Ortho/Rheum

Question 1

Differentiate between strain and sprain

Answer 1

Strain: muscle is stretched too much and tears
 Strain implies injury to paravertebral spinal muscles
Sprain: ligament causes by tearing of fibers of ligament
 Sprain describes ligamentous injuries

Question 2

Sx, Hx and PE of back strain/sprain

Answer 2

Sx: LBP is a symptom, not a diagnosis
 Pain can radiate to buttocks, difficulty standing straight
Hx of repeated lifting, twisting, or operation of vibrating equipment
Exam: Diffuse tenderness low back or SIJ, reduced ROM, Intact MMST (manual muscle testing) and reflexes

Question 3

Imaging and tx for back sprain/strain

Answer 3

Imaging: x-rays not helpful, MRI not indicated
Tx: NSAIDs and rest

Question 4

Differentiate between acute and chronic bursitis.

Answer 4

Acute Bursitis
 Trauma, infection, crystalline joint disease (gout)
 Pain with palpation of bursa
 ROM often ↓ due to pain
 Active motion elicits pain

Chronic Bursitis
 Inflammatory arthropathies, repetitive pressure/overuse
 Minimal pain or painless – bursa has had time to expand to accommodate increase in fluid → significant swelling.

Question 5

Bursitis Dx and Tx

Answer 5

Dx: typically clinical
Tx: most resolve w/o tx but can RICE and NSAIDs

Question 6

What are the 4 different types of bursitis? Describe them

Answer 6

Olecranon bursitis
* Caused by injury or repetitive pressure on elbow; pain with flexion
Trochanteric bursitis
* Caused by injury, overuse, arthritis, or surgery; pain w. lying or sleeping on affected side
* Most common in middle-aged and older women
Prepatellar bursitis
* Caused by repetitive pressure on the knees
Retrocalcaneal bursitis
* Caused by uphill running or wearing tight-fitting shoes

Question 7

What is tendinitis

Answer 7

Tendonitis (tendinitis) is the inflammation or irritation of a tendon that makes it swell. This condition usually happens after a repetitive strain or overuse injury. It’s common in your shoulders, elbows and knees.

Question 8

What are sx, imaging, and Tx for bicep tendinitis

Answer 8

S/Sx:
Anterior shoulder pain, may radiate down biceps
Weakened elbow flexion because of pain

PE:
Pain in bicipital groove
Speed’s test - pain with elbow flexion against resistance

Testing: MRI will confirm tear or tendinitis

Tx: Rest, NSAIDs, caution with steroid injection not to inject tendon

Question 9

What is the MC cause for elbow sx in pts w/ elbow pain?

Answer 9

Lateral epicondylitis

Question 10

What is another name for lateral epicondylitis?

Answer 10

Tennis elbow

Question 11

Lateral epicondylitis is caused by the inflammation of which muscle?

Answer 11

extensor carpi radialis brevis

Question 12

Lateral epicondylitis clinical presentation, Dx, PE and Tx

Answer 12

Clinical Presentation
* Insidious onset of pain
* Patient describes an overuse history without a specific inciting traumatic event
* Pain over the lateral elbow. Maximum over the lateral epicondyle
o Increased or reproducible pain with:
 Resisted wrist extension with the elbow extended and the forearm pronated (Cozen’s Test)
 Resisted extension of the middle finger (Maudsley Test)
* Connecting muscle(s) may exhibit tightness
* No radicular symptoms. No numbness/tingling

Dx: Clinical Diagnosis
* +/- Elbow XR to assess for arthritis or rule out other etiologies (ie. traumatic event to r/o fracture)
* +/- MRI to grade the severity of the tendon damage (rarely done)

Tx: Rest from offending activity. Oral/topical NSAIDs (spontaneous recovery but takes time)
* Icing, Stretching exercises
* Forearm counterforce straps to relieve tension (strap to relieve tension over tendon)
* Physical therapy if not solved on own
* Surgery – after 6-12 months of failed conservative treatment
* If computer-related: Buy a more ergonomic mouse

Question 13

Medial epicondylitis is caused by the over use of what tendon?

Answer 13

Caused by overuse or overload of medial common flexor tendon

Question 14

Medial epicondylitis clinical presentation, Dx, and Tx

Answer 14

Clinical Presentation
Insidious onset of pain
Patient describes an acute traumatic blow or repetitive elbow use, gripping, or valgus stress to the elbow
Pain over medial elbow
Aching with radiation down anterior dominant forearm
Increased or reproducible pain with:
Resisted pronation or flexion of the wrist
and/or numbness and tingling in an ulnar distribution
Swelling, erythema, or warmth in acute cases

Diagnosis
* +/- XR elbow – to access for arthritis or rule out other etiologies

Tx:
* Rest from offending activity. Oral/topical NSAIDs. Icing
* Physical therapy to learn stretching exercises

Question 15

Definition of cauda equina + what is it most commonly caused by?

Answer 15

Posterior compression of nerve tissue (cauda equine) and not posterolateral compression of nerve roots
MC cause is herniated disc

Question 16

Cauda equina sx, PE, dx, and tx

Answer 16

Sx:
 Most commonly caused by herniated disc
 Acute onset of lower back pain with weakness and numbness
 Sexual problems (loss of sensation/inability to ejaculate)
 Bladder disturbance (inability to urinate, loss of full bladder sensation)
 Bowel disturbance (inability to stop a BM or constipation)
 Saddle numbness

PE:
 Bowel and/or bladder dysfunction
 Decreased rectal tone
 Saddle anesthesia (sensory deficit over perineum, buttocks, & inner thighs)
 Variable motor and sensory loss in lower extremities
 Decreased lower extremity reflexes
 Sciatica

Dx: MRI (of entire spine if concern that it is related to metastasis, there is a chance of another mass)

Tx: Steroids ASAP (dexamethasone 10mg IV). C

Question 17

Costochondritis definition, sx, PE, dx, tx

Answer 17

Definition: Acute benign, painful, nonsuppurative (no pus) localized swelling of costal cartilages or the costosternal, sternoclavicular, or costochondral joints, most often involving the area of the second and third ribs

Clinical manifestations
 Pleuritic CP that maybe worse with inspiration, coughing, or certain body movements

PE
 Reproducible point chest wall tenderness without palpable edema

Dx
 Diagnosis of exclusion

Tx
 Supportive, NSAIDs, ice/heat

Question 18

Ecchymosis

Answer 18

Bruising; blood vessel is damaged and leaks blood under the skin. Takes 2 weeks to heal on its own. If painful can give NSAIDs

Question 19

Erythema

Answer 19

o Redness of the skin. Can be caused by a variety if disorders and can indicate an infection or inflammation.
o Tx depends on underlying cause

Question 20

Proximal humerus fx: sx, PE, dx, tx

Answer 20

Assoc. w. anterior or posterior dislocation of humeral head.

Sx: Pain in proximal humerus area & w. arm held in adduction at side.

PE: Palpation of proximal humeral area elicits pain. Pt Reluctant to move shoulder or arm.
 Perform neurovascular examination to assess for loss of distal sensation or vascular compromise.

XR: include a true AP, axillary, and scapular-Y view.

Tx: Sling and analgesics

Question 21

Clavicle fx: sx, dx, tx

Answer 21

Usually results from a fall onto the lateral shoulder or a direct blow to clavicle

S/Sx:
 Pain with palpation over the affected area
 Pain with abduction of the arm
 Tenting of the skin

Dx: XR

Tx: sling. depends on if group 1, 2, or 3

Question 22

Shoulder dislocation sx, PE, dx, tx

Answer 22

Humeral head is forced out of the glenoid fossa/ cavity
90% anterior

Sx:
o Diffuse shoulder pain
o Edema
o Decreased strength and motion
o Can usually recall the injury/cause

PE:
o Acute pain
o Obvious deformity
o Diminished ROM
o + apprehension test
o sulcus & fullness to front of their shoulder (if anterior dislocation)

Testing:
o XR: obvious dislocation and possibly HS & Bankart lesion
o MRI is helpful to determine soft tissue damage

Tx:
o Reduction, sling/shoulder immobilizer, physical therapy, referral to orthopedist

Question 23

Anterior vs posterior shoulder dislocation causes

Answer 23

Anterior (95-97%)
o Mechanism of injury: abduction, extension, and external rotation.
o Signs and symptoms: prominence of acromion process and flattening of normal contour of shoulder.
o XR: standard series = AP shoulder + scapular Y.
o Post-reduction - *axillary lateral

Posterior (2-4%)
o Mechanism of injury: Seizures or electric shock, fall on forward-flexed, adducted and internally rotated arm. IR > ER musculature.
o Signs and symptoms: Anterior flatness, posterior fullness and prominence of coracoid process.
o XR: Axillary lateral, when in doubt obtain CT.

Question 24

Radial head fx: MOI, sx, PE, dx, tx

Answer 24

Results from a fall on an outstretched arm (FOOSH)

S/Sx:
 Pain at the radial head
 Worse with palpation
 Worse with supination
 Limited passive ROM

Dx: Based on physical examination and plain-film x-rays
 AP, lateral, and oblique views of the elbow best seen on lateral view – posterior fat pad sign

Tx: Sling

Question 25

Colles fx: MOI sx, PE, dx, tx

Answer 25

o Fall onto an outstretched hand (FOOSH)
o Radial fracture with dorsal displacement and angulation

S/Sx: do the OK sign on PE and try to break the circle
 Pain, swelling
 Deformity – dinner fork

Dx: Based on PE and plain-film XR
 AP, lateral, and oblique views

Tx: Closed reduction

Question 26

Smith fx: MOI, sx, PE, dx, tx

Answer 26

Fall onto a flexed wrist or direct blow to the wrist
Radial fracture with volar displacement

S/Sx: do the OK sign on PE and try to break the circle
 Pain, swelling
 Deformity – dinner fork v garden spade deformity
 Abnormal function of the median nerve
* Numbness to tip of index finger
* Weakness with thumb and finger pinching

Dx: Based on PE and plain-film XR
 AP, lateral, and oblique views

Tx: Closed reduction
 If the fracture is open or if closed reduction is unsuccessful, open reduction with internal fixation (ORIF) by orthopedics may be necessary
 Volar splint with the wrist at 15-30 ̊ extension

Question 27

Radial head subluxation: dx, tx techniques

Answer 27

Diagnosis
 Hx and PE with typical findings are sufficient to diagnose

Management
 Closed reduction of a nursemaid’s elbow

Supination/flexion technique: Fully extend and supinate elbow and then take elbow into flexion
* Procedure is done while maintaining slight pressure over radial head; often, provider will feel a “click” in elbow
* Typically, child will be moving arm normally within 15 minutes

Hyperpronation technique:
* While applying mild pressure over radial head, provider holds elbow in a flexed position & hyperpronates forearm

Question 28

Finger tip fx: sx, dx, tx

Answer 28

Sx:
 Pain
 Swelling
 Hyperesthesia: excessive sensitivity that can be persistent
 Bleeding between nail plate and nail bed = subungual hematoma

Dx: Based on PE and XR (AP, lateral, and oblique views of affected finger)

Tx: Protective covering to affected finger for 2-4 weeks

Question 29

Metacarpal fx: MOI, sx, dx, tx

Answer 29

o Usually result from axial load (punching with a clenched fist)
o Document the mechanism of injury → punching someone in the mouth with resulting MCP wound = fight bite → start antibiotics
o 5th metacarpal is MC common metacarpal fracture (Boxer’s fracture)

Sx:
 Pain
 Swelling
 Sometimes rotational deformity
 Deviation of one or more of these lines, suggests a metacarpal fracture
 Associated extensor tendon laceration look @ open & closed hand to see if there’s a tendon injury

Dx: Based on PE and XR (AP, lateral, and oblique views of affected finger)

Tx:
o Immobilization with ulnar gutter splint for 4th and 5th metacarpal fractures for 4 weeks
o Reduction is required for:
 Rotational deformity of any metacarpal
 Fractures of the 2nd and/or 3rd metacarpals with angulation

Question 30

Scaphoid fx: MOI, sx, dx, tx, cx

Answer 30

MOI
o Most commonly injured carpal bone
o Wrist hyperextension injury (fall onto an outstretched hand (FOOSH))
o Possible severe complications:

Cx: Osteonecrosis due to disruption of the blood supply (dorsal branch of the radial artery) which enters the distal pole of the bone
* More proximal the fracture = greater the risk for osteonecrosis
* Nonunion

Sx:
* Radial side of the wrist:
o Pain
o Swelling
* Specific signs
o Pain with axial compression of the thumb
o Pain during wrist supination against resistance
o Tenderness in the anatomical snuffbox during ulnar deviation

Dx: Based on PE and plain-film x-rays
* PA, PA ulnar deviation, lateral, and oblique views

 Tx: For confirmed or suspected fracture, pt is placed in a thumb spica splint

Question 31

Digit disclocation: sx, PE, dx, tx

Answer 31

o Bones of finger or thumb are forced out of their normal position
o Causes: trauma ie. direct blow or a fall. Can also occur if there is a problem with ligaments
o Previous injuries to hand/fingers increase risk of further injury

Sx: Pain/stiffness. Deformity

PE: Obvious deformity. Pain
 Inability to use the digit/joint

Dx: XR will be needed, possible MRI get multiple views after reduced it

Tx: Reduction as soon as possible (longer joint or digit is dislocated = more difficult to reduce)
 XR and Splinting after reduction
 Avulsion fracture is typical

Question 32

Hip fx: cx, sx, dx, tx

Answer 32

• Common fractures of older patients, particularly pts w. osteoporosis as result of minimal force ○ Trauma in younger
  ○ Fracture locations:
  o Femoral head
  o Femoral neck – weakest part of femur
  o Intertrochanteric
  o Subtrochanteric

Complications:
* Osteonecrosis of femoral head
* Fracture nonunion
* Osteoarthritis

S/Sx:
* Groin pain – Increased pain with passive hip rotation & resistance of hip flexion
* Inability to ambulate
* Shortening and external rotation of the affected leg

Dx: Based on PE and plain-film XR
* AP pelvis and lateral view of the affected hip ie. Right hip with pelvis
* A full femur view is obtained if a fracture is identified
* CT or MRI is obtained for hips with negative plain XR, but high clinical suspicion

Tx:
* Open reduction with internal fixation (ORIF)
* Nondisplaced and impacted fractures in older patients
* All femoral neck fractures in younger patients
* Intertrochanteric fractures
* Total hip replacement
* Displaced femoral neck fractures in older patients

Question 33

Knee dislocation: MOI, sx, PE, dx, tx

Answer 33

• Cause: high energy injury ie. MVC or fall from height
• 50% reduce spontaneously before presenting to ED = so must have high suspicion if have high energy injury to knee

PE: Recurvatum (hyperextension) of knee to more than 30° when examiner lifts foot off the examination table suggests gross instability
* If laxity of at least 3 out of 4 of major knee ligaments (ACL, MCL, LCL, PCL) is present, one should assume that pt had a dislocation that has reduced

Tx: reduction and knee splint with 15–20 degrees of flexion
* Complications: vascular injury, peroneal nerve injury, and compartment syndrome; long-term complications include instability and arthrofibrosis.

Question 34

Ankle fx

Answer 34

• Common fractures that results from multiple mechanisms of injury
  o Inversion or eversion of the ankle
  o Direct blow
  o Medial or posterior malleolus fractures of the tibia
  o Lateral malleolus fracture of the fibula
• May be stable or unstable
  o Fractures that disrupt ≥ 2 of the ankle ligaments will be unstable
  o Disruption of the medial deltoid ligament may cause instability

S/Sx:
o Pain and swelling at the injury site initially, then extension diffusely around the ankle
o +/- unable to bear weight
o Tenderness at the proximal fibula
 Proximal fibula fracture (spiral fracture) with an unstable ankle injury (widening of the ankle mortise on x-ray), often comprising ligamentous injury (deep deltoid ligament) and/or fracture of the medial malleolus → Maisonneuve fracture

Dx: Based on PE and plain-film XR
■ AP, lateral, and oblique views of the affected ankle

Tx: Depends on stability of ankle
● Weber classification based on the lateral malleolus
● Weber Type B & C = goes to Ortho + surgery. Type A = walking boot.
o Walking boot
o Casting with no weight bearing
o Orthopedic consultation
o Open reduction with internal fixation (ORIF) – Maisonneuve fracture
 Some Weber B fractures
 All Weber C fractures

Question 35

Calcaneal fx: MOI, sx, dx, tx

Answer 35

o Fractures resulting from great force (axial load)
o Falling from a height onto the heels
o Often associated w. other injuries (ie. Thoracolumbar compression fracture) ○ If not diagnosed and treated properly → long-term disability

Sx:
 Tenderness and swelling to the heel and hindfoot
 Unable to bear weight “don’t even want to put weight onto toes”
 Mondor sign – a hematoma formed that extends distally along the sole of foot
* Pathognomonic finding for calcaneal fracture ○ Diagnosis & Treatment

Dx:
 Based on physical examination and imaging
 Axial and lateral XR views of the affected foot
 CT scan is done if:
● X-ray is negative, but clinical findings suggest a calcaneal fracture

Tx:
 Casting with no weight bearing
 Orthopedic consultation

Question 36

Fx of 5th metatarsal zones

Answer 36

Zone I – Base/Tuberosity
Zone II – Metaphysis
Zone III - Diaphyseal

Question 37

Fx of 5th metatarsal MOI, sx, dx, tx

Answer 37

MOI
* Can be acute or stress fractures
o Forced inversion of the foot and ankle

Sx:
o Pain, swelling, and tenderness well-localized to fracture site
o Ecchymosis may be present
o Pain is worse with weight bearing can put some weight but might want to only put weight on toes, not on back foot

Dx: Based on PE and plain-film XR
o AP, lateral, and oblique views of the affected foot
o Zone I fracture – Pseudojones fracture (Dancer’s fracture)
 Fracture through base (tuberosity) of 5th metatarsal d/t plantar flexion and inversion ○ Common fracture & less serious than other 5th metatarsal fractures
o Zone II fracture – Jones fracture
 Fracture at the metaphyseal-diaphyseal junction that often occurs with ankle sprains ○ Higher risk for nonunion d/t zone being avascular
o Zone III fracture – stress fracture

Tx:
oZone I fracture / Pseudojones
o Weight bearing as tolerated
o Walking boot. Send them home w. crutches too
oZone II or III fracture
● Casting with no weight bearing
● Orthopedic or podiatry consultation

Question 38

Gout sx, PE, dx, tx

Answer 38

sx:
 Sudden onset of pain (often nocturnal) “burning type pain & don’t want anything to touch it! No socks/sheets on foot)
 Typically monoarticular
 commonly occurs in lower extremities, most often at base of great toe (1st metatarsophalangeal joint) or knee
 Other sites: ankle, wrist, and elbow
 Intensely inflammation, causing severe pain, redness, warmth, swelling, and disability

Diagnosis
 Suspected in patients with acute monoarticular arthritis
Arthrocentesis / Joint aspirate microscopic analysis (diagnostic), which removes synovial fluid from joint capsule & shows:
* Crystals of MSU, which are negatively birefringent (yellow when parallel to polarizing light) & needle-shaped (yellow & parallel both have 2 L’s)
* WBC > 2,000/μL with > 50% neutrophils (an acute inflammatory synovial fluid)
* only tap joint to establish diagnosis… don’t need to tap joint again if have established diagnosis
XR: Shows no changes early in the disease (so only get XR if they’ve had some trauma)
■ Punched-out erosions with an overhanging rim of cortical bone develop with progressive disease
 Blood work may show: don’t have to get blood work
 Hyperuricemia (may be normal or low during a flare; best to measure 2 weeks after flare) (normal during acute flare, elevated 2 wks after) ■ Elevated WBC
 Elevated erythrocyte sedimentation rate (ESR)

Treatment for Acute Gout
 Goal is to reduce inflammation
 NSAIDs
* High-dose. Given for several days following resolution of pain & signs of inflammation to prevent relapse
* Contraindicated in gastric bypass, active peptic ulcer disease, impaired kidney function, CHF, & elevated INR
 Colchicine (next option after NSAIDs)
* Inhibits WBC migration
* Most effective if given within 12-24 hours of an acute flare
* Contraindicated in severe renal or liver disease

Question 39

Uric acid lowering medications for gout

Answer 39

Allopurinol – Most commonly prescribed and preferred initial urate-lowering therapy
* Drug class: xanthine oxidase inhibitor
* Works by reducing the production of uric acid in the body
* Inhibits xanthine oxidase, an enzyme in the purine catabolism pathway

Febuxostat
* Drug class: xanthine oxidase inhibitor
* Works by reducing production of uric acid in the body
* Inhibits xanthine oxidase, an enzyme in purine catabolism pathway
* Must give NSAIDs or colchicine concurrently to prevent acute flares.

Probenecid
* Drug class: uricosuric. Only uricosuric drug approved by FDA
* Works by inhibiting active transport sites of proximal tubules → reuptake of uric acid is blocked and increased amounts are excreted
* Give NSAIDs or colchicine concurrently to prevent acute flares

Question 40

Chronic vs acute herniated disc

Answer 40

Chronic:
 Structural most common cause – disc degeneration leading to intervertebral disc herniation or degenerative spondylolysis. Increased strain resulting of nucleus pulposus herniation.

Acute: large force on healthy disc causing extrusion of disc material
o Clinical manifestations
 Radicular back pain: usually unilateral, may radiate down the leg with paresthesia’s or numbness in a dermatomal pattern

Question 41

Herniated disc PE, dx, tx

Answer 41

PE
 Positive SLR
 Positive crossover test (pain of involved limb of hip flexion of uninvolved limb)

Dx
 Clinical. Imaging necessary if severe weakness
 XR: normal or loss of disc height
 MRI: test of choice, reserved for suspected herniation, persistent pain, or refractory pain

Tx
 Conservative: preferred initial management is NSAIDs, plus supportive tx
 Epidural injection: second line
 Operative: if not responding to anything

Question 42

Herniated disc: differentiate between sx of L4, L5, and S1 (per pance prep, unsure if this is actually important to know)

Answer 42

L4
 Anterior thigh pain into knee and medial aspect of leg. Sensory loss to the medial ankle
 Weakness in ankle dorsiflexion
 Reflex diminishes: loss of knee jerk. Weak knee extension.

L5
 Lateral thigh/leg, hip groin paresthesia and pain
 Dorsum of foot, esp btw 1 and 2 toes
 Weakness in big toe extension. Walking on heels more difficult than toes
 Reflexes usually normal

S1
 Loss of sensory in posterior leg/calf and plantar surface of the foot
 Weakness in plantar flexion. Walking on toes more difficult than on heels.
 Loss of ankle jerk—diminished reflexes

Question 43

Osteomyelitis Non-hematogenous vs hematogenous

Answer 43

Non-hematogenous osteomyelitis (MC in adults)
 Direct inoculation of bacteria due to: Surgery, Prosthetic devices, Trauma, Hardware for fracture fixation, Soft tissue infection
 Polymicrobial: “more than 1 bacteria on a knife”
* Staphylococcus aureus (>50%)

Hematogenous osteomyelitis (MC in children)
 Bacteria spread via blood supply from primary site of infection
 Monomicrobial:
* S. aureus (most common)

Question 44

Osteomyelitis Acute vs chronic clinical presentation

Answer 44

Acute – evolves over days or weeks
* Onset may be gradual
* S&Sx:
o Fever and chills
o Localized swelling
o Warmth
o Erythema
o Dull pain
o Limitation of function loss of function

Chronic – persists over months to years → bone ischemia and necrosis, bone loss, and/or sinus tract formation
* Similar to acute osteomyelitis
* Intermittent bone pain
* Draining sinus tract (pathognomonic)
* Fever and chills (less common)

Question 45

Osteomyelitis dx and tx

Answer 45

Dx
* Lab tests:
o ↑ WBC w. left shift & incr. neutrophils
o ↑ESR
o ↑ CRP – Correlates w. clinical response to therapy (decreases); used to monitor during tx
o Blood cultures – (+) in 50% – Obtain prior to initiating antibiotics
o Tissue culture – Obtain prior to initiating antibiotics
o Bone biopsy – best way to identify etiology
o Wound or abscess cultures are not reliable
* Imaging

Plain-film XR (1st-line)
o May not show changes in first 2 weeks of disease (false negative) → normal x-ray does NOT rule out osteomyelitis

MRI – Most sensitive & specific modality (gold standard) what you need to definitively diagnose
 Allows for identification of an assoc. abscess
 Detects infection within 3–5 days of onset
 Use is limited if surgical hardware is present

Key findings on x-ray:
§ Regional osteopenia
§ Loss of trabecular architecture
§ Bone destruction
§ Soft tissue gas (air = osteomyelitis)
o New bone apposition (cortical thickening) – Increase in diameter of bones by addition of bony tissue at surface of bone

Tx
o Vancomycin PLUS a 3rd or 4th generation cephalosporin
 Treat duration on average is 6 weeks; first 2 weeks via IV

Question 46

Septic arthritis: sx, dx, tx

Answer 46

o Joint infection due to direct inoculation, contiguous extension, or hematogenous spread of infectious organisms into joint space
o Surgical emergency: irreversible damage to tissue after 24 hours
o Etiology: majority of septic arthritis infections are monomicrobial
 Staphylococcus aureus (most common)
 Neisseria gonorrhoeae → Young, sexually active patient will present with more than 1 septic joint!
 Salmonella species → Sickle cell anemia
o Invasion through joint occurs through
 Hematogenous seeding (most common)

Clinical Presentation
 Constitutional symptoms:
* Fever
* Fatigue
* Tachycardia
 Signs and symptoms:
* Moderate-to-severe joint pain and effusion
* Erythema and warmth
* Tenderness to palpation
* Limited active and passive ROM
* Usually monoarticular, but may be oligo- or polyarticular

Dx: Arthrocentesis w. synovial fluid analysis
 Gram stain
 WBC count > 50,000 cells/μL
 Neutrophil predominance
o Imaging
 Plain-film XR: see osteopenia type changes & joint narrowing
* Joint-space narrowing or widening
* Subchondral bony changes, osteopenia
* Periarticular soft tissue swelling
* Normal studies do not rule out septic arthritis
o Ultrasound: To identify & help aspirate joint effusion
o MRI: (gold standard) (septic joint MRI = shouldn’t have difficulty ordering in ER)
 Sensitive for early identification of joint effusion
 Evaluates the extent of bone and soft-tissue abnormalities
 Assesses for associated osteomyelitis

Antibiotic therapy – Antibiotic selection based on initial Gram stain and tailored based on culture data
 Empiric regimen if Gram stain is negative: Vancomycin PLUS 3rd- or 4th-generation cephalosporin

Question 47

RTC tear: sx, PE, dx, tx

Answer 47

 Tear of rotator cuff tendon related to repetitive trauma (think impingement) or acute trauma

S/sx:
* Pain with shoulder motion overhead activities
* Deltoid pain
* Diminished AROM with decreased strength

PE:
* + Neer, Hawkins, empty can, drop arm ■ Good PROM, poor AROM
 Testing:
* MRI, injecting with contrast (arthrogram) will improve visibility of tears,
* XR will show proximal migration of humeral head “see high-riding humeral head”

Treatment:
* Partial thickness tears – typically non-operative and managed with PT and cortisone injections
* Full thickness tears – require surgery to prevent osteoarthritis and restore proper function – debridement and repair (8- to-12-week recovery, 6-to-12 month return to normal activity) ○ Pearls:
 Supraspinatus is MC
* Usually distinct injury with young, healthy people and slow, degenerative problem with middle-aged & elderly patients

Question 48

LCL: sx, PE, dx, tx

Answer 48

• Varus stress to the medial knee tears the LCL
• Traumatic blow to medial knee
• Most often seen in gymnasts & tennis players
  *
  Sx:
  o Pain/swelling along lateral knee
  o Instability near full knee extension – difficulty using stairs & cutting/pivoting
  o Swelling

Physical Exam: Effusion
o TTP over lateral joint line of knee
o Pain with varus stress
o Effusion, ecchymosis
* Tests: MRI – most tears are the fibular insertion

Tx:
o Incomplete tear – NSAIDs, rest, PT, bracing with immobilization or hinged brace. Return to sports 6-8 weeks

Question 49

MCL sx, PE, dx, tx

Answer 49

• Forceful valgus stress to lateral aspect of the knee (direct lateral blow to knee)
• MC ligamentous injury
• Common in athletes – skiing, rugby, soccer, football

Sx:
o Pain at medial knee
o Instability
o Edema

PE:
o Medial joint line TTP
o Instability with valgus stress (pushing medially)
o Effusion, Ecchymosis
* Tests: MRI

Tx:
o Incomplete tear: NSAIDs, rest, PT, bracing with immobilization or hinged brace
o Complete tears +/- need surgery, depends on if it is isolated or unstable with other structures are damaged
* Pearls: Typically, will have medial meniscus or ACL damage, Often not an isolated injury

Question 50

ACL sx, PE, dx, tx

Answer 50

• Tear of ACL, usually because of twisting injury or direct blow to the knee
  o Often because of sport injury – basketball. Soccer. d/t pivoting & turning ○ Sx:

Sx: Pain deep in knee (not always)
o Instability
o Hear a “pop” in the knee when it happens
o Immediate swelling/effusion

PE:
o Effusion. Little to no TTP
o + Lachman
o + Anterior drawer
o “Quadriceps avoidance” – do not want to extend knee

Tests: MRI

Tx: Almost always need surgical repair (unless older & inactive)
o Femoral/tibial tunnel, graft fixation
o Bone-Patella-Bone autograft*, quad tendon/ham autograft, allograft (from cadaver)
o Repair associated damaged structures (meniscus/MCL)
o ACL brace during recovery controversial
o Physical therapy after surgery
* Pearls: Often associated with MCL or medial meniscus injury (50%)

Question 51

PCL sx, PE, dx, tx

Answer 51

• Tear of the PCL related to hyperextension or direct blow to flexed knee (dashboard from car or athletic injuries) ○ Sx: Posterior knee pain, instability, swelling

sx/PE:
o Pain w/effusion
o Feeling of instability with posterior movement
o +posterior drawer
o +sag test (tibia sags in image on right)
* Tests: MRI

Tx: Usually does not require surgery (unlike ACL) unless an athlete
o Surgical intervention typically if multiple ligaments are compromised
o Can manage conservatively
o Rest, ice, bracing, PT – quad strengthening exercises
o 6-12 months for full recovery

Question 52

Meniscal tear sx, PE, dx, tx

Answer 52

• Tear of the cup-like structure as a result of twisting or deep squat
• Acute sports injuries in younger patient, degenerative condition in older population
• Medial more common (except in ACL tears). Bucket handle is common.

Sx:
o Pain
o Clicking/locking/pop/catching
o Knee “giving out” sensation “pops, locks & gives out”
o Delayed/intermittent swelling

PE:
o Vague localized pain at joint line
o Delayed swelling
o +McMurray test. Pressure on femur/pushing down on lateral knee joint line… externally & internally rotating tibia, trying to push against femur… trying to get pain response… most times you get a “pop” sound
o + Apley grinding test
o + Thessaly Test (most sensitive)
o Can occasionally get popping/locking reproducible when squatting

Tests:
o MRI

Tx:
o Conservative: Rest, NSAIDs, PT
o Operative: if symptoms do not resolve or tear is very large (there’s not a lot of vasculature to meniscus “see red & white zones of image) … with time it leads to = arthritis… then total joint repair
o Arthroscopy can be diagnostic and therapeutic
o Repair for large tears in outer third; debridement for other tears typically just have to remove the tear bc there’s no vasculature

Question 53

Patellar tendon rupture sx, PE, dx, tx

Answer 53

• Tension overload during activity (flexed or overload of extensor mechanism)
• Quad tendon 2x more likely than patellar tendon rupture

Sx: “basketball player went to go jump…”
o Felt/hear a pop & noticed immediate visible abnormality
o “Jumper’s knee” – sudden quad contraction with knee flexed ie. from basketball

PE: quad fires & bulges just above the knee
o Patella – difficulty w/ knee flexion, patella alta
o Quad – difficulty with straight leg raise, can’t extend knee, sulcus sign noted, patella baja
o +/- swelling, bruising
o Hemarthrosis

Tests: typically can identify w/o imaging!
o XR – abnormal patellar positioning
o MRI confirms tendon rupture – complete vs partial

Tx: Immobilization in KI
o Conservative tx w/ intact extensor mechanism
o Operative: surgical repair of tendon – suture anchor, end to end, graft

Question 54

Ankle sprain inversion vs eversion injury

Answer 54

Inversion injury “rolled my ankle” (lateral injury)
o Turning of foot inward
o Tears lateral ligaments – anterior talofibular ligament (MC)
o Can have an associated talar dome fracture

Eversion injury (medial injury)
o Turning the foot outward
o More often causes an avulsion fracture of medial malleolus than a ligament sprain d/t strength of deltoid ligament

Question 55

Ankle sprain sx, PE, dx, tx

Answer 55

• Sx:
  o Audible “pop” at time of injury
  o Pain – Location is variable with the type of injury
  o Inversion – maximal at anterolateral ligament
  o Eversion – maximal over deltoid ligament
  o Swelling
  o Ecchymosis will go below injury over time d/t gravity
  o Ligament injury: tenderness is maximal over damaged ligaments rather than over bone more anterior to malleolus
  o Fracture: tenderness is maximal over bone rather than over ligaments pain right over malleolus
   Healing: 6-8 weeks

Dx: Based on hx and PE
o Ankle anterior drawer test
o Plain-film XR to exclude fractures (don’t have to if using Ottawa rules)
 AP, lateral, and oblique

Tx:
o Protection, rest, ice, compression, & elevation
o Splinting alleviates pain
o Early mobilization for mild sprains
o Ice: applied for 15-20 minutes every 4-6 hours for the first 24-28 hours acute injury = ice
o Orthopedic referral – Evaluate for surgical repair for moderate to severe sprains