Ortho Flashcards
Muscles of the rotator cuff
SITS: Supraspinatus Infraspinatus Teres Minor Subscapularis
Scapular winging
Indicates weakness of the serratus anterior muscle
Yergason test
Tests if the biceps tendon is stable in the bicipital groove
Grasp flexed elbow in one hand while holding the wrist in the other, externally rotate patients arm as they resist.
Positive test: the tendon will pop out of the groove
Drop arm test
Will indicate if any tears in the rotator cuff
Patient will not be able to lower their arm smoothly from 90 degree ABDuction
Salter-Harris classification
Type 1: Seperation at epiphyseal plate straight accross
Type 2: Partially at epiphyseal plate but also into metaphysis
Type 3: Horizontal in epiphseal plate and also into the epiphysis
Type 4: Metaphysis through the epiphyseal plate and into the epiphysis.
Type 5: Crush, erasure of growth plate
Ottawa rules for ankle
X-ray are required if:
- any pain in the malleolar zone and
- bone tenderness along distal 6 cm of the posterior edge of the tibia or tip of medial malleolus
- bone tenderness along the distal 6 cm of posterior edge of the fibula or tip of the lateral malleolus
- an inability to bear weight both immediately and in the ED
Ottawa rules for the knee
X-ray is indicated if have acute knee pain and at least one of the following:
- Age 55 or greater
- Tenderness at the head of fibula
- Isolated tenderness of patella
- Inability to flex to 90 degrees
- Inability to bear weight both immediatedly and in the ED (4 steps)
Describe indications, CI, AE, etc. for muscle relaxants
Indication: muscle spasms
CI: Felxeril: hyperthyroidism, arrhytmias, acute MI, with MAOIs
Valium: preggo cat D, myasthenia gravis, actue ETOH WD, respiratory depression, avoid grapefruit juice
Soma: hx of porphyria
Skelaxin: hepatic/renal impairment, hx of drug induced hemolytic anemia
Robaxin: renal impairment
Name types of muscle relaxants and their MOA
cyclobenzaprine (Flexeril): similar to TCA
Diazepam (Valium): modulates postsynaptic effects of GABA transmission, also acts for calming (anxiety, seizures, status epilepticus, ETOH withdrawl
Carisoprodol (Soma): unknown
Metaxolone (Skelaxin): CNS depression
Methocarbamol (Robaxin): unknown (also used for tetanus)
Describe MOA, indications, CI, AE, etc. for Colchicine
MOA: decreases leukocyte mobility, reduces deposition of urate crystals
Indication: treat w/in 36 for gout attack
CI: pts w/ blood dyscrasias, hepatic or hepatobiliary dysfucntion
AE: GI 50-80% (N/V/D), and more
Interactions: CYP 3A4 inhibitors
Patient ed: narrow therapeutic range
Describe MOA, indications, CI, AE, etc. for Probenecid (Benemid)
MOA: promotes renal clearance of uric acid by inhibiting urate-anion exchanger in the proximal tubule
Indications: gout and to increase Beta-lactam ABX (prolongs plasma levels)
CI: Blood dyscrasias, young children, salicylates, uric acid kidney stones
Initiate treatment once attack has subsided
Pt. ed: hydrate
Describe MOA, indications, CI, AE, etc. for Allopurinol
MOA: lower production of uric acid
Indications: 2 weeks after gout attack, calcium renal calculus, hyperuricemia
CI: GFR less than 50, monitor CBC, serum uric acid
AE: acute gout attacks during the first months of tx, etc
Pt ed: keep taking during gout attack, start low go slow
Hyperextension/Hyperflexion of cervical spine
Hyperextension of C spine: (due to high force injury, aka MVA)
- acute onset of pain; can occur hours after injury: neck/jaw pain, stiffness, muscle spasm
Hyperflexion of C spine: (due to high force injury, aka MVA)
- acute onset of pain
- workup: teardrop fracture or compression fracture seen on x-ray
- managment: rest, possible neck brace, NSAIDs, ice
Intervertebral disc herniation
MOA: due to degenerative disease (bending, lifting, causing herniation and extrusion of disc contents)
- pain in dermatomal pattern (increased pain with coughing, straining, bending, sitting).
- most common L5-S1
Work up: straight leg test, cross over test, can have strength, relex and sensibility deficits; MRI diagnostic
Mgmt: NSAIDs, ice, PT, possible referral
Acute lumbosacral strain
Acute strain or tear of paraspinal muscles especially after twisting/lifting injuries
- back muscle spasms, loss of lordotic curve, decrease ROM, no neurologic changes
Workup: not much
Tx: very brief bed rest (less than 2 days), NSAIDs, muscle relaxants
Bicipital tenosynovitis
Eti: overuse injury or trauma (friction of head of biceps along the bicipital groove)
S/sx: anterior shoulder pain that can radiate down the bicep, abduction/external rotation painful, tendon can rupture (very painful)
Dx: yergason test, MRI, or exploratory surgery
Tx: NSAIDs, steroid injection, ortho surgery if rupture
Rotator cuff tendonitis/rupture
Eti: Fall on outstretch arm; also repetitive overuse movements
S/sx: Most commonly torn muscle (supraspinatus), difficulty lifting arm, limited ROM (especially overhead), pain when sleeping, anterior deltoid region
Dx: drop arm test, Neer/Hawkings test (help rule out bursitis), empty can test (tests supraspinatus), MRI, PROM greater than AROM
Tx: partial tears usually heal on own, full thickness need surgery
Subacromial bursitis
Eti: inflammation of bursa, can be due to autoimmune dx (RA), crystal deposition (gout), infection, etc.
S/sx: often presents as pain along front and side of shoulder (gradual or acute onset), pain when sleeping on affected shoulder
Dx: physical exam tests, MRI diagnostic
Tx: NSAIDs, PT, cryotherapy, steroid injection, ortho referral
Epicondylitis, lateral
Tennis elbow
Eti: inflammation of tendon insertion of extensor carpi radialis brevis due to repetitive pronation of forearm and wrist extension
Dx: Wrist extension against resistance, pain over lateral epicondyle and can radiate down the arm
Tx: Ice, NSAIDs, stretching/strengthening, steroid injection, PT
Epicondylitis, medial
Golfers elbow
Eti: inflammation over pronator teres, carpi radialis due to repetitive stress at tendon insertion of flexor forearm muscle
Dx: pain with wrist flexion against resistance
Tx: Ice, NSAIDs, stretching/strengthening, steroid injection, PT
Olecranon bursitis
Inflammation of bursa over the elbow
Eti: gout, inflammation, direct trauma, infections
S/sx: abrupt gooses egg swelling (boggy, tender, red), can be painless or painful
Dx: limited ROM with flexion, evaluate for skin breaks, aspirate. If septic bursitis: bursa aspiration shows WBC greater than 5000
Tx: rest, NSAIDs, local steroid injection, padding, motion restriction
Carpal tunnel syndrome
Eti: median nerve entrapment/compression at carpal tunnel
S/sx: paresthesias/pain of palmer 1st 4 digits especially at night
- pain can radiate to neck, shoulder, chest
- advanced: thenar muscle wasting (can cause weakness in the thumb)
Dx: tinel’s and phalen’s (30-60 seconds)
Tx: volar splint, NSAIDs, corticosteroids, surgery if refractory
Ganglion cysts
Most common soft tissue tumor of the hand and wrist
S/sx: palpable/visable lump, common on wrist, digital flexor sheath or DIP, no pain
Dx: clinical
Tx: leave alone, if removed high recurrence rate
De Quervain’s tenosynovitis
Eti: Stenosing tenosynovitis of abductor pollicus longus and extensor pollicus brevus. Due to repetitive thumb action
S/sx: pain along radial aspect of the wrist radiating to the forearm especially with thumb extension or gripping
Dx: finkelstein test
Tx: thumb spica splint x 3 weeks, NSAIDs, steroid injection, PT, surgery
Ulnar nerve entrapement
Eti: ulnar nerve compressed and irritated
S/sx: numbness and tingling in hands and fingers (5th and 1/2 of 4th digit), weak grip, muscle wasting if advanced
Dx: ?
Tx: avoid activities that keep the elbow bent over long time, NSAIDs, bracing/splinting, PT, surgery?
Dupuytren’s contracture
Most common in men 40-60 yo, genetic predisposition (NW Europeans). Contractures of palmar fascia due to nodules/cords; fixed flexion deformity at MCP
S/sx: nodules over distal palmar crease or proximal phalynx (ring, middle finger); nodules often painful
Dx: exam
Tx: intra-lesional steroid injection, collagease injection, PT, surgery if contracture greater than 30 degrees
Trochanteric bursitis
Eti: acute trauma (fall/tackle), repetitive trauma (ITB during running or walking)
S/sx: pain in the greater trochanteric region of lateral hip, can radiate down lateral aspect of ipsilateral thigh, but not down to the foot, hip movements may make symptoms worse
Dx: MRI, aspiriation
Tx: rest, ice, steroid injections, NSAIDs, surgery if refractory
Medial meniscus injuries
Eti: degenerative from squating, twisting, compression or trauma with rotation and axial loading
S/sx: locking, popping, giving away, effusion post activities, swelling along the joint line, antalgic gait, difficulty squating
Dx: McMurry sign (pop or click while tibia externally and internally rotated), Apley test, joint line tenderness, effusion, xrays, MRI confirmatory
Tx: NSAIDs and partial weight bearing until ortho eval
- ROM exercises, cryotherapy, steroid injections, bracing, surgery
Chondromalacia patellae
Idiopathic softening/fissuring of patellar articular cartilage (most common in runners)
S/sx: anterior knee pain behind or around the patella worse with prolonged sitting (knee bent), running, jumping, climbing stairs
Dx: apprehension sign (push laterally on the patella when knee is 30 degree in flexion)
Tx: Strengthen vastus medialis oblique, weight loss, NSAIDs, sleeve for patellar stabilization
Pre-patellar bursitis
Eti: inflammation of bursa in front of patella, pressure of constant kneeling (plumbers etc.), direct blow to the knee
S/sx: pain with activity, swelling of front of kneecap, tender and warm to touch
Dx: aspiration, xray, MRI
Tx: RICE, NSAIDs, aspiration if regractory
Baker’s cyst
Eti: synovial fluid effusion (ex from meniscal tear) is displaced to form cyst
S/sx: popliteal mass, aching, knee effusions, clicking, buckling, locking of the knee.
- cyst usually not painful, but rupture can mimic a DVT
Dx: US (helps rule out DVT)
Tx: Ice, assisted weight bearing, NSAIDs, intraarticular injections, surgical excision if refractory
Anterior cruciate ligamentous injuries
Most common knee ligament injured, usually sports injury. Non-contact pivoting injury, deceleration, hyperextension, internal rotation.
S/sx: associated with “pop and swelling”, hemarthrosis,, knee buckling, inability to bear weight
Dx: Lachman, anterior drawer, xray, MRI
Tx: RICE, crutches, NSAIDs, sometimes repair, PT always
Posterior cruciate ligamentous injury
Associated with dashboard injury, or direct blow injury, fall on flexed knee
S/sx: hemarthrosis, large effusion, inability to bear weight, instability of joint, antalgic gait
Dx: Posterior drawer test, MRI
Tx: Almost all treated operatively (RICE, NSAIDs)
Medial/ lateral collateral ligamentous injuries
MCL: VALGUS force, LCL: VARUS force
S/sx: effusion, tenderness, localized swelling, ecchymosis, stiffness
Dx: Valgus varus stress applied, MRI
Tx: RICE, NSAIDs, grade 1 and 2: conservative, grade 3: surgical repair
Hallux valgus
Aka: bunion Medial deviation of the first metatarsal Lateral deviation of the hallux Eti: Biomechanical instability? S/sx: Pain with 1st metatarsal lateral deviation Dx: clinical Tx: Footwear, surgery...
