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EOR Family Medicine > Orthopedics > Flashcards

Orthopedics Flashcards

1
Q

About ____% of patients with low back pain will have serous pathology

A

5%

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2
Q

Red flags for low back pain (5)

A
  1. Weight loss
  2. Over the age of 50
  3. History of CA
  4. Night time pain
  5. Fever
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3
Q

What to do if red flags present with low back pain?

A

Order XR

If no red flags, treat with NSAID

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4
Q

Three major medical conditions to look for with lower back pain

A

Cauda Equina Syndrome
CA
Spinal infection (osteomyelitis and spinal epidural abscess)

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5
Q

Radiculopathy may be present with ___________ (which most commonly affects _____ or ____ root), which will present as pain or numbness radiating to the leg (below leg)

A

Disk herniation

L5 or S1 root

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6
Q

A ___________ is done to assess herniation (sciatica).

A

Straight leg raise test

With the patient lying flat, lift the leg: a positive test will cause this maneuver to reproduce symptoms

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7
Q

Most commonly a result of a metastatic tumor and is actually the initial presentation of cancer in up to 20% of patients

A

Cauda equina

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8
Q

Symptoms of cauda equina

A

Saddle numbness, weakness, paresthesias, and motor deficits not localized to a single unilateral nerve root. Bladder/bowel dysfunction is a late finding.

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9
Q

The _____ is the most common site of metastasis. Therefore, anyone with a history of _______ and ___________ should be worked up for metastasis and pathological fracture.

A

Bone

CA and new onset back pain

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10
Q

Epidural abscess will present with ________ and _______

A

Back pain

Fever

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11
Q

There should be suspicion of an abscess in pts who are: (3)

A

Immunocompromised
Injection drug users
Recent spinal injection or epidural catheter placement

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12
Q

Presents as a gradual worsening of low back pain over days. May or may not have any other symptoms

A

Osteomyelitis

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13
Q

Risk factors for back compression fracture

A 
History of glucocorticoid use
Over 70 y/o
Trauma
Osteoporosis
Noticeable contusion
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14
Q

Pts will describe severe back pain and sudden onset of pain with focal tenderness

A

Compression fracture

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15
Q

Diagnostic testing for low back pain

A

If suspicion for one the major three serious medical conditions exists, immediate MRI and referral
Otherwise, NSAIDs

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16
Q

Treatment for low back pain

A
  • NSAIDs
  • PT should be offered
  • XR if not improved after 4-6 weeks
  • If no pathology found on MRI, trial of epidural glucocorticoids may be given
  • Final step is surgery
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17
Q

Acute inflammation of the costochondral, costosternal, or sternoclavicular joints

A

Costochondritis

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18
Q

Pleuritic chest pain, described as as an intermittent sharp, stabbing pain that is worse with inspiration, worse with coughing or certain movements of the upper limbs or torso. May radiate to the shoulder

A

Costochondritis

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19
Q

Physical exam with costochondritis

A

Localized pain and tenderness on palpation

No palpable edema

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20
Q

Inflammation of the bursa

A

Bursitis

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21
Q

Causes of bursitis

A

Direct trauma (can be repetitive motion)
Infectious
Gout
Inflammation

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22
Q

Abrupt “goose egg” swelling (boggy, redness) +/- tender or painless. Limited ROM with flexion. Evaluate for skin breaks to r/o septic

A

Bursitis (Olecranon)

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23
Q

Management of olecranon bursitis

A 
Rest 
NSAIDs
Local steroid injection
Padding
Avoid repetitive motions
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24
Q

Septic Bursitis

A

Joint aspiration - WBC count > 2,000

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25
Q

Idiopathic inflammatory condition causing synovitis, bursitis and tenosynovitis, causing pain/stiffness of the proximal joints in patients > 50 y/o

A

Polymyalgia Rheumatica

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26
Q

Most common joints affected by polymyalgia rheumatica

A

Shoulder
Hip
Neck

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27
Q

Polymyalgia rheumatica is closely related to:

A

Giant cell arteritis

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28
Q

Bilateral proximal joint aching/stiffness. Morning stiffness > 30 minutes of the pelvis, neck and shoulder girdle. Creates difficulty combing hair, putting on coat, getting out of chair

A

Polymyalgia Rheumatica

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29
Q

A pt with polymyalgia rheumatica will have __________ muscle weakness

A

No severe muscle weakness

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30
Q

Diagnosis of polymyalgia rheumatica

A

Clinical diagnosis
Increased ESR
Anemia (normocytic)

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31
Q

Management of polymyalgia rheumatica

A

Low dose corticosteroids
NSAIDs
Methotrexate

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32
Q

Chronic inflammatory disease with persistent symmetric polyarthritis, bone erosion, cartilage destruction and joint structure loss (due to destruction by pannus)

A

Rheumatoid arthritis

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33
Q

Granulation tissue that erodes into cartilage and bone

A

Pannus

Rheumatoid arthritis

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34
Q

Risk factors for rheumatoid arthritis

A

Females

Smoking

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35
Q

Prodrome of rheumatoid arthritis

A

Constitutional systemic symptoms

Fever, fatigue, weight loss, anorexia

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36
Q

Most common small joint stiffness with rheumatoid arthritis

A 
MCP
Wrist
PIP
Knee
MTP
Shoulder
Ankle
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37
Q

Characteristics of joint pain with rheumatic arthritis

A

Worse with rest
Morning joint stiffness > 60 minutes after initiating movement
Improves later in the day

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38
Q

Physical exam with rheumatoid arthritis

A

Swollen, tender, erythematous, “boggy” joint

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39
Q

Boutonniere deformity

A

Flexion @ PIP
Hyperextension of DIP
Rheumatoid arthritis

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40
Q

Swan neck deformity

A

Flexion @ DIP
Hyperextension @ PIP
Rheumatoidd arthritis

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41
Q

Felty’s Syndrome

A

Rare

Triad of RA + splenomegaly + decreased WBCs and repeated infxns

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42
Q

Caplan Syndrome

A

Pneumoconiosis + RA

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43
Q

Diagnosis of Rheumatoid Arthritis

A

+ Rheumatoid factor
Increased CRP and ESR
+ anti-cyclic citrullinated peptide antibodies
Arthritis > 3 joints
Radiologic findings: narrowed joint space, subluxation, deformities

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44
Q

Most specific test for RA

A

Anti-cyclic citrullinated peptide antibodies

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45
Q

Management of rheumatoid arthritis

A

Methotrexate first line
Often used with NSAIDs or corticosteroids
NSAID first line for pain control

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46
Q

Autoimmune response to an infection in another part of the body. Arthritis (asymmetric inflammation), conjunctivitis/uveitis, urethritis, cervicitis

A

Reactive Arthritis (Reiter’s Syndrome)

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47
Q

Most common cause of Reactive Arthritis (Reiter’s Syndrome)

A

1-4 weeks Chlamydia

Also: Gonorrhea, GI infections

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48
Q

Keratoderma blennorrhagicum

A 
Hyperkeratotic lesions on palms/sole. Circinate balanitis. 
Reactive arthritis (reiter's syndrome)
49
Q

Triad of conjunctivitis, urethritis, and arthritis (especially lower extremities). Sausage toes/fingers

A

Reactive arthritis (reiter’s syndrome)

50
Q

Diagnosis of reactive arthritis (reiter’s syndrome)

A

HLA B27
Increased WBC, ESR, IgG
Synovial Fluid: Increased WBC. Fluid is bacterial culture negative!

51
Q

Management of Reactive Arthritis (Reiter’s Syndrome)

A

NSAIDs mainstay of tx
If no response, methotrexate, steroids
Antibiotic use during precipitating disease decreases incidence

52
Q

Chronic disease due to articular cartilage damage and degeneration

A

Osteoarthritis

53
Q

Biggest risk factor for osteoarthritis

A

Obesity

54
Q

Osteoarthritis most commonly occurs in which joints?

A 
Weight bearing joints
Knees
Hips
Cervical/lumbar spine
Hip
55
Q

Characteristics of joints with osteoarthritis

A

Narrowed joint space (loss of articular cartilage)
Sclerosis
Osteophyte formation

56
Q

Characteristics of osteoarthritis joint pain

A

Evening joint stiffness
Decreases with rest
Worsens throughout day and changes with weather
Absence of inflammatory signs and hard bony joints

57
Q

Heberden’s nodes

A

Palpable osteophytes at DIP joint

Osteoarthritis

58
Q

Bouchard’s nodes

A

Palpable osteophytes at PIP joint

Osteoarthritis

59
Q

Management of osteoarthritis

A 
Acetaminophen preferred first
NSAIDs more effective for mild/moderate, elderly
Corticosteroid injections, glucosamine
Knee replacements
Avoid high-impact exercises
60
Q

Uric acid deposition in the soft tissue, joints and bonee

A

Gout

61
Q

Most commonly due to underexcretion of uric acid

A

Gout

62
Q

Purine-rich foods that cause rapid changes in uric acid concentrations and therefore gout

A

Alcohol
Liver
Seafood
Yeasts

63
Q

Medications that are known to cause gout

A 
Diuretics (thiazides, loop)
ACEI / ARBs
Pyrazinamide
Ethambutol
Aspirin
64
Q

Severe joint pain, erythema, swelling and stiffness

A

Acute gouty arthritis

65
Q

Collection of solid uric acid in soft tissues (helix of ear, eyelids, achilles tendon). Usually occurs after 10-20 years of chronic hyperuricemia

A

Tophi deposition

66
Q

Uric acid stones associated with low urine volume and acidic pH. May cause glomerulonephritis. May lead to renal failure

A

Uric acid nephrolithiasis and nephropathy

67
Q

Diagnosis of gout

A
  1. Arthrocentesis - negative birefringent needle-shaped urate crystals
  2. Radiographs - mouse/rat bite, punched out erosions, +/- tophi
  3. Clinical diagnosis
  4. Increased ESR and WBC during acute attacks
68
Q

Management of acute gout

A

NSAIDs drug of choice - indomethacin, naprosyn
Avoid aspirin
Colchicine second line

69
Q

Management of chronic gout (prophylaxis)

A

Allopurinol

Febuxostat - safer in pts with renal disease

70
Q

S/E of allopurinol

A

Taken with meals to prevent gastric irritation

HSN/SJS

71
Q

Injury to a ligament (connects bone to bone)

A

Sprain

72
Q

Injury to a tendon (connects muscle to bone)

A

Strain

73
Q

Most common ankle sprain

A

Inversion of the ankle

Causes damage to the lateral ligaments

74
Q

Most common ligament affected in ankle sprain

A

Anterior talofibular ligament

75
Q

Slight stretching to the ligament and very minimal damage. Able to ambulate.

A

Grade I Ankle sprain

76
Q

Partial tear of the ligament. Laxity is noted. Painful weight bearing

A

Grade 2 Ankle sprain

77
Q

Complete tear of the ligament. Severe pain and swelling. Instability noted and unable to bear weight.

A

Grade 3 Ankle sprain

78
Q

Diagnosis of strain/sprain

A

Clinical diagnosis

May need to get XR if severe presentation

79
Q

Treatment of strain/sprain

A

Rest, Ice, Compression, Elevation
NSAIDs used for swelling and pain relief
Range of motion should be started as early as possible

80
Q

Benign tumors that are attached to the joint (usually the wrist) and/or tendon sheaths

A

Ganglion cysts

81
Q

Mass is usually non tender, with regular borders, and is mobile. Pts may or may not present with wrist pain

A

Ganglion cysts

82
Q

Diagnosis of ganglion cyst

A

Clinical diagnosis

Imaging not necessary

83
Q

Treatment of ganglion cyst

A

Observation
NSAIDs as needed
If pain persists, corticosteroid injection
Final step: surgical resection

84
Q

Chronic, systemic, multi-organ autoimmune disorder of connective tissues. Type III HSN

A

Systemic Lupus Erythematosus

85
Q

Most common presentation of SLE

A 
Young females (9:1), onset in 20s-40s
Increased rates in african-americans, hispanics, native americans
86
Q

Medications that may cause SLE

A

Procainamide
Hydralazine
INH
Quinidine

87
Q

Signs/Symptoms of SLE

A
  1. Joint pain
  2. Fever
  3. Malar butterfly rash
  4. Discoid rash
  5. Systemic manifestations
88
Q

Systemic manifestations of SLE

A 
Photosensitivity
Cardiovascular
Glomerulonephritis
Oral ulcers
Alopecia
Seizures
Retinitis
Psychosis
89
Q

Diagnosis of SLE

A

+ anti nuclear aB: ANA best initial test
+ rheumatoid factor
+ anti double-stranded DNA and anti-smith AB - 100% specific for SLE - should be ordered if ANA positive

90
Q

Best initial test for ANA, and what test is ordered if positive

A

ANA

Anti double-stranded DNA and anti-smith AB

91
Q

Management of SLE

A

Acute flares: high dose steroids
Most pts started on hydroxychloroquine or chloroquine
NSAIDs/acetaminophen for arthritis

92
Q

Loss of bone density over time due to increased absorption of bone or decreased formation of bone

A

Osteoporosis

93
Q

Primary osteoporosis is typically due to:

A

Menopause

94
Q

Causes of secondary osteoporosis;

A

Chronic disease or medications

Prolonged corticosteroid use, Cushing’s disease, DM, hyperparathyroidism, low estrogen, etc.

95
Q

Osteoporosis is typically asymptomatic, the first symptom is often due to a:

A

Pathologic fracture, back pain or deformity

96
Q

Most common locations for pathologic fractures in osteoporosis

A

Vertebral
Hip
Distal radius (Colles)

97
Q

Trabeculae and cortical bone loss, leading to increased hip and pelvic fractures

A

Senile osteoporosis

98
Q

Diagnosis of osteoporosis

A
  1. Labs: calcium, phosphate, PTH usually normal
  2. Screen for thyroid/celiac dz
  3. DEXA scan
99
Q

> 1.0 T score

A

Normal DEXA bone scan

100
Q

-1.0 to -1.5 T score

A

Repeat DEXA scans every 5 years

101
Q

-1.5 to -2.0 T score

A

Repeat DEXA scans every 3-5 years

102
Q

< 1.0 to -2.5 T score

A

Osteopenia

103
Q

< -2.5 T score

A

Osteoporosis

104
Q

< -2.0 T score

A

Repeat DEXA scans every 1-2 years

105
Q

Management of osteoporosis

A 
Adequate vitamin D, calcium citrate and exercise
Bisphosphonates first line
(Alendronate, risedronate, ibandronate)
Raloxifene
Estrogen in postmenopausal women
106
Q

Last line therapy for osteoporosis

A

Calcitonin - injection or nasal spray

107
Q

Genetic mutation for type 1 collagen (necessary for bone integrity). Associated severe osteoporosis, spontaneous fractures in childhood, blue-tinted sclera and presenile deafness

A

Osteogenesis Imperfecta

108
Q

Widespread muscular (chronic) pain, fatigue, muscle tenderness, headaches, poor sleep/memory problems. May be due to increase in pain perception (increased substance P)

A

Fibromyalgia

109
Q

Fibromyalgia is seen most commonly in:

A

Middle aged women (9:1)

110
Q

Fibromyalgia has an increased incidence with:

A

Rheumatoid arthritis
Lupus
Ankylosing spondylitis

111
Q

Signs/Symptoms of fibromyalgia

A

Diffuse pain (esp in morning)
EXTREME fatigue
Stiffness
Painful, tender joints

112
Q

Diagnosis of fibromyalgia

A

Diffuse pain in 11 out of 18 trigger points > 3 months
Widespread pain
Muscle biopsy - moth eaten appearance of the type 1 muscle fibers, muscle damage

113
Q

Management of fibromyalgia

A

Exercise (swimming preferred)
TCAs, Duloxetine, SSRIs, Neurontin
Pregabalin approved for fibromyalgia as well

114
Q

Inflammation of the plantar fascia (aponeurosis) due to overuse (especially in pts with flat feet or heel spur)

A

Plantar Fasciitis

115
Q

Heel pain, tenderness of plantar fascia of the medial foot. Pain usually worse after period of rest (first steps in AM), pain usually decreases throughout day

A

Plantar Fasciitis

116
Q

Diagnosis of plantar fasciitis

A

Radiographs - may show flat foot deformity or heel spur

117
Q

Management of plantar fasciitis

A

Rest, ice, NSAIDs, heel/arch support
Plantar stretching exercises
Corticosteroids used with caution - may cause fascia rupture
Surgery in severe cases

118
Q

Clinical syndrome characterized by chronic pain and tendon thickening with ahx of repetitive tendon loading

A

Overuse syndrome

119
Q

Therapies for overuse syndrome

A 
Stretching
Tissue mobilization
Ice or heat
Topical glyceryl trinitrate
Reasonable to think about surgery after 6 months of diligent physical therapy

EOR Family Medicine (14 decks)

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