Orthopedics Flashcards
What is the first line treatment for osteoarthritis?
Exercise, ROM, and strengthening
What are heberdens nodes associated with?
Osteoarthritis
What type of arthritis affects the metacarpal joints?
Rheumatoid arthritis
What is the test for impingement syndrome (shoulder pain)
Painful arc test & Hawkins-Kennedy test
What is the McMurray’s test for?
Torn meniscus (knee)
Where is the lateral epicondyle?
Elbow
Lateral epicondylitis is tennis elbow
Where is the scaphoid?
Inner aspect of wrist bone
Common injury to wrist during fall?
Scaphoid fracture
What is the diagnostic test for a scaphoid fracture?
Snuffbox tenderness
What is the lower back pain test that is positive for radiculopathy?
Straight leg raise
What is an overreaction during physical exam with inappropriate physical signs?
Waddell’s signs
What type of lower back pain is from L5-S1 and radiates down leg, foot, or ankle?
Sciatica
What is the diagnostic test for sciatica?
Straight leg raise
What is the hip bone?
Trochanter
Osteoarthritis in a patient causes what type of hip joint pain?
Anterior hip/groin pain
When a patient complains of heel pain or tenderness, they have…
Plantar fasciitis
What test is for an acl in knee?
Anterior draw test
What condition is associates with a positive MTP squeeze test?
Mortons neuroma
What condition is associated with a positive finkelstein test?
DeQuervain’s tensosynovitis
Burning pain between the 3rd and 4th toes.
Morton’s neuroma
Positive tinel’s test & positive Phalen’s test
Carpal Tunnel Syndrome
Type of fracture secondary to systemic disease?
Pathologic fracture
Common cause of posterior knee pain
Bakers cyst
Overuse injury of a bone
Stress fracture/ takes 4-6 weeks to heal
Dorsal thumb pain is a classic symptom of
DeQuervains tenosynovitis
Injury to a bone that does not result in a fracture
Contusion
Injury to a muscle is a
Strain
Injury to a ligament is a
Sprain
What are the nodes on the PIP nodes secondary to arthritis?
Bouchnard’s nodes
Joint stiffness lasts <60 minutes usually
Osteoarthritis
RICE is acronym for treatment for
Sprain
Term that describes compression of the spinal cord
Cauda equine syndrome
Loss of bowel/bladder function
The Lachman maneuver is used to detect what
Knee instability
Heberden’s node’s are commonly seen in
Degenerative joint disease
The drawer sign is performed on the knee or ankle to assess for
Instability of the knee
What test is used to identify inflammation of the median nerve as seen with carpal tunnel syndrome
Phelan test
Wrist pain on palpation of the anatomic snuffbox. Pain on axial loading of the thumb. History of falling forward with outstretched hand to break the fall. Initial x-ray of the wrist may be normal, but a repeat x-ray in two weeks will show the scaphoid fracture. High-risk of a vascular necrosis and non-union. Splint rest and referred to a hand surgeon.
Navicular fracture (scaphoid bone fracture)
What is an important stabilizer of the metacarpal joint
Scaphoid
An injury to bone is a
Contusion
If a patient has a positive snuff box tenderness test, what should be done
Treat as a fracture until proven otherwise. If x-ray is negative, consider MRI or CT as definitive exams. Splint thumb
Fracture of the distal radius of the forearm along with dorsal displacement of wrist. History of falling forward with outstretched hand. This fracture is also known as the dinner fork fracture due to the appearance of arm and wrist after the fracture. The most common type of wrist fracture.
Colles fracture
History of slipping or falling. Sudden onset of one sided hip pain. Unable to walk and bear weight on affected hip. If mild fracture, may bear weight on affected hip. If displaced fracture, presence of severe hip pain with external rotation of the hip/leg and leg shortening. More common in elderly. Elderly have a one year mortality rate from 12% to 37%.
Hip fracture
If a patient has hip pain, at night, what must be ruled out
Malignancy, inflammatory process, osteomyelitis
If a patient has lateral hip pain that is aggravated by direct pressure what is a diagnostic consideration
Trochanteric bursitis
If a patient has hip pain with use, that is better with rest what diagnostic consideration
Structural joint problem or Osseo arthritis
If a patient has constant hip pain, especially at night what must be considered
Infectious, inflammatory, neoplastic
If a patient has anterior hip/groin pain, what diagnosis should be considered
Hip joints,osteo arthritis
If a patient complains of posterior hip pain what diagnosis should be considered
S I joint, LBP
History of significant or high energy trauma such as a motor vehicle or motorcycle accident. Signs and symptoms depend on degree of injury to the pelvic bones and other pelvic structures such as nerves, blood vessels, and pelvic organs. Look for ecchymosis and swelling in the lower abdomen, the hips, groin, and/or scrotum. May have bladder and/or fecal incontinence, vaginal or rectal bleeding, hematuria, numbness etc. may cause internal hemorrhage, which can be life threatening. Check airway, breathing, and circulation first
Pelvic fracture
Acute onset of saddle anesthesia, bladder incontinence, fecal incontinence. Accompanied by bilateral leg numbness and weakness. Pressure on a sacral nerve root results in inflammatory and ischemic changes to the nerves. A surgical emergency. Need spinal decompression. Refer to ED.
Cauda Equina Syndrome
Acute and sudden onset of tearing severe low back/abdominal pain. Presence of abdominal bruit with abdominal pulsation. Patient with signs and symptoms of shock. More common in elderly males atherosclerosis, white rice, and smokers.
Low back pain from a dissecting abdominal aneurysm
What conditions outside of the spine can cause back pain
Pancreatitis, nephrolithiasis, prostatitis, Pyelonephritis , AAA, herpes zoster
When a patient presents with lower back pain what are some clues to systemic disease
History of cancer i.e. breasts, prostate, lung, fibroid, kidney. Age over 50 years old. Unexplained weight loss. Duration of pain greater than four weeks. Nighttime pain. Only get lumbar x-ray in these situations.
What test do you perform for a patient that presents with lower back pain
Straight leg raise is positive it is radiculopathy
Inappropriate physical signs on physical exam, faking illness or pain, overreaction during exam
Waddell’s signs
Nerve root irritation at L5 through S1. Sharp or burning pain radiating down the leg to foot or ankle. May occur as numbness or tingling.
Sciatica
Examiner raises patients extended leg with the ankle Dorsiflexed. Positive if sciatica is reproduced between 10 and 60° in the affected leg. May confirm radiculopathy
Straight leg raise
What imaging is done for a patient that complains with lower back pain
Plain radiographs AP and lateral of lumbar spine; trauma, suspected malignancy, infection add ESR and CRP he.
When is an MRI indicated in a patient that presents with lower back pain
It is the gold standard test for disc disease. Demonstrates discs, ligaments, nerve roots, epidural that, shape and size of the spinal canal. Looks at soft tissue.
If cloudy synovial fluid is found what must be done
Order culture and sensitivity because this can be indicative of an infection
Damage to what joint may cause locking of the knees and knee instability
Meniscus
Connects muscle to the bone.
Tendon
Connects bone to bone
Ligaments
Saclike structures located on the anterior and posterior areas of the joints that act as padding. Filled with synovial fluid when inflamed.
Bursae
When bursae is filled with synovial fluid and is inflamed it os bursitis
What is the gold standard imaging study for injuries of the cartilage, meniscus, tendons, ligaments, or any joints of the body
MRI
What imaging study and emits radiation and detects bleeding, aneurysms, masses, pelvic and bone trauma and fractures
CT scan
Metal implants, pacemakers, aneurysm clips, and metallic joints are contraindicated in what diagnostic imaging study
MRI
What is Venus recurvatum
Hyper extension or backward curvature of the knees
What is genu valgum
Knock knees
Think of “gum stuck between the knees”
What is genu varum
Bow legs
When should RICE be initiated after musculoskeletal trauma
48 hours
When should isometric exercise be introduced after musculoskeletal trauma
It is useful during the early phase of recovery before regular active exercises performed. Defined as the controlled and sustained contraction and relaxation of a muscle group. Less stressful on joints than regular exercise. Usually done first before exercise post injury. Nonweightbearing exercises.
What is a test for knee stability
Drawer test. And diagnostic sign of a torn or ruptured ligament.
What causes DeQuervain’s tensovitis and where is it located in my hand
It is caused by inflammation of the tendon and it’s sheath and is located at the base of the thumb
What is the screening test for DeQuervain’s tendinitis
Finkelstein’s test
Which is positive if there is pain and tenderness on the wrist upon ulnar deviation
Knee pain and the click sound upon manipulation of the knee is positive. Suggests injury to the medial meniscus.
McMurray’s test
What is the gold standard test for joint damage
MRI
What test is for knee laxity and is suggestive of ACL damage of the knee and more sensitive than the anterior drawer test for ACL damage
Lachman’s sign
Acute or recurrent pain on the bottom of the feet that is aggravated by walking. Caused by micro tears in the plantar fascia due to tightness of the Achilles tendon. Higher risk with obesity, diabetics, aerobic exercise, flat feet, prolonged standing
Plantar fasciitis
What is the treatment plan for plantar fasciitis
NSAIDs. Use orthotic foot appliance at night times a few weeks. Ice pack to affected foot. Stretching and massaging of the foot: rolling a golf ball with soles of foot several times a week. Lose weight. Consider x-ray to rule out fracture, heel spurs, complicated case. Refer to podiatry as needed.
Inflammation of the digital nerve of the foot between the third and fourth metatarsal’s. Increased risk with high-heeled shoes, tight shoes, obesity, dancers, runners.
Morton’s neuroma
What condition can cause a small nodule on the space between the third and fourth toes on physical exam
Morton’s neuroma
What is the screening test for Morton’s Neuroma
Mulder rest
Grasp 1st & 5th metatarsals and squeeze the forefoot. + if hearing a click along with a pt report of pain during compression. Pain is relieved when the compression is stopped.
What is the treatment plan for Morton’s neuroma
Avoid wearing tight narrow shoes and high heels. Use for front foot pad. Where well padded shoes. Diagnosed by clinical presentation and history. Refer to podiatrist.
Pain exacerbated by activity; relieved by rest, sometimes occurring at night. A.m. stiffness resulting in less than or equal to 60 minutes. Tenderness to palpation of infected joints. Crepitus is audible. Joint effusion may be present. Osteophytes and joint space narrowing are present
Osteoarthritis or degenerative joint Disease
What is the first line treatment for osteoarthritis
Exercise and range of motion and strengthening.
Weight loss if appropriate, patient education, heat and ultrasound
What is the pharmacologic treatment for osteoarthritis
Acetaminophen PRN first then scheduled up to 3 g daily. If this doesn’t work then NSAIDs PRN 2-four week trial at high dose is no relief. If there is no release on three different NSAIDs, steroid injection, consider referral
Can you reprice an NSAID to a patient that had an MI
No. Use with caution in patients with cardiac problems.
A patient who has osteoarthritis takes NSAIDs almost daily. Which lab tests should be done annually
CBC, BUN/CR, ALT
What joints are mostly affected by osteoarthritis
Hips, knees, and the hands.
What risk factors are there for osteoarthritis
Older age, overuse of joints, and positive family history
Bony nodules on the distal interphalangeal joint’s associated with osteoarthritis
Heberden’s nodes
Bony nodules on the proximal interphalangeal joints associated with osteoarthritis
Bouchnard’s nodes
Age greater than 75 years old what pharmacologic treatment should be used for osteoarthritis
Topical NSAIDs vs. oral form
When a patient presents with osteoarthritis symptoms what must be ruled out
Osteoporosis
If a patient has a history of uncomplicated ulcer, aspirin, Coumadin, PUD, and platelet disorder, can they be on an NSAID
No
What type of arthritis causes joint stiffness to last longer, involves multiple joints, and has symmetrical distribution. It is also accompanied by systemic symptoms like fatigue, fever, normocytic anemia, etc.
Rheumatoid arthritis
What nobody is located at the DIP joint
Heberden’s
- the den ending on the word is the letter D for DIP joint
What is the treatment for rheumatoid arthritis
All of the treatments for osteoarthritis plus systemic steroids, antimalarial’s such as plaquenil, anti-metabolite such as methotrexate, and Biologics such as Humira or Enbrel
A woman of age 20 to 35 years old presents with a classic rash in a maculopapular Butterfly shaped rash on the middle of the face or Malar rash. May have non pruritus thick scaly red rashes on sun exposed areas called discoid rash. Urinanalysis is positive for protein urea.
Systemic lupus erythematosus
How do you manage lupus
Referral to rheumatologist
What is pertinence patient education for lupus
Avoid sun between 10 AM to 4 PM because it causes rashes to break out. Cover skin with high SPF sunblock. Sun protective clothing such as hats with wide Rams, long sleeved shirts. More sensitive to indoor fluorescent lighting. Use non-fluorescent lightbulbs.
Adult to middle-aged female complains of gradual onset of symptoms over months with daily fatigue, low-grade fever, generalized bodyaches, and myalgia. Complains of generalized aching joints, which usually involves the fingers/hands and wrist. Morning stiffness lasts longer than osteoarthritis with painful, warm, and swollen joints. Swollen fingers with warm tender joints (PIP & DIP). Also called sausage joints
Rheumatoid arthritis
Systemic autoimmune disorder that is more common in women. Mainly manifested through multiple joint inflammation and damage. Patients are at higher risk for other autoimmune diseases, graves disease, pernicious anemia, and others.
Rheumatoid arthritis
What conditions have poly arthritis
Lupus, rheumatoid arthritis, scleroderma, fitz disease
Morning joint stiffness lasts greater than 60 minutes, affected joints swell, symptoms present at least six weeks
Rheumatoid arthritis
What is the work up for rheumatoid arthritis
Rheumatoid factor, anti-– CCP antibody’s, ESR, CRP, ANA, CBC, BUN, LFT, CR, uric acid level, urinalysis
Heberden’s nodes are solely associated with
Osteoarthritis
The primary joint that is affected Are the hands and wrists, metacarpophalangeal, absent heberden’s nodes, joint is soft warm & tender, + RF, CCP, ESR, CRP
Rheumatoid arthritis
Hips and knees are the primary joint affected, carpometacarpal, DIO, + heberden’s nodes, joint is bony and hard, -RF, CCP, ESR, CRP
osteoarthritis
How do you manage rheumatoid arthritis
Early referral to rheumatology
patients aware prescribed biologics such as infliximab -mab
And nonbiologics such as methotrexate
Swan’s neck deformity is found in
Rheumatoid arthritis. It is found in 50% of patients. Flexion of the DIP joint with hyperextension of the PIP joints
Boutonnière deformity is found in
Rheumatoid arthritis. Hyper extension of the DIP with flexion of the PIP joint
If an x-ray shows bony erosion, joint space narrowing, and subluxations i.e. dislocation what must be considered
Rheumatoid arthritis
Can A patient with rheumatoid arthritis continue to take a biologic drug if they have signs and symptoms of infection such as fever or sore throat
No
Uveitis, scleritis, vasculitis, pericarditis, are all associated with
Rheumatoid arthritis
Uveitis needs an opthomologist STAT
Swelling of the uvea, the middle layer of the eye that supplies blood to the retina.
Uveitis. Refer to ophthalmologist immediately. Patient treated with high dosed steroid for several weeks.
What kind of drug is Plaquenil
Antimalarial
What type of drug is methotrexate
DMARD
Middle-aged male presents with painful, hot, red, and swollen metatarsal phalangeal joint of greater toe i.e. Podagra. Patient is limping due to severe pain from weight bearing on affected toe. History of previous attacks on the same site. Precipitated by alcohol, meets, or seafood.
Gout
What condition has tophi
Chronic gout.
Tophi are small white modules full of urates on ears and joints
What will the labs show in gout
Uric acid level will be elevated more than 7 mg.
What is the treatment for an acute presentation of gout
Indomethacin (Indocin) BID or naproxen sodium BID PRN.
If no relief, combine with colchicine 0.5mg 1 tan every hour until relief or diarrhea occurs. After acute phase is over, wait at least 4-6 weeks before initiating maintenance treatment.
Stop allopurinol during acute phase. Restart 4-6 weeks after resolved.
What is the maintenance medication for gout
Allopurinol (Zyloprim) daily for years to lifetime. Check CBC as it affects bone marrow.
Probenecid lowers uric acid
Colchicine has anti-inflammatory effects and can be used during acute phase with NSAIDs and for maintenance phase.
Can gout cause joint destruction
Yes
More common in males and HLA-B27+. Average age of onset is the early 20s. Chronic inflammatory disorder that affects mainly the spinal region and the sacroiliac joint. Some other joints affected are the shoulders and hips.
Ankylosing Spondylitis
Young adult male complains of a chronic case of back pain for more than three months that is worse in the upper back. Joint pain keeps him awake at night. Associated with generalized symptoms like low-grade fever and fatigue. May have chest pain with respiration. Long-term stiffness that improves with activity. Some have buttocks pain.
Ankylosing Spondylitis
Objective findings include marked loss of range of motion of the spine such as forward bending, rotation, and lateral bending. Decreased respiratory excursion down to less than 2.5 cm. Some have lordosis. Uveitis: complains of Eye irritation, photosensitivity, and Eye pain. Scleral injection and blurred vision. Refer to opthalmologist ASAP to be treated with steroids.
Ankylosing Spondylitis
What labs are ordered for ankylosing Spondylitis
Sedimentation rate and see reactive proteins which will be slightly elevated. RF will be negative. Spinal radiograph will show classic bamboo sign.
What is the treatment plan for ankylosing spondylitis
Referral to rheumatologist. Buy mattress with good support. Postural training.
First line treatment is NSAIDs
If high risk of bleeding, prescribe PPI with NSAIDs or COX-2 inhibitors (celecoxib or Celebrex)
For severe treatment DMARDs, biologics, and spinal fusion
What are complications of Ankylosing Spondylitis
Anterior uveitis
Aoritis (inflammation of the aorta)
Fusing of the spine with significant loss of range of motion. Spinal stenosis.
Patient greater than 50 years old with a new onset of back pain what should be ruled out
Cancer
If a patient presents with symptoms of spinal stenosis what must be ruled out
Ankylosing Spondylitis
What is the best imaging study for diagnosing a herniated disc
MRI
Acute pressure on a sacral nerve root results in inflammatory and ischemic changes to the nerve. Sacral nerves innovate pelvic structures such as the sphincters (anal and bladder). Considered a surgical emergency. Needs decompression. Referred to ED.
Cauda Equina syndrome
Bowel incontinence, bladder incontinence, & saddle anesthesia are all signs of
Cauda Equina Syndrome
Common cause of shoulder pain. Also called cuff tendinitis.
Supraspinatus Tendonitis
What test is for impingement syndrome
Hawkins-Kennedy Test
Painful arc test
Which condition would be consistent with the patient that has a history of diabetes, history of immobilizing condition of the shoulder, and diminished shoulder range of motion
Adhesive capsulitis
Forearm muscles attach to the
Lateral epicondyle
How do you manage lateral epicondylitis or tennis elbow
Rest is very important. Keep joints moving. Ice/heat is helpful. NSAIDs. Steroid injections. Physical therapy. Isometric resistance or wrist extension.
How is epicondylitis treated
If chronic neuropathy, it can be treated with TCAs, gabapentin, phenytoin and pain medications.
What grade of ankle sprain is a minimally torn ligament, stable joint
Grade 1
What grade of ankle sprain is an incomplete tear painful weight bearing
Grade 2
What grade of ankle sprain is completely torn ligament, severe pain, swelling, tenderness.
Grade 3
How do you manage an ankle sprain
RICE for 2-3 days
Early mobility with splints, braces
Analgesics: acetaminophen, NSAIDs
What scale is used to determine whether a patient needs radiographs of an injured ankle in the emergency room
Ottawa rules of the ankle
What do you consider x-ray and referral for a grade 2 sprain
Yes
Twisting injury with the foot fixed. Degenerative tears in the middle/older adults, maybe as a result of minor trauma.
Meniscal tear
This condition is almost always secondary to trauma, swelling after injury, laxity of ligaments on exam.
Torn ligaments
What tests should you perform on a patient that presents with acute knee pain
Anterior drawer test, posterior drawer test, Lachman test, McMurray’s test
Patient complains of locking of the knee or knees. Some patients are unable to fully extend affected knee. Patient may limp. Complains of knee pain and difficulty walking and bending the knee. Some complain of joint line pain. Decreased range of motion.
Meniscus tear of the knees
What is the best imaging study for a torn meniscus
MRI. Referred to orthopedic specialist for repair.
A type of bursitis that is located behind the knee i.e. popliteal fossa. Sometimes when a joint is damaged and or inflamed, synovial fluid production increases, causing the bursa to enlarge. Bursae are the protective synovial sacs that are located on certain joints.
Ruptured Baker’s cyst or bursitis
Physically active patient complains of a ball like mass behind one knee that is soft and smooth. Pressure pain or asymptomatic. If cyst ruptures, will cause an inflammatory reaction resembling cellulitis on the surrounding area i.e. the calf such as redness, swelling, tenderness.
Ruptured Baker’s cyst
How do you diagnose a ruptured Baker’s cyst
Diagnosed by clinical presentation and history. MRI if diagnosis is uncertain. Rule out plain bursitis from bursitis with infection i.e. septic joint.
What is the treatment plan for a ruptured Baker’s cyst
RICE
NSAIDS
Large bursa can be drained with syringe, 18 gauge needle if causing pain. Synovial fluid is a clear golden color. If cloudy synovial fluid and red, swollen, and hot joint, order C& S to rule out septic joint infection.
Anterior uveitis is a complication of
Rheumatoid arthritis and ankle losing spondylitis
Does an x-ray of the knee show meniscal injury or any joint cartilage
No
What is the gold standard test for assessing joint damage
MRI
Chronic widespread musculoskeletal pain greater than three months accompanied by fatigue, psych symptoms, and multiple somatic complaints. Ideology and pathophysiology are unknown. No evidence of tissue inflammation. Labs, and radiology are within normal limits. Physical exam is normal except for tenderness in nine pairs of specific fibromyalgia points on exam in the neck. ACR has diagnostic Criteria
Fibromyalgia
How do you treat fibromyalgia
Patient education, sleep hygiene, treat comorbid i.e. mood and sleep disorders, exercise: aerobic conditioning, stretching, strengthening, medications for pain: amitriptyline, duloxetine (cymbalta), pregabalin
Positive is point tenderness at heel
Plantar fasciitis
Positive MTP squeeze test
Morton’s neuroma
Associated with High purine diet
Gout
Nodes on the DIP joint secondary to arthritis
Heberden’s nodes
Positive Finkelstein test
DeQuervains tensosynovitis
Burning pain between third and fourth toes
Morton’s neuroma
Positive Tinel’s test and positive Phalen’s test
Carpal tunnel syndrome
Type of fracture secondary to a systemic disease
Pathologic fracture
Common cause of posterior knee pain
Baker’s cyst
Overuse injury of a bone
Stress fracture takes 4-6 weeks to heal
Dorsal thumb pain is a classic symptom
DeQuervains tensosynovitis
Injury to a bone that does not result in a fracture
Contusion
Injury to a muscle
Strain
Injury to a ligament
Sprain
Caused by deposition of urate crystals in joints
Gout
Nodes on PIP joints secondary to arthritis
Bouchnard’s nodes
Joint stiffness lasts less than 60 minutes usually
Osteoarthritis
RICE is the acronym for treatment for this
Sprain
Term that describes compression of the spinal cord
Cauda Equina Syndrome
Rupture of the biceps tendon
Popeyes disease
A 7 year old male presents with a painless with limp, antalgic gait, muscle spasm, mildly restricted hip abduction and internal rotation, proximal thigh atrophy, and slightly short stature. The most likely diagnosis is
Legg-Calve-Perthes Disease
What physical modalities recommended for treatment of rheumatoid arthritis provides the most effective long-term pain relief?
Exercise
Is osteo arthritis associated with chronic renal failure, long time anticonvulsant to use, and long-term steroid use
Yes
The most effective treatment for a noninfective bursitis includes
Rest, and intra-articular corticosteroid injection, and a concomitant oral NSAID
Radiographic evaluation of talipes equinovarus must be performed
While weight bearing
What disease process are Bouchard’s node’s most commonly associated with
Osteoarthritis
What is subluxation of the Radial Head
Nurses elbow
The complete resolution of symptoms of Osgood Schlatter disease through physiologic healing takes how long
12 to 24 month
