Ortho part 2 Flashcards
Ankylosing spondylitis
Inflammatory d/o involving the spine and sacroiliac joint
Onset 15-35 yoa male > female 3:1
Inflammation of the outer fibers of the annulus fibrosis may lead to ossification and complete fusion of vertebrae
Severe cases cause appearance of brittle “bamboo spine”
Strong genetic component HLA-B27 gene contributes approximately 37%
Presentation of ankylosing spondylitis
LBP with sacroiliitis
-LBP > 3 mos
-Worse with rest, better with bending forward
Flattening of lumbar lordosis and increasing kyphosis
May be associated with extraspinal inflammatory sx
-Uveitis (most common)
-Aortic and mitral regurgitation murmurs
-Progressive restrictive lung dz d/t fibrosis causing limited expansion
-Possible inflammatory enteritis, prostatitis, or tendonopathy
Dx of ankylosing spondylitis
Pelvic radiographs are essential for the dx of sacroiliitis showing subchondral bony erosions of SI joints
L-spine, T-spine and C-spine radiographs to exclude fxs and may reveal bamboo spine
ESR and CRP may be elevated
Basic labs may show leukocytosis, renal impairment, and elevated CPK
Tx of ankylosing spondylitis
NSAIDs
PT
Lumbar strain/sprain
Common complaint in ED and PCP office
D/t injury of paravertebral muscles (erector spinae multifidus or quadratus lumborum), ligamentous injury of facet joints, or anulus fibrosis
Often d/t lifting, twisting, or straining
Need to take careful hx and perform complete PE to r/o serious etiology of back pain, i.e., cauda equina, AAA, GI causes, fxs, etc.
Presentation of lumbar strain/sprain
Sx after injury
Pain may radiate into buttock or legs
Trouble with extension of low back
PE of lumbar strain/sprain
TTP over paravertebral muscles and SI joints
ROM is decreased, esp flexion
Senosry and DTR exam are nl
Straight leg raise elicits pain usually unilateral
Dx of lumbar strain/sprain
X-rays often unnecessary unless atypical sx or significant trauma
Tx of lumbar strain/sprain
Short period of bed rest
Cold therapy followed by heat therapy after 48 hrs
NSAIDs or other non-narcotic pain meds
Muscle relaxers may be helpful
Sciatica
LBP in the distribution of lower lumbar spinal roots
May cause neurosensory and motor defecits
Presentation of sciatica
Complaints of sharp, shooting, well-localized pain
Pain radiates down buttock into back of leg
Leg complaints often greater than back pain
Objective weakness
PE of sciatica
Straight leg raise- elevating leg while supine reproduces pain
Decrease ROM
R/o fever, saddle anesthesia, decreased rectal tone, GU findings, and abd pain
Dx of sciatica
Lumbosacral radiographs unnecessary unless:
- Significant trauma
- Fever
- Pain at rest
- IVDA
- Suspicion of tumor or hematoma
Tx of sciatica
APAP 1st line
NSAIDs
Muscle relaxers
Corticosteroids show no benefit in radicular or non-radicular back pain
Spinal stenosis
LBP caused by spinal canal narrowing or narrowing of neural foramina that compresses the thecal sac or nerve roots respectively
Can be caused by degenerative changes, congenital or Paget’s dz
Presentation of spinal stenosis
LBP, stiffness, and sx may develop after accident or minor trauma
Compression on nerve roots cause radicular sx in lower extremities
Pain is generally worse with walking but temporarily relieved with leaning forward
PE of spinal stenosis
Muscle weakness of the lower extremities
Decreased reflexes
May have decreased anal sphincter tone
Impaired proprioception
Dx of spinal stenosis
CT or MRI to evaluate for spinal stenosis when pt is neurovascularly impaired
Tx of spinal stenosis
NSAIDs, PT, and activity modification
Surgery for refractory cases
Herniated disc
LBP d/t herniation of nucleus pulposus into the spinal canal
Commonly occurs at L4-L5 or L5-S1
Presentation of herniated disc
Abrupt onset of pain that worsened by sitting, walking, or standing
Pain radiates down the back of the leg through buttock
PE of herniated disc
Pos straight leg raise
Limited ROM
Neurologic sc may be evident (weakness, numbness, tingling)
Dx of herniated disc
MRI
Tx of herniated disc
NSAIDs are used in acute phase
Bed rest for 1-3 days
Muscle relaxants and possible narcotics may be helpful
Corticosteroids may be useful in reducing pain and inflammation
Surgery may be needed if no improvement (laminectomy or disc excision)
Spondylolysis/spondylolisthesis
Spondylolysis- defect of the pars interarticularis between superior and inferior facets
Spondylolisthesis- slipping forward of one vertebrae upon another
Spondylolysis predisposes for spondylolisthesis
2-4 times more likely in males than women
Spondylolisthesis can cause nerve root impingement and radiculopathy
Presentation of spondylolysis/spondylolisthesis
Often gradual onset LBP
May be seen in children and athletic teens
Pain after exercise or hyperextension activities (diving, gymnastics, etc.)
Sitting or bending forward relieves pain
PE of spondylolysis/spondylolisthesis
Palpation may reveal step-off
Hamstring tightness
Hyperlordotic posture
Neurologic exam nl except with severe spondylolisthesis
Dx of spondylolysis/spondylolisthesis
Lateral and oblique X-rays may show radiolucent defect in pars (broken neck of Scottie dog)
X-rays may show grade I-grade IV spondylolisthesis (mild-severe degree of slippage)
Tx of spondylolysis/spondylolisthesis
Pain control with NSAIDs and muscle relaxants Restrict activities (sports) for 3-6 wks
Hip dislocation
Femoral head displacement from acetabulum
D/t high energy trauma
Posterior > anterior
AVN may occur d/t vascular compromise
Presentation of hip dislocation
Hx of trauma (MVC or falls) Posterior-internally rotated and short Anterior-externally rotated May have femoral artery, sciatic nerve or obturator nerve injury Check if pt is neurovascularly intact
Dx of hip dislocation
Plain film X-rays of affected side hip and pelvis
Tx of hip dislocation
After fracture ruled out, closed reduction ASAP
Limited weight bearing with crutches
Hip fx
Incidence of hip fxs doubles with each decade of life >50 yrs of age
Women > men
Increased mortality d/t DVT and PE
Often d/t osteoporosis and falls
PE of hip fx
Leg is shortened with external rotation
Pain over hip and inability to weight bear
Dx of hip fx
Plain film X-rays of hip and pelvis
Tx of hip fx
ORIF or hip arthroplasty
Knee bursitis
Pad-like fluid filled sac that reduces friction and cushions knee
Chronic injury or pressure leads to excess fluid formation, swelling, pain
Most commonly prepatellar (knee cap) or pes anserine (patellar tendon)
PE of knee bursitis
Swelling noted over knee depending on which bursa is involved
Pain with direct palpation
Dx of knee bursitis
Plain film X-rays generally not helpful
Aspiration of bursa fluid can assist in determining inflammatory, hemorrhagic, or septic etiology
Tx of knee bursitis
NSAIDs
RICE
Aspiration may be therapeutic
Corticosteroid injections
Meniscus injuries
Fibrocartilage pads that act as shock absorber between tibia and femur
MOI is usually twisting injury
Usually pt is able to ambulate with some swelling and stiffness
Pt complains of pain over lateral or medial aspect of knee
Pt describes pain as “locking” or catching of the knee
PE of meniscus injuries
Tenderness on palpation over the medial or lateral joint line
McMurray and Apley’s test positive
Effusion or hemarthrosis may be present on exam
Dx of meniscus injuries
MRI is needed to diagnose injury
Tx of meniscus injuries
RICE
Surgical debridement of microtears or surgical repair may be indicated
MCL injury
MOI direct blow to lateral knee
LCL injury
MOI direct blow to medial knee
ACL injury
MOI direct blow to knee or sudden change in direction of weight bearing knee
PCL injury
MOI direct blow to anterior proximal tibia or hyperextension
Presentation of MCL injury
Pain and swelling over medial knee and pt often report feeling a pop
Presentation of LCL injury
Pain and swelling over lateral knee
Presentation of ACL injury
Immediate pain and swelling after injury and weight bearing is difficult as knee is unstable
Presentation of PCL injury
May report dull ache in posterior knee, swelling not typical
PE of MCL injury
Valgus stress shows laxity
PE of LCL injury
Varus stress shows laxity
PE of ACL injury
Anterior drawer test or Lachman test positive
PE of PCL injury
Posterior drawer test positive
Dx of ligamentous injuries
Based on hx and physical or MRI
Tx of ligamentous injuries
Ranges from conservative tx for mild sprains to surgical repair for full tears
Knee fx
D/t direct trauma
Patellar fx occurs d/t direct blow to patella
Tibial plateau fxs d/t axial load or shearing type injuries
PE of knee fx
Pt has difficulty weight bearing and pain with movements and direct palpation
Significant swelling and ecchymosis
Straight leg raise show pt unable to lift leg with full extension
Dx of knee fx
4 view (including “sunrise” view) plain films likely show fx
MRI to evaluate soft tissue damage
CTA to evaluate popliteal vessel damage
Large lipohemarthrosis often evident on MRI
Tx of knee fx
Knee immobilizer
Pain control
Non-weight bearing
Surgical fixation
