Ortho Flashcards
DDx for neck and upper back pain
- Cervical radiculopathy
- Cervical sopndylosis or stenosis
- Herpes zoster
- Angina pectoris
- SAH
- Meningitis
- Epidural abscess
Sx of a mechanical injury
Poor posture/sleep: HA, stiffness, tightness, spasm, rarely weakness, sometimes paresthesias
Forced hyperflexion/extension (rear end collision): occipital HA, sometimes malaise, dizziness, fatigue
Sx radiculopathy / nerve root compession (foraminal stenosis, C6, C7 common)
Sharp, burning, tingling w/associated unilateral weakness often in a myotomal pattern
C6: weak biceps, brachioradialis, wrist ext
C7: weak triceps, finger flex/extensors
Sx cord compression (spondylosis, stenosis, disc herniation)
BL weakness/paresthesias UE LE
Cervical flexion often exacerbates
DDx for shoulder pain
- Rotator cuff tendinopathy
- Adhesive capsulitis
- Biceps tendinosis/tendonitis
- Calcific tendonitis
- Subacromial bursitis
- Septic arthritis
- Lyme
- Gout, pseudogout
- Arthritis
- Dislocation
- Referred pain (gallbladder, MI, etc)
DDx hand pain
- Traumatic: sprain, fracture, repetitive movement/overuse syndrome, mallet deformity, dislocation, depuytren’s contracture, fight bites
- Non-traumatic: ganglion cyst, arthritis (osteo, gouty, rheumatoid), infection, radiculopathy
Concern if tenderness at snuffbox
Scaphoid fracture
Risk of avascular necrosis
DDx wrist pain
Scaphoid fracture, dequervain’s, overuse, sprain, carpal tunnel
What is avulsion?
such a bad sprain that it pulls piece of bone off.
DDx elbow pain
- Lateral / medial epicondylitis
- Cubital tunnel syndrome (ulnar nerve entrapment)
- Olecranon bursitis
- Septic arthritis
- Local cellulitis
- Biceps tendon strain/rupture
- OA
What is neuropraxia?
- Saturday night palsy
- disorder of the peripheral nervous system in which there is a temporary loss of motor and sensory function due to blockage of nerve conduction, usually lasting an average of six to eight weeks before full recovery. Common after falling asleep on one’s outstretched arm
Etiology of low back pain
- Musculoligamentous strain, DDD or facet arthritis (usually responds to symptomatic tx)
- Disc dz – spondylosis, spondylitis, spondylolisthesis (recurring mild lumbar discomfort & episodes severe back pain w/sciatica (or any radicular sx))
- Occasionally problems outside spinal axis (renal, MI, AAA, statin, electrolyte imbalance)
If patient has lateral curve of spine when trying to stand, this indicates…
Muscle spasm
Sx of mechanical low back pain
- Stiffness, Tightness, Spasm, Rarely Weakness, Sometimes Paresthesias.
- Forced Hyperflexion/Extension (Rear End Collision) Common Cause.
Sx of radiculopathy as cause of low back pain
- Nerve root compression (l4-5, l5-s1 common). Sharp, burning, tingling with associated unilateral weakness often in a myotomal pattern, deep.
- Cord compression (spondylosis, stenosis, disc herniation) pain
- with bilateral weakness/paresthesias both le. Often exacerbates.
Diagnostic tests for AAA
CT, U/S ED eval
Diagnostic tests for MI
EKG, ED eval
Diagnostic tests for spinal epidural abscess
MRI w/contrast
Diagnostic tests for metastatic dz
LS plain film
Diagnostic tests for renal colic
UA, CBC, BUN, Cr, CT abd/pelvis w/o contrast, ED eval
What is spondylosis
- Degenerative OA of joints between center of spinal vertebrae and / or neural foraminae
- Also refers nonspecifically to any and all degenerative conditions affecting discs, vertebral bodies, and/or associated joints of lumbar spine
- Bone on bone
What is spondilolisthesis ?
- Vertebral bodies not lined up, shift forward
- Can happen acutely or overtime
- May be assoc w/spondylolysis, a break in vertebra typically in region of pars interarticulus
What is ankylosing spondylitis
- Chronic process that causes inflammation of various vertebral joints and joints between the spine and pelvis
- Eventually, affected spinal bones join – lordotic curve is straightened
Image of disc problems
When are dermatomes useful?
- Zoster, cervical/lumbar nerve root
- Not always perfectly in one dermatome
Short term mgmt. lumbar injuries
Reduce pain, increase mobility, minimize # missed work days
Long term mgmt / goals of lumbar injuries
- Complete resolution of strain/spasm
- Prevention of recurrence
- Avoid chronic pain
- Avoid dependence on controlled substances
When to do radiography for lumbar pain
- Plain film of lumbar spine if >55yo, trauma, hx ca
- Low utility – not for use if strained, spasm, no hx trauma
When to do MRI w/lumbar pain
- MRI w/o contrast if neuro sx persist >6-12w
- NOT for routine use, $$$
When to do CT for lumbar pain
Detailing bony or ligamentous changes
Not typically done
Labs for lumbar pain
Not usually necessary
If myopathy:
- Na, K, Ca, Mg, Glc
- AST, ALT, alk phosph, total bili
- CK
UA if UTI possible
Med MGMT of lumbar pain
- NSAIDS: ibuprofen 600mg PO QID PRN, naproxen 375-500 mg PO BID prn, Toradol 60mg IM, etc
- Muscle relaxants
- Topicals: lidocaine, Flector patches, Diclofenac gel…
- Opiates
Non-Rx mgmt. of lumbar pain
- Ice –often better than moist heat for strain/spasm
- Moist heat
- Massage
- Gentle ROM
- Refer to PT prn
When to refer to orthopedist for lumbar pain
- Neuro deficits
- Imaging reveals good candidate for steroid injections or surgery
- No better despite conservative tx
Ottawa Knee Rule
If any of following, get xray
- Tenderness at head of fibula
- Isolated tenderness of patella
- Inability to flex knee to 90 deg
- Inability to bear weight for four steps both immediately and in the exam room regardless of limping
Patellar dislocation: mgmt.
If you know it was this, only twisting injury, give medial pressure to knee and extend knee to reduce
S/S of a soft tissue infection
erythema, swelling, warmth, tenderness
Labs / imaging & tx for suspected soft tissue infection
- ESR, CBC w/diff, gram stain, tissue and blood cultures w/sensitivity
- Possible imaging studies to determine extent, r/o joint/bone involvement
- If pos gram stain or culture –> antibiotics
S/S of monoarthritic joint infection
pain, limitation of active/passive motion, fever, effusion
Risk factors to evaluate in joint infection
Evaluate risk factors: trauma, diabetes, RA, OA, HIV, complement deficiency, IV drug use, indwelling cath, SSA, immunosuppression, etc
DDx for monarthritis joint infection
nongonococcal septic arthritis
gonococcal arthritis
crystal
reactive arthritis
S/S of polyarthritic joint infection
fever, skin lesions, tenosynovitis
DDx for polyarthritic joint infection
NGSA, GA, bacterial, crystal, viral, reactive arthritis
Diagnostic investigation of suspected joint infection
arthrocentesis
Blood culture
if GA suspected: culture and PCR from cervix, urethra, rectum, throat
S/S of bone infection (osteomyelitis)
pain, swelling, erythema, drainage, fever, risk factors
Diagnostics for suspected osteomyelitis
- CBC w/diff: WBCs elevated
- ESR: elevated, may be nl if chronic
- blood cultures: may be pos, often neg if chronic
- imaging:
- U/S, PET, CT, MRI
- MRI is most sensitive/diagnostic unless orthopedic implants
- Refer for needle biopsy and aspiration if bony involvement present. C&S if positive
Common offender in osteomyelitis
SA
In what populations / anatomical areas is osteomyelitis most common?
bones of foot in adult patients w/diabetes, neuropathy, arterial insufficiency
Hematogenous seeding of spine from a distant infection: less frequent than in foot
Clinical picture of lumbar spinal stenosis
- Positions that extend the spine (standing, walking down hill, prone lying, and extending the back) worsen symptoms
- positions that flex the spine (sitting, bending forward, placing weight on a walker or cart, and lying in a flex position) relieve the symptoms.
- Pain in the lower back or legs, which comes on with prolonged standing and walking and is relieved with sitting.
- Leg pain: classic picture of sciatica (pain radiating from the posterior aspect of the buttock down to the foot) or an incomplete “pseudoclaudication” syndrome- patient feels pain only in the calf while standing and walking.
- should not produce pain lying to sitting or with bending, stooping, or lifting objects.
MRI and lumbar spinal stenosis
In a masked study comparing radiologic and electrodiagnostic diagnoses to clinical impression, MRI findings and their interpretation did not relate in any important way to the clinical diagnosis of lumbar spinal stenosis.
Majority of low back pain in older adults
not tumors, infections, lumbar spinal stenosis, or vertebral compression fractures
They are best described as patients with mechanical back pain of uncertain etiology
Characteristics of mechanical low back pain
- Intermittent sharp back pain
- Pain comes on and subsides rapidly
- Pain going from lying to sitting and with bending
- Asymmetric loss of motion of lumbar spine
- Weakness of L4, L5, L5, and S1 innervated muscles
Low back pain: disc herniation in younger vs older pts
- Pain is not from disc itself, but soft tissue displacement
- In a young lumbar spine, the central nucleus pulposus often herniates outside the annulus fibrosis and indents the pain-sensitive posterior longitudinal ligament and dura mater, producing pain that often lasts for several weeks and occasionally causing sciatica owing to nerve root irritation
- Because of decreased water content, the nucleus pulposus becomes less gel-like as one ages and rarely herniates after the age of 55 years.
What is “unstable lumbar spine” in older adults?
- asymmetric loss of range of motion in the lumbar spine, paravertebral muscle spasm, weakness of the L4-, L5-, and S1-innervated muscles, and pain going from the flexed to the erect position
- often have one intervertebral disc space narrowed and sclerotic out of proportion to other disc spaces, and anterior displacement of one vertebra on another (spondylolithesis)
- mechanical pain
Gradually worsening progressive pain, lasting more than a month, which is nonpositional and associated with systemic symptoms and signs, should suggest …
tumor
Pain that is worse when going from sitting to standing and that causes a limp …
indicates possible hip disease.
Hip disease can often mimic back problems.
Patient with vertebral compression fractures: PE
may have a good deal of tenderness in the lumbar spine but should have no neurologic abnormalities.
Patients with osteoporotic sacral fractures: PE
will have sacral tenderness, but a normal lumbar spine examination and no lower extremity muscle weakness.
Sciatica: PE
almost always have L4, L5 and L5, S1 weakness.
A patient with persistent, severe back pain, but with a normal examination of the lumbar spine, sacrum, and hips and no evidence of L4, L5 or L5, S1 muscle weakness, should be evaluated thoroughly for a…
possible neoplasm or infection.
Labs/imaging for lumbar back pain in older adults
Imaging: changes are common and not well correlated w/back pain. Should only be used to confirm.
CBC w/diff, ESR reasonable if suspect infection, tumor
