PANCE_MSK 8% Flashcards
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“Rupture of the flexor digitorum superficialis tendon will result in the significant loss of what function?”
“flexion at the proximal interphalangeal joint”
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Median Nerve motor hand function testing
OK sign
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Median Nerve sensory hand function testing
two-point discrimination of tip of index finger
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Ulnar Nerve motor hand function testing
abduct index finger (scissors motion)
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Ulnar Nerve sensory hand function testing
two-point discrimination over tip of fifth finger
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Radial Nerve motor hand function testing
wrist and finger extension
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Radial Nerve sensory hand function testing
dorsal thumb-index finger web space
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what chronic disease is strongly associated with adhesive capsulitis of the shoulder?
DM
DM is strongly associated with capsulitis, w/ an esp high prevalence in pts with type 1 DM
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initial presentation of adhesive capsulitis
pain worse at night
increasing stiffness over 2-9 months
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intermediate presentation of adhesive capsulitis
stiffness and severe loss of motion
less pain (4-12 months)
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recovery stage of adhesive capsulitis
gradual return of range of motion (5-24 months)
(RR)
what is most commonly serially monitored in pts on disease-modifying antirheumatic drugs (DMARDs)?
CBC
“one of the most common DMARD adverse events is bone marrow suppression, especially with sulfasalazine, methotrexate, gold preparations, leflunomide, cyclosporine and azathioprine”
(RR)
common PE findings of RA
symmetrical soft, red, tender swelling in joints: MCP, PIP
bilateral ulnar deviation at MCP, boutonniere deformity, swan-neck deformity
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lab findings for RA
positive RF
or
anti-cyclic citrullinated peptide antibodies;
increased ESR
increased CRP
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what should be done for all first metatarsal fractures?
all first metatarsal fractures should receive ORTHOPEDIC REFERRAL
including first metatarsal fracture with 1 mm displacement
b/c the 1st metatarsal is important for wt-bearing and balance
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“what is a Jones fracture?”
“fracture of the proximal fifth metatarsal diaphysis”
(RR)
septic arthritis synovial fluid findings
high WBC (>50,000 WBC/microL)
a predominance of neutrophils
(>75% PMNS)
low glucose
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“What do the crystals seen in the synovial fluid of a patient with a diagnosis of pseudogout consist of?”
calcium pyrophosphate
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MC cause of septic arthritis (overall)
S. aureus
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“Which of the following clinical findings differentiates rheumatoid arthritis from osteoarthritis?
A) Involvement of the proximal interphalangeal joints
B) Polyarticular involvement
C) Presence of constitutional symptoms
D) Symmetric joint involvement”
C) PRESENCE OF CONSTITUTIONAL SYMPTOMS
(RR)
OA vs RA: which worsens with usage of joint? which may improve with usage of joint?
RA: may improve with usage of joint
OA: worsens with usage of joint
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what is a torus (buckle) fracture?
buckling of the cortex in the distal metaphysis (visible on XR), or incomplete fractures of the shaft of a long bone
usually from a FOOSH
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Treatment for torus (buckle) fracture?
removable splint for 3 weeks
(considered stable)
(RR)
“what is the MC type of physeal fracture in children?”
“Salter-Harris II fracture”
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“An 85-year-old woman suffered a vertebral fracture after falling in the shower. Her DEXA scan revealed a T-Score of -3. [What] is first-line therapy for her underlying bone disorder?”
BISPHOSPHONATES such as alendronate
or ibandronate, risedronate, zoledronic acid
(MOA is inhibition of bone resorption)
(RR)
RF for osteoporosis
F sex
advancing age
chronic steroid use
ETOH/tobacco use
FH of fragility fx
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Dx of osteoporosis is made by……
DEXA/DXA scan
T-score <= -2.5
or presence of a fragility fx
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second line tx of osteoporosis
SERMs
recombinant PTH
denosumab
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63 y/o F w/ hip pain after fall presents w/ leg internally rotated and shortened - most likely diagnosis = ?
posterior dislocation of hip
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MC hip dislocations
posterior > anterior
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treatment of scaphoid fracture
thumb spica splint
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“Which nerve provides innervation to the ventral surface of the thumb, index, and long finger?”
Median Nerve
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The shoulder is most vulnerable to an anterior glenohumeral dislocation in what position?
abduction
and
external rotation
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what is the more common shoulder dislocation?
ANTERIOR > posterior
posterior shoulder dislocations are less common and are associated with grand mal seizures and electric shock
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“What is the most common type of major joint dislocation?”
glenohumeral joint (shoulder)
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when do we do trephination?
when subungual hematoma is >50% of nail bed surface
or
smaller hematomas if they are painful (“all painful acute (24-48 hrs old) subungual hematomas should be drained, irrespective of size”)
(RR)
is distal phalanx fracture a contraindication to nail trephination?
no
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“A 68 y/o F w/ worsening right knee pain. She has had pain there for years, but it has gradually increased in the past couple of months. Acetaminophen is no longer effective. Plain films show joint space narrowing bilaterally with osteophytes on the right. Medical history is unremarkable, except for the presence of pyrosis, peptic ulcer disease ten years ago, and lifelong obesity. What treatment would you likely prescribe next?”
tramadol
(50-100 mg up to qid)
it is a mild narcotic
low abuse potential
won’t worsen pyrosis
(ibuprofen is contraindicated w/ her PUD hx)
(RR)
osteoporosis (osteoARTHRITIS?!?)
pharm treatment
- oral NSAIDs
- topical NSAIDs
- topical capsaicin
- duloxetine
- intra-articular corticosteroid injections
acetaminophen doesn’t show benefit
consider joint replacement
(RR)
17 y/o M in ER with L ankle injury - tender to palpation over ant tibiofibular ligament. Dorsiflexing while externally rotating the ankle reproduces his pain. XR shows diastasis b/w distal tibia and fibula, no fx. What is most likely dx?
syndesmotic ankle sprain (“or high ankle sprain”)
this is ligamentous injury to one or more of the distal tibiofibular syndesmosis
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management of syndesmotic ankle sprain (or high ankle sprain)
grade 1 immobilization
non wt-bearing
surgical management is a possibility (grades 2/3)
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what type of sprain most commonly occurs as result of external rotation on planted foot?
syndesmotic ankle sprain
(RR)
what is delta pressure for compartment syndrome?
= diastolic bp - direct pressure
<30 is consistent with acute compartment syndrome
(RR)
what compartment pressure measurement is associated with ischemic necrosis?
greater than 30-40 mm Hg
(CME)
“The classic triad of nongonoccoccal urethritis, conjunctivitis and arthritis is seen in ______”
REACTIVE ARTHRITIS
(CME)
“A 19 y/o F follows up from a hospital admit last week for pericarditis. Upon further questioning she admits to complaints of progressive fatigue, anorexia, weakness, painless oral ulcers and a photosensitive rash for 4 months. Diagnosis?”
SLE
(systemic lupus erythematosus)
(CME)
“Which of the following typically involves the DIP?
a) fibromyalgia
b) osteoarthritis
c) poymyositis
d) RA
e) SLE”
B) OSTEOARTHRITIS
(CME)
if a pt has sausage fingers, what dx should be considered as most likely?
psoriatic arthritis
(CME
“What condition has more pain than weakness in the shoulders and hips mixed with constitutional symptoms?
a) polymyositis
b) polymyalgia rheumatica
c) polyarteritis nodosa
d) granulomatosis with polyangitis
e) scleroderma
B) POLYMYALGIA RHEUMATICA
(CME)
“When polymyositis is accompanied by a characteristic “heliotrope rash” it is called ____________”
DERMATOMYOSITIS
(CME)
“what is the most common ligament injured with ankle sprains?”
“anterior talofibular ligament”
(CME)
“A 13 y/o girl c/o bilateral leg pain just below the knees for 6 weeks. She states the pain is worse after playing basketball. Exam shows tender and prominent tibial tubercles bilaterally. Diagnosis?”
“Osgood-Schlatter disease”
(CME)
“What PE test is most sensitive for an anterior cruciate ligament tear?”
“Lachman’s test”
(CME)
What cruciate ligament is the most commonly injured?
anterior cruciate ligament
(CME)
“Which tendon reflex is innervated by C5 and C6 nerve roots?
a) biceps
b) brachioradialis
c) triceps
d) a & b
e) all of the above”
D) A & B
BICEPS AND BRACHIORADIALIS
(CME)
“What is the MC primary malignant bone tumor?”
MM
Multiple Myeloma
(RR)
How do you manage an Achilles tendon rupture?
short leg splint immobilization
keep foot in PLANTAR FLEXION
nonweight-bearing until seen by orthopedic surgeon
definitive repair is surgical
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“Which of the following statements made by a 25-year-old man with lower back pain would warrant a referral to a rheumatologist?
a) “pain gets worse w/ movement & improves w/ rest”
b) “pain gets worse w/ rest & improves w/ movement”
c) “pain improves as I lean forward on a shopping cart”
d) “pain is worse as the day goes along”
B) “PAIN GETS WORSE WITH REST AND IMPROVES WITH MOVEMENT”
“prolonged sitting or inactivity during the day will typically trigger a return in the symptoms”
(RR)
ankylosing spondylitis lab findings
increased ESR
positive HLA-B27
(RR)
treatment for ankylosing spondylitis
NSAIDs
physical therapy
TNF-alpha blockers
(RR)
diseases associated with HLA-B27
PAIR:
Psoriatic arthritis
Ankylosing spondylitis
Inflammatory bowel disease
Reactive arthritis
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What is a Jones fracture?
fractures of the proximal diaphysis of the fifth metatarsal near the intermetatarsal joint
(RR)
treatment of Jones fracture
- posterior short leg splint
- strict non-weight-bearing
- f/u in 3-5 days w/ orthopedics or podiatry
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why is it important to properly treat Jones fractures?
INCREASED RISK FOR MALUNION
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Salter-Harris fracture classification acronym
SALT-ER
I S - slipped (epiphyseal slip)
II A - above growth plate
III L - lower than growth plate
IV T - through the growth plate
V ER - ERasure of growth plate
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how are Salter-Harris fractures managed?
I - II: non op
IV - V: surgery required
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what is the MC type of Salter-Harris fx?
II
fracture above physis
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“Which of the following causes secondary osteoporosis in women?
a) corticosteroid use
b) estrogen use
c) hyperlipidemia
d) hypoparathyroidism”
A) CORTICOSTEROID USE
not hypoparathyroidism, “instead HYPERparathyroidism is known as a secondary cause of osteoporosis”
(RR)
what is Legg-Calve-Perthes disease?
idiopathic avascular necrosis
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age and demographics of those most commonly affected by Leg-Calve-Perthes disease?
aka idiopathic avascular necrosis
MC occurs in MALE children ages 4-10 yrs
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presentation of symptoms of Legg-Calve-Perthes disease
unilateral > bilateral
intermittent limp (worse after activity)
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a pt with PMH of HTN and CKD III presents with gout flare - what is most appropriate therapy?
prednisone
“advanced kidney disease is a contraindication to NSAID use….pts intolerant to NSAIDs may be treated with steroids”
(RR)
“What is the mechanism of action of colchicine in the management of acute gout?”
“inhibits microtubule formation”
(RR)
acute and chronic gout treatments
Acute: NSAIDs, steroids, colchicine (in that order)
chronic: allopurinol (first line), febuxostat, probenecid
(RR)
slipped capital femoral epiphysis (SCFE) clinically presents in what ways?
MC occurs in obese male children
as HIP PAIN REFERRED TO THE THIGH OR KNEE
(RR)
RF for slipped capital femoral epiphysis (SCFE)
obese
males > females
hypothyroidism
growth hormone deficiency
renal osteodystrophy
(RR)
what is increased thoracic kyphosis (dowager hump) a sign of in the elderly?
multiple compression fractures in the vertebrae from osteoporosis
(RR)
what is a tissue necrosis factor alpha blocker that can be used in the treatment of ankylosing spondylitis?
infliximab
(RR)
management of FOOSH and possible scaphoid fracture
FIRST - thumb spica splint
then
Repeat Xray in 10-14 days
(RR)
“Besides repeat X-rays, what imaging modality can confirm a scaphoid fracture?”
MRI (most accurate)
(RR)
what is the preferred treatment of radial head subluxation
hyperpronation method is preferred over supination and flexion method
put moderate pressure on radial head w/ one hand and hyperpronate the forearm with other hand
(RR)
“A 42 y/o M c/o difficulty washing his face & combing his hair w/ his right hand. On examination, a nodule, band, and slight contracture are noted in the right palm proximal to the fourth finger. This patient’s symptoms are associated with what?
DM
3-33% prevalence b/w Dupuytren contracture and diabetes
(associated with DM, ETOH, smoking, genetic predisposition)
(RR)
“A 57y/o M c/o awakening with severe pain in his left big toe. He ate at steakhouse and had several bottles of beer the night before. He has a past medical history of chronic kidney disease. His latest creatinine clearance was 25 mL/min. Joint aspiration reveals negatively birefringent crystals.” What is best tx?
PREDNISONE
NO IBUPROFEN FOR CKD or PUD pts
“colchicine should be used w/ caution in renal failure” “colchicine is used less commonly today due to narrow therapeutic window and many side effects”
(RR)
what kind of diuretics can trigger gout?
loop and thiazide diuretics
(RR)
a 21 y/o F athlete trips during a race, presents w/ erythema and edema. Stabilization of calcaneus and rotation of forefoot results in clicking sensation & severe dorsal foot discomfort. Toe flexion/extension is normal. Where is most likely dislocation?
tarsometatarsal joints
this is Lisfranc injury
(RR)
common presentation of Lisfranc injuries
dorsum of midfoot pain
key PE finding = pain with forefoot rotation against stabilized hindfoot (calcaneus)
“PE will show tenderness of the tarsometatarsal joint”
easily misdiagnosed as ankle sprains
(RR)
what test of infants indicates developmental dysplasia of the hip (DDH)?
Galeazzi - flexing the infants hips and knees and looking level at knee heights
(CME)
“Which of the following has morning stiffness that resolves within 30 minutes in the morning?
- osteoarthritis
- rheumatoid arthritis
- reactive arthritis”
OSTEOARTHRITIS
