Ortho Flashcards
red flags for back pain
night pain and weight loss (tumor)
fevers, chills, sweats (bone or disc infection)
acute bony tenderness (fracture)
morning stiffness > 30 min in young adult (seronegative spondyloarthropathy)
urinary/bowel retention, saddle anesthesia (cauda equina)
recent spinal instrumentation (spinal epidural abscess or hematoma)
immunodeficiency (bone or disc infection)
extremes of age
coagulopathy (spinal epidural hematoma)
others - failure to improve w tx, pain for > 6 weeks
sx herniated disc (nucleus pulposus)
radicular back pain usually unilateral may radiate down leg w paresthesias or numbness in a dermatomal pattern
where is herniated disc MC
L5-S1
MC cauda equina
massive lumbar disc herniation
Sx cauda equina
back pain
bilateral leg radiation of pain
weakness
saddle anesthesia - decreased sensation in butt, perineum, inner surface of thigh, erectile dysfunction
urinary/bowel dysfunction new onset
decreased anal sphincter tone (decreased anal wink test)****
dx cauda equina
immediate MRI
CT myelography if pacemaker
tx cauda equina
emergency decompression + corticosteroids
sx spinal stenosis
back pain, numbness, paresthesias worsened w extension
relieved w flexion - sitting, bending forward, leaning over shopping cart, walking uphill, cycling
dx spinal stenosis
MRI
sx lombosacral sprain/strain
back pain and spasms that are activity-related
DOES NOT RADIATE TO LEGS
no neurologic sx
PE lumbosacral sprain/strain
paraspinal muscle tenderness
no neurological changes
may be normal exam
MC cause spinal epidural abscess
staph aureus
classic triad for spinal epidural abscess
fever + spinal pain + progressive neurologic deficits
dx spinal epidural abscess
MRI w gadolinium
tx spinal epidural abscess
aspiration, drainage, abx (Vancomycin plus either Cefotaxime or Ceftriaxone)
Cobb angle to dx scoliosis
> /= 10 degrees
tx scoliosis
observation if < 25 degrees
bracing 25-39 degrees
surgical correction if > 40 degrees
spondylosis
pars interarticularis defect due to failure of fusion or stress fracture
MC location spondylosis
L5-S1
sx spondylosis
low back pain w activity
most asx
dx spondylosis
lateral radiographs - radiolucent defect in pars
oblique radiographs - scotty dog
spondylolisthesis
forward slipping (subluxation) or a vertebra on another due to b/l fracture or defect of pars interarticularis
MC cause septic bursitis
staph aureus
pts w limitation of joint movement should be evaluated for
septic arthritis
gold standard bursitis
bursa fluid culture
tx MSSA bursitis
cephalexin or dicloxacillin
tx MRSA bursitis
trimethoprim-sulfamethoxazole or IV vancomycin and Cefazolin
MC locations septic bursitis
olecranon
infrapatellar
pre patellar bursa
difference btwn costochondritis and Tietze syndrome
costochondritis - pleuritic chest pain that may be worse w inspiration, coughing, certain body movements; reproducible point wall tenderness + absence of palpable edema; more than one area of reproducible tenderness
age < 40
can be caused by carrying book-bag over one shoulder***
Tietze syndrome - pleuritic chest pain that may be worse w inspiration, coughing, certain body movements; reproducible point chest wall tenderness w palpable edema
age > 40
in what population is fibromyalgia MC
women 20-50
sx fibromyalgia
multiple tender points (>/= 11 out of 18)
fatigue
chronic headache
sleep disorders
subjective numbness
more prominent in the morning and aggravated by minor exertion
American college of rheumatology criteria for dx of fibromyalgia
widespread pain index > 7
symptom severity scale > 5
OR
widespread pain index 3-6
symptom severity scale > 9
sx present for at least 3 mos
conservative tx fibromyalgia
sleep hygiene
low impact aerobic exercise (swimming, walking, biking)
CBT
pharm therapy for fibromyalgia
TCA (amitriptyline)
SSRI (fluoxetine)
SNRI (duloxetine, Milnacipran)
cyclobenzaprine
pregabalin
gabapentin
MC soft tissue tumor of the hand
ganglion cyst
MC location ganglion cyst
dorsal aspect of wrist over scapholunate joint
will ganglion cysts transilluminate
yes
solid tumors will not
tx asx ganglion cyst
observation and reassurance
tx sx ganglion cyst
brace
needle aspiration
surgical excision - definitive; if needle aspiration ineffective
a ganglion cyst is associated w
a degenerated joint capsule or synovial tendon sheath that contains gelatinous fluid
is gout more common in men or women
men
meds that trigger gout attack
thiazide and loop diuretics
ACEI
pyrazinamide
ethambutol
aspirin
ARBS (losartan is exception)
sx gout
intermittent, acute mono or oligoarthritis esp of the first metatarsophalangeal joint
flares usually occur overnight and early morning
flares reach max intensity in 12-24 h
resolution 2 weeks
may have fever, chills, malaise, fatigue
dx gout
arthrocentesis - negatively birefringent needle shaped crystals
radiographs - mout or rate bite lesions (punched out erosions w sclerotic and overhanging margins)
tx acute gout
NSAIDs
glucocorticoids
colchicine
MC joint in PSEUDOgout
knee
pseudogout
calcium pyrophosphate dihydrate deposition in joints and soft tissues
dx pseudogout
arthrocentesis - positive birefringent, rhomboid-shaped calcium pyrophosphate crystals
radiographs - linear calcification of cartilage (chonedrocalcinosis)
tx pseudogout
corticosteroids
NSAIDS
colchicine
PE osteoarthritis
hard body joint
crepitus
audible grating sound
Heberden node (DIP enlargement)
Bouchard node (PIP enlargement)
dx osteoarthritis
asymmetric joint space narrowing
marginal osteophytes (bone spurs)
subchondral bone sclerosis or cysts
normal DEXA
1 or greater
DEXA osteopenia
T score -1 to -2.5
DEXA osteoporosis
T score -2.5 or less
bisphosphonates
alendronate
ibandronate
pamidronate
risedronate
zoledronate
sx plantar fasciitis
pain in the plantar region of the foot (inferior and medial heel, sole of the foot), often sharp, usually worse AFTER period of rest when initiating walking
pain decreases after further ambulation, massage, stretching
PE plantar fasciitis
local point tenderness of plantar fascia and plantar medial calcanea tuberosity
pain can be reproduced w passive dorsiflexion of foot and toes
sx psoriatic arthritis
asymmetric inflammatory oligoarthritis
DIP involvement
dactylitis - uniform swelling of fingers/toes (sausage digits)
sacroiliitis and spondylitis
enthesitis - Achilles tendon, plantar fasciitis, medial and lateral epicondyles
psoriasis - erythematous plaques w thick silvery-white scales and nail pitting
dx psoriatic arthritis
pencil in a cup deformities
tx psoriatic arthritis
NSAIDs
risk ankylosing spondylitis
young males 15-30
HLA-B27 positive
sx ankylosing spondylitis
low back pain and neck pain - insidious onset, stiffness, decreased ROM worse at night and in morning, not improved w rest
improves w exercise and activity
sacroiliitis and arthritis
enthesopathy
dactylitis
dx ankylosing spondylitis
bamboo spine - loss of normal lumbar curvature + bridging syndesmophwytes
tx ankylosing spondylitis
NSAIDs
MC cause reactive arthritis
chlamydia trachomatis
sx reactive arthritis
arthritis + conjunctivitis/uveitis + urethritis/cervicitis/balanitis
keratoderma blennorrhagicum - hyperkeratotic lesions on palms and soles
circinate balanitis - painless erythematous lesions w small shallow ulcers on glans penis and urethral meatus
tx reactive arthritis
NSAIDS
sx rheumatoid arthritis
joint pain, stiffness, swelling worse in morning w morning stiffness > 1 hour after initiating movement, improves later in the day
spares the DIP
PE rheumatoid arthritis
symmetric inflamed joints - warm, erythematous, soft “boggy”
ulnar deviation
rheumatoid nodules
dx rheumatoid arthritis
rheumatoid factor
Anti-CCP more specific
radiographs - symmetric joint narrowing, osteopenia, bone and joint erosions
may have C1-C2 subluxation
tx rheumatoid arthritis
DMARD - Methotrexate or Leflunomide + NSAIDs or glucocorticoids
