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R9 - Emergency Medicine > Orthopedics/Rheumatology > Flashcards

Orthopedics/Rheumatology Flashcards

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1
Q

gout etiology and dx

A
  • inflamm monoarticular arthritis caused by crystalization of monosodium urate in jnts
  • precipitants: cold, dehydration, stress, excessive ETOH, starvation
    • 90% are men >30yo
  • dx: joint aspiration and synovial fluid analysis (needle shaped and neg birefringent urate crystals), gram stain and cx, serum uric acid is NOT helpful, XR (punched out erosions
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2
Q

Four stages of gout

A
    1. asx hyperuricemia
    1. acute gouty attacks (peak onset 40-60yo) - initial attack = one jnt of lower extremity, sudden onset exquisite pain, most often first MT joint, pain and redness, swelling, warmth, +/- fever
    1. intercritical gout - sxatic period after initial attack, attacks become polyarticular and increase in severity
    1. chronic tophaceous gout (ppl with poorly controlled gout for >10-30ys), tophi (urate crystals surrounded by giant cells in inflammatory rxn, cause deformity and destruction of hard and soft tissue, common locations = extensor surfaces of forearms, elbows, knees, achilles tendon, pinna of external ear
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3
Q

tx of gout

A
  • do not tx asx hyperuricemia
  • avoid secondary causes of hyperuricemia (meds that increase uric acid, obesity, ETOH, dietary purines
  • acute gout: bed rest, NSAIDs (indomethacin), colchicine, steroids if not responding or intolerant to NSAID/colchicine
  • prophylaxis: must have 2-3 attacks before initiating prophylactic tx → NSAIDs x 3-6mos, uricosuric drugs (probenecid, sulfinpyrazone), allopurinol (not for acute exacerbations, watch for SJS)
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4
Q

bursitis

A
  • inflam of bursa, caused by trauma or overuse
  • common sites: subacromial, subdeltoid, trochanteric, ischial, iliopsoas, olecranon, prepatellar, suprapatellar
  • sxs: pain, swelling, tnederness for weeks
  • tx: prevent precipitating factors, rest, heat, time, NSAIDs steroid injctions only if no infxn, abx if unclear cause (aspirate)
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5
Q

pes anserine bursitis

A
  • pes anserine = gracilis, sartorius, and the semitendinosus, which meet at the medial tibia below the knee jnt and above MCL and medial fem condyle
  • sxs: anterior medial knee pain (common in obese women with OA of knee, runners, various overuse syndromes), ant pain below jnt line, focal swelling over the bursa, increased TTP
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6
Q

Prepatellar bursitis (housemaid’s knee, nun’s knee, carpet layer’s knee)

A
  • pain anterior to patella, inflamed through repetitive kneeling on hard surfaces
  • pain mild and restricted ROM from swelling
  • presents as effusion over lower pole of patella, tender to palpation with bursal margins palpable
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7
Q

olecranon bursitis

A
  • caused by acute injury or repetitive trauma to olecranon bursa, less frequehntly caused by break in the skin, leading to septic cause (S. aureus)
  • sxs: swelling over olecranon process (MC finding), mildly painful (acute) or painless (chronic), ROM preserved
  • dx: no imaging indicated
  • tx: avoid continued trauma to elbow and ace wrap for compression, NSAIDs and warm compresses, surg removal of bursa if nonresponsive to tx
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8
Q

tendinitis and tenosynovitis

A
  • common cause: overuse, arthritides
  • commonly appears at: rotator cuff, supraspinatus, biceps, flexor carpi ulnaris, flexor carpi radialis, flexor digitorum, patella, hip adductor, achilles
  • sxs: commonly occur together, pain w/ mvmt, swelling, impaired fn, may resolve over several weeks, but recurrence is common
  • tx: rest, ice, stretching, NSAIDs, steroid injection and anesthesia alongside tendon (avoid intratendon injection dt rupture), excise scar tissue and necrotic debris
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9
Q

subacromial or bicipital tendiitis

A
  • produced by friction on the tendon of the long head of the biceps as it passes through bicipetal groove
  • sxs: ant shoulder pain radiates down biceps into forearm, worse with overhead activity
  • signs: limited abduction and external rotation, bicipital groove TTP
  • dx; yergason supination sign + = pain with resisted supination of forearm with elbow at 90 degrees
  • tx: young - repair surgically; older - surg not necessary if little to no pain
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10
Q

achilles tendinitis

A
  • pain attributed to inflammation and degeneration of Achiles tendon and attachment to calcaneus, common in runners and pts who suddenly increase their activity level or ppl who improperly stretch or train
  • sxs: gradual onset during activity or after activity, pain on post calf, TTP over post calf above calcaneus (pain on passive dorsiflexion and resisted plantar flexion), ankle ROM and strength = normal
  • dx: thompson test to rule out rupture
    • XR: soft-tissue shadow and calcifications along tendon and insertion
    • MRI: hypertrophy of Achilles tendon to rule out rupture
  • tx: NSAIDs, PT for stretching and strength exercises; if left untreated, may progress to rupture of achilles
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11
Q

sprain vs strain

A
  • strain = inj to bone-tendon unit at myotendinous jn or the muscle itself
  • sprain = involves collagenous tissue, such as ligaments or tendons (90% ankle injuries result from inversion and plantar flexion
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12
Q

acute low back strain

A
  • minor, self-limiting, usually associated w/ heavy lifting, fall, prolonged uncomfortable postures
  • signs: paraspinous muscle spasms
  • tx: short duration bed rest, apply ice, heat and massage, NSAIDs during first few days, muscle relaxants (cyclobenzaprine, carisoprodol, metaxalone, and diazepams), wt bearing resumed
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13
Q

ankle sprain/strain

A
  • one of the MC sports-related injuries; 85% from inversion inj., mostly involves lateral ligaments (anterior talofibular ligament)
  • sxs: hear a “pop”, ecchymosis and tenderness of lateral ankle
  • dx: XR to r/o fx, especially if unable to bear wt or TTP over bone (often not required to guide mngmt)
  • tx: if able to bear weight (RICE) - compressive wrapping, icing, early mobilization, supervised PT (isometric exercises), once 90% strength, active isotonic as well as isokinetic exercise
    • if unable to bear weight - crutches 48-72hrs, brace for support, posterior splint
    • refer to PT
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14
Q

Ottawa ankle rules

A
  • X-rays needed if pain in the malleolar zone (anterior crook of the ankle) and 1 or more of the following:
    • tenderness over the lateral malleolus
    • tenderness over the medial malleolus
    • inability to bear wt for 4 steps both immediately postinjury and in the ED
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15
Q

chronic low back pain

A
  • Nerve root irritation: pain in back, radiates down leg
  • musculoskeletal: localized area of tenderness
  • sciatica: pain in distribution of sciatic nerve (buttcok, post thight, posterolateral aspect of leg around lat. malleolus to dorsum of foot and entire sole)
  • sacroiliac jnt: unilateral low back and buttock pain, worse with standing in one position
  • spinal stenosis: pain in elderly, increased with walking, relieved by leaning forward
  • dx on all: XR of spine (nontraumatic)
    • Red flags: fever, wt loss, morning stiffness, hx of IV or steroid use, trauma, hx of cancer, saddle anesthesia, loss of anal sphincter tone, major motor wkness
    • CT: shows bony stenosis and lateral nerve root entrapment
    • MRI: identifies cord pathology, neral tumors, stenosis, herniated discs, infxns
  • tx: short term relative rest w/ support under knees and neck, progressive ambulation as tolerated, fitness program (postural exercises - McKenzie exercises)
    • if no improvement x 6wk → bone scan, CT, MRI, or EMG
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16
Q

Sensory exam spinal cord levels

A
  • C6 (thumb), C7 (middle finger), C8 (pinky)
  • T4 (nipple), T10 (umbilicus)
  • L3 (upper thigh), L4 (anterior knee, medial maleolus), L5 (dorsal aspect of foot, lateral malleolus), S1 (heel)
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17
Q

cauda equina

A
  • lesions below spinal cord termination at the L1 vertebral level (L4-L5)
  • sxs: flaccid, areflexic asymmetric paraparesis (bilateral lower extremity weakness), bowel and bladder incontinence, sensory loss below L1 (saddle anesthesia), leg pain projected to perineum or thighs
  • dx: XR, MRI (preferred)
  • tx: emergent surgery
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18
Q

Herniated disk (lumbar) etiology, signs and sxs

A
  • MC: L5-S1; major cause of severe and chronic or recurrent low-back and leg pain
  • Mostly 30-40yo, sudden movment cuases weakened and frayed nucleus pulposus to prolapse and protrude through the annulus where they impinge on one or more nerve roots and cause sciatica or radicular pain
  • sxs: pain referral (sciatica), stiff or unnatural posture, weakness (plantar flexor and hamstring), reflex change (absent or diminished ankle jerk), paresthesias
  • signs: pain with straight leg raise and tenderness over lumbosacral joint and sciatic notch, discomfort walking on heels, drop foot (L5) and weakness with plantar flexion (S1)
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19
Q

Herniatted disk dx and tx

A
  • dx: straight leg raise with healthy leg (Lasegue maneuver) - flexion at hip, extension at knee - produces sciatic pain on contralateral side
    • MRI of lumbar spine - herniated nucleus pulposus (not needed unless persistent pain for weeks), CT with myelography
  • tx: MC lying supine with legs flexed at knees and hips, shoulders raised on pillows; NSAIDs or opioids for a few days, surgical decompression
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20
Q

osteomyelitis etiology and sxs

A
  • inflammation of bone, may be hematogenous, exogenous, surgical, true contagious spread, may be complicaiton from otitis externa or sinusitis, sickle cell, diabetic ulcers, stasis ulcers, and arterial leg ulcers
  • MCC: S aureus, Strep pyogenes, if puncture wound - psuedomonas aeruginosa
  • sxs: acute - worsening pain, swelling, tenderness, dec ROM
    • chronic - recurrent acute flare-ups of tender, warm, swollen areas with constitutional sxs (malaise, anorexia, fever, wt loss, night sweats) - duration = acute or chronic; site = spine, hip, otther; extent = size of defect; specify type of pt (infant, child, adult, or immunocomp)
    • fever, drainage (rare)
  • signs: pnt tenderness over vertebral bodies or spinous processes
21
Q

osteomyelitis dx and tx

A
  • Laboratory tests: CBC, CRP/ESR - elevated if chronic; XR = periosteal new bone (involucrum) - signs lag behind sxs and changes take 7-10d; 2x blood cx or open bone bx (most accurate); US for acute cases; MRI shows changes before XR or bone scan; good for pts with diabetes with sxs related to foot
  • tx:
    • acute: 1wk IV FQ, 2wk PO FQ, adjunt (hyperbaric O2, neg pressure wound tx - vacuum-assisted closure)
    • chronic: minimum 4wk-24mo IV and PO abx, PO rifampin and bactrim
    • immobilization and surgical debridement may be required (indefinite oral abx if known or presumed infected hardware)
    • surgery: remove sequestra, sinus tract, infected bone, scar tissue
    • MC tumor associated with chronic osteomyelitis: squamous cell carcinoma
22
Q

septic arthritis etiology, sxs, signs

A
  • 45% older than 65, also common in immunosuppressed and elderly, 56% males, direct inoculation or contagious spread from periarticular tissue, via blood-stream (MC): intra-articular injections
  • MCC: S aureus
  • sxs: acute onset jnt pain (75%), pain superimposed on chronic pain, previous hx of jnt dz of trauma, recent cath or IVDU, extra-articular sxs, fever (40-60%), low grade <102F, chills, impaired ROM
  • signs: MC involved jnt: knee, hip, shoulder ankle, wrists, swelling (90%), erythema, warmth, tenderness, effusion with marked limited ROM
23
Q

septic arthritis dx and tx

A
  • dx: synovial fluid for analysis (r/o infxn or crystals), typically yellow, green, most septic jnts have WBC >50,000, >75% PMNs, low synovial glucose
    • if + crystals, gram stain - treat for crystal arthritis
    • if - crystals, treat pt for presumed infection even if - gram stain
    • send fluid for cx regardless of result
    • 2 sets of blood cx - ro bacteremia, ESR/CRP elevated, XR - periarticular soft tissue swelling - imaging not helpful
  • tx: drainage, abx, native jnt (IV cegtriaxone x 2wk or dicloxacillin), immobilization of jnt to control pain; no mvmnt x3d, PT, arhtrotomy and arthrocentesis often required
    • poor prognosis = age >60, infxn of hip or shoulder, underlying RA, + synovial fluid cx after 7d of tx, delay of 7d in starting tx
24
Q

gonococcal septic arthritis

A
  • MC pathogen among young, sexually active: Neisseria gonorrhoeae (75%)
  • sxs: polyarticular, fever, multiple skin lesions (dermatitis) developing after gonococcal infxn from cervix, urethra, or pharynx
    • hands (most), knee, wrist, ankle, elbow
    • lesions: papular pustular, vesicular, nevrotic, may recur over several months
    • may recur over several mos
    • monoarticular, tenosynovitis, lesions, septic bursitis - olecranon or prepatellar bursae, swelling, pain
  • tx: add chlamydia tx: 2g azithromycin or 7d doxycycline twice weekly
25
Q

nongonococcal septic arthritis

A
  • S. aureus in adults and children >2, viridans, strep pneumo, GBS
  • GU infxn with chlamydia trachomatis
  • sxs: monoarticular; if >1 jnt, most likely s aureus
  • tx: IV linezolid + rifampin x4wk, especially for prosthetic jnt infxns where CoNS is suspected
26
Q

vertebral compression fracture

A
  • MC in elderly >60 with osteoporosis, thoracic spine: wedge compression fx; Lumbar: compression or burst fx
  • sxs: axial pain localized to fx level, dowager hump - loss of height, pts “back becomes rounded”, no neurologic dysfn and no radiation of pain
  • dx: XR, CT scan, DEXA = most useful
  • tx: key = prevention of osteoporosis
    • HRT if no hx of breast CA, VTE, or endometrial dz, calcitonin tx if HRT contrainidicated, bisphosphonates prevent osteoclastic resorption of bone, surgery (ant decompression and fusion) for neuro defs or significant compression
27
Q

Spondylolysis

A
  • congenital and probably genetic bony defect in the pars interarticularis of the lower lumbar vertebrae
  • MCC of persistent low back pain in adolescents, associated with sports related injuries, MOSTLY CHILDREN 5-7yo
  • affects cervical spine (c5-c6), caused by degen disc dz - nerve root irritation and canal narrowing
  • sxs:
    • cervical (neck and shoulder pain and spasms, fatigue, sleep disturb, radicular pain or muscle weakness)
    • lumbar (sensorimotor impairment and pain worse with standing and walking or exercising - unilateral low back aching pain, worse with hyperextension and twisting, better with flexion
  • dx: straight leg raise , XR (osteophytes and disc narrowing - scotty dog view shows defect), CT scan, bone scan
  • tx: rest, isomettric abd exercises, pelvic tilt, flexion exercises, NSAIDs, wtt reduction, lumbar epidural injections for sxatic relief, decomp and fusion for compressive sxs and decreased QOL - cervical collar, traction, pt, analgesics, ACDF in advanced dz
28
Q

spondylolisthesis

A
  • anterior displacement of one vertebral body in relation to the adjacent on
  • MCC: degenerative arthritis of the spine, in the usual bilateral form, small fractures at the pars interarticularis allows the vertebral body, pedicles, and superior articular facets to move anteriorly, leaving the posterior elements behind
  • sxs: dull, aching pain, neuro sxs more common, paresthesias and numbness, feeling of weakness in extremity, fingers or referred pain to shoulder, radiation down leg to buttocks or posterior thigh
  • dx: palpation of spinous processes: “step off” forward displacement of spinous process and exaggerated lordosis, meyerding system to stage
  • tx: try conservative tx i.e. spondylolysis
29
Q

costochondritis

A
  • tietze syndrome: <40, M = F; age >40 mostly F
  • sxs; anterior chest pain, sudden or gradual, sharply localized or radiates to arms or shoulders, worse with sneezing, cough, deep insp, or twisting, brief and darting, persistent dull ache
    • reproduced with palpation
  • dx: XR, bone scan, vitD, bx
  • tx: analgesics, anti-inflamm, local steroid injections
30
Q

soft tissue injuries

A
  • ottawa knee rules are less sensitive in children; use Pittsburgh rules too determine whether or not to obtain radiographs
  • MRI is 95% and 90% accurate in identifying ACL tears and meniscal injuries, respectively
  • pain . with varus or valgus stress is more suggestive of ligament damage than a meniscus tear
  • the MCL is the primary static stabilizer against valgus stress at the knee
  • the LCL is the primary static stabilizer against varus stress at the knee
  • the ACL is the primary statis stabilizer of the knee against anterior translation of the tibia with respect to the femur
  • the PCL is the primary static stabilizer of the knee against posterior translation of the tibia with respect to the femur
  • WB, NWB = wtt bearing or non-wt bearing
  • ligament injuries are graded as follows:
    • grade 1: stretching of the ligament with no detectable instability
    • grade 2: further stretching of the ligament with detectable instability, but with the fibers in continuity
    • grade 3: complete disruption of the ligament
31
Q

Nursemaid’s elbow (radial head subluxation)

A
  • mechanism of inj: fall onto dorsiflexed hand, MC fx of elbow in adults
  • nursemaid’s elbow: subluxation of the radial head in children is cuased by excessive longitudinal traction (MC before age 4, radial head slips anteriorly)
  • sxs: crying with any mvmt, holding arm at side, refuses to move arm)
  • signs: forearm extended and in pronation, no edema, deformity, or erythema, distal pulses and capillary refill normal)
  • dx: AP and lateral XR of elbow - displacement of posterior fat pad implies hemarthrosis, r/o fx in children
  • tx: subluxations can be reduced (hold affected arm above wrist and just below elbow, place the thumb of the proximal hand over radial head, while fully supinating and flexing forearm, apply direct posterior pressure)
32
Q

radial head fx

A
  • 33% of all elbow fx, mech = FOOSH with pronated forearm or with elbow slightly flexed, direct blow to lateral elbow
  • sxs: elbow pain, swelling and pain oon mvmt of the forearm
  • signs; elbow tender to palpation over radial head, just distal to lateral epicondyle
  • complications: loss of elbow motion
  • dx: AP and lat XR - elbow jnt effusion (sail sign and/or posterior fat pad)
    • Mason classification:
      • type 1: nondisplaced, no mech obstruction to mvmt
      • type 2: displaced >2mm or angulation >30
      • type 3: comminuted
      • type 4: associated elbow dislocation
  • tx: type 1 - no ortho referral, posterior split or sling for up to 1wk; type 2-4 - ortho referral required
  • health maintenance; follow up XR in 2wk, elbow mvmt ASAP, normal fn by 2-3 mo
33
Q

Cubital tunnel syndrome

A
  • ulnar nerve entrapment at the elbow, 2nd most common after carpal tunnel
  • sxs: neuropathy in small and ring fingers: numbness, tingling, aching, burning, shooting, or stabbing pain (worse with elbow flexion or resting on work surface), allodynia 9normal touch is painful), weakness
  • signs: tenderness over ulnar nerve, elbow flexion sign: full elbow flexion x60s (wrists straight) worsens sx, abnl sensory exam, weakness and atrophy of interossei or thumb adductor muscles
  • dx: + tinel signs, wartenberg sign (pts have difficulty placing hand in pocket because small finger gets stuck outside - unopposed abductor digiti quinti muscle), froment sign (inability of thumb to oppose index finger - ask pt to hold piece of paper between thumb and index, if you can . pull paper away or thumb flexes at IP jnt to compensate for weakness = (+), nerve conduction studies of ulnar nerve
  • tx: activity modification (avoid elbow flexion of 90 deg or more), nighttime elbow splints (maintain elbow in 45 deg of flexion), surgical decomp (medial epicondylectomy)
34
Q

radial tunnel syndrome

A
  • radial nerve compressed in radial tunnel (proximal radius), usually occurs in combo with lat epicondylitis
  • sxs: pain over midportion of mobile wad (brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis), pain with resisted forearm supination
  • dx: long-finger extension test - worse with extension of the wrist and fingers, while the long finger is passively flexed by the examiner
  • tx: avoid forceful extension of the wrist and fingers, splint . the wrist in dorsiflexion while forearm is immobilized in supination, surgical decomp of radial nerve
35
Q

golfer’s elbow - medial epicondylitis

A
  • dt repetitive resisted motion of wrist flexion and pronation
  • sxs: pain over medial side of the elbow dt repeated wrist flexion and pronation (radiates into the forearm)
  • signs: tenderness distal to medial epicondyle, pain reproduced by resisting wrist flexion and pronation with elbow extended
  • dx: XR
  • tx: conservative (RICE, NSAIDs), splint, steroid injections, surgical release of flexor muscle at its origin
  • health maintenance; rest at least 1 mo, start PT once pain subsides
36
Q

tennis elbow (lateral epicondylitis)

A
  • tendon tears and necrosis at attach of the extensory carpi radialis brevis to lat humeral epicondyle and extensor carpi radialis longus origin along supracondylar line, related more to fibrosis and degen changes than acute inflamm
  • mech: overuse, hitting backhand with elbow flexed
  • sxs: pain after work or 4d supination againstt resistance (tennis, pulling weeds, carrying suitcases, using screwdriver, worse with shaking hands, opening doors, steering wheel), pain radiates into the dorsal aspect of forearm (occurs at night and rest)
  • signs: local tenderness, pain at distal third of humerus, weakness with grasp
  • dx: clinical - cozen test (extend elbow, extend the pt’s wrist against resistence), MRI to ro intraarticular pathology
  • tx: RICE, steroid injections, rest x1mo, surgical release of extensor aponeurosis
  • health maintenancec: once asxatic, begin rehab with isometric and concentric exercises, avoid forceful pinching or gripping, especially with wrist extension
37
Q

supracondylar humerus fxs

A
  • mech of injury = FOOSH with hyperextension of elbow
  • sxs: pain with minimal swelling
  • complications: Volkmann ischemic contractures, injury to all 3 nerves, varus (gunstock) or valgus deformities of elbow
  • dx: full neovasc exam, attention to brachial artery injuries looking for Volkmann ischemic contracture, AP and lateral views, in children obtain comparative views
  • tx: closed reduction or posterior splint application for displaced fxs in children, ORIF in adults
38
Q

Maisonneuve fx

A
  • combination of oblique proximal fibular fx, disruption of interosseous membrane and tibiofibular ligament distally, and a medial malleolar fx or tear of the deltoid ligament, produced by an external rotational force applied to the foot
  • sxs: ankle pain
  • signs: tenderness at medial and anterolateral ankle joint, tenderness at proximal fibula
  • tx: sugar-tong splint, surgery (most)
39
Q

Colle’s fx (distal radius)

A
  • MC injury of wrist, mech of injury = FOOSH
  • sxs: pain, swelling, palmar paresthesias from compression of median nerve
  • signs: swelling, tenderness at distal forearm
  • complications: median nerve compression, tendon damage, ulnar nerve contusion or compression, acute compartment syndrome
  • dx: AP and lateral XR, dorsal displacement of distal fragment, dorsal angulation of distal intact radius with radial shortening
  • tx: cast immob in most after ruduction (volar or sugar-tong splint) definitive tx depends on pt and fx
    • if good bone density and nondisplaced - functional brace
    • if minimally displaced or osteopenia - cast
    • any cast or splint should not obstruct motion of the lebow, MCP, or fingers
    • refer to ortho if unstable for internal fixation
  • Reassess at 3wk intervals
40
Q

Smith’s fx (reverse Colles’ fx)

A
  • break of the distal end of the radius, results from a blow or fall on the hyperflexed hand, results from a blow or fall onto a hyperflexed wrist
  • dx: AP and lateral XR - volar displacement of the distal fragment, volar angulaiton of the distal intact radius with radial shortening and comminuted
  • tx: similar to Colles’ - during reduction, pressure is applied in the opposite direction
41
Q

Carpal tunnel syndrome etiology and sxs

A
  • numbness and tingling and/or pain in median nerve distribution, F > M (3:1)
  • RF: obesity, female, comorbidity (DM, preg third trimester), RA, hypothyroid, genetics, aromatase inhib use
  • sxs: Pain - involvement of first 3 digits and radial half of the 4th digit, worse at night and awaken the pt from sleep, better by shaking or wringing hands or placing them under warm water; paresthesias - may radiate proximally into the forearm or above the elbow to shoulder, provoked by flexion or extension of the wrist or raising arms (driving, reading, typing, holding phone), weakness (less commonly)
  • signs: weakness of thumb adduction and opposition, thenar atrophy
42
Q

carpal tunnel dx and tx

A
  • clinical dx: phalen maneuver, tinel test (less sensitive than Phalen sign), wrist compression test (pressure over median nerve provokes sxs in 30s), nerve conduction study with EMG (excludes polyneuropathy, plexopathy, and radiculopathy, delayed distal latencies and slowed conduction velocity)
  • tx: mild - nocturnal wrist splinting in neutral position x1mo, steroid injections no more than 1 per wrist q6mo, oral steroids 20mg daily 10-14d, PT/OT or yoga
    • moderate-severe = electrodiagnostic studies, surgical decompression
43
Q

boxer fracture

A
  • fracture of metacarpal neck of 4th or 5th finger
  • cause: punch to another’s mouth, direct blow to the hand or fall, also known as street fighter’s fx
  • sxs: loss of prominence of knuckle with tenderness and pain
  • signs: decreased grip strength swelling
  • complications: decreased ROM
  • dx: AP and lat XR, oblique pronated XR of the 4th and 5th metacarpals - dorsal angulation dt interosseous muscle pull
  • tx: fxs with 25-30deg angulation = closed reduction with ulnar gutter x3-4 wk; surgical management
  • health maint: continue casting until sxatic resultion and clinical healing, 2wk postcasting XR
44
Q

dequervain tenosynovitis

A
  • inflammation of abductor pollicis longus and extensor polliciis brevis
  • cause: repetitive twisting of wrist
  • sxs: pain upon grasping with thumb (pinch)
  • signs: swelling and tenderness over radial styloid process
  • dx: finkelstein sign +
  • tx: forearm-based thumb spica splint, NSAIDs, Steroid injections
45
Q

gamekeeper’s thumb

A
  • aka skier’s thumb
  • sprain or tear of the ulnar collateral ligament of the thumb from forcible radial deviation, hx of sprained thumb or fall on the hand
  • sxs: pain over ulnar border of the MCP joint
  • signs: increased ligamentous laxity of the UCL; instability of the MCP and weakness of pinch (check radial deviation in full extension and 30deg of flexion), tenderness over the MCP joint, stener lesion
  • dx: XR of thumb - ro avulsion fx
  • tx: immobilization with a thumb spica cast x6wk for partial rupture, must wear at all times except for skin care, avoid any radial deviation when off; surgical repair for complete rupture
46
Q

trigger finger or trigger thumb (flexor tenosynovitis)

A
  • stenosing flexor tenosynovitis, hx of repetitive strain, more common in diabetic pts
  • sxs: pain referred to the PIP jnt, catching or snapping with forceful flexion (finger becomes locked in flexed position, worse in morning)
  • signs: tenderness over proximal tendon pulley at the MCP joint
  • tx: long-acting steroid injection into flexor sheath (insert proximal palmar crease for the index finger, insert at distal palmar crease for middle, ring, small fingers), surgical release of A1 pulley if refractory to steroids
47
Q

scaphoid (navicular0 fracture

A
  • mc fractured carpal bone, caused by forceful hyperextension of the wrist dt FOOSH with wrist dorsiflexed and radially deviated
  • a scaphoid fx is stable unless there is: displacement >1mm, scapholunate angulation >60deg, radiolunate angulation >15deg
  • sxs: painful wrist over anatomic snuffbox, paresthesias of the affected hand, swelling
  • signs: tenderness over anatomic snuffbox, swelling over the region, pain with radial deviation and axial compresison of thumb
  • complications; nonunion of fx, development of AVN (ground glass appearance of proximal pole or increased bone density)
  • dx: AP, lateral, and scaphoid views (PA view in ulnar deviation), bone scan or MRI
  • tx: nondisplaced or minimally displaced (<1mm) - short-arm thumb spica cast used for nondisplaced fxs, refer to ortho surg if displaced >1mm ORIF required
  • health maintenance: 2wk FU AP, lateral, oblique XR, rehab 3-6mo
48
Q

mallet finger, “baseball” or “drop” finger

A
  • traumatic disruption of the terminal slip of extensor tendon at the DIP caused by direct blow to the tip of the finger - sudden forceful flexion of distal phalanx, mC closed tendon injury of the finger
  • MC: middle aged man, middle finger
  • sxs: pain over the dorsum of DIP jnt (swelling, ecchymosis, deformity), inability to extend the DIP joint fully (flexed DIP at rest); hold the PIP in full extension and test active extension at the DIP (should be able to perform passively, assess neurovasc fn)
  • dx: XR AP, lateral, oblique - all mallet finger deformities (may see avulsion . or volar subluxation of distal phalanx)
  • tx: splinting with immobilization of DIP jnt in full extension or slight hyperextension (stack (mallet) splint x6-8wks), FU q1-2wk
49
Q
A

R9 - Emergency Medicine (12 decks)

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