Ortho/Rheum Flashcards
Stiffness/pain in the neck; presents with paraspinal muscle tenderness and spasm and + Spurling test
Cervical sprain
Tx of Cervical Sprain
Treat with soft cervical collar (2-3 days), application of ice /heat, analgesics, gentle active ROM soon after injury
MC cause of back pain usually due to lifting, twisting, or strenuous activity
Back strain
Sx of back strain
- Stiffness, difficulty bending, axial back pain, and no radicular symptoms
- No neurological changes (no pain below the knees)
Tx of back strain
Treatment: in the absence of “red-flag” symptoms treat conservatively with NSAIDs, heat, ice, PT, home-based exercise
- Bed rest < 2 days + NSAIDs ± muscle relaxants (cyclobenzaprine) or short-term benzodiazepine
- Resume activity as tolerated; re-eval if not improved in 4 weeks
Inflammation of the bursa (thin-walled sac lined with synovial tissue); caused by trauma/overuse
Bursitis
Tx of Bursitis
- Tx: prevention of precipitating factors, rest, brace/support, NSAIDs, steroid injections
Tx of olecranon bursitis
- Treat with PT, rest and ice, systemic antibiotics based on culture if septic, NSAIDS, injected corticosteroids and joint, operative bursectomy.
MCC of nonseptic bursitis
- Nonseptic bursitis: acute trauma or repetitive trauma causes inflammation of the olecranon bursa.
Housemaids knee MC in what population
- Pain with direct pressure on the knee (kneeling)
- Swelling over the patella
- Common in wrestlers: concern for septic bursitis in wrestlers - aspiration with gram stain and culture
Tx of prepatellar bursitis (housemaids knee)
- Treatment: compressive wrap, NSAIDs, +/- aspiration, and immobilization
caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon from the overlying coracoacromial ligament, acromion, and coracoid (the acromial arch) and from the deep surface of the deltoid muscle
Subacromial bursitis
Tx of subacromial bursitis
- Treatment includes prevention of the precipitating factors, rest, and NSAIDs. Cortisone injections can be helpful.
Tx of tendonitis
-
Tx: ice, rest, stretching for inflammation
- NSAIDs help but don’t penetrate tendon circulation; steroid injection + anesthesia may be beneficial
- Surgery for excision of scar tissue / necrotic debris if conservative measures fail
- Activity-related anterior knee pain associated with focal patellar tendon tenderness. Also known as “jumper’s knee” (up to 20% of jumping athletes)
Patellar tendinitis
What is Bassets sign?
- Basset’s sign: tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at the distal pole of the patella in full flexion
What sign is associated with patellar tendinitis
Bassets sign = tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at the distal pole of the patella in full flexion
Patellar tendinitis signs on xray
- Radiographs - AP, lateral, skyline views of the knee - usually normal -may show inferior traction spur (enthesophyte) in chronic cases
What dx would you perform for patellar tendinitis
- Radiographs - AP, lateral, skyline views of the knee - usually normal -may show inferior traction spur (enthesophyte) in chronic cases
- Ultrasound - thickening of the tendon and hypoechoic areas
- MRI in chronic cases - demonstrates tendon thickening
Tx of patellar tendinitis
- Ice, rest, activity modification, followed by physical therapy. Surgical excision and suture repair as needed
- Cortisone injections are contraindicated due to the risk of patellar tendon rupture
- pain at the biceps groove
- Anterior shoulder pain - may have pain radiating down the region of the biceps, symptoms may be similar in nature and location to the rotator cuff or subacromial impingement pain
- Pain with resisted supination of the elbow
Biceps tendonitis
What dx would you perform for biceps tendonitis
- X-Ray to r/o fracture. Ultrasound: can show thickened tendon within the bicipital groove
What would an MRI show with Biceps tendonitis?
- MRI: can show thickening and tenosynovitis of proximal biceps tendon - increased T2 signal around the biceps tendon
What deformity indicates rupture of biceps tendonitis
Popeyes deformity
Tx of biceps tendonitis
- Treat with NSAIDS, PT strengthening, and steroid injections
- Surgical release reserved for refractory cases for bicep pathology seen during arthroscopy
What special tests are performed w/ biceps tendonitis
-
Special tests:
- Speed test: Pain elicited in the bicipital groove when the patient attempts to forward elevate shoulder against examiner resistance while the elbow extended, and forearm supinated. Positive if the pain is reproduced. May also be positive in patients with SLAP lesions.
- Yergason’s test: Elbow flexed 90 degrees, wrist supination against resistance. Positive if the pain is reproduced.
What level does cauda equina syndrome occur?
L4/L5
- s/sx: Leg pain, numbness, saddle anesthesia, bowel/bladder dysfunction and/or paralysis.
- dx: MRI – new-onset urinary symptoms with associated back pain/sciatica need and MRI
- tx: This is a surgical emergency requiring immediate referral.
Pain and tenderness on the breastbone, pain in more than one rib, or pain that gets worse with deep breaths or coughing
Costochondritis
RF of costochondritis
age >40, high-impact sports, manual labor, allergies, rheumatoid arthritis, ankylosing spondylitis, reactive arthritis
Tx of costochondritis
- Anti-inflammatories acetaminophen, nonsteroidal ibuprofen
- Applying heat with compresses such as heating pads
- Physical therapy, local steroid injection
What is Tiezte syndrome
is an inflammatory process causing visible enlargement of the costochondral area “slipping rib syndrome”
MC site of radial nerve injury
Humerus
posterior fat pad/sail sign seen with what fracture/dislocation?
Humerus
How to tx humerus fracture/dislocation
treat with sugar tong splint (distal) and coaptation splint (shaft) with ortho follow up in 24-48 hours
MC cause is falling on an outstretched arm causing what type of fracture/dislocation
Radial head
Tx of radial head fxr/dislocation
treat with a sling, long arm splint at 90 degrees, ORIF
(proximal ulnar shaft fracture with radial head dislocation)
Monteggia
MonteggiA = ulnA
vs Galaeazzi = Radial fracture
MUGR = Monteggia = Ulna; Proximal
Galaezzi = Radius
orsally angulated extra-articular distal radius fracture; “fragility fracture”; FOOSH; causes dinner fork deformity;
Colles fracture
FOOSH, snuffbox tenderness = treat as a fracture; pain on radial surface of the wrist at anatomical snuffbox, the fracture may not be evident for up to 2 weeks
Scaphoid fracutre
MC type of shoulder dislocation
Anterior: MC (arm = anterior) ⇒ arm is abducted and externally rotated (FOOSH)
What is a bankart lesion associated with shoulder dislocation
fracture of anterior inferior glenoid following impaction of the humeral head against glenoid
Which nerve is MC affected in shoulder dislocation
Axillary nerve C5, C6
MC area of clavicular fracture
Middle third
Tx of clavicular fracture
- simple arm sling or figure of eight sling: 4-6 weeks adults, ortho consult if proximal 1/3; begin PT after 4 weeks with light strengthening after 6 weeks
Which artery is MC affected in hip fracture with femoral neck?
medial circumflex femoral artery
Which maneuver is used to assess for hip fracture?
Log roll maneuver (internal and external rotation of leg elicits hip pain) which suggests femoral neck fracture
ip pain with leg shortened and internally rotated/adducted after trauma = MC cause (fall from heigh, MVA);
Hip dislocation
MC type of hip dislocation
- Posterior dislocation in 90% = adducted, flexed, internally rotated; anterior dislocation = abducted, flexed, externally rotated
Tx of hip dislocation
- Tx: closed reduction under conscious sedation; open reduction if failure of closed reduction; repeat XR and neurovascular exam after reduction
Ottawa knee rules
- Age > 55
- Tenderness to the head of the fibula
- Isolated tenderness to the patella
- Inability to flex the knee to 90 degrees
- Inability to bear weight for 4 steps both immediately and in examination room regardless of limp
Which rules of obtaining xrays of knee or more sensitive?
Ottawa = More sensitive
Pittsburgh = More specific
Pittsburgh rules of knee xray
- Recent fall or blunt trauma
- Age < 12 y/o or > 50 y/o
- Unable to take 4 unaided steps
Which artery is of concern in a knee dislocation
worry about popliteal artery injury
If knee dislocation is of concern , what imaging should be obtained?
CT angiogram = Popliteal artery evaluation
Get pre and post-reduction X-ray
MRI required to eval soft tissue injury for surgical planning
Foot drop should make you concerned of what type of fracture?
Tibial plateau fracture
Ottawa ankle rules
Need for X-ray based on Ottawa ankle rules:
- Pain along lateral malleolus, medial malleolus
- Midfoot pain, 5’th metatarsal or navicular pain
- Unable to walk more than four steps in the ER or exam room
Which type of fracture affects the 5th metatarsal? What about the 3rd?
5th = Jones fracture ; Proximal 5’th metatarsal diaphysis fracture; pain over the lateral border of the foot; not benign (poor blood supply to that area)
3rd = Stress ; common in athletes, military (overuse), Most common in 3’rd metatarsal
What is the weber ankle classification?
Level of fibular fracture relative to the syndesmosis
- fibular fracture below mortise, tibiofibular syndesmosis intact, usually unstable
- fibular fx at the level of the mortise, tibiofibular syndesmosis intact or mild tear, deltoid ligament intact or may be torn, stable or unstable
- fibular fx above Mortise, tibiofibular syndesmosis torn with a widening of talofibular joint, deltoid ligament damage or medial malleolar fracture, unstable = ORIF
What causes gout?
Altered purine metabolism and sodium urate crystal precipitation into the synovial fluid, M>W (9:1) until menopause (1:1)
How do you diagnose gout?
Diagnosis is by arthrocentesis – rod-shaped negatively birefringent. Serum uric acid level >8 (not diagnostic)
- Imaging: small, punched-out lesions on XR = high likelihood diagnosis
Drug of choice for tx of gout
pharm: NSAIDs = drug of choice (indomethacin TID); colchicine = effective but bad GI s/e; steroid injections for those who can’t take NSAIDs, oral pred if other meds not tolerated
posterolateral at C5-C6/C6-C7; pain into arm/shoulder, numbness/tingling pain into the arm with pain at rest vs rotator cuff no pain at rest until there’s movement; confirmed with MRI
Cervical herniated disc
Which nerve root would be affected if threre is diminished triceps reflex
affects C7 nerve root – pain at the shoulder blade, pectoral area, medial axilla, posterolateral upper arm, dorsal elbow and forearm, index, and medial digits or all of the fingers; diminished triceps reflex
pain in a dermatomal pattern – increases with coughing, straining, bending, and sitting
Lumbar herniated disc - (L5-S1 is most common)
back pain radiating through thigh/buttocks (lower leg below the knee down L5-S1)
Sciatica
straight leg raise, crossover test; dx = non-contrast MRI; tx: NSAIDs, rest, steroids, PT, epidural steroid injection, surgery if warranted
Which vertebrae is MC affected in lumbar pain
L5 = MC radiculopathy: lateral aspect of the leg into the foot; strength can be reduced in foot dorsiflexion, toe extension, foot inversion, and foot eversion.
MCC of lower back pain
The most common causes of lower back pain = prolapsed intervertebral disk and low back strain. Usually occurs within 24 hours of injury/overuse
MC organism in osteomyelitis
- S. aureus is the most common organism (80%)
Dx of osteomyleitis
Diagnose with bone aspiration = gold standard
- X-ray triad: demineralization, periosteal reaction, bone destruction (lags behind symptoms 7-10 days); MRI shows changes before XR
- Labs: CRP elevated for 4-6 weeks, WBC and ESR high in most cases
- Definitive diagnosis = blood culture or by needle aspiration/bone biopsy
Tx of osteo
Treat with empiric therapy directed toward most probable organism and tailored once culture results are available
- All hardware removed
- IV antibiotics ⇒ 4-6 weeks for acute OM and > 8 weeks for chronic or MRSA
- If diabetic foot ulcer is > 2 cm x 2 cm or bone is palpable osteomyelitis is likely
MC organisms in septic arthritis
- S. aureus is most common (40-50%); N. gonorrhea in sexually active young adults, streptococci; pseudomonas in IVDU
How is septic arthritis diagnosed
- Diagnose with arthrocentesis: joint fluid aspirate for definitive diagnosis (WBC > 50,000 primarily PMNs)
Tx of septic arthritis:
Staph
Gonorrhea
IVDU
Treatment is based on gram stain- 2–4-week course of antibiotics + arthrotomy with joint drainage
- Staph aureus = Vanco/nafcillin (Vanco or Clindamycin if PCN allergic)
- Gonorrhea = ceftriaxone
- IVDU = Cipro/Levaquin
Tests associated w/ diagnosis of carpal tunnel
pain/paresthesia in median nerve distribution (first 3 digits and radial half of 4th digit; sx worse at night); + Phalen (pushing backs of hands together) and + Tinel test (tapping over nerve); cli
pain and swelling at base of thumb that radiates into the radial aspect of forearm
De Quervains tensosynovitis
pain and swelling at base of thumb that radiates into the radial aspect of forearm; + Finkelstein; tx = thumb spica splint x 3 weeks, NSAIDs 10-14 days, steroid injections, PT
lnar collateral ligament injury from fall on an abducted thumb
Thumb collateral ligament injury
Gamekeeper = chronic; skier = acute
avulsion of extensor tendon ⇒ forced flexion; can’t straighten distal finger,
Mallet finger
tear at DIP joint
PIP flexion and DIP hyperextension; usually from jammed finger;
Boutonniere deformity (tear at PIP joint – jammed finger
noncancerous mucin-filled synovial cyst caused by trauma, mucoid degeneration, synovial herniation usually on the dorsal aspect of the wrist; usually asymptomatic,
Ganglion cyst
What test is associated with ganglion cysts
Allens test = Ensure radial + ulnar artery flow
fall directly on shoulder or FOOSH, may have an elevation of the clavicle (step off deformity) and point tenderness
AC Joint separation of the shoulder
2 tests to assess for biceps tendonitis
- Speed’s: pt attempts to forward elevate shoulder against examiner resistance while the elbow extended and forearm supinated; positive with pain (SLAP lesion)
- Yergason’s elbow flexed at 90, wrist supination against resistance
MC injury in rotator cuff tear/tendinopathy
supraspinatus = MC injury;
- Supraspinatus: empty can test, full can test, arm drop
- Subscapularis: lift-off test (elbow at 90, rotate medially against resistance)
- Teres minor/infraspinatus: elbow at 90, rotate laterally against resistance
Which 3 tests are used to assess rotator cuff injuries
- Supraspinatus: empty can test, full can test, arm drop
- Subscapularis: lift-off test (elbow at 90, rotate medially against resistance)
- Teres minor/infraspinatus: elbow at 90, rotate laterally against resistance
What imaging is used for rotator cuff injuries
XR = initial imaging (loss of subacromial space due to upward migration of humeral head), MRI = most accurate; tx = NSAIDs, steroid injection and surgical repair if you fail 3-6mo of conservative
Pain with reaching/lifting and pain with overhead motion
Subacromial impingement
3 tests associated with subacromial impingement
pop and swelling along with instability or “giving out” the knee after plant and twist injury; quickly stopping movement and changing direction while running / landing jump
ACL tear
Most sensitive test for ACL tears
Lachman’s = most sensitive, MRI confirms the diagnosis; PT and lifestyle modifications for low demand pt; surgery for young/active
Valgus stress injury (hit in football); “pop” along with medial joint line pain,
MCL
LCL test
trauma to the inside of the knee; rare; MRI = definitive study; conservative treatment with bracing and therapy usually effective; surgery for grade III injury; Varus stress test
fter twist injury with locking, feeling of knee giving away, a triad of joint line pain, effusion, locking; effusion usually 6-24 hours after injury;
Meniscal tear of knee
Ankle sprians MC involve which ligaments
85% are in collateral ligaments → anterior talofibular ligament during inversion; deltoid affected by eversion
pop” then weakness, palpable gap + increased resting ankle dorsiflexion in a prone position with knees bend
Achilles tendon rupture
Thompson test
painful mass near tarsal heads; MC in women with tight-fitting shoes, high heels; sharp pain with ambulation at 3rd metatarsal head; associated with numbness/paresthesia
Mortons Neuroma
The most common location for a sprain is the
Ankle
Classifications of sprain
- First-degree sprain (mild) the fibers of the ligament are stretched but intact
- Second-degree sprain (moderate) is a tear of a ligament, from a third to almost all its fiber
- Third-degree sprain (severe) is a complete rupture of the ligament, sometimes avulsing a piece of bone
Which 2 locations are MC locations for muscle strain
hamstring muscle and the lower back
When assessing swelling/deformities what is important to asses first?
vascular area distal to the swelling and/or the deformity is intact
Mallet finger deformity tx
Splint in extension for 6-8 weks
History of forced hyperflexion of the DIP + Inability to extend the DIP
Mallet finger
Tx = Splint in extension 6-8 wks
Most sensitive finding in cauda equina syndrome?
Urinary retention
- Diagnosis is made by MRI or CT myelogram
- Most commonly caused by a herniated disc
- Treatment is operative decompression
A 54-year-old woman presents with a swollen knee. On examination, a large joint effusion is present. With which of the following spaces does the knee joint communicate?
Suprapatellar bursa
The suprapatellar bursa, the largest of the bursae, is not a true bursa but rather an extension of the knee joint capsule. When a knee effusion or hemarthrosis is present, fluid can freely flow into and distend the suprapatellar bursa. One technique to increase detection of small effusions is to “milk” the suprapatellar bursa, forcing fluid back into the knee joint.
What condition is caused by prolonged or frequent kneeling?
Prepatellar bursitis.
What is the most common site of compartment syndrome?
Anterior compartment of lower leg
Skiers/gamekeepers thumb is rupture of what ligament
Ulnar collateral ligament
Gamekeeper’s Thumb, Skier’s Thumb
- History of skiing
- Pain, swelling, and tenderness on the ulnar side of the metacarpophalangeal joint of the thumb
- Most commonly caused by the forceful radial abduction of the thumb
- Treatment is thumb spica splint
GRUesome MURder mneumonic
- Galeazzi: Radius fracture, Ulna (radioulnar joint) dislocation
- Monteggia: Ulna fracture, Radial head dislocation
What are two primary physical exam techniques used to diagnose shoulder impingement?
The Neer test (passively flexing the glenohumeral joint while simultaneously preventing shoulder shrugging) and the
Hawkins test (internally rotating the shoulder while the shoulder is forward flexed 90 degrees and the elbow is flexed at 90 degrees).
