Orthopedics and Rheumatology

Question 1

Weakness plantar flexor and hamstring weakness, absent or diminished ankle jerk, paresthesias Pain with straight leg raise and tenderness over the lumbosacral joint and sciatic notch Discomfort walking on heels Drop foot (L5) and weakness with plantar flexion (S1)

Answer 1

Herniated disc, lumbar disc

Question 2

Dx of herniated disc

Answer 2

The straight leg raise test:

• With the patient lying down on their back on an examination table or exam floor, the examiner lifts the patient’s leg while the knee is straight.
• A variation is to lift the leg while the patient is sitting. However, this reduces the sensitivity of the test
  
  • Pain radiating down the leg when the straight leg is at an angle of between 30 and 70 degrees is + ⇒ herniated disk is a possible cause of the pain (sensitivity 91%, specificity 26%)

Question 3

Tx for herniated disc

Answer 3

Most comfortable lying supine with legs flexed at knees and hips, shoulders raised on billows

• Analgesics—NSAIDs or opioids for a few days
• Repeated epidural injections of steroids with unconfirmed efficacy
• Surgical decompression—emergent if a bilateral sensorimotor loss, sphincteric paralysi

Question 4

MCC of back pain

Answer 4

Back strain -commonly due to lifting or strenuous activity

Question 5

narrowing of the central or lateral lumbar spinal canal caused by degenerative joint disease, which puts pressure on the cord or sciatic nerve roots before their exit from the foramina

Answer 5

Lumbar spinal stenosis

Question 6

positional back pain and referred buttock pain, symptoms of nerve root compression, and lower-extremity pain during walking or weight-bearing

Answer 6

Neurogenic claudication

Question 7

Dx of spinal stenosis

Answer 7

• DX: X-ray, CT myelogram, MRI

Question 8

Tx of spinal stenosis

Answer 8

TX:

• (abdominal muscle strengthening), weight loss and bracing
• Steroid injections (epidural and transforaminal) for advanced symptoms
• Surgical decompression laminectomy and/or fusion when neural compression and poor quality of life.

Question 9

Vertebral compression fracture MC affects

Answer 9

Vertebral compression fracture; elderly (>60) with osteoporosis

Question 10

degenerative osteoarthritis of the joints between the center of the spinal vertebrae or neural foramina

Answer 10

Spondylosis

Question 11

Pain that worsens with extension, twisting, and improved with flexion

Answer 11

Spondylosis

Question 12

Spondylosis tx

Answer 12

TX: NSAIDS, PT, lumbar epidural injections, facet injections (selective nerve blocks), ACDF in advanced disease

Question 13

• Pain with direct pressure on the knee (kneeling)
• Swelling over the patella
• Common in wrestlers: concern for septic bursitis in wrestlers - aspiration with gram stain and culture

Answer 13

Prepatellar bursitis (handmaids knee)

Question 14

Tx of prepatellar bursitis

Answer 14

• Treatment: compressive wrap, NSAIDs, +/- aspiration and immobilization

Question 15

inflammation of the bursa that separates the superior surface of the supraspinatus tendon from the overlying coracoacromial ligament, acromion, and coracoid (the acromial arch) and from the deep surface of the deltoid muscle

Answer 15

Subacromial bursitis

Question 16

Tx of subacromial bursitis

Answer 16

Treatment includes prevention of the precipitating factors, rest, and NSAIDs. Cortisone injections can be helpful.

Question 17

Tx of tendonitis

Answer 17

• Tx: ice, rest, stretching for inflammation
  
  • NSAIDs help but don’t penetrate tendon circulation; steroid injection + anesthesia may be beneficial

Question 18

• Activity-related anterior knee pain associated with focal patellar tendon tenderness. Also known as “jumper’s knee” (up to 20% of jumping athletes)

Answer 18

Patellar tendinitis

Question 19

Dx of patellar tendinitis

Answer 19

• Radiographs - AP, lateral, skyline views of the knee - usually normal -may show inferior traction spur (enthesophyte) in chronic cases

Question 20

Tx of patellar tendinitis

Answer 20

• Ice, rest, activity modification, followed by physical therapy. Surgical excision and suture repair as needed
• Cortisone injections are contraindicated due to the risk of patellar tendon rupture

Question 21

pain at the biceps groove

Answer 21

Biceps tendonitis

Question 22

• Anterior shoulder pain - may have pain radiating down the region of the biceps, symptoms may be similar in nature and location to the rotator cuff or subacromial impingement pain
  
  • Pain with resisted supination of the elbow

Answer 22

Biceps tendonitis

Question 23

Tx of biceps tendonitiis

Answer 23

• Treat with NSAIDS, PT strengthening, and steroid injections
• Surgical release reserved for refractory cases for bicep pathology seen during arthroscopy

Question 24

Special tests associated w/ biceps tendonitis

Answer 24

• Speed test: Pain elicited in the bicipital groove when the patient attempts to forward elevate shoulder against examiner resistance while the elbow extended and forearm supinated. Positive if the pain is reproduced. May also be positive in patients with SLAP lesions
• Yergason’s test: Elbow flexed 90 degrees, wrist supination against resistance. Positive if the pain is reproduced.

Question 25

• Altered purine metabolism and sodium urate crystal precipitation into the synovial fluid, M>W (9:1) until menopause (1:1)

Answer 25

Gout

Question 26

morning stiffness lasting < 30 minutes, evening joint stiffness worsens with use and improves with rest

Answer 26

Osteoarthritis

Question 27

Signs associated with osteoarthritis

Answer 27

• Heberden nodes: swelling of the distal interphalangeal joints
• Bouchard nodes: Swelling of the proximal interphalangeal joints

Question 28

Which joints does osteoarthritis not affect

Answer 28

• DOES NOT affect MCP joints

Question 29

The current recommendations for frequency of DEXA scans for postmenopausal women based on their T score are:

Answer 29

• T score of -1.0 to -1.5 every 5 years
• T score -1.5 to -2.0 every 3-5 years
• T score of greater than - 2.0 every 1 to 2 years

Question 30

• Pain on the plantar surface, usually at the calcaneal insertion of plantar fascia upon weight bearing, especially in the morning or on the initiation of walking after prolonged rest.

Answer 30

Plantar fasciitis

Question 31

Tx of plantar fasciiitis

Answer 31

Stretching, ice, calf strengthening, shoe inserts, and NSAIDs. Rarely surgery

Question 32

MORNING JOINT STIFFNESS > 30 minutes after initiating movement and improves later in the day

Answer 32

Rheumatoid arthritis

Question 33

Dx studies for rheumatoid arth

Answer 33

1. (+) Rheumatoid Factor (sensitive but not specific); Increased CRP and ESR
2. (+) Anti-citrullinated peptide antibodies (most specific for RA)

Question 34

Sprain involves _____while a strain involves _____

Answer 34

A sprain involves ligaments and a strain involves muscles and tendons

Question 35

The most common location for a sprain is the

Answer 35

Ankle joint