denosumab, bisphos, oestrogen replacement) 2. DEXA scan -> if T score start Rx, if T score >-1.5 - refer for specialist r/v

Orhtopaedics/MSK Medicine Flashcards by Viet Nguyen

Osteoarthritis radiological features (4)

Joint space narrowing
Subchondral sclerosis
Osteophytes
Subchondral cysts
?Joint erosions

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?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

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?Diagnosis

Pain/swelling posterior to medial malleolus
Worse w/ weight bearing, inversion against resistance/plantarflexion against resistance

Posterior tibial tendinopathy

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?Which conditions (2)

Too many toes sign

-Medial ankle tendinopathy (posterior tib, flex. hal. longus)
-Posterior tib tendon rupture

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?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

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?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

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Rheumatoid arthritis radiological features (4)

Loss of joint space
Erosions of joint margins
Subluxation
Subchondral cysts

Gout = punched out erosions

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Ottawa Ankle rules

Need inability to weight-bear immediately + in ED
+ bone tenderness at posterior aspect of lat/med. malleolus, navicular/5th metatarsal base

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How to differentiate between:

Tibia stress fractures vs. shin splints (medial tibial stress syndrome)

Stress # - pinpoint pain
Shin splints - wider area of pain

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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

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Gastroc. tear Rx principles (4)

Firm elastic bandage
RICE (48 hrs)
Heel raise
–> passive stretching, strength training

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?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

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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

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Osteoarthritis examination findings (5)

○ Bony enlargement, weakness/wasting of muscles around joint
○ Crepitus
○ No redness/warmth/swelling
○ Joint line/peri-articular tenderness
○ Reduced ROM

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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

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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

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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

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?Diagnosis

consistent shoulder pain
Nocturnal pain + weakness
older age >65 y.o

Rorator cuff tendinopathy
or gleonhumeral/shoulder osteoarthritis

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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 ## Footnote 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 Less common * Inflammatory (IBD/sarcoidosis) * Infection - OM/Lyme disease * SLE, HSP * Acute lymphocytic leukaemia

AC subluxation/seperation: return to sport timeframe?

2-6 weeks ## Footnote 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 ## Footnote ?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