Orthopedics Flashcards
Snuffbox pain
navicular fracture
Navicular fracture is high risk for
avascular necrosis and nonunion
Navicular fracture requires…
referral to hand surgeon
Colles fracture
fracture of the distal radius of the forearm along the dorsal displacement of wrist
-falling forward with outstretched hand
Severe hip fracture may present with
-severe hip pain with external rotation and leg shortening
Pelvic fracture may present with
ecchymosis and swelling in lower abdomen, hips, groin, scrotum
may have urine and/or fecal incontinence
Most common cause of cauda equina syndrome
-bulging disk on sacral nerve root
Low-back pain from dissecting abdominal aneurysm
- acute and sudden onset of “tearing” severe low-back/abdominal pain
- abdominal bruit with pulsation
Genu recurvtaum
hyperextention or backward curvature of legs
Genu valgum
knock-knees
“gum” knees stuck with gum
Genu varum
bowlegs
Acutely inflamed joints should NOT
- in 48 hours
- not be exercised
- no heating applications
- no ROM exercises
Isometric exercises
-non-weight bearing
Drawer sign
- knee stability
- dx of torn or rupture ligament
- (+) anterior: torn ACL
- (+) posterior: torn PCL
FInkelstein’s test
-De Quervain’s tenosynovitis
McMurray’s test
- knee pain and click with maniuplation is positive
- suggests injury to medial meniscus
Gold standard test for meniscal tear
MRI
Lachman’s sign
- knee joint laxity
- Suggestive of ACL damage
- More sensitive than anterior drawer test
- Pull femur and lower leg apart
Valgus stress test
-MCL damage
Varus tress test
-LCL stress test
MRI is gold standard for which body parts
- cartilage
- menisci
- tendons
- ligaments
- other joints
Medial tibial stress syndrome
- aka shin splints
- common in runners and flat feet
Medial tibial stress syndrome presentation
- recurrent shin pain in one or both legs
- located along inner border of tibia and comes during and after exercise
- mild swelling with focal tenderness
Medial tibial stress syndrome treatment
- RICE for several weeks
- cold packs
- low impact exercise
- bone scan or MRI, if no stress fracture, refer to orthopedic specialist
Plantar fasciitis patho
- acute or recurrent pain on bottom of feet with walking
- microtears in plantar fascia due to tight Achilles tendon
People at risk for plantar fasciitis
- obese
- diabetic
- aerobic exercise
- flat feet
- prolonged standing
Plantar fasciitis treatment
- NSAIDS, topical or oral
- orthotic foot appliance at night for a few weeks
- ice pack
- stretching and massaging
- roll a golf ball with sole of foot several times a day
- weight loss
- consider X-ray
Morton’s neuroma patho
- inflammation of digital nerve of foot between third and fourth metatarsals
- increased risk with tight shoes, high heels, dancers, runners
Mulder test
test for Morton’s neuroma
- grasp first and fifth metatarsals and squeeze forefoot
- (+) click along with report of pain, pain relieved with release
Morton’s neuroma treatment
- avoid tight fitting shoes
- use forefoot pad
- refer to podiatrist
Osteoarthritis presentation
- gradual
- early morning stiffness with inactivity
- shorter duration of join stiffness compared to RA
- absence of systemic symptoms
- Heberden’s and Bouchard nodes
Heberden’s nodes location
DIP
-den = D
Bouchard nodes location
PIP
First line pharm treatment for OA
- NSAID’s
- acetaminophen has little effect on pain
SLE is more common in men or women
women
SLE presentation
- child bearing age
- maculopapular butterfly-shaped rash on middle of face
- nonpruritic thick scaly red rashes on sun-exposed areas
- UA positive for proteinuria
SLE treatment
-refer to rheumatology
SLE patient education
- avoid sun between 10am-4pm
- use sunblock
- use sun-protective clothing
- use nonfluorescent light bulbs
RA patho
- more common in women
- inflammation of multiple joints, leading to joint damage
- higher risk for other autoimmune disorders
RA presentation
- adult women
- gradual onset of fatigue, low-grade fever
- generalized body aches
- myalgia
- generalized joint pains (fingers, hands, elbows, wrists, feet)
- early morning stiffness/pain and warm, tender, and swollen fingers
RA objective findings
- symmetrical joint involvement
- Sausage joints
- morning stiffness >1 hour
- rheumatoid nodules
- swan neck deformity
- Boutonniere deformity
Swan neck deformity
- flexion of DIP joint with hyperextension of PIP
- RA
Boutonniere deformity
Hyperextension of DIP with flexion of PIP
-RA
RA labs
- ESR elevated
- CBC mild microcytic or normocytic anemia common
- Rheumatoid factor positive in ~80%
- xray: bony erosions, joint space narrowing, subluxations
RA treatment
-rheumatology referral
RA complications
- uveitis
- scleritis
- vasculitis
- pericarditis
- certain malignancies
- Plaquenil: need eye exam prior to starting with frequent eye exam every 6 months
Which nodes present with both OA and RA
Bouchard
Which node is only present with OA
Heberden
COX-1
mucosal protective effect
Gout patho
-deposits of uric acid crystals inside joints and tendons due to genetic excess production or low excretion of purine crystals
Gold standard for gout diagnosis
-aspiration of synovial fluid of joint
Chronic gout presents as
tophi
small white nodules full of urates on ears and joints
Uric acid level and gout
> 7
- during acute phase: uric acid levels are normal
- test uric acid 2 weeks after acute attack
Acute gout treatment
- Indomethacin and naproxen
- if no relief, combine NSAID with colchicine 1.2 mg (two tabs) at onset of attack
- may repeat colchicine 0.6 mg in 1 hour
- continue colchicine 0.6 mg one-two times daily until symptoms resolve
- stop when symptom free for 2-3 days
- wait until 4-6 weeks before maintenance treatment
- patients taking allopurinol should stop during acute phase and restart 4-6 weeks after resolution of symptoms
Gout maintenance treatment
- allopurinol daily for years to life
- Check CBC
- Colchicine can be used during acute phase with NSAIDs
Ankylosing spondylitis is most common in
males with HLA-B27 positive
Ankylosing spondylitis patho
chronic inflammation of axial skeleton and sacroiliac joints
pain improved with exercise and not relieved by rest
Ankylosing spondylitis presenation
- loss of ROM of spine
- decreased respiratory excursion
- uveitis
Ankylosing spondylitis labs
- ESR and CRP elevated
- Spinal xray: classic “bamboo spine”
Ankylosing spondylitis treatment
- refer to rheumatologist
- postural training
- buy a mattress with good back support
- NSAID’s first line treatment
- Prescribe PPI or COX-2 inhibitor if high risk of bleed
- severe: DMARDs, biologics, spinal fusion
Ankylosing spondylitis complications
-anterior uveitis
-aortitis
fusing of spine, spinal stenosis
Patient >50 with new onset back pain, need to rule out what
cancer
Common site of herniated disk with symptoms
L5 to S1
Best method for diagnosing herniated disk
MRI
NSAID with fewest CVD effects
Naproxen
Supraspinatus tendinitis
aka cuff tendinitis
Movement that aggravates supraspinatus tendinitis
- arm elevation and abduction (reaching to back pocket)
- local point tenderness over tendon on anterior area of shoulder
Lateral epicondylitis
Tennis elbow
- gradual onset of pain outside elbow
- sometimes radiates to forearms
- pain worse with twisting or grasping movements
Medial epicondylitis
- golfers elbow
- gradual onset of pain along medial elbow
- higher risk in baseball, bowlers, golfers
- occurs around funny bone
Impingement syndrome
-compression of rotator cuff tendons and subacromial bursa
Rotator cuff tendinopathy complaint
shoulder pain with overhead activity
Trigger finger grade I
pain/history of catching
Trigger finger grade 2
demonstrable catching, but can actively extend the digit
Trigger finger grade 3
demonstrable catching
require passive extension
Trigger finger grade 4
fixed flexion contracture
If positive snuffbox tenderness with - xray, what to do
repeat xray in 5-7 days
consider CT, MRI if patient cannot wait
provide spica cast
Straight leg raise positive when
-pain reproduced between 10-60 degrees of affected leg
Waddell’s sign
- c/o physical pain with poss psych component
- Physical exam is not representative of patients complaint of pain
- press down on head and ask if back hurts
Ottawa rules of ankle
- rules to determine if radiographs are needed
- mild to mod –> use RICE and elastic bandage wrap
Grade I sprain
mild
- able to bear weight and ambulate
- slight stretching and some damage to ligament fibers
Grade II sprain
- moderate
- partial tearing of ligament
- ecchymosis, moderate swelling and pain.
- ambulation and weight bearing painful
- consider x-ray
- referral
Grade III sprain
- complete rupture
- referral to ED
- inability to bear weight immediately after injury
- inability to ambulate at least 4 steps
- tenderness over posterior edge of lateral or mdeial malleolus
Which ligmanet sprain has high chance of avulsion fracture
medial ligament
eversion sprain
Meniscus tear presentation
- clicking, locking, or buckling of knees
- some unable to fully extend knee
- may limp
- some have joint line pain
- decreased ROM
Meniscus tear treatment
- MRI
- refer to orthopedics for repair
Baker’s cyst
-bursitis located behind knee
Rupture baker’s cyst presentation
- active patient
- ball-like mass behind knee
- soft and smooth
- can cause pressure pain or asymptomatic
- when ruptured, causes inflammation, similar to cellulitis
Ruptured Baker’s cyst treatment
- RICE
- Compression!!
- NSAIDs
- large bursa can be drained with 18 gauge needle of causing pain
- if cloudy fluid, C&S to rule out infection
Apley scratch test
Attempt to touch opposite scapula to test ROM
-rotator cuff problem
Neer’s sign
- arm in full flexion with arm internally rotated and raise up
- (+) subacromial impingement
Hawkin’s test
- Forward flexion of shoulder to 90 degrees, passive internal rotation
- (+) supraspinatus tendon impingement
Drop-arm test
- arm lowered slowly to waist, lower arm slowly with pain
- (+) pain with lowering or sudden dropping of arm
- (+) rotator cuff tear (supraspinatus)
Pain with wrist flexion and pronation
medial epicondylitis
Pain with wrist extension
Lateral epicondylitis
Dietary causes of gout
high-purine diet
- seafood (scallops, mussels0
- organ meat
- beans
- spinach
- asparagus
- oatmeal
- baker’s and brewer’s yeast
Pseudogout is caused by
-calcium pryophosphate deposition
What is pseudogout associated with
hypothyroidism or hyperparathyroidism
Glucosamine
no improvement in arthritis symptoms, some may report reduction in pain, increased joint flexion, increased articular function
-must be used consistently for 2 weeks, benefits may not be seen until 3 months
-
Why should glucosamine be used with caution
possible bronchospasm
Chondroitin and glucosamine mechanism
not well understood
NSAIDs cause gastric injury primarily by
thinning of the protective GI mucosa
COX-2 function
- inflammatory response
- pain transmission
- renal arteriole constriction
no role in GI
Sjogren syndrome
autoimmune disease that usually occurs with other chronic inflammatory disorders
- decreased oral and ocular secretions
- mouth ulcers and dental caries
- salivary gland biopsy is useful
Most common cause of meniscal tear
twisting of knee
Apley grinding test
patient supine, press down on foot with knee at 90 degrees
indicative of meniscal tear
Nerve conduction test in person with CTS would show
-slowing of nerve impulses at carpal tunnel
Primary osteoporosis Type 1
common in women 55-70
due to loss of estrogen
-decrease osteoblast activity in setting of increased osteoclast activity
Primary osteoporosis Type 2
- senile osteoporosis
- 70-90
- decreased osteoblast activity with normal osteoclast activity
Empty can test
aka Jobe test
- full extension and internal rotation and pronation of arm
- (+) if unable to push against resistance
What is often found with rotator cuff tendonitis
bursitis
Form of vitamin D measured in labs to determine vitamin D status
25-hydroxyvitamin D
Treatment of vitamin D deficiency
-50,000 IU of vitamin D3 by mouth once per week for at least 8 weeks
Osteoclast
absorbs bone tissue during growth and healing
Osteoblast
synthesize bone
Chvostek’s sign
contraction of facial muscles when facial nerve is tapped briskly
-due to hypocalcemia
Colchicine dosing
- take one tab every 1-2 hours until relief or adverse GI side effects like abdominal pain, nausea, diarrhea
- only prescribe 10 tabs at a time during a flare-up
- many patients develop adverse GI effects before pain relief
- can be taken daily in small amounts for prophylaxis
Baseline exam prior to starting hydroxychloroquine
- comprehensive eye exam
- can cause retinal toxicity
Fibromyalgia criteria
- widespread pain index
- symptoms present at a similar level for at least 3 months
- presence of pain or tenderness at certain body sites
- neck, jaw, shoulder girdle, upper and lower arm, chest, abdomen, upper and lower back, upper and lower leg, hip
- fatigue, sleep problems, cognitive problems
- cause unknown
- symptomatic treatment
Which population are medial tibial stress fractures common in
sports involving running and/or jumping
females
exacerbated by increase in training or overuse
Difference between medial tibial stress fracture and syndrome
- pain is more persistent and worsens until it also occurs at rest
- focal area of tenderness on anterior medial aspect of tibia
Imaging choice for MDSS
MRI
- xray will not show a stress fracture
- RICE
- refer to ortho
Cast type for navicular/scaphoid fracture
thumb spica cast
