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MSK/Rheum Exam- Clin Med > Ortho-lower > Flashcards

Ortho-lower Flashcards

1
Q

Degeneration of articular cartilage
Thickening of subchondral bone
Periarticular osteophyte formation
Synovial inflammation

A

Osteoarthritis of hip

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2
Q

Percentage of adults over 70 w OA

A

80%

Leading cause of disability in elderly

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3
Q

Predisposing factors to OA

A

Advanced age
Increased BMI
Possible genetic
Increased external forces..running, weight lifting

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4
Q

Systemic secondary predisposing factors to OA

A 
Gout
Hemachromatosis
Hyperparathyroidism
Pagets
Hypothyroidism
Acromegaly
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5
Q

Localized secondary predisposing factors to OA

A 
Congenital deformity
Trauma
Perthes dz
RA
Septic arthritis
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6
Q 
Progressive hip or groin pain
Increased pain w activity 
AM pain>PM pain
Crunching noises
Decreased ROM
A

OA in hip

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7
Q 
PE shows..
Limp w ambulation
Decreased AROM and PROM (int and ext rotation)
Palpable/audible crepitus w motion
Possible tenderness over groin 
Possible decreased MMT
A

Hip OA

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8
Q

X rays in hip OA

A 
AP pelvis, lateral hip
Looking for...
Osteophyte formation
Decreased joint space 
Subchondral sclerosis and cysts
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9
Q

Hip OA conservative treatment

A 
NSAIDs / acetaminophen 
Activity modification
Weight reduction 
PT
Cortisone injection
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10
Q

Hip OA surgical tx

A

Total hip arthroplasty
Arthroscopic debridement
Femoral head resurfacing..younger patients

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11
Q

Osteonecrosis
Bone death due to disruption of blood supply to bone/femoral head
Osteocytes, osteoblasts, osteoclasts die within 24-48 hrs of oxygen deprivation
Reperfusion may occur to regenerate bone growth

A

Avascular necrosis

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12
Q

Avascular necrosis epidemiology

A

Male>female
30-50 yo
Up to 60% bilateral
Kids age 5-9… Legg Calves Perthes dz

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13
Q

Causes of avascular necrosis

A 
ETOH
Steroid use
Chemo
HTN
Vasculitis
Thrombosis
Sickle cell anemia
Deep sea diving 
Radiation
Smoking 
Trauma
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14
Q 
Pain in groin, buttock, thigh
Unknown MOI
Usual gradual onset
Decreased activity due to pain
Pain typically decrease w rest
A

Avascular necrosis

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15
Q

Hip normal ROM

A 
Flexion 120
Extension 10
Abduction 30
Adduction 30
Internal rotation 40
External rotation 60
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16
Q

PE shows…
Limp
Painful AROM/PROM
Groin tenderness

A

Avascular necrosis

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17
Q

Avascular necrosis x ray

A

Early disease may not show bone collapse

**“Crescent sign” =collapsing subchondral bone

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18
Q

Avascular necrosis MRI

A

Better at showing early changes

Most specific and sensitive for diagnosis

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19
Q

Bone scan in avascular necrosis

A

Helpful in determining increased bone activity

Non specific

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20
Q

Avascular necrosis conservative tx

A 
NSAIDs
Anticoags (heparin, Coumadin)
Exercise/PT
Rest
Statins
Bisphosphonates
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21
Q

Avascular necrosis surgical tx

A

Hip resurfacing
Core decompression
Fibular bone grafting
Total hip arthroplasty

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22
Q

Causes of greater trochanteric bursitis

A 
Overuse
Trauma
ITB syndrome 
Weak abductors
Prior surgery 
Unequal leg length
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23
Q

No MOI, gradual onset
Pain w laying on affected side
Pain w repetitive motions (running, cycling, walking)

A

Greater trochanteric bursitis

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24
Q 
PE shows...
Possible limp
No swelling, erythema, ecchymosis
Pain w resisted abduction/passive adduction 
Point tender over Great trochanter
A

Greater trochanteric bursitis

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25
Conservative tx of great trochanteric bursitis
``` NSAIDs Ice/heat Physical therapy Activity modification Cortisone injection ```
26
Surgical tx of greater trochanteric bursitis
Excision of Bursa
27
Grade 1 quad/hamstring strain
Mild stretch injury to muscle or tendon
28
Grade 2 quad hamstring strain
Partial tear but functionally in tact
29
Grade 3 quad hamstring strain
Complete tear or rupture of structure
30
Predisposing factors of quad or hamstring strain
Inflexibility Overtraining Poor bio mechanics Muscle imbalance
31
``` Known moi/ identifiable injury Sudden onset Pain w activity Possible muscle spasm Muscle weakness ```
Quad or hamstring strain
32
``` PE shows... Limp Swelling Ecchymosis Palpable hematoma in muscle belly Decreased ROM in hip and or knee Decreased strength ```
Quad or hamstring strain
33
Conservative tx of quad or hamstring strain
RICE PT, stretching, strengthening Gradual return to activity May take several months to regain fxn
34
Surgical repair of quad or hamstring strain
Repair complete disruption of muscle/tendon Evacuate hematoma Fasciotomy for compartment syndrome
35
Extensor mechanism is made up of..
Quadriceps Quadriceps tendon Patella Patella tendon (Acts to extend knee)
36
"I tore my knee" "I felt a pop" Generalized pain Inability to bear weight
Extensor mechanism rupture
37
Chronic inflammation/degeneration Cortisone injections in/around patella tendon Weakening of tendons Can cause...
Extensor mechanism rupture
38
Extensor mechanism rupture conservative treatment
Only for pts that are too sick for surgical repair | Treat in immobilized for 6-8 weeks, then gradual ROM progression
39
Extensor mechanism rupture surgical repair
Repair w sutures/hardware Can wt bear as tolerated w immobilizer PT
40
Causes of knee OA
``` Genetic Trauma Over use Joint instability Obesity Ligament insufficiency Biomechanical deformity (varus valgus) ```
41
``` Knee pain worse in am Swelling Stiffness Giving away or locking Gradual onset ```
Knee OA
42
``` PE shows... Knee joint hypertrophy Tenderness at joint line Effusion Decreased ROM Quad atrophy Crepitus ```
Knee OA
43
X-rays with knee OA
``` **gold standard* Osteophyte formation Decreased joint space Subchondral sclerosis Cyst formation ```
44
Conservative tx for knee OA
``` NSAIDs/acetaminophen Ice and or heat Activity modification Decreased weight Cortisone injections Hyaluronic acid injections ```
45
Surgical tx for knee OA
Knee arthroscopy Tibial/femoral osteotomy Total knee arthroplasty
46
Anterior knee pain | Most common and frequent complaint with teens
Patellofemoral pain syndrome
47
Causes of patellofemoral pain syndrome
Biomechanical Muscular Trauma Over use
48
``` Increased Q angle Pes planus/pes cavus feet (pronation) Tibial internal rotation Patella instability Shape of femoral sulcus and or patella Angle of flexed knee ```
Biomechanics that can cause patellofemoral syndrome
49
Quadriceps weakness Hip flexor weakness Can cause..
Patellofemoral pain
50
Tight hamstrings, IT band, gastrocs can cause...
Patellofemoral pain
51
Pain with squatting, kneeling, going down stairs, sitting for long periods of time Stiffness, sometimes swelling
Patellofemoral pain
52
``` PE shows.. Possible effusion Mild peri-patella tenderness Quadriceps weakness Pain w resisted knee extension ```
Patellofemoral pain
53
Special tests for patellofemoral pain
Patella apprehension | J sign
54
X ray for patellofemoral syndrome
A/P, Lateral, sunrise Abnormal bone morphology... ...shallow femoral sulcus ...tilted patella
55
Conservative tx of patellofemoral pain
``` NSAIDs/acetaminophen Ice or heat PT (quad strength) Patella support base Foot orthotics Activity modification ```
56
Surgical fx for patellofemoral
Medial patellofemoral ligament reconstruction Lateral release Tibial tubercle osteotomy
57
Sprain is an injury to....
Ligament
58
Most often injure ligament of knee
MCL
59
Provides lateral stability Prevents valgus deformity Associated w medial meniscus injury
MCL
60
``` Known MOI Loose knee Giving away sensation Stiffness swelling Decreased ROM due to pain swelling Ecchymosis possible ```
MCL
61
``` PE shows... Limp, inability to wt bear Medial femoral condyle tenderness Decreased ROM Pain w valgus stress Variable laxity w valgus stress ```
MCL
62
Provides lateral stability Prevents varus deformity Associated w fibular head fx
LCL
63
PE shows... Point tender over fibular head Ligament is palpable in figure 4 position Pain and laxity on varus stress
LCL
64
PCL injury
Provides posterior and rotational stability MOI is anterior to posterior force on tibia Ex dash board injury, total knee dislocation Associated w multi ligament injuries
65
Posterior or popliteal pain Stiffness, decreased ROM Swelling Knee is "un hinged"
PCL
66
PE shows.. Swelling, effusion, ecchymosis Decreased rom due to swelling Possible hyperextension on PROM
PCL
67
Special tests for PCL
Posterior drawer | Sag sign
68
MOI is combination of medial tibial rotation and anterior tibial translation 80% non contact
ACL injury
69
Reasons females tear ACL more than males
``` Hormone cycles Increased Q angle Strength Proprioception Skill, technique ```
70
Special tests for ACL
Quad inhibition Lachmans Anterior drawer Pivot shift test
71
X-ray w ACL injury
Possible associated fxs - medial femoral condyle avulsion - lateral tibial fx - tibial spine/eminence fx
72
Definitive test for determining ligament damage
MRI
73
Fibrocartilage made up of 70% type I collagen
Meniscus
74
``` Fxn: Lubrication of joint Nutrition Diffused forced from femur on tibia Decreases hyalin cartilage wear Shock absorption ```
Meniscus
75
Medial meniscus
C shaped Firmly attached to tibia, joint capsule, MCL 2 mm of motion at knee flexes
76
Lateral meniscus
O shaped Loosely attached 10mm motion allowed as knee flexes
77
Meniscus tears in elderly due to..
OA | Degenerative tear
78
Meniscus tears in younger..
Associated w trauma | Rotational injury
79
``` Persistent swelling Pain w rotation and squatting Giving away or locking knee Decreased ROM Fullness behind knee ```
Meniscus tear
80
Joint line tenderness Swelling Decreased ROM
Meniscus tear
81
Special tests for meniscus
McMurrys test | Appleys compression test
82
Definitive test to dx meniscus
MRI
83
White zone meniscus
Inner avascular portion of meniscus
84
Red zone of meniscus
Outer vascularized area near joint capsule
85
What is considered when deciding repair vs menisectomy
``` Age of patient Type of tear Zone of tear (red or white) Associated injuries Activity demands ```
86
Housemaids knee | Inflammation of pre patella bursa (lies between patella and skin)
Pre patella bursitis
87
Frequent in roofers, floorers, carpenters | Injury due to repetitive kneeling
Pre patella bursitis
88
"Water on knee" Mild erythema Decreased ROM due to swelling No drainage
Pre patella bursitis
89
``` PE shows... No effusion Palpable fluid over patella Full ROM Mild tenderness on palpation ```
Pre patella bursitis
90
Symptoms in an infected/septic pre patella bursitis
``` Moderate to severe erythema Moderate pain w ROM Drainage Fever and or chills Pain on palpation ```
91
When to aspirate in pre patella bursitis?
If question of sepsis | Send fluid for gram stain, cell count and culture
92
Pre patella bursitis treatment
``` NSAIDs Compression wrap Ice/heat Activity modification Knee pad Therapeutic aspiration Cortisone (IF 100% NO SEPSIS) ```
93
Shin pain related to load bearing activity | Disruption of tibial cortex as a result of repetitive stress
Shin splints
94
15% of all runner complaints
Shin splints More common in women Women 3x more likely to progress to stress fx
95
``` No MOI Gradual onset Dull ache in middle 1/3 of tibia Pain w load bearing Decreased pain w rest ```
Shin splints
96
Pain with passive dorsiflexion/toe extension
Shin splints
97
Shin splints treatment
``` NSAIDs Rest PT, strengthening, stretching Footwear, orthotics Crutches if stress fx present ```
98
Risks for Achilles' tendon rupture
Prolonged immobilization/atrophy Medications (Fluoroquinolones) Corticosteroid injections Prior injury
99
``` PE shows... Ecchymosis Palpable defect in tendon Decreased plantar flexion strength if partially torn Swelling and fullness ```
Achilles' tendon rupture
100
Special test for Achilles rupture
Thompson test
101
Best diagnostic test for Achilles rupture
MRI
102
Conservative tx for Achilles' tendon rupture
For partial or non retracted tears... Cast up to 12 weeks Change cast every 2 weeks, progressively increase DF to neutral position
103
Surgical tx for Achilles' tendon tears
Preferred method in healthy patient Cast for up to 8 weeks, decreasing DF to neutral PT *up to 6 months before full activity
104
Ligament involved in a high ankle sprain
Syndesmotic ligaments
105
Grade I, II, III ankle sprains
I: stretch of Ligament II: partial tear of ligament III: complete disruption of ligament
106
Special test for ankle sprains
Anterior drawer test
107
Ottowa ankle rules
Bone tenderness over distal 6cm of posterior edge of tibia (medial malleolus) Bone tenderness over distal 6cm of posterior edge of fibula (lateral malleolus) Inability to walk/weight bear for 4 steps
108
Inflammation of plantar fascia Pain in AM.."stepping on a knife" Limp w ambulation Gradual onset
Plantar fasciitis
109
Risks for plantar fasciitis
Overweight Poor footwear Weight bearing activities
110
Tight fascia on palpation Tenderness over medial calcaneus Pain with passive toe extension/dorsiflexion
Plantar fasciitis
111
Plantar fasciitis treatment
``` NSAIDs Ice/heat Activity modification Stretching Arch support/orthotics/foot wear Night splints Cortisone injection ```
112
Mid foot pain generated from the metatarsals and associated structures Most commonly at head of 1st metatarsal Stress fracture develops at 2nd and 3rd metatarsal shafts
Metatarsalgia
113
Characterized by joint dislocations, pathologic fxs and anatomical deformities In foot
Charcot foot
114
Acute arthritis caused by sudden increase and deposition of uric acid crystals in s joint Most common form of inflammatory arthritis in men and women over age 40
Gout
115
Hyperuricemia
Can cause gout Renal under excretion of uric acid (90% of cases) Over production of uric acid..10% cases
116
Risks for gout
``` Etoh Fructose Meat Seafood (Purines) ```
117
Sudden onset..usually at night Very tender joint Pain with motion, weight bearing Painless nodules at joint (tophi)
Gout
118
Needle like, uric acid crystals
Gout
119
Acute gout treatment
``` NSAIDs Colchicine Steroids Elevation Ice ```
120
Chronic gout treatment
Xanthine oxidase inhibitor - allopurinol - blocks uric acid production
121
Rod shaped calcium pyrophosphate crystals
Pseudo gout
122
Most common joint affected in pseudo gout
Knees
123
Infection of the bone (bacterial, fungal)
Osteomyelitis
124
Inoculation in osteomyelitis
Blood stream (sepsis) Through local infection (cellulitis) Trauma (wounds/surgery)
125
Most common bones in adults involved in osteomyelitis
Vertebrae Maxilla Pelvis
126
Most common bones in osteomyelitis in children
Femur Tibia Humerus
127
Osteomyelitis pathology
Leukocytes attack pathogens resulting in enzymes release causing bone lysis Pus formation impedes blood flow in bone causing tissue necrosis Bacteria can enter into bone cells
128
Pathogens causing osteomyelitis in children
S. Aureus in 90%
129
Pathogens in osteomyelitis for adults
S aureus 80%
130
``` PE shows... Swelling Erythema Point tender over bone May have superficial wound/ulcer over area ```
Osteomyelitis
131
What is needed for accurate diagnosis of osteomyelitis
Bone biopsy
132
X ray of osteomyelitis
May show bone destruction/lysis | May show heterotopic bone formation
133
Conservative tx for osteomyelitis
Antibiotics..at least 6 weeks Monitor lab values Symptomatic treatment Hyperbaric treatment
134
Surgical treatment osteomyelitis
Aggressive debridement required in most cases Removal of foreign bodies (surgical hardware) May require multiple wash outs Amputation for persistent infections
135
Infection of a joint caused by a number of different pathogens - bacterial - viral - fungal - mycobacterial
Septic arthritis
136
Common septic joint sites
Hips and knees most common | Elbow, ankle, shoulder
137
Pathogens involved in septic arthritis
S. Aureus***** Streptococcus H. Influenzae (common in children)
138
``` No MOI Sudden onset of joint pain Swelling Erythema Pain w joint motion Fever/chills Malaise ```
Septic joint
139
Labs in septic joint
Elevated ESR High WBC count Elevate CRP
140
Appearance of joint fluid in septic joint
Cloudy, turbid, purulent appearance | **must send for gram stain, culture/sensitivity and crystals
141
Conservative treatment of septic joint
Not indicated! | *oral antibiotics will not irradiate pathogens****
142
Surgical treatment in septic joint
Aggressive incision an drainage Remove prosthesis if applicable IV abx for up to 6 weeks

MSK/Rheum Exam- Clin Med (7 decks)

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