Orthopedics/Musculoskeletal

Question 1

What percentage of back pain resolves on its own?

Answer 1

90% resolve in 6 weeks, <5% become chronic

Question 2

What is the pathophysiology of a pinched nerve (radiculopathy)?

Answer 2

When the inner core (nucleus pulposus) of the intervertebral disc bulges out through the outer layer of ligaments that surround the disc (annulus fibrosis). This tear in the annulus fibrosis causes pain in the back at the point of herniation. If the protruding disc presses on a spinal nerve, the pain may spread to the area of the body that is served by that nerve.

Question 3

What are the stages of nuclear herniation?

Answer 3

Nuclear herniation, disc protrusion, nuclear extrusion and nuclear sequestration

Question 4

What is the etiology of back pain?

Answer 4

Mechanical (98%):
- Sprain (ligament), strain (muscle), facet joint degeneration (OA), disc degeneration/herniation, spinal stenosis (e.g. spondylosis), spondylolisthesis, compression fracture

Non-Mechanical (2%):

• Surgical Emergencies: cauda equina syndrome), AAA (pulsatile abdominal mass)
• Medical Conditions:
• Neoplastic (primary, metastatic, multiple myeloma)
• Infectious (osteomyelitis, TB)
• Metabolic (osteoporosis, osteomalacia, Paget’s disease)
• Rheumatologic (ankylosing spondylitis, polymyalgia rheumatica)
• Referred pain (perforated ulcer, pancreatitis, pyelonephritis, ectopic pregnancy, herpes zoster)

Question 5

What time period is acute back pain?

Answer 5

Acute: <4wks

Question 6

What time period is sub-acute back pain?

Answer 6

Subacute: 4-12wks

Question 7

What time period is chronic back pain?

Answer 7

Chronic: >12 wks

Question 8

Herniated disc is unlikely in a _____ as the nucleus pulposus is already _____, thus commoner in younger people. Older people can still have pinched nerves but different process - smaller joint spaces

Answer 8

50+ yo

Fibrotic

Question 9

When discs protrude at a level, they often compress the spinal nerve root (has dorsal and ventral root) of the segment _____!

Answer 9

Below

For instance if you have an L4/L5 nerve root disc herniation, you can affect the L4 root which is in that area, but often affects the L5 one. Why? The intervertebral foramina are pretty big in the lumbar region (small in the cervical region). But the nerve root is up really high in the foramen, above the disc. If the disc pushes out, it is likely to spare the nerve root because the root will be above, but instead it will push against the level below

Question 10

What are the red flags of acute lower back pain?

Answer 10

B: owel or bladder dysfunction; sudden onset (Emergency, refer w/n hours)

A: nestheia (saddle) (Emergency, refer w/n hours)

C: onstitutional symptoms, weight loss, hx of cancer, fever (Urgent, refer w/n 24-48 hours)

K-(C): hronic disease, severe, constant or worsening pain (PM or supine) (Urgent, refer w/n 24-48 hours)

P: aresthesia (Urgent, refer w/n 24-48 hours)

A: ge > 50 (Soon, refer w/n weeks) + mild trauma (Urgent, refer w/n 24-48 hours)

I: V drug use/infection (Urgent, refer w/n 24-48 hours)

N: euromotor deficits (Urgent, refer w/n 24-48 hours)

Question 11

What are the yellow flags of acute lower back pain?

Answer 11

Belief that pain and activity are harmful, sickness behaviours (extended rest), low/negative mood, social withdrawal, treatment expectations that do not fit best practice, problems with claim/compensation, history of back pain/time-off/other claims, problems at work, poor job satisfaction, heavy work, unsociable hours (shift work), overprotective family or lack of support

Question 12

Clinical features of cauda equina syndrome and features on physical exam?

Answer 12

Pain is usually the first symptom of cord compression, but motor (lower extremity weakness, areflexia, decreased anal tone) and sensory findings (saddle anesthesia). Fecal incontinence, urinary retention are often late findings

Question 13

Clinical features of infectious back pain and features on physical exam?

Answer 13

Long use of corticosteroids; Unexplained fever, malaise; IV drug use, Recent spinal injection or epidural catheter placement. The pain is not relieved with rest and is provoked by weight bearing. On examination there will be focal tenderness at the involved spinous process.

Question 14

Clinical features of cancer for back pain and features on physical exam?

Answer 14

Hx of Ca + new back pain; Unexplained weight loss; Duration > 6wks; Age >70. Focal tenderness at the involved vertebrae

Question 15

In patients with a history of cancer, sudden, severe pain raises concern for ______?

Answer 15

Pathologic fracture.

Question 16

What is pinched nerve (radiculopathy)?

Answer 16

Pressure or impingement on nerve roots in spinal canal

Question 17

Clinical features of vertebral compression fracture and features on physical exam?

Answer 17

Acute onset of localized back pain which may be incapacitating - worse with flexion and often point tenderness on palpation. There may be no history of preceding trauma

Question 18

What is sciatica?

Answer 18

Sciatica is a nonspecific term used to describe a variety of leg or back symptoms. Usually, sciatica refers to a sharp or burning pain radiating down from the buttock along the course of the sciatic nerve (the posterior or lateral aspect of the leg, usually to the foot or ankle).

Question 19

What are the causes of spinal stenosis?

Answer 19

Spondylosis (degenerative arthritis affecting the spine), spondylolistheses (slipping of a vertebra in relation to the one below), and thickening of the ligamentum flavum

Question 20

What is spinal stenosis?

Answer 20

Narrowing of the spinal canal by a piece of bone

Question 21

Over 90 percent are ______ radiculopathies.

Answer 21

Over 90 percent are L5 and S1 radiculopathies

Question 22

Risk factors for osteoporotic fracture include _____ and _____.

Answer 22

Advanced age and chronic glucocorticoid use

Question 23

What are the causes of pinched nerve (radiculopathy)?

Answer 23

Causes: herniated disc, degenerative disc disease, bone spurs/osteophytes, spinal stenosis.

Question 24

_____ is a hallmark of lumbar spinal stenosis

Answer 24

Neurogenic claudication

Question 25

What are the symptoms of spinal stenosis?

Answer 25

Ambulation-induced (walking, standing or extension) pain localized to the calf and distal lower extremity resolving with sitting or leaning forward

Question 26

Clinical features of ankylosing spondylitis and associated features?

Answer 26

Morning stiffness; Improves with exercise; Younger age males, pain at night. Associated with uveitis and colitis

Question 27

Clinical features of lumbosacral muscle strains/sprains and features on physical exam?

Answer 27

Often following isolated traumatic incidents or repetitive overuse; pain worse with movement, relieved by rest; examination may reveal restricted range of motion, muscle tenderness, or trigger points

Question 28

Clinical features of lumbar spondylosis?

Answer 28

More common in persons older than 40 years; pain may be present in or radiate from the hips; pain is worse with activity; pain may worsen with lumbar spine extension or rotation

Question 29

Clinical features of osteoarthritis and in which age group does it commonly present in?

Answer 29

Low back pain may be a symptom of osteoarthritis of the facet joints spine. Patients may also complain of hip pain, either from osteoarthritis of the hip or referred pain from the spine. Osteoarthritis most commonly presents in patients over the age of 40. Pain is typically exacerbated by activity and relieved by rest

Question 30

______ may contribute to the severity symptoms of low back pain or may be a cause of nonorganic back pain

Answer 30

Psychologic distress (eg, depression or somatization)

Question 31

What is spondylolysis and activities that can cause it?

Answer 31

Break in the pars interarticularis, (scotty dog has a ring around his neck), typically stress fracture, pain with activities involving lumbar extension - weightlifting, gymnastics. Pain in young adolescent athletes

Question 32

What should be asked on history for back pain?

Answer 32

o OPQRST o Back/Buttock dominant vs leg dominant o Constant vs intermittent pain o What increases your typical pain? ▪ Flexion (possibly extension) – disc pain ▪ Extension only – facet joint pain ▪ All movements (improved with rest) – compressed nerve pain ▪ Walking or standing (relieved with sitting or flexion) – spinal stenosis o Red Flags – bowel or bladder incontinence o Medications

Question 33

Indications for Lumbar Xray

Answer 33

``` ▪ No improvement after 6 wk ▪ Fever >38oC ▪ Unexplained weight loss ▪ Prolonged corticosteroid use ▪ Significant trauma ▪ Progressive neurological deficit ▪ Suspicion of ankylosing spondylitis ▪ History of cancer (rule out metastases) ▪ Alcohol/drug abuse (increased risk of osteomyelitis, trauma, fracture) ```

Question 34

Work up for back pain?

Answer 34

Work-Up: plain films not recommended in initial evaluation o If Infection/Cancer Suspected: CBC, CRP o If Neuro Deficits Worsening or Infection/Cancer Suspected: consider CT or MRI

Question 35

What are the special tests that can be done for back pain?

Answer 35

``` ▪ Straight leg raise ▪ Crossed straight leg raise ▪ Femoral stretch test ▪ FABER ▪ Thomas ▪ Romberg ▪ Schober ```

Question 36

What are the symptoms of benign back pain?

Answer 36

Benign Back Pain: moderate, dull, aching, worse with movement or cough

Question 37

What vascular emergencies should you rule out for acute back pain?

Answer 37

Aortic dissection, AAA, PE, MI, retroperitoneal bleed

Question 38

What are the causes of spinal emergencies?

Answer 38

Osteomyelitis, cauda equina, epidural abscess or hematoma

Question 39

How do you evaluate risk for fracture/infection/cancer/vascular causes of acute back pain?

Answer 39

Osteoporosis, age, IV drug user, recent spinal intervention, immunosuppression, cardiac risk factors

Question 40

What are the physical exam

Answer 40

o Inspection: curvature, posture, gait o Palpation: bony deformities/spine for bony tenderness, paraspinal muscle bulk/tenderness, trigger points o Percussion: of spine to elicit pain due to fracture or infection o Move: ROM and peripheral pulses o Neuro Exam: for L4/L5/S1 helps determine level of spinal involvement (power, reflexes, sensation) o Other Exam: precordial, respiratory, abdominal and neurological exams guided by history o Special Tests

Question 41

What is straight leg raise and what does it help diagnose?

Answer 41

Straight leg raise (positive if pain at <70 degrees and aggravated by ankle dorsiflexion) = (+)Sciatica

Question 42

What is the femoral stretch test and what does it help diagnose?

Answer 42

Femoral stretch test (patient prone, knee flexed, examiner extends hip) to diagnose L4 radiculopathy

Question 43

What is FABER and what does it help diagnose?

Answer 43

FABER (Flex, abduct, externally rotate knee) SI joint pain– osteoarthritis

Question 44

What is crossed straight leg raise?

Answer 44

Crossed straight leg raise (raising of uninvolved leg elicits pain in leg with sciatica), more specific than straight leg raise

Question 45

What is the Thomas test and what does it help diagnose?

Answer 45

Hand under lumbar spine, flex opposite knee, observe angle between femur and table Angle >0 – Flexed hip contracture

Question 46

What is the Romberg test and what does it help diagnose?

Answer 46

Patient stands feet together, arms outstretched at 90, eyes closed Loss of balance - Pathology of dorsal columns or vestibular system

Question 47

What is the Schober test and what does it help diagnose?

Answer 47

Mark 5cm below and 10cm above L5, patient bends forward, measure distance between marks Distance increase <5cm - Muscle tightness, ankolyosing spondyitis, scoliosis

Question 48

Management of chronic back pain (>12wks since onset)?

Answer 48

▪ Rx: physical or therapeutic exercise ▪ Analgesics: acetaminophen, NSAIDs (consider PPI), low dose TCAs (amitriptyline), short term cyclobenzaprine PRN ▪ Referral Options: community based rehab or self-management/CBT ▪ Additional Options: progressive muscle relaxation, acupuncture, massage, TENS, aqua therapy, yoga

Question 49

Management of moderate to severe chronic back pain (>12wks since onset)?

Answer 49

Opioids, multidisciplinary chronic pain program, epidural steroids (short term relief of radicular pain), prolotherapy, facet joint injections, surgery(?)

Question 50

Management of spinal infection?

Answer 50

Early IV antibiotics and ID consultation

Question 51

Management of lumbosacral strain + disc herniation?

Answer 51

Analgesia and continue daily activities as much as tolerated; discuss red flags and organize follow-up ▪ Discectomy (removal of part of disc that is compressing nerve) ▪ Disc prosthesis occasionally used (newer procedure, beneficial in younger more active patients) ▪ Epidural Injection

Question 52

Management of cauda equine syndrome?

Answer 52

Dexamethasone + lumbosacral MRI + early neurosurgical consultation

Question 53

Management of acute back pain (<12wks since onset)?

Answer 53

▪ Education: low back pain typically resolves within a few weeks (70% in 2 weeks, 90% in 6 weeks) ▪ Rx: alternating cold and heat, continue activities as tolerated; encourage early return to work, physical activity and/or exercise ▪ Analgesics: acetaminophen > NSAIDS, short course muscle relaxants, short-acting opioids (rarely), spinal traction ▪ Follow-up in 1-6 weeks ▪ Consider Referral: physical therapist, chiropractor, physiatrist, spinal surgeon (if unresolving radicular symptoms), multidisciplinary pain program (if not returning to work)

Question 54

Definition of monoarthritis?

Answer 54

1 joint involved

Question 55

Definition of oligoarthritis?

Answer 55

2-4 joints involved

Question 56

Definition of polyarthritis?

Answer 56

>5 joints involved

Question 57

The spondyloarthropathies are classically ____, whereas rheumatoid arthritis (RA) is usually ____.

Answer 57

Oligoarticular | Polyarticular

Question 58

Polyarticular/Oligoarticular DDx

Answer 58

1. Mechanical: OA 2. Inflammatory 3. Infections 4. Endocrine/metabolic: hypo/hyperthyroidism, hyperparathyroidism, hemochromatosis, Wilson’s disease 5. Malignancies: acute leukemia 6. Sarcoidosis: lofgren's syndrome 7. Familial mediterranean fever 8. Polymyalgia rheumatica 9. Mucocutaneous disorders: dermatomyositis, erythema nodosum, erythema multiforme, pyo derma gangrenosum, pustular psoriasis

Question 59

Inflammatory etiology of polyarticular/oligoarticular disease?

Answer 59

- Rheumatoid arthritis - Spondyloarthropathies - psoriatic arthritis, enteric arthritis, reactive arthritis, AS - Crystal induced: gout, pseudogout - Connective tissue diseases – SLE, Sjogrens, myositis - Vasculitis: polymyalgia rheumatica, wegener's Granulomatosis, behcet's disease, still's disease

Question 60

Infectious etiology of polyarticular/oligoarticular disease?

Answer 60

- Bacterial: septic (gonococci) – usually monoarticular, meningococci, endocarditis, lyme disease, whipple's disease, mycobacteria - Viral: parvovirus, rubella, hbv, hcv, hiv, ebv - Fungal - Post-infectious/reactive: enteric infections, genitourinary infections, rheumatic fever, inflammatory bowel disease

Question 61

Red flags for polyarticular/oligoarticular disease?

Answer 61

Abnormal vitals, symptoms > 6 weeks, immunocompromised, rapid onset/progression, STI/IVDU, non-weight bearing, constitutional symptoms

Question 62

Questions asked on HPI for polyarticular/oligoarticular disease?

Answer 62

HPI: - Timing of onset (acute vs chronic) – symmetric vs asymmetric - Jt swelling, jt pain, decreased ROM - Hx of joint trauma - Identify involved joints - Features of RA or OA - Reactive arthritis symptoms - rash, conjunctivitis, urethritis/cervicitis

Question 63

Lofgren syndrome triad?

Answer 63

Triad: bilateral ankle swelling, erythema nodosum, hilar lymphadenopathy

Question 64

Possible skin and nails findings on physical exam for polyarticular/oligoarticular disease?

Answer 64

- Rashes: pustular lesions (disseminated gonococcal infection), erythema migrans (Lyme), erythema nodosum (IBD, sarcoidosis), psoriasis/nail pitting/onycholysis - Tophi (gout) - Lesions on glans penis (reactive arthritis)

Question 65

Investigations for polyarticular/oligoarticular disease?

Answer 65

1. Labs - CBCd – may have anemia of chronic disease, leukocytosis/leukopenia, thrombocytosis/thrombocytopenia - Electrolytes, Cr, CRP* (main one), liver enzymes, urinalysis, serum urate - If Suspected RA: RF (>20), anti-CCP - If suspected connective tissue disorder: ANA, anti-dsDNA, C3/C4, urine protein-Cr ratio, CK - If suspected seronegative spondyloarthropathy: HLA-B27 - If suspected vasculitis: ANCA, anti-GBM 2. Arthrocentesis 3. Xray

Question 66

What should you send the synovial fluid for in an arthrocentesis

Answer 66

Complete cell count + differential, gram stain, culture, crystals (gold standard)

Question 67

Synovial fluid findings for OA?

Answer 67

- Cell count = 200-2000 - Polys = <25% - Crystals = occasional CPPD (calcium pyrophosphate disease) - Pseudogout, can calcify cartilage be aging - Gm stain and culture = negative

Question 68

Synovial fluid findings for inflammatory arthritis?

Answer 68

- Cell count = 2,000-50,000 - Polys = >50% - Crystals = none - Gm stain and culture = negative

Question 69

Synovial fluid findings for septic arthritis?

Answer 69

- Cell count = >50,000 - Polys = >75% - Crystals = none - Gm stain and culture = positive

Question 70

Inflammatory arthritis symptoms?

Answer 70

- Pain at rest, relieved by gentle motion - Morning stiffness >1 h - Warmth, swelling, erythema - Malalignment/deformity (late finding) - Extra-articular manifestations - Nighttime awakening due to pain

Question 71

Degenerative arthritis symptoms?

Answer 71

- Pain with motion, relieved by rest - Morning stiffness <1/2 h - Joint instability, buckling, locking - Bony enlargement, malalignment/deformity (late finding) - Evening/end of day pain

Question 72

Seronegative spondyloarthropathies Ddx?

Answer 72

- Psoriatic arthritis - Enteric arthritis - Ankylosing spondylitis - Reactive arthritis - Undifferentiated

Question 73

Clinical features of seronegative spondyloarthropathies

Answer 73

- SPONDYLOARTHROPATHY spondylitis, sacroiliitis, morning stiffness >30 min - OLIGOARTHRITIS asymmetric, dactylitis, usually larger joints, lower extremities (exception: PsA) - ENTHESOPATHY inflammation at the sites of insertion of ligaments, tendons, joint capsule, and fascia to bone, with both destruction and new bone formation. This results in Achilles tendonitis, plantar fasciitis, tenosynovitis, and dactylitis/sausage fingers

Question 74

Extraarticular changes of seronegative spondyloarthropathies

Answer 74

Nail pitting, onycholysis, psoriasis, tenosynovitis, dactylitis, synovitis, acute uveitis, aortic regurgitation, apical pulmonary fibrosis, chin to chest distance, occiput to wall distance, decreased chest expansion, cauda equine compression, and enthesitis (costochondritis, patellar and Achilles tendonitis, plantar fasciitis).

Question 75

Serology HLA B27 ____, rheumatoid factor ____ (hence, why they are called seronegative spondyloarthropathies).

Answer 75

Positive | Negative

Question 76

Back exam for seronegative spondyloarthropathies?

Answer 76

- INSPECTION swelling, erythema, atrophy, scars, and loss of thoracic kyphosis and cervical/lumbar lordosis - RANGE OF MOTION check gait and flexion, extension, lateral bending, rotation - PALPATION tenderness over spinous processes and sacroiliac joints - SPECIAL TESTS Schober's test (place mark 5 cm below and mark 10 cm above the spine at level of PSIS/L5 with patient standing. A distance increase of <5 cm [<2 in.] between the marks with the patient bending forward suggests limited lumbar flexion), finger to floor distance, occiput to wall distance. Perform FABER test (SI joint stability) and straight leg raising test (sciatica)

Question 77

Clinical features/physical exam findings of ankylosing spondylitis?

Answer 77

- Spondylitis, sacroiliitis, morning stiffness, and arthritis of the hips, knees, shoulders, and occasionally peripheral joints. - Loss of lumbar lordosis and thoracic kyphosis with significant decreased range of motion and chest expansion - Positive Schober's test and occiput to wall test.

Question 78

Extraarticular manifestations of ankylosing spondylitis?

Answer 78

Extraarticular manifestations include anterior uveitis, C1-2 subluxation, restrictive lung disease, aortic regurgitation, conduction abnormalities, and secondary amyloidosis.

Question 79

Imaging findings of ankylosing spondylitis?

Answer 79

Imaging reveals bamboo spine (syndesmophytes), shiny corners (squaring and increased density anteriorly of vertebral bodies), and whiskering (new bone and osteitis at tendon and ligament insertions) • Large joints: synovitis indistinguishable from RA • Spine: enthesitis: inflammation visualized as bone marrow edema at entry of ligaments into bone. (not synovitis here)

Question 80

New York diagnostic criteria for ankylosing spondylitis?

Answer 80

- CLINICAL CRITERIA low back pain and morning stiffness of >3 months, limitation of motion of the lumbar spine in both the sagittal and frontal planes, and limitation of chest expansion (<2.5 cm [1 in.]) - RADIOLOGIC CRITERIA sacroiliitis with more than minimum abnormality bilaterally or unequivocal abnormality unilaterally - DIAGNOSIS one clinical plus one radiologic criterion = definite AS; three clinical criteria or one radiologic criterion only = probable AS

Question 81

Treatment of ankylosing spondylitis?

Answer 81

Aggressive NSAID (indomethacin) and exercise, TNF-inhibitors

Question 82

Clinical features of reactive arthritis?

Answer 82

- <5 joints involved, proximal and distal, asymmetric, other systems include urethritis, dysentery, skin, eye - Spondylitis, sacroiliitis, morning stiffness, lower limb arthritis (asymmetric oligoarthritis of lower limbs), and enthesitis (Achilles tendonitis, plantar fasciitis, chest wall changes, and sausage fingers/toes).

Question 83

Pathophysiology of reactive arthritis?

Answer 83

Preceding/ongoing infectious disorders such as urethritis (Chlamydia), diarrhea (Shigella, Salmonella, Campylobacter, Yersinia) or HIV, usually within 6 weeks.

Question 84

Physical exam findings of reactive arthritis?

Answer 84

- Genital lesions (circinate balanitis with shallow painless ulcers on the glans or urethral meatus, urethritis, prostatitis) - Skin lesions (keratoderma blennorrhagica with vesicles that progress to macules, papules and nodules on palms and soles) - Eye lesions (conjunctivitis, iritis [acute, unilateral, photophobia, pain, redness, impaired vision]) - Bowel inflammation (acute enterocolitis, chronic ileocolitis) - Cardiac abnormalities (aortic regurgitation, conduction abnormalities).

Question 85

Imaging findings of reactive arthritis?

Answer 85

Plain film reveals fluffy erosions, periosteal spurs, and asymmetric syndesmophytes

Question 86

Reactive arthritis triad?

Answer 86

- “can’t see, can’t pee, can’t climb a tree”--> conjunctivitis, urethritis/cervicitis, arthritis - Urethritis (chlamydia) or dysentery (SEXCY) followed by arthritis, conjunctivitis, painless oral ulcers and typical skin lesions (balanitis, keratoderma)

Question 87

Treatment of reactive arthritis?

Answer 87

NSAIDs, sulfasalazine, anti-TNF agents, methotrexate, azathioprine, leflunomide

Question 88

Ddx for musculoskeletal lump/mass?

Answer 88

1. Soft tissue - Benign (e.g., lipoma) - Malignant (e.g., leiomyosarcoma) 2. Bone (e.g., cyst) - Benign (e.g., cyst) - Malignant (e.g., Ewing sarcoma) 3. Non-neoplastic - Infectious (e.g., osteomyelitis) - Traumatic (e.g., hematoma) - Inflammatory (e.g., rheumatoid nodules, tendonitis)

Question 89

What should be asked on history for musculoskeletal lump/mass?

Answer 89

- Lump: Onset, recent changes (size, colour, rapid growth), provoking factors, trauma (hematoma), cut (abscess), warmth, pain - Systemic: fever, night sweats, weight loss, fatigue - PMHx: previous malignancy, illnesses - FHx: cancers in family - Meds: - Social: smoking, alcohol intake

Question 90

Physical exam for musculoskeletal lump/mass?

Answer 90

- Inspection: location, appearance, SEADS - Palpation: temp, tenderness, consistency (soft, rubbery, firm, stony hard, or nodular, lobulated), contour (irregular), surface (smooth, rough, irregular), depth, size, pulsation - Tethered to skin (mobile or fixed), muscle or tendon involvement - Special tests: transilluminability - should be done in a darkened room, with pen torch directly on lump. Fluid-filled lumps like cysts or hydrocele are transilluminable, while solid lumps are not. - Regional LN exam, neuro exam

Question 91

What should you comment on an Xray of a musculoskeletal lump/mass?

Answer 91

- Internal calcification may be signs of a vascular tumour, heterotopic ossification, or rare forms of sarcoma. - Advanced imaging including MRI may demonstrate signs of malignancy or aggressive masses. - Large size (>5cm). - Deep. - Heterogeneous. - Incorporating the neurovascular bundle.

Question 92

Treatment of musculoskeletal lump/mass?

Answer 92

- Infection should be treated with irrigation & debridement and antibiotics - Most benign masses may be excised in symptomatic - Most malignant masses benefit from radiation treatment followed by wide resection

Question 93

What is a lipoma?

Answer 93

Single or multiple non-tender subcutaneous tumours that are soft and mobile

Question 94

_____ tumours to bone are much more common than primary bone tumours, particularly if age >40 yr

Answer 94

Metastatic

Question 95

Pathophysiology of a lipoma?

Answer 95

Adipocytes enclosed in a fibrous capsule

Question 96

Investigations for a lipoma?

Answer 96

Biopsy only if atypical features (painful, rapid growth, firm)

Question 97

Management of a lipoma?

Answer 97

Reassurance, excision or liposuction only if desired for cosmetic purposes

Question 98

Clinical features of bone tumors?

Answer 98

- Malignant (primary or metastasis): local pain and swelling (weeks to months), worse on exertion and at night, soft tissue mass - Benign: usually asymptomatic - Minor trauma often initiating event that calls attention to lesion

Question 99

Xray findings of bone tumors?

Answer 99

- Lytic, lucent, sclerotic bone - Involvement of cortex, medulla, soft tissue - Radiolucent, radiopaque, or calcified matrix - Periosteal reaction - Permeative margins - Pathological fracture - Soft tissue swelling

Question 100

Red flags of bone tumors?

Answer 100

- Persistent skeletal pain - Localized tenderness - Spontaneous fracture - Enlarging mass/soft tissue swelling

Question 101

Ddx of benign active bone tumors?

Answer 101

1. Bone-Forming Tumors - Osteoid Osteoma 2. Fibrous Lesions - Fibrous Cortical Defect - Osteochondroma - Enchondroma 3. Cystic Lesions - Unicameral/Solitary Bone Cyst

Question 102

What is an osteoid osteoma?

Answer 102

Bone tumour arising from osteoblasts

Question 103

When and where do osteoid osteoma typically occur?

Answer 103

- Peak incidence in 2nd and 3rd decades, M:F=2:1 - Proximal femur and tibia diaphysis most common locations - Not known to metastasize

Question 104

Radiographic findings of osteoid osteoma?

Answer 104

Small, round radiolucent nidus (<1.5cm) surrounded by dense sclerotic bone ("bull's-eye")

Question 105

Symptoms of osteoid osteoma?

Answer 105

Produces severe intermittent pain from prostaglandin secretion and COX1/2 expression, mostly at night (diurnal prostaglandin production), thus is characteristically relieved by NSAIDs

Question 106

Treatment of osteoid osteoma?

Answer 106

NSAIDs for night pain; surgical resection of nidus; ablation of the small radiolucent zone with percutaneous radiofrequency energy

Question 107

Most common benign bone tumour in children, typically asymptomatic and an incidental finding

Answer 107

Fibrous Cortical Defect i.e.non-ossifying fibroma, fibrous bone lesion

Question 108

What are fibrous cortical defects?

Answer 108

These lesions are developmental defects in which parts of bone that normally ossify are instead filled with fibrous tissue

Question 109

Location of fibrous cortical defects?

Answer 109

Femur and proximal tibia most common locations, 50% of patients have multiple defects that are usually bilateral, symmetrical, metaphysis

Question 110

Radiographic findings of fibrous cortical defects?

Answer 110

Diagnostic, radiolucent metaphyseal eccentric 'bubbly' lytic lesion near physis; thin, smooth/lobulated, well-defined sclerotic margin

Question 111

Treatment of fibrous cortical defects?

Answer 111

Most lesions resolve spontaneously

Question 112

What is an osteochondroma?

Answer 112

- Cartilage capped bony tumour | - Most common of all benign bone tumours: 45%

Question 113

What are the two types of osteochondroma?

Answer 113

Sessile (broad based and increased risk of malignant degeneration) vs. pedunculated (narrow stalk)

Question 114

Location of osteochondroma?

Answer 114

Metaphysis of long bone near tendon attachment sites (usually distal femur, proximal tibia, or proximal humerus)

Question 115

Radiographic findings of osteochondroma?

Answer 115

Cartilage-capped bony spur on surface of bone ("mushroom" on x-ray)

Question 116

Treatment of osteochondroma?

Answer 116

Typically observation; surgical excision if symptomatic (compressing nerve/vessel)

Question 117

What is an enchondroma?

Answer 117

Benign cartilaginous growth, an abnormality of chondroblasts, develops in medullary cavity

Question 118

Where do enchondromas occur?

Answer 118

60% occur in the small tubular bones of the hand and foot; others in femur, humerus, ribs

Question 119

Pain in absence of pathologic fracture is an important clue for malignant degeneration to _____ for suspected enchondroma?

Answer 119

Chondrosarcoma

Question 120

Radiographic finding of enchondromas?

Answer 120

- Single/multiple enlarged rarefied areas in tubular bones | - Lytic lesion with sharp margination and irregular central calcification (stippled/punctate/popcorn appearance)

Question 121

Treatment of enchondromas?

Answer 121

Observation with serial x-rays; surgical curettage if symptomatic or lesion grows

Question 122

Most common cystic lesion; serous fluid-filled lesion

Answer 122

Unicameral/Solitary Bone Cyst

Question 123

In unicameral/solitary bone cyst the cortex thins and predisposes the area to a ____

Answer 123

Buckle-like pathologic fracture

Question 124

Most common location of unicameral/solitary bone cyst

Answer 124

Proximal humerus and femur most common

Question 125

Symptoms of unicameral/solitary bone cyst

Answer 125

Asymptomatic, or local pain; complete pathological fracture (50% of presentations) or incidental detection

Question 126

Radiographic findings of unicameral/solitary bone cyst

Answer 126

Lytic translucent area on metaphyseal side of growth plate, cortex thinned/expanded; well-defined lesion

Question 127

Treatment of unicameral/solitary bone cyst?

Answer 127

Aspiration followed by steroid injection; curettage ¬ ± bone graft indicated if re-fracture likely

Question 128

When do giant cell tumours/aneurysmal bone cyst/osteoblastomas occur?

Answer 128

Affects patients of skeletal maturity, peak 3rd decade

Question 129

Location of osteoblastoma?

Answer 129

Found in the distal femur, proximal tibia, distal radius, sacrum, tarsal bones, spine

Question 130

Radiographic findings of giant cell tumors?

Answer 130

Eccentric lytic lesions in epiphyses adjacent to subchondral bone; may break through cortex; T2 MRI enhances fluid within lesion (hyper-intense signal)

Question 131

Radiographic findings of aneurysmal bone cyst?

Answer 131

- Either solid with fibrous/granular tissue, or blood-filled - Expanded with honeycomb shape

Question 132

Symptoms of giant cell tumours/aneurysmal bone cyst/osteoblastomas?

Answer 132

Local tenderness and swelling, pain may be progressive (giant cell tumours), ± symptoms of nerve root compression (osteoblastoma)

Question 133

Treatment of giant cell tumours/aneurysmal bone cyst/osteoblastomas?

Answer 133

- Intralesional curettage + bone graft or cement | - Wide local excision of expendable bones

Question 134

Radiographic findings of osteoblastoma

Answer 134

Often nonspecific; calcified central nidus (>2 cm) with radiolucent halo and sclerosis

Question 135

Ddx of malignant bone tumors?

Answer 135

- Osteosarcoma - Chondrosarcoma - Ewing's Sarcoma - Multiple Myeloma - Metastatic bone cancer

Question 136

Most frequently diagnosed in 2nd decade of life (60%), 2nd most common primary malignancy in adults

Answer 136

Osteosarcoma

Question 137

Ask about history of what if suspecting osteosarcoma?

Answer 137

History of Paget's disease (elderly patients), previous radiation treatment

Question 138

Location for osteosarcoma

Answer 138

Predilection for sites of rapid growth: distal femur (45%), proximal tibia (20%), and proximal humerus (15%)

Question 139

Radiographic findings of osteosarcoma

Answer 139

- characteristic periosteal reaction: Codman's triangle or "sunburst" spicule formation (tumour extension into periosteum) - destructive lesion in metaphysis may cross epiphyseal plate

Question 140

Management of osteosarcoma?

Answer 140

Complete resection (limb salvage, rarely amputation), neo-adjuvant chemo; bone scan- rule out skeletal metastases, CT chest - rule out pulmonary metastases

Question 141

Symptoms of osteosarcoma

Answer 141

Painful symptoms: progressive pain, night pain, poorly defined swelling, decreased ROM

Question 142

What is primary chondrosarcoma?

Answer 142

Primary (2/3 cases): previous normal bone, patient >40 yr; expands into cortex to cause pain, pathological fracture

Question 143

What is secondary chondrosarcoma?

Answer 143

Malignant degeneration of pre-existing cartilage tumour such as enchondroma or osteochondroma. Age range 25-45 yr, better prognosis than primary chondrosarcoma

Question 144

Symptoms of chondrosarcoma?

Answer 144

Progressive pain, uncommonly palpable mass

Question 145

Radiographic findings of chondrosarcoma?

Answer 145

In medullary cavity, irregular "popcorn" calcification

Question 146

Treatment of chondrosarcoma?

Answer 146

Unresponsive to chemotherapy, treat with aggressive surgical resection + reconstruction; regular follow-up X-rays of resection site and chest

Question 147

What is Ewing's sarcoma?

Answer 147

- Malignant, small round cell sarcoma | - Most occur between 5-25 yr old

Question 148

Radiographic findings of Ewing's sarcoma?

Answer 148

Presents with pain, mild fever, erythema, and swelling; anemia, increased WBC, ESR, LDH (mimics an infection)

Question 149

Signs/symptoms of Ewing's sarcoma?

Answer 149

Moth-eaten appearance with periosteal lamellated pattern ("onion-skinning") in metaphyses of long bone with diaphyseal extension

Question 150

Treatment of Ewing's sarcoma?

Answer 150

Resection, chemotherapy, radiation

Question 151

What is multiple myeloma?

Answer 151

Proliferation of neoplastic plasma cells

Question 152

Most common primary malignant tumour of bone in adults

Answer 152

Multiple myeloma

Question 153

Treatment of multiple myeloma

Answer 153

Chemotherapy, bisphosphonates, radiation,s surgery for symptomatic lesions or impending fractures - debulking, internal fixation

Question 154

Diagnosis of multiple myeloma

Answer 154

- serum/urine immunoelectrophoresis (monoclonal gammopathy) | - CT-guided biopsy of lytic lesions at multiple bony sites

Question 155

Radiographic findings of multiple myeloma

Answer 155

Multiple, "punched-out" well-demarcated lesions, no surrounding sclerosis, marked bone expansion

Question 156

Signs and symptoms of multiple myeloma

Answer 156

Localized bone pain (cardinal early symptom), compression/pathological fractures, renal failure, nephritis, high incidence of infections (e.g. pyelonephritis/pneumonia), systemic (weakness, weight loss, anorexia)

Question 157

Labs for multiple myeloma

Answer 157

Anemia, thrombocytopenia, increased ESR, hypercalcemia, increased Cr

Question 158

Risk factors for neck pain?

Answer 158

- Non-modifiable: F, middle-age, occupation, more children - Modifiable: smoking/enviro tobacco, inactivity, occupational. - Others: psychology (depression, anxiety, poor coping skills), trauma (TBI)

Question 159

Etiology of neck pain

Answer 159

- Mechanical – strain, whiplash, DDD, OA - Traumatic – fracture, ligamentous - Neurological – stenosis, radiculopathy, myelopathy - Inflammatory – RA, PMR - Infectious, malignant, metabolic

Question 160

Investigations for neck pain

Answer 160

- X-ray – In the absence of red flags - imaging is not necessary in patients with mild acute or chronic neck pain that does not limit or interrupt daily activities, does not affect performance of occupation, and is easily ignored when distracted - MRI - should be performed urgently in patients suspected of having an infection, malignancy, or spinal cord compression - Infection: White blood cell (WBC) count, CRP, imaging (usually MRI or CT), and culture of infected tissue

Question 161

Treatment for neck pain

Answer 161

- Spinal Manipulation – short term evidence that it is helpful - Acupuncture – good for muscle based pain - Massage – superior to no treatment - Exercise Therapy – strong evidence - Surgery – Used for radiculopathy, NOT neck pain

Question 162

Questions to ask on history for neck pain

Answer 162

- OPQRST - changes in position, weight bearing, and time of day (eg, at night, when awakening), previous problems - Stiffness, numbness, paresthesias, weakness, concussion (WAD)

Question 163

Physical exam for neck pain

Answer 163

- Spinal examination: visible deformity, area of erythema, or vesicular rash, - Neuro: muscle strength, sensory, reflex and gait testing, and evaluation for upper motor neuron signs - Neck: range of motion (rotation and lateral flexion), palpation of the trapezius and paraspinal muscles

Question 164

Symptoms of C4 radiculopathy

Answer 164

Pain in the lower neck and trapezius area with paresthesias involving the lower neck and upper shoulder girdle

Question 165

Symptoms of C5 radiculopathy

Answer 165

- Pain in neck, shoulder, and dorsal forearm with paresthesias and numbness involving the dorsal arm - Weakness of deltoid, biceps, rotator cuff - Decrease in the biceps reflex

Question 166

Symptoms of C6 radiculopathy

Answer 166

- Pain in the trapezius ridge and tip of the shoulder, often radiating to the thumb and index finger, with paresthesias and numbness in the same areas - Weakness of the wrist extensors - Decreased brachioradialis reflexes

Question 167

Symptoms of C7 radiculopathy

Answer 167

- Pain, paresthesias, and numbness in the shoulder blade and axilla, radiating to the long and ring fingers - Weakness of triceps - Decreased triceps brachii reflex

Question 168

Red flags for neck pain?

Answer 168

- Neck pain associated with lower extremity weakness, gait or coordination difficulties, and/or bladder or bowel dysfunction - A shock-like paresthesia occurring with neck flexion (Lhermitte's sign) - Fever - Unexplained weight loss - Headache, vision changes - Anterior neck pain

Question 169

Definition of whiplash associated disorders?

Answer 169

Whiplash injury is defined as neck injury resulting from an acceleration-deceleration mechanism that causes sudden extension and flexion of the neck

Question 170

Symptoms of whiplash associated disorders?

Answer 170

- Neck pain and stiffness which may present immediately after the injury or may be delayed for several days - Associated WAD symptoms: tinnitus, headache, dizziness, memory loss, TMJ pain.

Question 171

Classification of whiplash associated disorders?

Answer 171

- Grade 0: no complaints about neck, no physical signs. Treat: reassure. - Grade 1: pain/stiffness or tenderness only, full ROM (no physical signs). Treat: pain relief. - Grade 2: pain/stiffness or tenderness, MSK SIGNS on physical exam (ROM, tenderness). Treat: prompt investigation. - Grade 3: neck complaints with NEURO SIGNS on physical exam – reflexes, weakness, numbness. Treat: prompt investigation. - Grade 4: neck complaint with fracture/dislocation. Treat: prompt investigation.

Question 172

What should you include in the description of fractures?

Answer 172

- Site - Open vs. closed - Length - Articular - Rotation - Translation - Alignment/Angulation - Type e.g. Salter-Harris, etc.

Question 173

Indications for open reduction for fractures?

Answer 173

"NO CAST" - Non-union - Open fracture - Neurovascular Compromise - Displaced intra-Articular fracture - Salter-Harris 3,4,5 - PolyTrauma

Question 174

Definition of open fractures?

Answer 174

Communication between fracture site and external surface of skin – increased risk of osteomyelitis

Question 175

Management of open fractures?

Answer 175

- Remove gross debris, irrigate, cover with sterile dressing - formal irrigation and debridement often done in the OR - Control bleeding with pressure (no clamping) - Splint - Antibiotics (1st generation cephalosporin and aminoglycoside) and tetanus prophylaxis - Standard of care is to secure definitive surgical management within 6h

Question 176

MOA of anterior shoulder dislocation?

Answer 176

Abducted arm is externally rotated/hyperextended; Blow to posterior shoulder

Question 177

Symptoms of anterior shoulder dislocation?

Answer 177

Pain, arm slightly abducted and externally rotated with inability to internally rotate

Question 178

Shoulder exam findings for anterior shoulder dislocation?

Answer 178

- “Squared off” shoulder - Positive apprehension test - Positive relocation test - Positive sulcus sign

Question 179

What is a Hill-Sachs lesion

Answer 179

Compression fracture of posterior humeral head due to forceful impaction of an anteriorly dislocated humeral head against the glenoid rim

Question 180

What is a bony bankart lesion?

Answer 180

Avulsion of the anterior glenoid labrum (with attached bone fragments) from the glenoid rim

Question 181

Treatment of anterior shoulder dislocation?

Answer 181

- Closed reduction with IV sedation and muscle relaxation - Traction-countertraction: assistant stabilizes torso with a folded sheet wrapped across the chest while the surgeon applies gentle steady traction

Question 182

What should be done on neurovascular exam for anterior shoulder dislocation?

Answer 182

- Axillary nerve: sensory patch over deltoid and deltoid contraction - Musculocutaneous nerve: sensory patch on lateral forearm and biceps contraction

Question 183

MOA of posterior shoulder dislocation?

Answer 183

- Adducted, internally rotated, flexed arm FOOSH | - 3 Es (epileptic seizure, EtOH, electrocution)

Question 184

Symptoms of posterior shoulder dislocation?

Answer 184

Pain, arm is held in adduction and internal rotation; external rotation is blocked

Question 185

Shoulder exam findings for posterior shoulder dislocation?

Answer 185

- Anterior shoulder flattening, prominent coracoid, palpable mass posterior to shoulder - Positive posterior apprehension (“jerk”) test

Question 186

Treatment of posterior shoulder dislocation?

Answer 186

- Closed reduction with sedation and muscle relaxation Inferior traction on a flexed elbow with pressure on the back of the humeral head - Obtain post-reduction x-rays - Check post-reduction NVS - Sling in abduction and external rotation x 3 wk, followed by shoulder rehabilitation (dynamic stabilizer strengthening)

Question 187

What is the posterior apprehension (“jerk”) test?

Answer 187

With patient supine, flex elbow 90° and adduct, internally rotate the arm while applying a posterior force to the shoulder; patient will “jerk” back with the sensation of subluxation

Question 188

MOA for acromioclavicular joint pathology

Answer 188

Fall onto shoulder with adducted arm or direct trauma to point of shoulder

Question 189

Clinical features of acromioclavicular joint pathology

Answer 189

- Pain with adduction of shoulder and/or palpation over AC joint - Palpable step deformity between distal clavicle and acromion (with dislocation) i.e. piano key sign - Limited ROM

Question 190

Indication for operative treatment for acromioclavicular joint pathology

Answer 190

Rockwood Class IV-VI (III if labourer or high level athlete)

Question 191

Non-operative treatment for acromioclavicular joint pathology

Answer 191

Sling 1-3 wk, ice, analgesia, early ROM and rehabilitation

Question 192

MOA for clavicle fracture?

Answer 192

Fall on shoulder (87%), direct trauma to clavicle (7%), FOOSH (6%)

Question 193

Clinical features of clavicle fracture?

Answer 193

- Pain and tenting of skin | - Arm is clasped to chest to splint shoulder and prevent movement

Question 194

Treatment for medial and middle-third clavicle fractures

Answer 194

- for nondisplaced fractures, simple sling x 1-2 wk prn - early ROM and strengthening once pain subsides - if fracture is shortened >2 cm, consider ORIF

Question 195

Treatment for distal-third clavicle fractures

Answer 195

- undisplaced (with ligaments intact): sling x 1-2 wk | - displaced (CC ligament injury): ORIF

Question 196

MOA of proximal humeral fractures?

Answer 196

- young: high energy trauma (MVC) | - elderly: FOOSH from standing height in osteoporotic individuals

Question 197

Clinical features of proximal humeral fractures?

Answer 197

Proximal humeral tenderness, deformity with severe fracture, swelling, painful ROM - – do PASSIVE ROM initially to avoid rotator cuff pulling on ligaments, bruising extends down arm and chest

Question 198

Investigations for proximal humeral fractures?

Answer 198

- Test axillary nerve function (deltoid contraction and skin over deltoid) - X-rays: AP, trans-scapular, and axillary views of the shoulder are essential - CT scan: to evaluate for articular involvement and fracture displacement

Question 199

Classification system used for proximal humeral fractures?

Answer 199

Neer classification is based on 4 fracture locations or 'parts'

Question 200

MOA of humeral shaft fractures?

Answer 200

High energy: direct blows/MVC (especially young); low energy: FOOSH, twisting injuries, metastases (in elderly)

Question 201

Non-operative treatment of proximal humeral fractures?

Answer 201

- nondisplaced and minimally displaced (85% of patients): broad arm sling immobilization, begin ROM within 14 d to prevent stiffness - most displaced fractures in low-demand elderly patients

Question 202

Operative treatment of proximal humeral fractures?

Answer 202

- ORIF (anatomic neck fractures, displaced, associated irreducible glenohumeral joint dislocation) - hemiarthroplasty or reverse TSA may be necessary, especially in elderly

Question 203

Clinical features of humeral shaft fractures?

Answer 203

- Pain, swelling, weakness ± shortening, motion/crepitus at fracture site - Must test radial nerve function before and after treatment: look for drop wrist, sensory impairment in dorsum of hand

Question 204

Investigations for humeral shaft fractures?

Answer 204

X-ray: AP and lateral views of the humerus, including the shoulder and elbow joints

Question 205

Indications for operative treatment for humeral shaft fractures?

Answer 205

“NOCAST” ,pathological fracture, “floating elbow” (simultaneous unstable humeral and forearm fractures)

Question 206

Non-operative treatment for humeral shaft fractures?

Answer 206

- ± reduction; can accept deformity due to compensatory ROM of shoulder - hanging cast (weight of arm in cast provides traction across fracture site) with collar and cuff sling immobilization until swelling subsides, then Sarmiento functional brace, followed by ROM

Question 207

Operative treatment for humeral shaft fractures?

Answer 207

ORIF: plating (most common), IM rod insertion, external fixation

Question 208

MOA for distal humeral fracture?

Answer 208

- young: high energy trauma (MVC) | - elderly: FOOSH

Question 209

Clinical features of distal humeral fracture?

Answer 209

- Elbow pain and swelling | - Assess brachial artery

Question 210

Investigations for distal humeral fracture?

Answer 210

- X-ray: AP and lateral views of the humerus and elbow - CT scan: helpful when suspecting shear fracture of capitulum or trochlea - Assess NVS: radial, ulnar and median nerve

Question 211

What population receives non-operative treatment for distal humeral fracture?

Answer 211

Pediatric patients only

Question 212

Operative indications for distal humeral fracture?

Answer 212

Displaced, supracondylar, bicolumnar

Question 213

Non-operative treatment for distal humeral fracture?

Answer 213

Cast immobilization (in supination for lateral condyle fracture; pronation for medial condyle fractures)

Question 214

Operative treatment for distal humeral fracture?

Answer 214

- closed reduction and percutaneous pinning (children); ORIF; total elbow arthroplasty (bicolumnar in elderly) - adult fractures are almost always treated operatively due to risk of elbow stiffness with non-operative

Question 215

For distal humeral fracture, goal is to restore ROM to ___

Answer 215

30-130° flexion

Question 216

Subclass of distal humerus fracture: extra-articular, fracture proximal to capitulum and trochlea, usually transverse

Answer 216

Supracondylar fracture

Question 217

Clinical features of supracondylar fracture?

Answer 217

- pain, swelling, point tenderness | - neurovascular injury: median and radial nerves, radial artery

Question 218

Xray findings for supracondylar fracture?

Answer 218

- Disruption of anterior humeral line suggests supracondylar fracture - Fat pad sign: a sign of effusion and can be indicative of occult fracture

Question 219

Non-operative treatment for supracondylar fracture?

Answer 219

Nondisplaced (pediatric): long arm plaster slab in 90 flexion x 3 wk

Question 220

Operative indications for supracondylar fracture?

Answer 220

Displaced >50%, vascular injury, open fracture

Question 221

Operative treatment for supracondylar fracture?

Answer 221

- requires percutaneous pinning followed by limb cast with elbow flexed <90 - in adults, ORIF is necessary

Question 222

Investigations for supracondylar fracture?

Answer 222

- X-ray: AP and lateral views of the elbow | - Assess NVS: median and radial nerves, radial artery

Question 223

MOA of anterior hip dislocations?

Answer 223

Posteriorly directed blow to knee with hip widely abducted

Question 224

Clinical features of anterior hip dislocations?

Answer 224

Shortened, abducted, externally rotated limb

Question 225

Treatment of anterior hip dislocations?

Answer 225

- closed reduction under conscious sedation/GA | - post-reduction CT to assess joint congruity

Question 226

Most frequent type of hip dislocation

Answer 226

Posterior hip dislocation

Question 227

MOA of posterior hip dislocation

Answer 227

Severe force to knee with hip flexed and adducted e.g. knee into dashboard in MVC

Question 228

Clinical features of posterior hip dislocation

Answer 228

Shortened, adducted, internally rotated limb

Question 229

Treatment of posterior hip dislocation

Answer 229

- closed reduction under conscious sedation/GA only if no associated femoral neck fracture or ipsilateral displacement - ORIF if unstable, intra-articular fragments, or posterior wall fracture - post-reduction CT to assess joint congruity and fractures - if reduction is unstable, put in traction x 4-6 wk

Question 230

Types of hip fractures?

Answer 230

- Femoral Neck (Subcapital) - Intertrochanteric - Subtrochanteric

Question 231

Treatment of femoral neck fractures

Answer 231

- Garden I, II: internal fixation to prevent displacement - Garden III, IV: young: ORIF, old: hemi-/total hip arthroplasty - The goal is rigid early fixation to allow early weight bearing and mobilization – want them standing and walking within first 24 hours after injury

Question 232

Treatment of intertrochanteric femoral fractures

Answer 232

Closed reduction under fluoroscopy then dynamic hip screw or IM nail

Question 233

Treatment of subtrochanteric femoral fractures

Answer 233

Closed/open under fluoroscopy, then plate fixation or IM nail

Question 234

Complications of hip fractures?

Answer 234

DVT, non-union, AVN, dislocation

Question 235

MOA for ACL tear?

Answer 235

Usually non-contact, decel, landing from jump or pivot/changing direction

Question 236

History of ACL tear?

Answer 236

- Audible “pop” - Immediate swelling - Knee “giving way” - Inability to continue activity

Question 237

Physical exam findings of ACL tear?

Answer 237

- Effusion (hemarthrosis) - Posterolateral joint line tenderness - Positive anterior drawer - Positive Lachmann - Pivot shift - Test for MCL, meniscal injuries

Question 238

What injury is commonly associated with ACL tears acutely and chronically?

Answer 238

Concurrent lateral meniscal tear is common acutely, but medial chronically

Question 239

What is a second fracture?

Answer 239

Avulsion fracture (small) of the lateral surface of the lateral tibial condyle. Usually results from excessive internal rotation and varus stress resulting in increased tension on the lateral capsular ligament of the knee joint. Pathognomonic for ACL tear.

Question 240

Treatment of ACL tear

Answer 240

- Stable knee with minimal functional impairment: immobilization 2-4 wk with early ROM and strengthening - High demand lifestyle: ligament reconstruction

Question 241

MOA of PCL tear?

Answer 241

Sudden posterior displacement of tibia when knee is flexed or hyperextended (e.g. dashboard MVC injury)

Question 242

History for PCL tear?

Answer 242

- Audible “pop” - Immediate swelling - Pain with push off - Cannot descend stairs

Question 243

Physical exam findings for PCL tear?

Answer 243

- Effusion (hemarthrosis) - Anteromedial joint line tenderness - Positive posterior drawer - Reverse pivot shift - Other ligamentous, bony injuries

Question 244

Treatment of PCL tear?

Answer 244

- Unstable knee or young person/high-demand lifestyle: ligament reconstruction - Most people can cope with being PCL deficient.

Question 245

MOA for MCL tear?

Answer 245

Valgus force to knee = MCL tear

Question 246

MOA for LCL tear?

Answer 246

Varus force to knee = LCL tear

Question 247

O’Donoghue’s unhappy triad

Answer 247

- ACL rupture - MCL rupture - Meniscal damage (medial and/or lateral)

Question 248

Clinical features of MCL + LCL tears?

Answer 248

- Swelling/effusion - If there is large effusion present, think about ACL tear because MCL tears don’t usually cause effusions. - Tenderness above and below joint line medially (MCL) or laterally (LCL) - Joint laxity with varus or valgus force to knee - laxity with endpoint suggests partial tear - laxity with no endpoint suggests a complete tear - Test for other injuries (e.g. O’Donoghue’s unhappy triad), common peroneal nerve injury

Question 249

Treatment of MCL + LCL tears?

Answer 249

- Partial tear: immobilization x 2-4 wk with early ROM and strengthening - Complete tear: immobilization at 30° flexion

Question 250

MOA of meniscal tear

Answer 250

Twisting force on knee when it is partially flexed (e.g. stepping down and turning)

Question 251

Lateral meniscal tear is associated with ___ injury but medial ones are associated with ___ tear.

Answer 251

Acute ACL | Chronic ACL

Question 252

Clinical features of meniscal tear

Answer 252

- Immediate pain, difficulty weight-bearing, instability, and clicking - Increased pain with squatting and/or twisting - Effusion (hemarthrosis) with insidious onset (24-48h after injury) - Joint line tenderness medially or laterally - Locking of knee (if portion of meniscus mechanically obstructing extension)

Question 253

Non-operative indication for meniscal tear?

Answer 253

Not locked

Question 254

Non-operative treatment for meniscal tear?

Answer 254

ROM and strengthening (NSAIDs)

Question 255

Operative indication for meniscal tear?

Answer 255

- Locked (i.e. patient cannot fully extend knee, due to mechanical block) or failed non-operative treatment - Meniscal repair is done if tear is peripheral with good vascular supply, is a longitudinal tear and 1-4 cm in length

Question 256

Operative treatment for meniscal tear?

Answer 256

Arthroscopic repair/partial meniscectomy - Partial meniscectomy is done with tears not amenable to repair (complex, degenerative, radial)

Question 257

MOA for quad/patellar tendon rupture?

Answer 257

- Sudden forceful contraction of quadriceps during an attempt to stop - More common in obese patients and those with pre-existing degenerative changes in tendon

Question 258

Risk factors for quad/patellar tendon rupture?

Answer 258

DM, SLE, RA, steroid use, renal failure on dialysis

Question 259

Clinical features for quad/patellar tendon rupture?

Answer 259

- Inability to extend knee or weight-bear - Possible audible "pop" - Patella in lower or higher position with palpable gap above or below patella, respectively - May have an effusion

Question 260

Investigations for quad/patellar tendon rupture?

Answer 260

- Perform straight leg raise (unable to with complete rupture) - Knee X-ray to rule out patellar fracture, MRI to distinguish between complete and partial tears - Lateral view: patella alta with patella tendon rupture, patella baja (infera) with quadriceps tendon rupture

Question 261

Non-operative indications for quad/patellar tendon rupture?

Answer 261

Incomplete tears with preserved extension of knee

Question 262

Non-operative treatment for quad/patellar tendon rupture?

Answer 262

Immobilization in brace

Question 263

Operative indications for quad/patellar tendon rupture?

Answer 263

Complete ruptures with loss of extensor mechanism

Question 264

Clinical features of knee dislocation?

Answer 264

- Classified by relation of tibia with respect to femur: anterior, posterior, lateral, medial, rotary - knee instability - effusion - pain - ischemic limb

Question 265

Investigations for knee dislocation?

Answer 265

1. X-ray: AP, lateral, and skyline views of the knee - associated radiographic findings include tibial plateau fracture dislocations, proximal fibular fractures, and avulsion of fibular head 2. Assessment of NVS: - ABI (abnormal if <0.9) - arteriogram or CT angiogram if abnormal vascular exam (such as abnormal pedal pulses) - assessment of peroneal nerve, tibial artery, and ligamentous injuries

Question 266

Treatment for knee dislocation?

Answer 266

- Urgent closed reduction - Assessment of peroneal nerve, tibial artery, and ligamentous injuries - Emergent operative repair if vascular injury, open fracture or dislocation, irreducible dislocation, compartment syndrome - Knee immobilization x6-8wk

Question 267

MOA for patellar fracture

Answer 267

Direct blow to the patella: fall, MVC (dashboard)

Question 268

Clinical features for patellar fracture

Answer 268

- Marked tenderness - Inability to extend knee or straight leg raise - Proximal displacement of patella - Patellar deformity - ± effusion/hemarthrosis

Question 269

Investigations for patellar fracture

Answer 269

- X-rays: AP, lateral, skyline - Do not confuse with bipartite patella: congenitally unfused ossification centres with smooth margins on X-ray at superolateral corner

Question 270

Non-operative indications for patellar fracture

Answer 270

Non-displaced (step-off <2-3 mm and fracture gap <1-4 mm)

Question 271

Operative indications for patellar fracture

Answer 271

Displaced (>2 mm), comminuted, disrupted extensor mechanism

Question 272

Non-operative treatment for patellar fracture

Answer 272

- Straight leg immobilization 1-4wk with hinged knee brace, weight bearing as tolerated - Progress in flexion after 2-3wk - physiotherapy: quadriceps strengthening when pain has subsided

Question 273

Operative treatment for patellar fracture

Answer 273

ORIF, if comminuted may require partial/complete patellectomy

Question 274

MOA for patellar dislocation

Answer 274

- Usually a non-contact twisting injury - Lateral displacement of patella after contraction of quadriceps at the start of knee flexion in an almost straight knee joint

Question 275

Risk factors for patellar dislocation

Answer 275

- young, female - obesity - high-riding patella (patella alta) - genu valgus - Q-angle (quadriceps angle) >20 - Shallow intercondylar groove - weak vastus medialis - tight lateral retinaculum - ligamentous laxity (Ehlers-Danlos)

Question 276

MOA of tibial shaft fracture

Answer 276

- Low energy pattern: torsional injury | - High energy: including MVC, falls, sporting injuries

Question 277

Clinical features of patellar dislocation

Answer 277

- Knee catches or gives way with walking - Severe pain, tenderness anteromedially from rupture of capsule - Weak knee extension or inability to extend leg unless patella reduced - Positive patellar apprehension test - increased Q-angle - J-sign

Question 278

What is the J sign

Answer 278

Associated with patella alta; increased lateral translation in extension which pops into the patellofemoal groove as the patella engages the trochlea early in flexion

Question 279

Non-operative treatment for patellar dislocation?

Answer 279

- NSAIDs, activity modification, and physical therapy - short-term immobilization for comfort, then 6 wk controlled motion - progressive weight bearing and isometric quadriceps strengthening – try to strengthen VMO (vastus medius obliquus)

Question 280

Operative treatment for patellar dislocation?

Answer 280

Surgical tightening of medial capsule and release of lateral retinaculum, possible tibial tuberosity transfer, or proximal tibial osteotomy

Question 281

Operative indications for patellar dislocation?

Answer 281

If recurrent or if loose bodies present

Question 282

Clinical features of tibial shaft fracture

Answer 282

- Pain, inability to weight bear - Open vs. closed - Neurovascular compromise

Question 283

Investigations of tibial shaft fracture

Answer 283

- X-ray: AP and lateral views: full length, plus knee and ankle

Question 284

Non-operative indications for tibial shaft fracture

Answer 284

Closed and minimally displaced or adequate closed reduction

Question 285

Operative indications for tibial shaft fracture

Answer 285

Displaced or open

Question 286

Non-operative treatment for tibial shaft fracture

Answer 286

Long leg cast x8-12wk, functional brace after

Question 287

Operative treatment for tibial shaft fracture

Answer 287

- if displaced and closed: ORIF with IM nail, plate and screws, or external fixator - if open: antibiotics, I&D, external fixation or IM nail, and vascularized coverage of soft tissue defects

Question 288

Operative indications for ankle fracture

Answer 288

- any fracture-dislocation: restore vascularity, minimize articular injury, reduce pain and skin pressure - most of type B, and all of type C - trimalleolar (medial, posterior, lateral) fractures - talar tilt >10 - medial clear space on X-ray greater than superior clear space - open fracture/open joint injury

Question 289

Operative treatment for ankle fracture

Answer 289

ORIF

Question 290

Non-operative indications for ankle fracture

Answer 290

Non-displaced, no history of dislocation

Question 291

Non-operative treatment for ankle fracture

Answer 291

Below knee cast, NWB, or aircast WBAT

Question 292

Treatment for microscopic tear (Grade I) ankle ligamentous injuries?

Answer 292

- rest, ice, compression, elevation

Question 293

Treatment for macroscopic tear (Grade II) ankle ligamentous injuries?

Answer 293

- strap ankle in dorsiflexion and eversion x 4-6 wk | - physiotherapy: strengthening and proprioceptive retraining

Question 294

Treatment for complete tear (Grade III) ankle ligamentous injuries?

Answer 294

- below knee walking cast x 4-6 wk - physiotherapy: strengthening and proprioceptive retraining - surgical intervention may be required if chronic symptomatic instability develops

Question 295

Inversion ankle ligamentous injury, >90% of all ankle sprains

Answer 295

Lateral ligament complex

Question 296

Eversion ankle ligamentous injury?

Answer 296

Medial ligament complex (deltoid ligament)

Question 297

Clinical features of lateral ligament ankle complex injury

Answer 297

- Swelling and tenderness anterior to lateral malleolus - ++ ecchymosis - Positive ankle anterior drawer

Question 298

In Weber's classification of ankle fractures what is Type A?

Answer 298

Below level of talar dome very distal fibula, usually transverse

Question 299

In Weber's classification of ankle fractures what is Type B?

Answer 299

At level of joint, widening of distal tibiofibular joint indicating syndesmotic injury, medial malleolus may be fractured

Question 300

In Weber's classification of ankle fractures what is Type C?

Answer 300

Above the level of ankle joint, tibiofibular syndesmosis is disrupted, medial malleolus fracture or deltoid ligament injury, worst stability

Question 301

MOA for talar fractures

Answer 301

Axial loading or hyperdorsiflexion (MVC, fall from height)

Question 302

Investigations for talar fractures

Answer 302

AP, lateral, Canale view (XRay), CT (better characterize the fracture), MRI (define AVN extent)

Question 303

Non-operative indications for talar fractures

Answer 303

Non-displaced

Question 304

Non-operative treatment for talar fractures

Answer 304

NWB, below-knee cast x 6wks

Question 305

Operative indications for talar fractures

Answer 305

Displaced

Question 306

High risk for __ with displaced talar fractures

Answer 306

AVN

Question 307

Operative treatment for talar fractures

Answer 307

ORIF - high rate of nonunion, AVN – neck fracture: ORIF

Question 308

Most common tarsal fracture

Answer 308

Calcaneal fracture

Question 309

MOA for calcaneal fracture

Answer 309

High energy axial loading (fall from height onto heels)

Question 310

Symptoms and signs for calcaneal fracture

Answer 310

Marked swelling, bruising on heel/sole – wider, shortened, flatter heel if viewed from behind, varus heel

Question 311

What is a Haglund deformity?

Answer 311

Enlargement of the posterior-superior tuberosity of the calcaneus

Question 312

Investigations for calcaneal fracture

Answer 312

AP, lateral, oblique foot (mandatory view); can also assess with Broden view, Harris view, or AP ankle – loss of Bohler’s angle, CT (gold standard to assess intra-articular extension)

Question 313

Treatment of calcaneal fracture

Answer 313

Reduction, NWB cast x 3 months with early ROM and strengthening; avoid wound complications, restore articular congruity and normal calcaneal width and height – maximum functional recovery may take longer than 12 months

Question 314

Definition of psoriatic arthritis?

Answer 314

Arthritic inflammation associated with psoriasis

Question 315

Signs and symptoms of psoriatic arthritis?

Answer 315

1. Dermatologic - well-demarcated erythematous plaques with silvery scale - nail involvement: pitting, transverse or longitudinal ridging, discolouration, subungual hyperkeratosis, onycholysis, and oil drops o musculoskeletal - other findings: dactylitis, enthesopathy, morning stiffness >30 min (50%) 2. Ophthalmic - conjunctivitis, iritis (anterior uveitis) 3. Cardiac and respiratory (late findings) - aortic insufficiency - apical lung fibrosis 4. Neurologic - cauda equina syndrome 5. Radiologic - floating syndesmophytes - pencil-in-cup appearance at IP joints - osteolysis, periostitis

Question 316

5 subtypes of psoriatic arthritis?

Answer 316

- Sacroiliitis, Spondylitis (usually older, male patients) - Asymmetric oligoarthritis (70%) - DIP arthritis - Symmetrical polyarthritis (similar to RA) - Arthritis mutilans (destructive and deforming small joint polyarthritis)

Question 317

Treatment of psoriatic arthritis?

Answer 317

- Treat skin lesions (e.g. steroid cream, salicylic and/or retinoic acid, tar, UV light) - NSAIDs or IA steroids (benefit should be seen within a few weeks, should not be the sole therapy >3mo) - DMARDs to minimize erosive disease (use early in peripheral joint involvement) - Biologic therapies include anti-TNF agents, anti-IL-17 (secukinumab), and anti-IL-12/23 (ustekinumab)

Question 318

What are the symptoms of systemic lupus erythematosus (SLE)?

Answer 318

SOAP BRAIN MD: include fever, rash (malar rash - erythematous, raised lesions with sparing of nasal folds, discoid rash subcutaneous forms→ annular plaques), photosensitivity (rash lasts weeks), alopecia (discoid lupus → hyperkeratosis plugs up hair follicle), oral/nasal ulceration, arthritis (small joint, inflammatory, polyarthritis – need 2 or more joints, not erosive), serositis, renal disease, hematological disease (cytopenia, anemia, lymphopenia, leukopenia, ITP), neurological disease (seizures, psychosis)

Question 319

How many SOAP BRAIN MD symptoms do you need for SLE diagnosis?

Answer 319

4

Question 320

Investigations for SLE?

Answer 320

Anti-nuclear Abs (ANA) positive in 99% SLE patients (but 5% normal), anti-ds DNA and anti-Smith (Sm) antibodies more specific to SLE

Question 321

Is SLE more common in females or males?

Answer 321

More likely in females (estrogen)

Question 322

Treatment of SLE?

Answer 322

Respond to DMARDs similar to RA; anti-malarial medications*, topical + systemic corticosteroids, immunosuppressive/cytotoxic agents if severe (cyclophosphamide), supportive care (antihypertensives, Ca channel blockers for Raynaud’s, photoprotection)

Question 323

Risk factors for RA?

Answer 323

Age >50, female (3:1), first degree relative with rheumatoid arthritis, smoking, low level of education

Question 324

Pathophysiology of RA

Answer 324

Destruction mediated process - proteases produced by synovial cells destroy proteoglycans in the articular cartilage - irreversible damage 6 months to 1 year from disease onset

Question 325

Definition of RA

Answer 325

Rheumatoid arthritis is a systemic inflammatory disease characterized by symmetric, relapsing, or chronic destructive synovitis. There may also be multisystem involvement.

Question 326

Triggers of RA?

Answer 326

Viruses (Parvovirus, EBV, HTLV), super antigens (from bacteria/viruses), auto antigens (QKRAA)

Question 327

Epidemiology of RA?

Answer 327

The condition is more common in women, with onset between ages 30 and 60 years.

Question 328

Classic sites for RA?

Answer 328

1. HANDS - MCP, PIP, and wrist joints most commonly involved - DIP SPARING 2. FEET - MTP joint involved 3. LEGS knees (80%), ankles (80%), hips (50%) 4. ARMS shoulders (60%), elbows (50%), acromioclavicular (50%) 5. ATLANTOAXIAL (C1, C2) subluxation may lead to spinal cord (cervical myelopathy with hand weakness/numbness) 6. TEMPOROMANDIBULAR (30%)

Question 329

Symptoms of RA?

Answer 329

- History of pain and stiffness in multiple joints with initial symptoms predominantly at 1 location or a few scattered sites and fatigue, weight loss, and myalgia. - The most common presentation is the insidious development of arthralgia, arthritis, malaise, and fatigue over several weeks, however, an acute polyarticular development over a few days is possible. - Morning stiffness (gelling) usually lasting > 30 minutes is a common feature and is usually relieved with activity and warmth.

Question 330

Physical exam findings of hands and feet of RA

Answer 330

1. Hands: Deformities include Boutonniere, swan neck, Z (thumb), ulnar deviation at MCP joint, volar subluxation of proximal phalanx from MCP head, radial deviation of carpus, compression of the carpal bones, subluxation at the wrist 2. Feet: Deformities include valgus of the ankle and hindfoot, pes planus, forefoot varus and hallux valgus, cock up toes

Question 331

Xray findings of RA?

Answer 331

X rays of affected joints (particularly hands, knees, and ankles; soft tissue swelling, periarticular osteopenia, narrowing of joint space, marginal bony erosions, subluxation, joint destruction, bony ankylosis) – good to have a baseline for follow-up

Question 332

Investigations for RA?

Answer 332

- LABS: CBCD, lytes, urea, Cr, AST, ALT, ALP, bilirubin, ESR, CRP, RF (IgM), anti CCP (most specific), ANA, urinalysis - Patients frequently anemic, inflammatory markers may be normal, high platelets - INFECTIOUS WORKUP serologies (Parvovirus, HBV, HCV, EBV, CMV, Borrelia burgdorferi)

Question 333

Prior to starting DMARDs for RA what should you screen for?

Answer 333

Screen for hepatitis B, hepatitis C, and latent tuberculosis infections, give all age-/risk-appropriate immunizations

Question 334

___ are recommended as first-line therapy for RA and should be started early in the diseases course.

Answer 334

DMARDs - In most patients, begin DMARD therapy with either methotrexate 10-25 mg once weekly or leflunomide 10-20 mg/day orally.

Question 335

Adjunct pharmacological therapy for RA

Answer 335

- Nonsteroidal anti-inflammatory drugs (NSAIDs) orally or topically may help to control symptoms but are not disease modifying. - Corticosteroids orally or intra-articularly may be used for symptom control. Early low-dose steroids added to DMARD therapy may be used to reduce joint destruction and increase clinical remission rates.

Question 336

Nonpharmacologic patient management of RA

Answer 336

Patient education, exercise, physical and occupational therapies, and cognitive therapies.

Question 337

Predisposing factors to septic joint?

Answer 337

Advance age, Pre-existing joint disease, Recent joint surgery or injection, Skin or soft tissue infection, Intravenous drug use, Indwelling catheters, Immunosuppression (including diabetes)

Question 338

Most common mechanism of infect for septic joint?

Answer 338

Most commonly, septic arthritis arises via hematogenous seeding of the synovial membrane (which has no limiting basement membrane, thus allowing organisms to enter the joint space). Septic arthritis due to hematogenous seeding is most commonly caused by organisms with propensity to adhere to the synovial tissues (such as Staphylococcus aureus)

Question 339

Most common bacteria of septic joint?

Answer 339

S. aureus (including methicillin-resistant S. aureus) is the most common cause of septic arthritis in adults.

Question 340

Signs and symptoms of septic joint?

Answer 340

- Joint pain, swelling, warmth, and restricted movement occur in 80 percent of patients with septic arthritis. Most patients are febrile - The knee is involved in more than 50 percent of cases; wrists, ankles, and hips are also affected commonly

Question 341

The diagnosis of septic arthritis should be suspected in patients with

Answer 341

Acute onset of at least one swollen, painful joint, with or without relevant risk factors (including bacteremia, pre-existing joint disease, and immunosuppression).

Question 342

The diagnosis of septic arthritis is made based on synovial fluid analysis and culture:

Answer 342

- Cell count = >50,000 - Polys = >75% - Crystals = none - Gm stain and culture = positive

Question 343

what should the synovial fluid be sent for if suspecting septic joint?

Answer 343

Synovial fluid should be sent for Gram stain, bacterial culture, white blood cell count with differential, and assessment for crystals (monosodium urate and calcium pyrophosphate crystal deposition crystals) with a polarizing microscope.

Question 344

Treatment of septic joint

Answer 344

- Joint drainage — In general, patients with septic arthritis warrant joint drainage, since this condition represents a closed abscess. Approaches to joint drainage for management of septic arthritis in adults include needle aspiration, arthroscopic drainage, or arthrotomy (open surgical drainage). Treat till at least 2 negative cultures - Antibiotics - If the initial Gram stain of synovial fluid demonstrates gram-positive cocci, empiric treatment with vancomycin (15 to 20 mg/kg/dose intravenously [IV] every 8 to 12 hours) should be administered for 2 weeks

Question 345

Most common sites of gout?

Answer 345

1st MTP – podagra, feet, ankles, knees also common

Question 346

Risk factors for gout?

Answer 346

Male, obese, >40yo, HTN, EtOH, family Hx, renal failure, leukemia (tumor lysis syndrome), metabolic abnormalities

Question 347

Triggers for gout?

Answer 347

- Fluid shifts (diuretics, low dose ASA, illness, surgery) - High cell turnover/chemo - Diets high in meat/seafood - EtOH - Starting or stopping allopurinol (do not give/take away in acute phase)

Question 348

Stages of gout?

Answer 348

1. Asymptomatic hyperuricemia (elevated uric acid, no gouty attacks) 2. Acute gouty arthritis 3. Intercritical gout (asymp between flares) 4. Chronic tophaceous gout

Question 349

Presentation of gout

Answer 349

Recurrent acute mono/oligoarthritis. Extreme pain, red, hot and swollen, typically subsides in 3-10 d.

Question 350

During a gout flare should the blood be hyperuricemic

Answer 350

In blood, there is serum hyperuricemia that elevations postmenopause in women and after puberty with men however NOT DURING A FLARE (since all of it goes into the joints). During a flare the blood test should be normal and when not, it should be hyperuricemic!

Question 351

Pathophysiology of gout?

Answer 351

IMBALANCE decreased urate excretion and/or increased urate production - uric acid crystals deposited in joints, skin, and kidneys - arthritis, tophi, and renal failure.

Question 352

Diagnosis of gout?

Answer 352

- Arthrocentesis (aspiration): Urate crystals microscopy/polarized light - negatively birefringent, needle shaped. MUST rule out septic arthritis (infected joints can have crystals present) - Radiology: soft tissue swelling, if chronic→ tophi + bone erosions “punched out”, rocker bottom shoes

Question 353

Treatment of gout?

Answer 353

- Intra-articular steroid injection - Methylprednisolone 100 150 mg intra articularly once - Colchicine - microtubule interference to prevent inflammation. 1.0-1.2mg initially then 0.6 mg PO daily BID during acute attack. Risk for diarrhea - NSAIDs early careful if risk factors – renal insufficiency, GI bleeds - Only start allopurinol if >3flares/yr, tophi, joint destruction, renal stones, or tumour lysis syndrome. Continue allopurinol if already on it prior to acute attack

Question 354

Definition of pseudogout?

Answer 354

Calcium pyrophosphate dihydrate crystals (CPPD) deposited in cartilage, positive birefringent, rhomboid shape

Question 355

Clinical presentation of pseudogout?

Answer 355

Acute arthritis, swelling, pain, erythema, swollen tender joint, can mimic gout but affects large joints

Question 356

Diagnosis of pseudogout?

Answer 356

- Aspiration - rhomboid shaped and +vely birefringent (unlike gout which is needle shaped and –vely bifringent). - Radiology: Suspect if chondrocalcinosis on Xray

Question 357

Risk factors of pseudogout?

Answer 357

Metabolic (hemochromatosis, hyperparathyroidism, low PO4/Mg, Wilson’s), pre-existing OA, renal failure/dialysis, idiopathic (most common)

Question 358

Treatment of pseudogout?

Answer 358

NSAIDs, local steroid injection, rarely oral steroids. RICE (rest, ice, compression, elevation). NOTHING PREVENTS CPPD (unlike Allopurinol in gout)

Question 359

Definition of OA

Answer 359

Mechanical joint disease and the most common joint disease

Question 360

Epidemiology of OA

Answer 360

F=M <50yo, F>M slightly in >50yo (generalized nodal osteoarthritis in perimenopausal women)

Question 361

Clinical features of OA

Answer 361

- Any time of day, minimal morning stiffness <30mins, worse with activity – improved with rest, - Deformity, bony enlargement, crepitus, limitation of movement, peri-articular muscle atrophy

Question 362

Risk factors for primary OA

Answer 362

Excess weight, excess wear (due to occupation or sports), genetics (multigenic, 65% heritability, esp. in hands)

Question 363

Risk factors for secondary OA

Answer 363

Other joint disorders (rheumatoid arthritis, hemophilia, crystal, congenital dysplasias); injury (traumatic, post surgical); metabolic diseases

Question 364

Distribution of primary OA

Answer 364

Hands (DIPs=Heberdan, PIPs=Bouchard; 1st CMCs (thumb squaring), scaphotrapezial joint of wrist), hips, knees, 1st MTPs, cervical and lumbar spine

Question 365

Distribution of secondary OA

Answer 365

Atypical sites/presentations (wrists, elbows, shoulders, ankles, MCPs) and young patients

Question 366

Physical exam findings of OA

Answer 366

- Bony enlargement/overgrowth - Malalignment in 50% (varus > valgus knee; angulation of fingers) - Muscle atrophy (esp. quad mms with knee) - Limited ROM active and passive (articular problem), tenderness, crepitus - +/- effusion

Question 367

Radiographic findings of OA

Answer 367

Joint space narrowing, subchondral sclerosis, subchondral cysts, osteophytes

Question 368

Conservative treatment of OA

Answer 368

Patient education, weight loss, low impact exercise, walking aids (canes)

Question 369

Pharmacological treatment of OA

Answer 369

1st line: acetaminophen up to 4 g/d (OA is not an inflammatory disorder) 2nd line: NSAIDs (COX-2 selective) in low doses for short durations 3rd line: combination analgesics (e.g. acetaminophen and codeine) Other pharmacological adjuncts: - intra-articular corticosteroid or hyaluronic acid injections - topical NSAIDS (diclofenac) - capsaicin cream - oral glucosamine

Question 370

When should surgery be considered for OA?

Answer 370

Consider if persistent significant pain and functional impairment despite optimal pharmacotherapy

Question 371

Surgical treatment for OA?

Answer 371

Debridement, osteotomy, total joint arthroplasty

Question 372

Red flags of non-articular musculoskeletal pain?

Answer 372

- Recent trauma - Pain at rest - Pain awakening them at night - New medications - An immuno-compromised state - A history of cancer - Constitutional symptoms - Vascular or neurological symptoms.

Question 373

Questions to ask on history for non-articular musculoskeletal pain?

Answer 373

- HPI: OPQRST - Recent trauma, repetitive strain, infective or constitiutional sx - Risk factors for DVT

Question 374

Ddx of localized non-articular musculoskeletal pain <6 weeks?

Answer 374

- Trauma (dislocation or torn tendon) - Infections (necrotizing fascitis, cellulitis, or osteomyelitis) - Vascular compromise (DVT, compartment syndrome, or sickle cell disease)

Question 375

Ddx of localized non-articular musculoskeletal pain >6 weeks?

Answer 375

- Mechanical strains (bursitis or tendinitis) - Vascular disease (peripheral vascular disease or intermittent claudication) - Neoplastic

Question 376

Ddx of diffuse non-articular musculoskeletal pain?

Answer 376

- Viral illness - Drug reaction - Polymyalgia rheumatica (PMR) - Fibromyalgia

Question 377

Definition of myofascial pain syndrome?

Answer 377

A non-inflammatory disorder of musculoskeletal origin, associated with pain and muscle stiffness, characterized by the presence of hyperirritable palpable nodules in the skeletal muscle fibers, which are termed myofascial trigger points (knots)

Question 378

Diagnosis of myofascial pain syndrome?

Answer 378

- Essential - taut band palpable, spot tenderness of a nodule, painful limit to full stretch - Confirmatory – local twitch response, Pain or altered sensation (in expected distribution) on compression of tender nodule, Imaging of a local twitch response induced by needle penetration of a tender nodule.

Question 379

Risk factors of myofascial pain syndrome?

Answer 379

- Ergonomic factors – head, shoulder posture, repetitive activities – more of a mechanical disorder than a neurological one - Structural factors – scoliosis (Scoliosis - certain muscles have to compensate and can lead to imbalance and increased risk of MPS), pelvic asymmetry, arthritis of joints, trauma - Medical factors

Question 380

Pathophysiology of myofascial pain syndrome?

Answer 380

Trauma – taut band (chronically contracted fibres within muscle, with more concentrated areas of contraction in nodules)– latent MTrP (palpable, no symptoms) either goes to spontaneous recovery, active MTrP (palpable, tender and symptoms) or persistence without progression

Question 381

Common sites for myofascial pain syndrome?

Answer 381

- Sternocleidomastoid – might cause referred pain in the forehead, occipital area (therefore could headaches is on differential) - Extremities, lower back

Question 382

Treatment for myofascial pain syndrome?

Answer 382

- Active – education, exercise, postural/mechanical/ergonomic modifications. Focus is on active treatments. - Passive – pharmacologic (NSAIDs for short-term or flare, TCA, SSRI for chronic pain modulators), trigger point injections – saline, local anesthetic, corticosteroid, botox, CAM therapies (acupuncture, massage)

Question 383

Mechanism of injury for muscle strains

Answer 383

Occurs when muscle is elongated passively or activated while being stretched. Eccentric exercise highest. Sudden acceleration or deceleration.

Question 384

Common sites of muscle strains

Answer 384

Hamstring (biceps femoris most common) and Quads (rectus femoris most commonly affected) and Gastrocnemius. All cross 2 joints.

Question 385

What is a grade 1 muscle strain

Answer 385

Small amount of fibers are stretched – pain but usually full strength, not much swelling. Muscle is very vascular so when you have significant muscle injury, there is bruising and swelling

Question 386

What is a grade 2 muscle strain

Answer 386

Partial tear – pain, swelling and weakness. Most of them are actually across the whole muscle area but there still is continuity remaining across the tear

Question 387

What is a grade 3 muscle strain

Answer 387

Complete tear, usually occurs at the musculotendinous junction. Pain, swelling, loss of function. If you're tight, especially when you're growing, muscles elongate but tendons stay tight

Question 388

Treatment of muscle strain

Answer 388

RICE – rest, ice, compression, elevation. Short term NSAIDS. Worsens if exercise resumed prematurely even though exercise decreases symptoms. If in hamstring, takes 6-9months to recover.

Question 389

Contributing factors of muscle strain

Answer 389

Inadequate warm-up, muscle imbalance, excessive muscle tightness, insufficient joint ROM, inadequate recovery

Question 390

Mechanism of injury of muscle contusion

Answer 390

Direct blow to a muscle “charley horse”. Bleeding from muscle damage

Question 391

Mechanism of injury of tendon ruptures

Answer 391

Sudden loading of the musculotendinous unit (usually in older people) can cause this as can weak/poorly vascularized tendons from a history of tendonitis. As tendons get further away from muscle, they have less blood supply and this makes them vulnerable as we age or with repeated injuries.

Question 392

Complications of muscle contusion

Answer 392

Trying to avoid compartment syndrome and myositis ossificans – occurs when a hematoma calcifies. Consider when not improving or devastating stiffness or shortening of muscle. If it happens posteriorly, there are some neurovascular complications that can occur

Question 393

Treatment of muscle contusion

Answer 393

PRICE, codeine, followed by gentle ROM and strengthening. NSAID use can decrease platelets early on and this can cause more bleeding. Heat can also cause more bleeding.

Question 394

Mechanism of injury for biceps brachialis ruptures?

Answer 394

Proximal (lifting weights) or distal (sudden loading).

Question 395

Clinical presentation of proximal biceps brachialis rupture

Answer 395

Proximal pain, tenderness, bunching up of muscle belly, weak ARM flexion (not much elbow flexion) and supination. So people don’t have much dysfunction with elbow flexion but you can break their supination

Question 396

Clinical presentation of distal biceps brachialis rupture

Answer 396

Distal pain, tenderness, palpable defect, weak supination. Hook test – can’t hook tendon with index finger. Usually the next day they get significant bruising and swelling and it becomes more obvious

Question 397

Treatment of proximal biceps brachialis rupture

Answer 397

Treat conservatively with physio. Only need surgery if professional athlete

Question 398

Treatment of distal biceps brachialis rupture

Answer 398

Treat OPERATIVELY – up to 50% loss of flexion/supination strength with cons. All biceps muscles have a common insertion distally so NEEDS repair

Question 399

Mechanism of injury for knee extensor rupture?

Answer 399

Sudden forceful contraction of quadriceps during an attempt to stop

Question 400

Risk factors for knee extensor rupture?

Answer 400

More common in obese patients and those with pre-existing degenerative changes in tendon - DM, SLE, RA, steroid use, renal failure on dialysis

Question 401

Clinical features of knee extensor rupture?

Answer 401

- Inability to extend knee or weight-bear - Possible audible "pop" - Patella in lower or higher position with palpable gap above or below patella, respectively - May have an effusion

Question 402

Investigations for knee extensor rupture?

Answer 402

- Straight Leg Raise – unable to with complete rupture - Knee X-ray to rule out patellar fracture, MRI to distinguish between complete and partial tears - Lateral view: patella alta with patella tendon rupture, patella baja (infera) with quadriceps tendon rupture

Question 403

Non-operative indications for knee extensor rupture?

Answer 403

Incomplete tears with preserved extension of knee

Question 404

Operative indications for knee extensor rupture?

Answer 404

Complete ruptures with loss of extensor mechanism

Question 405

Operative treatment for knee extensor rupture?

Answer 405

- Early surgical repair: better outcomes compared with delayed repair - Begin active knee flexion, passive extension 2 weeks post op. Physio start @ 6wks usually - Delayed repair complicated by quadriceps contracture, patella migration, and adhesions

Question 406

Non-operative treatment for knee extensor rupture?

Answer 406

Immobilization in brace

Question 407

Mechanism of injury of achilles tendon rupture

Answer 407

- Loading activity, stop-and-go sports (e.g.squash, tennis, basketball) - Secondary to chronic tendonitis, steroid injection

Question 408

Clinical features of achilles tendon rupture

Answer 408

- Audible pop, sudden pain with push-off movement - Pain or inability to plantar flex - Palpable gap - Apprehensive toe off when walking - Weak plantar flexion strength - Thompson test: with patient prone, squeeze calf, normal response is plantar flexion. No passive plantarflexion is positive test = ruptured tendon

Question 409

Investigations for achilles tendon rupture

Answer 409

X-ray (to rule out other pathology), U/S or MRI (for partial vs. complete ruptures)

Question 410

Non-operative indication for achilles tendon rupture

Answer 410

Low athletic demand (new level 1 evidence suggests no difference in re-rupture rates between operative and non-operative management with functional rehabilitation)

Question 411

Non-operative treatment for achilles tendon rupture

Answer 411

Initial cast foot in plantar flexion (to relax tendon), with functional rehabilitation x 8-12 wk

Question 412

Operative treatment for achilles tendon rupture

Answer 412

Surgical repair, followed by functional rehabilitation x 8-12 wk

Question 413

Operative indication for achilles tendon rupture

Answer 413

High athletic demand

Question 414

Mechanism of injury of tendonitis

Answer 414

Thought to be from a repetitive mechanical load with a subsequent inflammatory response. Histopathological studies in the 1990s showed more degenerative tendon changes rather than inflammation.

Question 415

Clinical presentation of tendonitis

Answer 415

- Pain, stiffness, and crepitus with ROM - Thickened tendon, palpable bump - More frequently the morning after exercise, with use

Question 416

Treatment of tendonitis

Answer 416

- Rest, NSAIDs, shoe wear modification (orthotics, open back shoes) - Heel sleeves and pads are mainstay of non-operative treatment - Gentle gastrocnemius-soleus stretching, eccentric training with physical therapy, deep tissue calf massage - Shockwave therapy in chronic tendonitis - Do not inject steroids (risk of tendon rupture)

Question 417

Definition of plantar fasciitis?

Answer 417

- Inflammation of plantar aponeurosis at calcaneal origin | - Common in athletes (especially runners, dancers)

Question 418

What is plantar fasciitis associated with?

Answer 418

Associated with obesity, DM, seronegative and seropositive arthritis

Question 419

Mechanism of injury of plantar fasciitis

Answer 419

Repetitive strain injury causing microtears and inflammation of plantar fascia

Question 420

Clinical features of plantar fasciitis

Answer 420

- Insidious onset of heel pain, pain when getting out of bed, and stiffness - Intense pain when walking from rest that subsides as patient continues to walk, worse at end of day with prolonged standing - Swelling, tenderness over sole - Greatest at medial calcaneal tubercle and 1-2 cm distal along plantar fascia - Pain with toe dorsiflexion (stretches fascia)

Question 421

Investigations for plantar fasciitis

Answer 421

- Plain radiographs to rule out fractures - Often see bony exostoses (heel spurs) at insertion of fascia into medial calcaneal tubercle - Spur is secondary to inflammation, not the cause of pain

Question 422

Definition of ligament injury

Answer 422

Ligaments increase the stability of a joint. Load is transferred in the direction of the ligaments from bone to bone. Injuries occur when a ligament is under excessive load

Question 423

What is grade 1 ligament injury

Answer 423

Mild sprain, few fibres torn, stretching of the ATFL. Clinically, ligament is stable (no laxity) with solid endpoint

Question 424

What is grade 2 ligament injury

Answer 424

Moderate sprain, incomplete tear. Clinically, swelling is present and there is increased laxity with an end point

Question 425

Non-operative treatment of plantar fasciitis

Answer 425

- pain control and stretching programs are first-line - rest, ice, NSAIDs, steroid injection - physiotherapy: Achilles tendon and plantar fascia stretching, extracorporeal shockwave therapy - orthotics with heel cup - to counteract pronation and disperse heel strike forces

Question 426

Operative treatment of plantar fasciitis

Answer 426

- very rarely indicated | - when performed, includes endoscopic release of fascia

Question 427

What is grade 3 ligament injury

Answer 427

Severe sprain with complete tear. Grade 3 injuries can have less pain as sensory fibers are completely divided.

Question 428

Investigations for ligament injury

Answer 428

X-Ray (check for bony injury – Ottawa Ankle Rules), MRI (usually not needed unless not improving)

Question 429

Treatment for ligament injury

Answer 429

Restore stability to joint. Grade 1 + 2 = physio and brace and RICE (rest, ice, compression, elevation) but Grade 3 = usually conservative but may brace or do surgery.

Question 430

Etiology of bursitis?

Answer 430

- Overuse injuries in the bursa are common - Excessive shearing or compressive forces - Traumatic

Question 431

Common areas of bursitis?

Answer 431

Subacromial bursa, greater trochanteric bursa, prepatellar bursitis, Iliotibial band friction syndrome

Question 432

Treatment of bursitis?

Answer 432

- Removal of irritating loads, lengthening, strengthening - Reduction of inflammation - PRICE, NSAIDs - Corticosteroid injections – under ultrasound guidance - Traumatic – pre-patellar - aspiration and compression to avoid increased swelling