orthopedics

Question 1

Study of the musculoskeletal system: bones, ligaments (bone to bone for stability at joint) , joints, muscles, tendons(muscle to bone causing action)

Answer 1

orthopedics

Question 2

Sub-specialty in internal medicine and pediatrics, devoted to the diagnosis and therapy of rheumatic diseases- medical specialty, not surgical

Answer 2

rheumatology

Question 3

pathogenesis of major rheumatological dzs

Answer 3

autoimmune

Question 4

disorder of purine/ protein metabolism with uric acid crystallization in synovial fluid, inflammatory & provokes immune system

Answer 4

gout

Question 5

name of erythema and swelling on a toe with gout

Answer 5

tophus

Question 6

5 function of the ms system

Answer 6

Movement Structural support Organ protections Storage of minerals Hematopoiesis

Question 7

end portion of bone

Answer 7

epiphysis

Question 8

growth plate

Answer 8

physis

Question 9

phalanged portion of bone

Answer 9

metaphysis

Question 10

living unit of bone; help build bone tissue, break down bone tissue

Answer 10

osteocytes, osteoblasts, osteoclasts

Question 11

which part of a joint doesn’t have its own blood supply and heals poorly?

Answer 11

articular cartilage

Question 12

freely mobile joints and examples

Answer 12

diarthrodial: ball and socket, hinge, saddle, pivot, condyloid

Question 13

joints that allow some movement and examples

Answer 13

amphiarthrodial/fibrocartilaginous: pubis symphysis, costosternal, acromioclavicular

Question 14

joints that don’t move and examples

Answer 14

synarthrodial, cranial sutures

Question 15

bowlegged): distal extremity is inward

Answer 15

varus

Question 16

(knock-kneed): distal extremity is outward

Answer 16

valgus

Question 17

occurs when joint between two bones separates Usually from excessive tension to or disruption of supporting ligaments

Answer 17

dislocation

Question 18

acute injury of partial dislocation, or can be a chronic problem

Answer 18

subluxation

Question 19

stretching of ligaments from excessive force

Answer 19

sprain

Question 20

stretching or partial tearing of the muscle-tendon unit from excessive force

Answer 20

strain

Question 21

why do joint injuries and fxs bruise?

Answer 21

there are micro tears that cause bleeding from blood vessels under the skin

Question 22

buckling of the cortex –almost exclusive to peds patients

Answer 22

torus fracture (buckle)

Question 23

caused by a tendon or ligament pulling a piece of bone off- cause instability of a joint

Answer 23

avulsion

Question 24

fx usually a result of normally minor injury - should be suspicious of osteoporosis/osteopoenia

Answer 24

impacted fx

Question 25

if any air is found in an X-ray of a bone/joint, what do you do?

Answer 25

immediate surgical consult b/c this signifies an open fx and surgical emergnecy

Question 26

fx caused by caused by non-traumatic, cumulative overload on a bone –usually a chronic axial force like running, chronic flexion of naturally curved bones like the plantar arch

Answer 26

stress fx

Question 27

through the physis- low risk of growth arrest, treat like a normal fracture

Answer 27

salter harris I

Question 28

through the physis with extension ot Metaphysis- can be easily viewed on Xray

Answer 28

salter harris II

Question 29

through physis with extension to epiphysis- can disrupt the joint surface itself, risk of premature/post-traumatic arthritis

Answer 29

salter harris III

Question 30

hrough Metaphysis, physis, and epiphysis- bone fragment can break off and die, joint will collapse on one side

Answer 30

salter harris IV

Question 31

impaction/crush injury to the physis- Xray can show normal physis, use a contralateral Xray to compare, highest risk of growth arrest so treat aggressively- completely non-weight bearing, refer to ortho

Answer 31

salter harris V

Question 32

what should you include when describing an X-ray of a fx of limb/joint?

Answer 32

view, R or L anatomy, where fracture indicated, what distance along bone, what type of fracture, relationship of fragments (simple v comminuted) displacement or angulation, communication with atmosphere, whether growth plate is involved

Question 33

Elevated pressure in a closed muscle compartment due to injury- commonly crushing component or repetitive stress which releases blood/inflammatory cells and causes swelling: most common areas?

Answer 33

anterior tibial and volar forearm

Question 34

7 P’s of compartment syndrome

Answer 34

pain, pallor, paresthesias, paresis (weakening), poikiolothermia, pressure, pulseless

Question 35

The standard radiographs for musculoskeletal trauma. how many views needed?

Answer 35

plain films, views needed at 90 degree angles

Question 36

More sensitive delineation of fractures than plain film; Evaluation for bone tumors May help guide operative planning

Answer 36

CT

Question 37

best for soft tissue injuries like ligaments, etc and occult fx

Answer 37

MRI

Question 38

• Developmental defect with no bone at growth plate • Usu in kids and teens • XR shows “soap bubble” in metaphysis • Bone does not enlarge beyond growth plate • Heals spontaneously • Watch for fractures • Tx: steroids, observe, surgery

Answer 38

unicameral bone cyst

Question 39

• Kids and teens • Cortex destroyed by periosteal rxn and bone balloons out • Proximal fibula usu • Can be aggressive but not malignant • High recurrence rates • XR shows fluid/fluid levels on CT/MRI • Tx: curettage

Answer 39

aneurysmal bone cyst

Question 40

what are examples of benign bone- forming tumors?

Answer 40

 Paget’s disease – old, bone enlarged  fibrous dysplasia – young, bone enlarged  osteopetrosis – “marble bone”, no marrow space  melorheostosis – candlewax  fractures!  osteoma – “bone island”, cancellous, pelvis  osteoid osteoma/osteoblastoma…

Question 41

• A benign cartilage-capped outgrowth, connected to bone by a stalk • The marrow cavity of the stalk is in continuity with the parent bone marrow and grows away from the joint • The cap is slow growing cartilage. Marrow is continuous into it. • As the cap thickens, it outgrows its nutrition, becomes calcified, and then is mineralized. • A cartilage cap > one cm in thickness, is thought to be malignant. • Grows during growth spurts • Presentation: +/- limited ROM, pain from lump • XR: no periosteal rxn, continuity of stalk with canal. • Tx: excise if sx. If multiple :HMO

Answer 41

osteochondroma

Question 42

• Benign but painful, especially at night. • Pain often relieved by ASA. • Can be found just about anywhere, including hip, spine, tibia, foot, etc • The nidus stimulates hypertrophic bone.. • The nidus is hypervascular and needs to be removed or destroyed to stop the pain. • Can be done with radiofrequency ablation. • night pain, NSAIDs (ASA) help • younger patients (2cm, spine, cystic

Answer 42

osteoid osteoma

Question 43

• Cartilage within bone marrow space • Starts from epiphysis to metaphysis • May calcify later in life • Esp in metacarpals and feet • May be painful or incidental finding • Can be alarming due to size. • Should not cause any endosteal (internal) scalloping of the cortex- lesion is growing and creating pressure on inside of bone. If scalloping, or increase in pain or size, consider malignancy. • Should not be especially hot on bone scan. • Should not occupy more marrow than one can see on the xray • Dx: XR with bagel sign, well marginated, periosteal rim • Tx: observe

Answer 43

enchondroma

Question 44

• Seen in teens or adults with Paget’s disease. • Often pretreated with chemo before surgery to shrink the soft tissue mass. • Used to have >80% mortality, usually from lung metas. • Prognosis improved with aggressive chemotherapy protocols. • Limb salvage possible in some cases. • Not sensitive to irradiation treatment. • Presentation: minimal sx, pts not sick. • Imaging: metaphyseal and expansile mass. Eats away bone, no sclerotic rim. Lucent areas not yet calcified. “sunburst appearance. • Tx: bx, staging. Also get CXR, chest CT, bone scan, MRI. Pre-op chemo to shrink, wide resection, post-op chemo, surveillance with alk phos.

Answer 44

osteosarcoma

Question 45

what are examples of benign cartilage forming tumors?

Answer 45

• osteochondroma • enchondroma

Question 46

what are examples of malignant bone forming tumors?

Answer 46

osteosarcoma

Question 47

what are examples of malignant cartilage forming tumors?

Answer 47

chrondrosarcoma

Question 48

• Note the well-defined border of the hole. • 20% of population • Implies slow growth. • Tumor remains within the bone of origin. • Looks like it might be healing. • Somewhat scalloped appearance internally. • May heal spontaneously- name is a misnomer- can heal in children • These lesions are eccentric in metaphyseal bone. • Well marginated. • May heal spontaneously if observed long enough. Treatment of NOF • Observation- annually if they remain asymptomatic until healing assured. • Curettage and grafting with a bone-graft substitute for a large painful lesion. ORIF- occasional pathologic fracture may require internal fixation.

Answer 48

non ossifying fibroma

Question 49

benign but locally aggressive and high recurrence rates grows rapidly in pregnancy spans epiphysis and metaphysis XR: large, expansile, well-defined, lytic lesion, expands up to subchondral bone rarely metastasizes after excision treatment: curettage, radiation sensitive

Answer 49

giant cell tumor

Question 50

malignant,lytic lesion rarely isolated middle-aged adults painful – out of proportion to degree of bone destruction rule out mets or myeloma (primary rare – 1%) treatment: radiation and chemo (no OR)

Answer 50

lymphoma

Question 51

• Cancer of the plasma cells in bone • Usually seen in adults >50yrs. • X-ray may be solitary lytic, permeative, or soap bubble-like, osteoporosis, punched out lytic lesions or osteoblastic • Solitary lesions can be treated with moderate doses of XRT. • Plasma and urine electrophoresis used to diagnose • SPEP/UPEP, bone scan, BM biopsy

Answer 51

myeloma

Question 52

• neuroectodermal tumor • Usually in preteens or teens, caucasians • C/O bone pain, +/- fevers, increased ESR (necrosis) • Associated soft tissue swelling. • May mimic osteomyelitis because of pattern of bone destruction. • X-ray pattern varies from onion skin periosteal reaction, to permeative destruction. • Usu metaphyseal with assoc soft tissue mass • Dx: BM bx • Tx: treatment: chemo and resection, ?radiation • 5-year survival 63% (80% if local and

Answer 52

ewings sarcoma

Question 53

what does the fat pad sign suggest?

Answer 53

occult supracondyllar fracture in kids or occult radial head fracture in adults.

Question 54

Usu presents as direct pain on lateral epicondyle. May present as a dull ache on outer aspect of the elbow that increases with grasping, twisting and resisted extension of the wrist or fingers

Very local, focal tenderness over insertion of extensor tendon on lateral elbow (on the bone)

Increasing pain with (resisted) extension of wrist- hold on to wrist and push down on hand while patient resists

Increasing pain with (resisted) supination of wrist- try to shake patient’s hand

tx?

Answer 54

lateral epicondylitis

tx:

Pain will cycle in 12-18 month periods

Rest, avoid aggravating activities like gripping

Ice if acute or rep. injury

?Compression, ace wrap. Beware of tennis elbow bands b/c they can be put on too tight. Idea is that bending elbow transmits force to band

Massaging may make it feel better for them

Anti-inflammatories

NSAIDs first

+/-Injection with steroid and

Question 55

pain on medial elbow:

Tender to palpation on the medial epicondyle

-Increased pain with resisted flexion and pronation of the wrist

patho phys

dx

tx

Answer 55

patho phys:

Microtrauma to the flexor carpi radialis tendon insertion on the medial epicondyle

Flexor-pronator wad of muscles attach to medial epicondyle

tx:

Treatment—more aggressive like an acute injury

Rest, avoid aggravating activity

+/-Ice

NSAIDs

PT for iontophoresis, throwing eval

Referral for resistant cases- but typically resolve after a few weeks

Use significant caution when considering injection- Ulnar nerve

-don’t do it if you don’t do it on a regular basis

Question 56

pain and swelling over the olecranon process.

dx:

tx:

Answer 56

dx: olecranon bursitis
causes: trauma, infection, inflammatory conditions, gout

how to make dx:

X-ray if trauma or suspicion of foreign body and +/- gout

CBC for white count if suspicious of infection

ESR, CRP and serum uric acid if suspicious of gout

Aspiration is controversial, consider specialist consultation

Avoid temptation to poke b/c secondary iatrogenic infections are common

tx:

Nothing for non infectious- Typically will resolve spontaneously in 2-4 weeks

Rest-avoid direct trauma

Elbow padding might be effective

NSAIDs if pain is present

Aspiration (orthopedist or hand surgeon only)

If for some reason they ask you to aspirate—use good sterile technique, if looks like uric acid don’t put in formalin or it will degrade. Leave in syringe or put in saline.

Gram stain and culture

>5000 WBC per ml indicates infection (Staph Aureus is most common)

• high white cell and low glucose usu means there is an organism in there
• if no organism and low WBCs probably just traumatic

Do not inject steroids unless you are absolutely sure there is no infection. Some literature says steroids help bursitis go away faster, but if there is even 1% chance there is an infection that steroid is stuck in there for about 3 months and infection gets worse.

Close follow up after steroid injections

usu resolves spontaneously in 2-4 weeks

Question 57

Paresthesias in the ulnar side of the ring finger and small fingers

Weakness and atrophy of the ulnar innervated intrinsic muscles of the hand- lumbrical muscles and Hypothenar muscle EXCEPT THENAR muscles of thumb unaffected, most evident at web space between thumb and second finger

Weakness of adduction of 5th digit—the pink will drift out

dx, tx

Answer 57

ulnar nerve entrapment

cause: chronic pressure on it or hypertrophied muscle or trauma

dx; electromyelogram

tx: splinting elbow in extension; NSAIDS, poss. surgery

Question 58

Wrist Drop (weakness of extension) and loss of sensation in dorsal web space between thumb and index finger

Usually from extrinsic compression of axilla and radial nerve entrapment

History:

Usu fell asleep on arm or feel asleep with arm over a chair

“Saturday night syndrome” b/c usu pass out/sleep hard in that position after etoh or other medical conditions

Answer 58

dx: radial nerve palsy

Cock-up splint for wrist

Orthopedic follow-up, OT

prognosis:

benign, temporary paralysis/injury of nerve

“neuropraxia”

usu get a flicker of extension in their fingers, then wrist, etc.

Claw hand in non-resolving cases

Question 59

Actually compression of posterior interosseous nerve in forearm.

Hypertrophy of extensor muscles from repetitive movements or extrinsic compression-

History

Burning tenderness

If using tennis elbow strap that is cinched down with lots of tightness

Answer 59

radial tunnel syndrome

Question 60

Arm usually held in slight flexion and pronation against body

usu does not hurt at time of dislocation

Child will not want to use arm to grab a toy, candy, etc. can test and see if they will grab it

X-ray first if any question of fracture

Answer 60

subluxation of radial head

x ray if suspicious of fradcture

reduce, reexamine, follow up xrays, sling if still bothering them

Question 61

how does a supracondylar fracture develop and what do you have to examine closely?

Answer 61

happens by falling backward on an hyperextended elbow

Be suspicious for vascular compromise, especially of the brachial artery

Be suspicious for nerve injury of median, ulnar or radial nerve

Question 62

Mechanism

FOOSH- fall on an outstreched hand

Radial head driven into capitellum

Symptoms

Elbow pain, +/- swelling

Inability to completely extend

Pain on pronation and supination (occurs at radial head) +/- crepitus

Physical examination

Tenderness over radial head

Limitation of motion, especially in extension and pro-supination

Diagnosis

AP, lateral and oblique x-ray series.

There are specialized radial head views if necessary

Positive fat pad sign - fluid in the anterior joint capsule

tx?

Answer 62

radial head fracture

tx:

Sling for comfort- immobilize

Ice for swelling, pain

Analgesics like oxycodone etc especially during sleep, avoid NSAIDS in fractures- inhibit prostaglandins

Encourage early AROM

Follow x-rays at interveals wk. 1,3,6 to make sure things not displacing further, not necessarily looking for healing which will be mostly clinical via lack of pain, etc.

At 6 weeks usu pain is gone and you can “turn em loose”

Question 63

ddx of radial head fx

Answer 63

Differential Diagnosis

Elbow dislocation (clinical deformity and diffuse pain)

Hemarthrosis of the elbow (present with radial head fracture

or with other bony or soft-tissue injury)

Olecranon fracture (pain and tenderness over the posterior tip

of the elbow)

Supracondylar fracture of the humerus (location of pain,

tenderness, and deformity)

Question 64

what’s in the ddx for lateral epicondylitis?

Answer 64

Differential Diagnosis

Cubital tunnel syndrome (compression of the ulnar nerve, paresthesias in little and ring fingers)

Fracture of the radial head (radiographs should differentiate; pain and tenderness over the radial head that are exacerbated by passive pronation and supination)

Lateral plica (patient describes locking episodes and loss of elbow extension)

Osteoarthritis of the radiocapitellar portion of the elbow joint (radiographs should differentiate; similar examination to radial head fracture but without a history of acute trauma)

Osteochondral loose body (medial or lateral joint line pain, symptoms of locking)

Radial tunnel syndrome (compression of the posterior interosseous nerve, tenderness typically approximately 5 cm distal to lateral epicondyle)

Synovitis of the elbow (swelling, palpable effusion)

Triceps tendinitis (tenderness above the olecranon)

Question 65

ddx for olecranon bursitis

Answer 65

Differential Diagnosis

Fracture of the olecranon process of the ulna (evident on radiographs)

Gouty tophus or rheumatoid nodule (a tophus or nodule generally will be smaller and more discrete than an inflamed olecranon bursa)

Question 66

management of “fight bites”

Answer 66

Usually polymicrobial (from mouth and skin) and require urgent surgical I&D.

Presentation: laceration on mP joint +/- swelling, cellulitis, pain

Beware of occult extensor tendon injury from laceration

Infection can spread through extensor tendons to elbow

Question 67

patient presents with Flexion deformity of the PIP with a secondary hyperextension of the DIP joint after an injury. what is it and how do you tx?

Answer 67

boutinneiere finger

A rupture, usually traumatic, of the central slip of the extensor tendon mechanism on middle phalanx

Extensor mechanism then slides to the sides of the PIP joint instead of on top of knuckle

strict splinting for 8-10 weeks

Question 68

what’s in ddx for carpal tunnel

Answer 68

Arthritis of the carpometacarpal joint of the thumb (painful motion)

Cervical radiculopathy affecting the C6 nerve (neck pain, numbness in the thumb and index fingers only)

Diabetes mellitus with neuropathy (history)

Flexor carpi radialis tenosynovitis (tenderness near the base

of the thumb)

Hypothyroidism (abnormal results on thyroid function tests)

Pronator syndrome (median nerve compression at the elbow)

(tenderness at the proximal forearm)

Ulnar neuropathy (first dorsal interosseous weakness, numbness of the ring and little fingers)

Volar radial ganglion (mass near the base of the thumb above the wrist flexion crease)

Wrist arthritis (limited motion evident on radiographs)

Question 69

swelling or stenosis of sheath that surrounds abductor pollicis longus and extensor pollicus brevis

=tendon and synovial tissue are both hypertrophied and hurts when pass under retinaculum

Affects women eight to 10 times more often than men.

Pain on radiostyloid, tender to palpation

Forced /repetitive radial deviation of wrist- enlarged tendons in tenosynovium causing friction and pain

Idiopathic, triggered by overuse, a direct blow to the thumb, repetitive grasping, and inflammatory conditions like RA (impacts synovial tissue)

tx?

Answer 69

dequervain’s tenosynovitis

tx:

Conservative treatment: rest, ice, anti-inflammatory medications and splinting in a thumb spica splint.

Spica splint prevents wrist from ulnar deviating and thumb from extending

Tell them to wear the sprint and pick up the baby in a different way

PT for tendon gliding exercises and iontophoresis may be helpful.

Corticosteroid injection into the first dorsal extensor compartment if frequently helpful and may be curative.

surgery if refractory

Question 70

ddx of dequervain’s tenosynovitis

Answer 70

ddx: Carpometacarpal arthritis of the thumb (swelling over the joint, pain with joint compression) 


Dorsal wrist ganglion (palpable mass) 


Flexor carpi radialis tendinitis (pain and swelling over the 
tendon) 


Fracture of the scaphoid (tenderness over the anatomic 
snuffbox) 


Intersection syndrome 


Superficial radial neuritis 


Wrist arthritis (pain with movement, evident on radiographs) 


Question 71

Autosomal-dominant condition

Usually on ulnar side of hand

It’s not a tendon problem but a skin problem

When you move digit the tendon won’t slide, it’ll stay stiff

Localized formation of fibrosis of palmar fascia - starts with bump on palm may get dimpling/pitting of skin

As it progresses, more of the fascia becomes thickened and shortened- not painful

Dimpling and puckering of the skin over the area eventually occurs.

Ultimately contracture of the MP joints occurs, DIP joints involved later

More common in men over age 40 and in people of northern European descent.

tx?

Answer 71

dupuytren’s contracture

tx:

Tx: observe it, have them put their hand down on the table, if they can’t do that, it’s a good idea to refer them on

don’t have them try to manipulate it, it can make it worse, leave it alone and go about their normal business

Treatment is usually conservative until patient is unable to put hand flat on table top, then surgical fasciectomy is indicated

Question 72

dupuytren contracture ddx

Answer 72

flexion contracture secondary to join or tendon injury (no cords or bands) or locked trigger finger (no assoc nodules)

Question 73

animal bite microorangism. how can the infection manifet itself?

Answer 73

Pasteurella Multocida, it can present with ascneidng lymphangitis

Question 74

typical pathogens in paronychia

Answer 74

staph aureus and strep epidermidis

Question 75

dorsally displaced distal radius from fOOSH

Answer 75

colle’s fx

Question 76

volar displaced distal fragment of radius

Answer 76

smiths fx

Question 77

what’s in the ddx for ganglion and mucus cysts?

Answer 77

Arthritis (evident on radiographs) 


Bone tumor (evident on radiographs) 


Intraosseous ganglion (evident on radiographs) 


Kienböck disease (collapse of the lunate) 


Soft-tissue tumor, benign or malignant (solid mass on 
palpation, rare) 
Hand and Finger 


Dupuytren disease (presence of cords or bands) 


Epidermal inclusion cyst (history of laceration and repair) 


Giant cell tumors (different locations, but usually about the 
phalanges) 


Lipoma (larger in size, often in the palm) 


Soft-tissue

Question 78

how to manage a snuff box tenderness

Answer 78

For a patient who has the correct mechanism of injury (scaphoid injury),

has pain in the snuff box and normal x-rays:

Treat the injury as if they had a fracture

TSS (thumb spica splint)

RICE

No NSAIDS- block prostaglandins that help fracture heal

Smoking cessation b/c that affects microvasculature

F/U 7-10 days for repeat x-ray

Maybe do specialized scaphoid views or advanced imaging

Still tender in snuff box with normal x-rays- consider advanced imaging (CT- bone)

Question 80

acute low back strain/sprain:

dx

tx

Answer 80

Occurs when the muscles surrounding the spine are asked to stretch too far, lift to much weight, or move in such a way that they sustain very small tears. “weekend warriors”

Because of the tearing of the muscles, small microscopic bleeding occurs which in turn results in pain and muscle spasm

dx :symptoms: pain stiffness, local tenderness, shifted

pain worse with bending, sitting, twisting, coughing, lifting. Gets better as they go throughout the day

resolves in 2-6 weeks

self limiting problem

Rx: ice, modified activity, NSAIDS, mm relaxants*, oral steroids*, resume activity as tolerated.

narcotics have limited short term benefit, avoid benzos

PT, chiropractic

*X-ray: A/P lateral spine standing (debatable)

no MRI unless red flag symptoms (i.e. hx of cancer), follow up

90% improve within 4 weeks, but re injury is common.

Once healing occurs, high level strength, conditioning and body mechanics training for lifting.

Question 81

where is the most common area for a herniated disc? how do you tx?

Answer 81

Most common location is in the lumbar spine; L4-5 or L5-S1

Usu in corner of disk=weakest area

tx:

85-90% of first time disk herniations will resolve within the first 6 weeks to 3 months of onset of symptoms w/ without any treatment modalities.

Initially treated with short term bed rest for 1-2 days with gradual return to normal activities.

Anti inflammatories, ice, heat

Other conservative modalities include: physical therapy, chiropractic, acupuncture, pilates, yoga- work into it

Surgical treatment is warranted when all conservative measures fail or neurologic deficit is present like weakness

Question 82

spondylosis

Answer 82

Degenerative process of the spine. “Arthritis of the spine”

Question 83

spondylolysis

Answer 83

Defect that occurs in the posterior aspect of the spine known as the pars interarticularis

Essentially a stress fracture in the vertebral body.

** DEFECT=LYSIS=FRACTURE

Question 84

most common age of spondylolysis

tx

Answer 84

Usu in adolescence age 10-15

Common cause of low back pain in children.

5% of the general population has this condition with the vast majority being asymptomatic.

Most common in football lineman and young gymnasts with det lift or clean and jerks with hyperextension

dx:

Typical symptoms include low back pain especially when involved in activities that place the spine in an extended position from hip or hamstring

findings: hamstring tightness, paraspinal spasm and guarding, pain with palpation, + standing extension test (stork test)
tx: Initial treatment is rest and possible bracing with hopes of the fracture healing. (since most kids won’t rest the whole time—she knows kids)

Question 85

positive scotty dog sign= ?

Answer 85

fracture of pars interarticularis: area where superior articular process and transverse process attach to spinous process

Question 86

spondylolisthesis

sx:

dx:

tx:

Answer 86

symptoms: back and leg pain( radicular)

hip pain, often mistaken for bursitis

mechanical pain when getting up from chair

pain with standing and walking

pain worse with extension, better with pulling knees to chest.

Treatment: PT, injections,NSAIDS, surgery

Question 87

spondylosis:

presentation:

dx:

tx:

Answer 87

spondylosis:

presentation:

Natural degenerative process “arthritis”

affects joints/disc

inflammation/narrowing

mechanical back pain

paresthesia,weakness

leg pain/radicular pain

cervical =myelopathy

dx: xray

tx:

Cate’s rule of activity dosing (pre dose and after dose to avoid having to use it all the time)

ROM exercises

Core muscle exercise

Pool ex’s if not land tolerant

Facet injections/Rhizotomy in some cases, epidural steroid shots if radicular pain.

If primary back pain and mechanical in nature its all about management.

If stenotic/radicular pain then surgery

Question 88

vertebral compression fractures:

presentation:

dx:

tx:

Answer 88

vertebral compression fractures: Fracture of the vertebrae. Causes may include osteoporosis, trauma, infection and tumors.

Compression fractures affect 25% of postmenopausal women.

Only 33% of fractures in elderly women are diagnosed. Often misdiagnosed as “arthritis”

presentation:Typical presentation is an elderly female with acute onset of mid back pain. This may be traumatic or non-traumatic.

dx:

plain x-ray studies. Other imaging studies may include: MRI, CT, Bone Scan

tx:

Majority of mild to moderate compression fractures are treated with immobilization in a brace or corset for 6-12 weeks

Surgery: see PP

Balloon Kyphoplasty/Vertebroplasty.

Surgical stabilization

Question 89

most common mets to spine are from where?

Answer 89

lung, breast, prostate

Question 90

what sign is pathopneumonic for spinal stenosis?

Answer 90

the grocery cart sign:

Question 91

tx of spinal stenosis:

Answer 91

Avoid activities or motion that put the spine in extension or backward bent positions

NSAIDS or other oral analgesics.

Epidural steroid injections, no more than 3/ year.

Physical therapy should consist of exercises that emphasize “flexion” type exercises and pelvic tilts

Surgical decompression of the stenotic neuro- aliments. Goal of surgery is to “take the pressure off the nerves”

Fortunately, surgical intervention for spinal stenosis is successful and rewarding

Question 92

where do most c spine injuries occur? who should you contact first?

Answer 92

Most fractures occur at 2 areas: 1/3 from C2, over ½ occur at C6 or C7.

Most fatal injuries occur at C1-2

After assessment of airway and medical stability, always consult spine or neurosurgery regarding management.

This is a medical emergency- prompt evaluation and treatment is essential.

Question 93

tx of cervical fractures:

Answer 93

Initially- complete immobilization of the cervical spine.

Various forms of diagnostic imaging is warranted including: X-RAY, MRI, CT.

Minor fractures may require simple soft collar bracing with observation.

Severe fracture/dislocations may require halo traction and surgical stabilization

Two type of meds: 1)antiresorptive medications that slow bone loss and 2)anabolic drugs that increase the rate of bone formation.

Antiresorptive:Bisphosphonates, calcitonin, denosumab, estrogen and estrogen agonists/antagonists. (Fosamax, Boniva, Actonel)

Anabolic: Teriparatide (Forteo) a form of parathyroid hormone, increases the rate of bone formation

Question 94

flexion teardrop fx

definition

management

Answer 94

flexion teardrop fx

definition:

Flexion injury with compression force

Involves ligament disruption

Unstable

High incidence of cord injury

Most common level C5-6

Diving into a pool

management: surgery

Question 95

hangman’s fracture

defintion:

managemetn:

Answer 95

defintion:

Traumatic bilateral par’s interarticularis fracture of C2

Hyperextension and distraction injury

High speed auto, dashboard injury, falls in elderly

Neurological injury 25%

Unstable

managemetn: rigid bracing or surgery

Question 96

odontoid fractures

definition:

h/o slip and fall but doesn’t hurt right away but gets worse and worse

Lateral and open mouth view

management: type 1: soft collar

type 2: fx thru base: halo +/- surgeyr

type 3: fx thru c2, rigid collar +/- surgery

Question 97

jefferson fx

cause

sx

managment

Answer 97

cause Cause: hyperextension/axial falls, playground falls, mva, diving

sx Neck pain, rarely neurological issues, horner’s syndrome

managment: open mouth view, CT,

Overhang of C1 lateral mass over C2

Unstable fracture

Ranges from rigid brace, halo, surgery

Like a life saver that breaks and shatters in a bunch of directions and you get the overhang

Question 98

CAUDA equina

sx:

managment

Answer 98

Causes:

Tumors/Lesions

Trauma

Spinal Stenosis (Lumbar)

Inflammatory conditions

Hemorrhage

Fx

Spinal infection

sx:

Usu d/t central disk herniation, can start as a smaller disk herniation and then got worse, they may say all of a sudden they wet themselves

Tell patient if you start losing control of bowel and bladder you need to call me right away

Weakness, Saddle-anesthesia, Incontinence are common

low back pain, pain radiating into both legs, numbness or paralysis in the legs, saddle anesthesia, and bowel and bladder incontinence or retention.

With rectal exam there should be some sphincter tone resistance, and an anal wink if poked, and ask if they have sensation when they wipe

managment:

Medical emergency requiring surgical decompression

Failure to recognize = BAD, PERMANENT DEFICITS

Innervate B&B- lifetime incontinence

Question 99

how should scoliosis be managed?

Answer 99

always refer b/c there are many different kinds and curves and there is no “one way” to measure

Question 100

ankylosing spondylits

presentation

managment

Answer 100

presentation:

seronegative spondyloarthropathy (ie -RF,-ANA)

+HLA B-27

males>females mid 20s.

symptoms: pain and stiffness, relieved with movement/activity, they can get to sleep but are awaken with night pain

Inflammatory sacroilitis,enthesis, autofusion from SI to cervical (play video)

By the time this shows up on xray, they’ve probably had it for 7-10 years

managment:

Early diagnosis is key

Rheumatology referral

NSAIDs

DMARD

mobility exercises, yoga, posture

Important: ***If a patient with known AS falls, and has pain, it is a fracture until proven otherwise. Need to get CT scan for them

CT scan

Question 101

what are red flags with back pain?

Answer 101

Red flag symptoms

• Severe unremitting pain
• Unremitting night pain—pain that waxes and wanes or you can reproduce it is less concerning
• Night sweats
• General malaise
• Trauma
• Unexplained weight loss >10% 3-6 mos
• Bony tenderness
• Multiple myotomal loss
• Thoracic pain
• Immuno-suppressed

Saddle anesthesia

Bowel or bladder retention or incontinence ,gait disturbance—need to do a rectal exam

Bandlike pain (herpes zoster—it can happen up to 3-4 weeks before zoster’s finding)

Can’t lie supine

Pins/needles both hands and feet: MS, diabeters

More red flags

• PMH of:

• cancer
• TB or other infections
• IV drug use
• long term steroid use: can cause bone fx
• HIV
• osteoporosis

Also consider:

• age - < 20 or > 55 (kids don’t complain of back pain—if they do check on it!) and scoliosis usu doesn’t call pain
• any previous surgery

children:

don’t complain of back pain

Rare compared to adults

Must be evaluated

Painful scoliosis is a red flag

(scoliosis is typically not painful)

Adolescent

Tumor

Infection

Spondylolysis/fracture (athlete)

Scheuerman’s Disease

Scoliosis

Elderly

Osteoporotic or senility fracture

Tumor

Infection

Question 102

malignant spinal cord compression: def and tx

Answer 102

Spinal mets can cause MSCC

5% of all patients with cancer present with MSSC

First symptoms are pain

Reduced control of legs, ataxia and vague weakness are other signs often overlooked

Can present with radicular pain due to compression

tx:

MRI gold standard

MRI whole axial spine(emergent)

Biopsy and labs

Oncology work up

Source primary lesion

Surgical treatment

Question 103

most common primary malignant spinal cnacer

Answer 103

myeloma

Question 104

myeloma

sx

tx

Answer 104

sx:

Myeloma

Most common primary malignant spinal cancer

White count, platelets and hemoglobin go down but calcium goes up

Results in bone being resorbed secondary to excessive plasma cells which produce abnormal quantities of immunoglobulins

Early diagnosis reduces risk of spinal cord compression.

Average age 65

Male 2:1 over female

Looks like moth eaten bone or punched out

Symtpoms:

Bone pain, lumbar spine, pelvis, ribs

Tired, fatigues easily(anemia)

Bruise easily (thrombocytopenia)

Associated fractures (apendicular)

L/E radiculopathy

Managmenet:

Full axial spine MRI

Skeletal survey

Full body bone scan ?

Bone marrow biopsy

Labs/Oncology

Urinalysis: Bence Jones Protein

Question 105

osteo porosis prevention

Answer 105

Get enough Calcium and Vitamin D and eat a balanced diet

Get regular exercise that includes weight bearing and strengthening

Avoid smoking

Limit Alcohol to 2 drinks/day

exercise

Load bearing: anything on your feet

Weight training: muscle building

Often overlooked

Balance and Coordination

Question 106

what ligaments keep the foot from rotating laterally?

Answer 106

Anterior talo-fibular

Calcaneo-fibular

Posterior talo-fibular

Question 107

where can you find the plantar flexors?

Answer 107

Pass posterior to medial malleolus- at end of tibia and wrap under foot

Tom, Dick and Harry tendons

Question 108

where can you find the peroneals or evertors of the foot?

Answer 108

Pass posterior to lateral malleolus and wrap under foot

Peroneal brevis- inserts on base of 5th metatarsal

Question 109

what is usually assoc with a deltoid ligament sprain?

Answer 109

usu also fibular fx b/c of force requ’d to forcibly evert the foot like that

Question 110

which ligaments are most often sprained in the foot?

Answer 110

>90% of the time the lateral ligaments are sprained

Lateral ligaments tear in sequence, anterior to posterior- most anterior is anterior talo-fibular >90%, bad sprains can involve 2+ ligaments (calcaneofibular or posterior talofibular)

Question 111

managment of ankle sprains

Answer 111

rest, Ice, compression, elevation

Immobilize with plastic or plaster splint- stabilize ankle so the ligament can rest and heal, should be able to bear weight. Fits inside their shoe and usually they can walk with that

Consider crutches if moderate-severe or difficulty bearing weight with splint

Third degree sprains may need surgery (rare)- all ligaments torn so it won’t heal on its own

Usually takes 4-6 weeks to heal

If still not healed, unstable, refer to ortho b/c they might need surgery

Question 112

achilles tendon tear:

MOA

sx

dx

tx

ddx

Answer 112

moa

Usually due to forced dorsiflexion of ankle- initiating sprint, slipping on stair

Also seen with direct trauma- blow to taut tendon, laceration

sx:

Hx: were doing something, then sudden pain like a “gunshot wound”

Patient may have heard a “snap”

Difficulty stepping off or walking, won’t want to push off on foot

pe:

Swelling of distal calf

Palpable tendon defect

Difficulty bearing weight

Weak plantar flexion (if asked to press foot down on hand like pressing down on a gas pedal) b/c of tom dick and harry tendons

May still be able to flex toe flexors, tibialis posterior, peroneal- not indicative of injury

dx: thompson test

management:

Initial, splint in equinus- aka plantar flexion so no tension on achille tendon (dorsi flexion puts tension on it)

Non-weight bearing

Refer to ortho: they need to decide tx: casting vs. surgery

Conservative: casting x8 weeks, PT

Surgical: recommended for younger, athletic patients

ddx:

Achilles tendinitis or tendinosis (thick, tender Achilles tendon or crepitus may be noted on palpation)

Deep vein thrombosis (no history of injury, negative Thompson test)

Medial gastrocnemius tear (pain on palpation over the medial head of the gastrocnemius-soleus complex)

Plantaris rupture (pain but little loss of function)

Stress fracture of the tibia (constant pain over a localized area

of the tibia)

Question 113

what are the ottawa ankle rules?

Answer 113

criteria to determine if Xray required. Cost effective and well validated. Need xray if any of the following are positive:

Bony tenderness along distal 6 cm. of tibia or fibula—push on medial and lateral portions.

Bony tenderness at base of 5th metatarsal (b/c peroneal brevis can pull off a piece of that 5th metatarsal in inversions)

Inability to bear weight, both immediately after injury and in ED

Question 114

ddx of arthritis of foot

Answer 114

Charcot arthropathy (history of diabetes mellitus, swelling that is disproportionate to symptoms)

Gout (redness and swelling)

Tendinitis (normal radiographs)

Question 115

tx of hallux rigids

Answer 115

Rx: rocker-soled shoes that help walking without bending MTP joint, NSAIDs, surgery possible (joint replacement vs. fusion)

Question 116

calcaneous fx:

mOI

presentation

dx

tx

px

Answer 116

Req a lot of force; mechanism usually due to compression- ie fall from height or in head on collision in car accidents

Usu assoc with other issues b/c of force req’d

10% associated with lumbar fx- axial load distributed to spine

26% associated with other extremity injury

Needs a good head to toe PE b/c of distraction pain

Clinical- swelling, pain located at heel, ecchymosis over calcaneus

Xray- standard foot films usually demonstrate (AP and lateral)

Calcaneal view- more elongated view of the calcaneus, can get if if doesn’t show up on AP or lateral but you suspect fx

Treatment- surgical by a foot specialist to restore anatomy b/c comminuted

Bilateral calcaneus fractures are common

Px: can be really devastating. Often they might have a limp for the rest of their life even if they get surgery by the best foot surgeon

Question 117

talar fx:

MOI

presentation

dx

tx

px

Answer 117

Usually due to foot hyper-plantar flexion

Drives talus into tibia, maybe from running and you catch your foot

Fracture may involve dome, neck, or body

Important b/c Talus covered by cartilage, its blood supply tenuous and can be disrupted

1% may lead to avascular necrosis if not recognized and treated appropriately

Clinical

Intense pain

Inability to bear weight

Localized tenderness and swelling- anteriorly, where foot meets ankle

May have loss of normal foot contour: instead of nice 90 degree angle it will be softened

Caution “ankle sprain” misdiagnosis- pt says they have ankle pain, get xray and often you can miss them on ankle xrays. usually the CC

Diagnosis with foot xrays

Ice, elevation, immobilization

Nonsurgical, if non-displaced minor chip fracture of dome

Surgery if displaced fracture of neck or body

Question 118

metatarsal fx:

MOI

presetnation

dx

tx

Answer 118

Stress fractures

Stress fractures of midshaft metatarsals

Usually 2nd and 3rd MTs which are relatively fixed compared to mobile 1,4,5- take more of the impact from physical activity

Due to excessive stress over time (i.e. training for marathon)

May not appear on xray for 2-3 weeks b/c at that point you start to lay down calcium (a white line) at fx site

If suspected and need to know right now: bone scan (with isotopes—goes to area of fx), repeat xray in 2-3 weeks

But this doesn’t change tx—the only way it will heal is to stop running, etc

No one wants to hear that…but its what they have to do or it will get worse

Rx: rest, possibly immobilize- can turn into complete bone fracture

Question 119

proximal 5th metatarsal fx

mOI

presentation

dx

tx

Answer 119

Most common metatarsal fracture

Often occurs with lateral ankle sprain

Usually due to inversion/avulsion of proximal bone by peroneus brevis tendon- can pull part of the bone off

Always check for tenderness at base of fifth metatarsal when evaluating ankle sprain- second Ottawa ankle rule

Ankle xrays must visualize this area

If can’t see 5th metatarsal with ankle xray get a foot xray

Rx: Usually conservative, Immobilize, Crutches

At right: Jones fx vs. proximal 5th

Question 120

broken toe: mOI, presentation, sx, dx, tx

Answer 120

Phalanges (toe fractures) –forefoot fracture

Common, often see fracture-dislocation

Usually due to direct trauma or hyper-extension or crush

Exam: pain/swelling, deformity if dislocated, ecchymosis

Dx: xray

Treatment

Reduce fracture and/or dislocation

Immobilize with dynamic splinting- “buddy taping” to toe next to it

Tell them to wear the stiffest-soled shoes that they have

Great toe bears 1/3 of body weight on that side, may require walking cast, may want to refer them to orthopedist to see if they need something else to get it to heal

If unable to reduce, may require internal fixation (rare) surgery

Question 121

plantar fasciits: presentation, dx, tx

Answer 121

Usually an overuse injury: runners, standing occupations, RA and gout

Strain of fascial fibers, friction causes periostitis of calcaneus

Plantar fascia runs along bottom of foot and attaches to calcaneous

Clinical

Pain over plantar surface or at insertions of fascia on calcaneous

Increased with walking or running, relief with rest

Tender to palpation over anterior calcaneus

Pain with passive dorsiflexion (strains fibers)

Management

Rest, NSAIDs- stretch facial fibers gently

Heel and arch supports

If refractory, steroid injection- may last months without resolve

Takes time, sometimes months. Can be frustrating.

Question 122

ddx of Ra

Answer 122

Hepatitis (abnormal liver function tests)

Lyme disease (serology, rash, anemia)

Seronegative arthropathies (human leukocyte antigen [HLA]

tests, abnormal radiographs, urethritis)

Systemic lupus erythematosus (antinuclear antibodies,

peripheral blood smear)

Question 123

ddx of OA

Answer 123

Charcot joint (primarily foot and ankle, diabetic neuropathy)

Chondrocalcinosis (crystals in joint aspirate)

Degenerative changes secondary to inflammatory arthritis

(positive rheumatoid factor)

Epiphyseal dysplasia (short stature)

Hemochromatosis (abnormal liver function studies)

Hemophilia (bleeding tendency)

Question 124

ddx of seronegative arthopathies

Answer 124

Achilles tendinitis or plantar fasciitis (no associated symptoms)

Degenerative disk disease (no associated symptoms, normal skin distraction on flexion of the spine)

Rheumatoid arthritis (positive rheumatoid factor, peripheral joint involvement)

Question 125

ddx of fibromyalgia

Answer 125

AIDS (blood test)

Bursitis or tendinitis (usually single joint or extremity)

Complex regional pain syndrome (usually a single extremity)

Hypothyroidism (abnormal thyroid function tests)

Lyme disease (serology test)

Multiple sclerosis (abnormal MRI of the brain)

Polymyalgia rheumatica (elevated erythrocyte sedimentation

rate)

Polymyositis (skin rash)

Rheumatoid arthritis (positive rheumatoid factor)

Systemic lupus erythematosus (antinuclear antibodies,

elevated erythrocyte sedimentation rate)

Tenosynovitis (single focus, associated with tendon motion)

Question 126

ddx for polymyalgia rheumatica (aka what you need to exclude)

Answer 126

Rotator cuff disorders

DJD, neck, shoulders, hips

Large Joint RA

Statin-induced myalgias

Hypothyroidism

Infection – UTI in elderly

Amyloidosis (elevated ESR)

Rarely- occult or metastatic malignancy

Question 127

what disorder is polymyalgia rheumatica linked to?

Answer 127

giant cell arteritis

Question 128

what dz?

70-95% with shoulder pain

50-70% with hip involvement

Systemic sx in 1/3

Occasionally a red, hot swollen joint (somewhat related to RA somehow—need more studies to understand)

MRI shows subdeltoid and subacromial bursitis as most frequent lesions in PMR; frank synovitis less common.

Distal swelling of UE with pitting edema in 8% (extensor tenosynovitis) not tender (pseudogout is tender)

usu acute onset, not as fast as gout

MRI below shows inflammation of bursa

Answer 128

polymyalgia rheumatica

Question 129

what blood tests are specific for lupus activity?

Answer 129

anti double stranded DNA and complements

Question 130

which autoimmunity extractable nuclear antigens is specific for sjogens? SLE MIXED ctd? inflammatory myophaty? systemic scleroderma/

Answer 130

sjogens SSA and SSB, SLE anti smith MIXED ctd U1-RNP inflammatory myophaty Jo-1 systemic scleroderma Scl-70

Question 131

what are the criteria req’d for SLE?

Answer 131

ACR Revised Classification Criteria

4 of 11 criteria required:

Malar Rash

Discoid Rash

Photosensitivity(sun exposed places get overly burned with minimal exposure)

Oral ulcers

Arthritis

Serositis (pericarditis, pleuritis)

Nephritis

Neurologic disorder

Hematologic disorder

Positive ANA

Other positive antibodies (Smith, DNA antibody, antiphospholipid antibodies, etc)

Question 132

what manifestations are seen in limited scleroderma? how about diffuse scleroderma?

Answer 132

limited=centromere antibody, distal sclerosis, and CREST (

Calcinosis, Raynaud’s, Esophageal dysmotility(swallowing issues/strictures), Sclerodactyly (tightening of skin), Telangectasia

Distal sclerosis)

diffuse: SCL 70 +

Raynaud’s phenomenon

Lung involvement (interstitial lung disease)

Pulmonary hypertension

Renal (hypertensive, renal crisis)

Upper or lower GI (reflux, dysphagia, decrease peristalsis, bacterial overgrowth)

Musculoskeletal

Question 133

with which AI rheumatic disorder should you always check for other malignancies?

Answer 133

adult dermatomyositis

Question 134

what are the dx criteria for takayasu’s arteritis?

Answer 134

age <40, claudication of extremities, decreased brachial artery pulse, BP difference >10 mm hg between arms, bruit oversubclavian, arteriogram abnormality: occlusion or narrowing in aorta or main branches (need 3/6)

Question 135

what are the classifications for polyarteritis nodosa?

weight loss >4kg, livedo reticularis, testicular pain or tenderness, myalgias/weakness/leg tenderness, mononeuropathy or poyneuropathy, mononeuropathy or polyneuropathy, diastolic BP >90, elevated BUN or creatinine, hep B, arteriographic abnormality, bx of small or medium artery containing PAN

Question 136

what are the criteria for churg strauss syndrome?

Answer 136

asthma, eosinophilia >10% WBC, mononeuropathy or polyneuropathy, transitory pulmonary infiltrates, paransal sinus abnormality, bx with extravascular eosinophils

Question 137

what are the criteria for vasculitis with polyangitis (wegener’s):

Answer 137

nasal or oral inflammation (oral ulcers or bloody nasal drainage), abnormal chest radiographs (nodules, fixed infiltrates, cavities), urinary sediment (>5 RBc) granulomatous inflammation on biopsy

Question 139

ddx for ACL tear

Answer 139

Fracture (tenderness over the bone, evident on radiographs)

Meniscal tear (continued tenderness along the joint line, pain

or trapping with circumduction) (may occur with ACL tear)

Patellar dislocation/subluxation (positive apprehension sign

when displacing the patella laterally)

Patellar tendon or quadriceps rupture (inability to perform

straight-leg raise)

Posterior cruciate ligament tear (positive posterior drawer test,

firm end point on Lachman test)

Question 140

ddx of OA of knee

Answer 140

Herniated L3 or L4 disk with radiculopathy (diminished knee reflex, numbness)

Meniscal tear (history of trauma and/or locking and catching) (may be concomitant)

Osteonecrosis of the femur or tibia (patient older than 50 years, female, history of steroid use, blood dyscrasia)

Pigmented villonodular synovitis (unexplained recurring hemarthrosis)

Primary hip pathology (dermatomal referred pain to the knee, limited range of hip motion)

Septic arthritis (fever, malaise, abnormal joint fluid)

Tendinitis/bursitis (tenderness directly over a tendon or bursa)

Question 141

ddx of bursitis in knee

Answer 141

Inflammatory arthritis (multiple joint involvement, abnormal laboratory studies)

Medial meniscal tear (catching, locking, effusions)

Osgood-Schlatter syndrome (preadolescent patients)

Osteoarthritis of the knee (intra-articular effusion,

osteophytes)

Patellar fracture (intra-articular hemarthrosis, history of

trauma)

Patellar tendinitis (jumper’s knee) (tenderness at the inferior

pole of the patella)

Saphenous nerve entrapment (numbness over the medial shin,

dysesthesia)

Septic arthritis of the knee (effusion of the joint but the

patella can be palpated in its subcutaneous position, knee held

in more flexion)

Septic knee (flexion contracture, pain with knee motion, intra-

articular swelling)

Tumor (pain, mass)