Orthopedics Flashcards
1
Q
About ____% of patients with low back pain will have serous pathology
A
5%
2
Q
Red flags for low back pain (5)
A
- Weight loss
- Over the age of 50
- History of CA
- Night time pain
- Fever
3
Q
What to do if red flags present with low back pain?
A
Order XR
If no red flags, treat with NSAID
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)
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
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
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
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.
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
10
Q
Epidural abscess will present with ________ and _______
A
Back pain
Fever
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
12
Q
Presents as a gradual worsening of low back pain over days. May or may not have any other symptoms
A
Osteomyelitis
13
Q
Risk factors for back compression fracture
A
History of glucocorticoid use Over 70 y/o Trauma Osteoporosis Noticeable contusion
14
Q
Pts will describe severe back pain and sudden onset of pain with focal tenderness
A
Compression fracture
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
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
17
Q
Acute inflammation of the costochondral, costosternal, or sternoclavicular joints
A
Costochondritis
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
19
Q
Physical exam with costochondritis
A
Localized pain and tenderness on palpation
No palpable edema
20
Q
Inflammation of the bursa
A
Bursitis
21
Q
Causes of bursitis
A
Direct trauma (can be repetitive motion)
Infectious
Gout
Inflammation
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)
23
Q
Management of olecranon bursitis
A
Rest NSAIDs Local steroid injection Padding Avoid repetitive motions
24
Q
Septic Bursitis
A
Joint aspiration - WBC count > 2,000
25
Idiopathic inflammatory condition causing synovitis, bursitis and tenosynovitis, causing pain/stiffness of the proximal joints in patients > 50 y/o
Polymyalgia Rheumatica
26
Most common joints affected by polymyalgia rheumatica
Shoulder
Hip
Neck
27
Polymyalgia rheumatica is closely related to:
Giant cell arteritis
28
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
Polymyalgia Rheumatica
29
A pt with polymyalgia rheumatica will have __________ muscle weakness
No severe muscle weakness
30
Diagnosis of polymyalgia rheumatica
Clinical diagnosis
Increased ESR
Anemia (normocytic)
31
Management of polymyalgia rheumatica
Low dose corticosteroids
NSAIDs
Methotrexate
32
Chronic inflammatory disease with persistent symmetric polyarthritis, bone erosion, cartilage destruction and joint structure loss (due to destruction by pannus)
Rheumatoid arthritis
33
Granulation tissue that erodes into cartilage and bone
Pannus
| Rheumatoid arthritis
34
Risk factors for rheumatoid arthritis
Females
| Smoking
35
Prodrome of rheumatoid arthritis
Constitutional systemic symptoms
| Fever, fatigue, weight loss, anorexia
36
Most common small joint stiffness with rheumatoid arthritis
```
MCP
Wrist
PIP
Knee
MTP
Shoulder
Ankle
```
37
Characteristics of joint pain with rheumatic arthritis
Worse with rest
Morning joint stiffness > 60 minutes after initiating movement
Improves later in the day
38
Physical exam with rheumatoid arthritis
Swollen, tender, erythematous, "boggy" joint
39
Boutonniere deformity
Flexion @ PIP
Hyperextension of DIP
Rheumatoid arthritis
40
Swan neck deformity
Flexion @ DIP
Hyperextension @ PIP
Rheumatoidd arthritis
41
Felty's Syndrome
Rare
| Triad of RA + splenomegaly + decreased WBCs and repeated infxns
42
Caplan Syndrome
Pneumoconiosis + RA
43
Diagnosis of Rheumatoid Arthritis
+ Rheumatoid factor
Increased CRP and ESR
+ anti-cyclic citrullinated peptide antibodies
Arthritis > 3 joints
Radiologic findings: narrowed joint space, subluxation, deformities
44
Most specific test for RA
Anti-cyclic citrullinated peptide antibodies
45
Management of rheumatoid arthritis
Methotrexate first line
Often used with NSAIDs or corticosteroids
NSAID first line for pain control
46
Autoimmune response to an infection in another part of the body. Arthritis (asymmetric inflammation), conjunctivitis/uveitis, urethritis, cervicitis
Reactive Arthritis (Reiter's Syndrome)
47
Most common cause of Reactive Arthritis (Reiter's Syndrome)
1-4 weeks Chlamydia
| Also: Gonorrhea, GI infections
48
Keratoderma blennorrhagicum
```
Hyperkeratotic lesions on palms/sole. Circinate balanitis.
Reactive arthritis (reiter's syndrome)
```
49
Triad of conjunctivitis, urethritis, and arthritis (especially lower extremities). Sausage toes/fingers
Reactive arthritis (reiter's syndrome)
50
Diagnosis of reactive arthritis (reiter's syndrome)
HLA B27
Increased WBC, ESR, IgG
Synovial Fluid: Increased WBC. Fluid is bacterial culture negative!
51
Management of Reactive Arthritis (Reiter's Syndrome)
NSAIDs mainstay of tx
If no response, methotrexate, steroids
Antibiotic use during precipitating disease decreases incidence
52
Chronic disease due to articular cartilage damage and degeneration
Osteoarthritis
53
Biggest risk factor for osteoarthritis
Obesity
54
Osteoarthritis most commonly occurs in which joints?
```
Weight bearing joints
Knees
Hips
Cervical/lumbar spine
Hip
```
55
Characteristics of joints with osteoarthritis
Narrowed joint space (loss of articular cartilage)
Sclerosis
Osteophyte formation
56
Characteristics of osteoarthritis joint pain
Evening joint stiffness
Decreases with rest
Worsens throughout day and changes with weather
Absence of inflammatory signs and hard bony joints
57
Heberden's nodes
Palpable osteophytes at DIP joint
| Osteoarthritis
58
Bouchard's nodes
Palpable osteophytes at PIP joint
| Osteoarthritis
59
Management of osteoarthritis
```
Acetaminophen preferred first
NSAIDs more effective for mild/moderate, elderly
Corticosteroid injections, glucosamine
Knee replacements
Avoid high-impact exercises
```
60
Uric acid deposition in the soft tissue, joints and bonee
Gout
61
Most commonly due to underexcretion of uric acid
Gout
62
Purine-rich foods that cause rapid changes in uric acid concentrations and therefore gout
Alcohol
Liver
Seafood
Yeasts
63
Medications that are known to cause gout
```
Diuretics (thiazides, loop)
ACEI / ARBs
Pyrazinamide
Ethambutol
Aspirin
```
64
Severe joint pain, erythema, swelling and stiffness
Acute gouty arthritis
65
Collection of solid uric acid in soft tissues (helix of ear, eyelids, achilles tendon). Usually occurs after 10-20 years of chronic hyperuricemia
Tophi deposition
66
Uric acid stones associated with low urine volume and acidic pH. May cause glomerulonephritis. May lead to renal failure
Uric acid nephrolithiasis and nephropathy
67
Diagnosis of gout
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
Management of acute gout
NSAIDs drug of choice - indomethacin, naprosyn
Avoid aspirin
Colchicine second line
69
Management of chronic gout (prophylaxis)
Allopurinol
| Febuxostat - safer in pts with renal disease
70
S/E of allopurinol
Taken with meals to prevent gastric irritation
| HSN/SJS
71
Injury to a ligament (connects bone to bone)
Sprain
72
Injury to a tendon (connects muscle to bone)
Strain
73
Most common ankle sprain
Inversion of the ankle
| Causes damage to the lateral ligaments
74
Most common ligament affected in ankle sprain
Anterior talofibular ligament
75
Slight stretching to the ligament and very minimal damage. Able to ambulate.
Grade I Ankle sprain
76
Partial tear of the ligament. Laxity is noted. Painful weight bearing
Grade 2 Ankle sprain
77
Complete tear of the ligament. Severe pain and swelling. Instability noted and unable to bear weight.
Grade 3 Ankle sprain
78
Diagnosis of strain/sprain
Clinical diagnosis
| May need to get XR if severe presentation
79
Treatment of strain/sprain
Rest, Ice, Compression, Elevation
NSAIDs used for swelling and pain relief
Range of motion should be started as early as possible
80
Benign tumors that are attached to the joint (usually the wrist) and/or tendon sheaths
Ganglion cysts
81
Mass is usually non tender, with regular borders, and is mobile. Pts may or may not present with wrist pain
Ganglion cysts
82
Diagnosis of ganglion cyst
Clinical diagnosis
| Imaging not necessary
83
Treatment of ganglion cyst
Observation
NSAIDs as needed
If pain persists, corticosteroid injection
Final step: surgical resection
84
Chronic, systemic, multi-organ autoimmune disorder of connective tissues. Type III HSN
Systemic Lupus Erythematosus
85
Most common presentation of SLE
```
Young females (9:1), onset in 20s-40s
Increased rates in african-americans, hispanics, native americans
```
86
Medications that may cause SLE
Procainamide
Hydralazine
INH
Quinidine
87
Signs/Symptoms of SLE
1. Joint pain
2. Fever
3. Malar butterfly rash
4. Discoid rash
5. Systemic manifestations
88
Systemic manifestations of SLE
```
Photosensitivity
Cardiovascular
Glomerulonephritis
Oral ulcers
Alopecia
Seizures
Retinitis
Psychosis
```
89
Diagnosis of SLE
+ 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
Best initial test for ANA, and what test is ordered if positive
ANA
| Anti double-stranded DNA and anti-smith AB
91
Management of SLE
Acute flares: high dose steroids
Most pts started on hydroxychloroquine or chloroquine
NSAIDs/acetaminophen for arthritis
92
Loss of bone density over time due to increased absorption of bone or decreased formation of bone
Osteoporosis
93
Primary osteoporosis is typically due to:
Menopause
94
Causes of secondary osteoporosis;
Chronic disease or medications
| Prolonged corticosteroid use, Cushing's disease, DM, hyperparathyroidism, low estrogen, etc.
95
Osteoporosis is typically asymptomatic, the first symptom is often due to a:
Pathologic fracture, back pain or deformity
96
Most common locations for pathologic fractures in osteoporosis
Vertebral
Hip
Distal radius (Colles)
97
Trabeculae and cortical bone loss, leading to increased hip and pelvic fractures
Senile osteoporosis
98
Diagnosis of osteoporosis
1. Labs: calcium, phosphate, PTH usually normal
2. Screen for thyroid/celiac dz
3. DEXA scan
99
> 1.0 T score
Normal DEXA bone scan
100
-1.0 to -1.5 T score
Repeat DEXA scans every 5 years
101
-1.5 to -2.0 T score
Repeat DEXA scans every 3-5 years
102
< 1.0 to -2.5 T score
Osteopenia
103
< -2.5 T score
Osteoporosis
104
< -2.0 T score
Repeat DEXA scans every 1-2 years
105
Management of osteoporosis
```
Adequate vitamin D, calcium citrate and exercise
Bisphosphonates first line
(Alendronate, risedronate, ibandronate)
Raloxifene
Estrogen in postmenopausal women
```
106
Last line therapy for osteoporosis
Calcitonin - injection or nasal spray
107
Genetic mutation for type 1 collagen (necessary for bone integrity). Associated severe osteoporosis, spontaneous fractures in childhood, blue-tinted sclera and presenile deafness
Osteogenesis Imperfecta
108
Widespread muscular (chronic) pain, fatigue, muscle tenderness, headaches, poor sleep/memory problems. May be due to increase in pain perception (increased substance P)
Fibromyalgia
109
Fibromyalgia is seen most commonly in:
Middle aged women (9:1)
110
Fibromyalgia has an increased incidence with:
Rheumatoid arthritis
Lupus
Ankylosing spondylitis
111
Signs/Symptoms of fibromyalgia
Diffuse pain (esp in morning)
EXTREME fatigue
Stiffness
Painful, tender joints
112
Diagnosis of fibromyalgia
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
Management of fibromyalgia
Exercise (swimming preferred)
TCAs, Duloxetine, SSRIs, Neurontin
Pregabalin approved for fibromyalgia as well
114
Inflammation of the plantar fascia (aponeurosis) due to overuse (especially in pts with flat feet or heel spur)
Plantar Fasciitis
115
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
Plantar Fasciitis
116
Diagnosis of plantar fasciitis
Radiographs - may show flat foot deformity or heel spur
117
Management of plantar fasciitis
Rest, ice, NSAIDs, heel/arch support
Plantar stretching exercises
Corticosteroids used with caution - may cause fascia rupture
Surgery in severe cases
118
Clinical syndrome characterized by chronic pain and tendon thickening with ahx of repetitive tendon loading
Overuse syndrome
119
Therapies for overuse syndrome
```
Stretching
Tissue mobilization
Ice or heat
Topical glyceryl trinitrate
Reasonable to think about surgery after 6 months of diligent physical therapy
```
