Rheum/Ortho - Surgery Flashcards
What is post amputation pain?
Phantom limb pain: onset usually within 1 week; increased risk in pts with severe acute pain; intermittent cramping, burning felt in distal limb
Acute stump pain: tissue and nerve injury; severe pain lasting 1-3 weeks
Post-traumatic neuroma: weeks to months after amputation, focal TTP, altered local sensation, decreased pain with anesthetic injection
Ischemic pain: swelling, skin discoloration; wound breakdown, decrease in transcutaneous oxygen tension
What is post-traumatic neuroma?
etiology: due to transection of nerve fibers; weeks to months after amputation, focal TTP, altered local sensation, decreased pain with anesthetic injection
local anesthetic provides transient relief and confirms dx; mgmt = excision of neuroma
mgmt prior to surgery: TCAs and antiepilectic meds
What is a popliteal (Baker) cyst?
Etiology: Extrusion of fluid from knee jt space into semimembranous/gastrocnemius bursa
RF: trauma (e.g., meniscal tear); underlying jt disease (eg osteoarthritis, RA)
Presentation: asx bulge behind knee that diminishes w/ flexion; posterior knee pain, swelling, stiffness;
arch of ecchymosis visible distal to medial malleolus (crescent sign)
Dx: U/S can rule out DVT and confirm popliteal cyst
Complications: venous compression (leg/ankle swelling); dissection into calf (erythema, edema, positive Homan sign); cyst rupture (acute calf pain, warmth, erythema, ecchymosis)
What is Paget disease?
Assoc. with increased bone remodeling, which dramatically increases the risk of osteosarcoma
Presentation: bone pain, headaches, unilateral hearing loss, bowing of the bones, soft tissue swelling
Imaging: destructive bone lesion, sunburst periosteal reaction, Codman triangle (periosteal elevation)
Risk of osteosarcoma: greater with RB1 (retinoblasatoma) and TP53 (Li Fraumeni) mutation
Characterized by focal increase in bone turnover, in which osteoclast dysfunction lends to bone breakdown and a compensatory increase in bone formation
What is osteoarthritis?
Etiology: non-inflammatory destruction of articular cartilage
Often involves several jts (eg knees, hips), DIP and 1st MCP
RF: obesity, prior jt injury, abnormal joint alignment
Presentation: jt pain that is worse w/activity, wt bearing; decreased ROM on exam; crepitus
Prominent osteophyte formation at the DIP (Heberden nodes) and PIP (Bouchard nodes)
Imaging: thickening of subchondral bone, jt space narrowing, formation of osteophytes
Dx: XR
Mgmt: Nonpharmacologic tx (exercise (strengthening of quadriceps), wt loss)–>NSAIDs PRN–>topical agents, intrarticular glucocorticoids, hyaluronic acid–>surgery for chronic pain mgmt
What is giant cell tumor of bone?
Benign, but locally destructive neoplasm most common at epiphysis of long bones in young adults
Presentation: pain, swelling; pulmonary metastasis and malignant transformation may occur
XR: eccentric lytic lesion, resembling soap bubbles
Dx: confirmed w/ biopsy showing multinucleated giant cells
Tx: surgery, first line; denosumab against RANKL can be used to shrink tumors
What is Charcot joint (neurogenic arthropathy)?
RF: diabetic neuropathy, other peripheral neuropathy (eg vit. B12 deficiency), spinal cord injury, syringomyelia, tabes dorsalis (tertiary syphilis)
Pathogenesis: impaired sensation and propioception, altered wt bearing and recurrent trauma, acute inflammatory response
Presentation: impaired ambulation; foot and ankle deformity (swelling, collapsed arch, decreased ROM); mild pain
XR: bone and jt destruction/loss of jt spaces, fragmentation, subluxation/dislocation
Mgmt: mechanical offloading and correction of jt mechanics (eg casting, orthotics)
What is Rheumatoid Arthritis?
Presentation: pain, soft tissue swelling, and MORNING STIFFNESS in mulitple jts; symmetric, polyarticular arthritis, most pts have upper extremity (eg hands, wrists) involvement - PIPs and MCPs, MTPs, spares the DIPs; rheumatoid nodules (firm, nontender, subq nodules at pressure points); though any jt can be affected
Cervical spine involvement
Wt loss
Labs: + rheumatoid factor and anti-ccp antibodies*; elevated CRP, ESR
XR: periarticular osteoporosis/erosions, jt erosions, jt space narrowing
Tx: NSAIDs, glucocorticoids to acutely reduce pain (do not alter long term prognosis and not for definitive therapy)
1st line - DMARDs (Methotrexate, hydroxychloroquine, sulfasalazine, leflunomide, azathioprine)
2nd line - Biologic agents (etanercept, infliximab, adalimumab, tocilizumab, rituximab)
Pts should be tested for hep B, C, and tuberculosis prior to therapy
What should be assessed in a clavicle fracture?
Neurovascular exam (angiogram) should accompany all clavicle fractures due to proximity to subclavian artery and brachial plexus; r/o injury to vessels Middle 1/3 fracture: non-operative brace, rest, and ice Distal 1/2 fracture: open reduction and internal fixation to prevent nonunion
What is compartment syndrome?
Etiology: caused by direct trauma or prolonged compression of an extremity or after revascularization of an acutely ischemic limb
RF: anticoagulation, bleeding diathesis
Presentation: excruciating pain worsened w/ passive ROM, does not respond well to narcotics; parasthesia (early), loss of sensation, weakness, diminished pulses
Dx: measuring compartment pressures in affected extremity; delta pressure (DBP-compartment pressure) less than 30
Tx: time to fasciotomy is most critical prognostic indicator, should be performed w/o delay
What is De Quervain’s tenosynovitis?
Classically affects new mothers who hold infants with thumb outstretched (abducted/extended)
Abductor pollicis longus and extensor pollicis brevis tendons are affected;
Finkelstein test: passive stretch of these tendons elicits pain
What is fat embolism syndrome?
Etiology: fracture of marrow-containing bone (eg femur, pelvis); orthopedic surgery, pancreatitis; fat enters venous circulation following event
Presentation: 24-72h following inciting event; clinical triad (respiratory distress - hypoxemia, dyspnea, tachynpea, tachycardia;
neurologic dysfunction (eg confusion, visual field def); petechial rash)
Dx: clinical presentation
Prevention and tx: early immobilization of fracture; supportive care (eg mechanical ventilation)
What is TRALI?
Blood transfusion-related pulmonary capillary damage
Presentation: respiratory distress
Crackles on lung ausculation
XR: bilateral infiltrates (due to pulmonary edema)
What is succinylcholine?
Depolarizing neuromuscular blocker.
Used during rapid-sequence intubation due to rapid onset and offset
MOA: binds to postsynaptic acetylcholine receptors to trigger influx of Na ions and efflux of K ions through ligand-gated ion channels
Complications: life-threatening cardiac arrhythmia due to severe hyperkalemia
To avoid life-threatening hyperkalemia, nondepolarizing neuromuscular blocking agents (eg vecuronium, rocuronium) should be used as they do not affect postsynaptic ligand-gated ion channels
[skeletal muscle trauma, burn injury, stroke can cause upregulation of postsynaptic acetylcholine receptors]
What is anterior cruciate ligament injury?
MOA: rapid deceleration or direction changes; pivoting on LE with foot planted
Sxs: pain - rapid onset, may be severe, a “popping” sensation at time of injury; signficant swelling (effusion/hemarthrosis); jt instability
Exam findings: anterior laxity of tibia relative to femur (anterior drawer test, Lachman test)
Dx: MRI
Tx: RICE measures, +/- surgery
What is a meniscal tear?
Medial more commonly injured than lateral
Etiology: younger pts - rotational force on planted foot; older pts - degeneration of meniscal cartilage
Sxs: acute “popping” sensation; catching, locking, reduced ROM; slow onset jt effusion
Exam: jt line tenderness, pain or catching in provocative tests (Thessaly, McMurray)
Dx: MRI, arthroscopy
Mgmt: mild sxs, older pts - rest, activity modification; persistent sxs, impaired activity - surgery
What are special tests for knee examination?
MCL injury: Valgus stress test - stabilize lateral thigh; apply abduction force to lower leg; laxity indicates MCL injury
ACL injury: Anterior drawer test - pt supine w/ knee flexed, grip proximal tibia w/ both hands and pull anteriorly
Lachman test - place knee at 30 degrees flexion, stabilize distal femur w/1 hand and pull proximal tibia anteriorly w/ the other; laxity of tibia indicates ACL injury
Meniscal tear: Thessaly test - pt stands on 1 leg w/ knee flexed 20 degrees, pt then internally and externally rotates on flexed knee
McMurray test - passive knee flexion and extension while holding knee in internal or external rotation
Pain, clicking, or catching indicates meniscal tear
What is osteomyelitis?
Pathogenesis: hematogenous spread, s. aureus most common cause; pseudomonas aeruginosa infection prevalent after puncture wound through sole of a shoe
Presentation: fever, pain, refusal to bear wt; limited function (eg limp), bony tenderness, swelling
Chronic: involucrum, sequestrum; draining sinus tract; fragmentation of bone, irregular fracture lines on XR
Dx: Elevated ESR, CRP, WBC count; blood culture;
XR (often normal),
MRI; definitive - bone biopsy/culture
Tx: vancomycin
What is osteoporosis?
Significant fracture due to ground level fall is uncommon, indicates underlying bone fragility due to osteoporosis
Most common cause: women - declining estrogen after menopause; men - secondary cause
Bone loss common in celiac disease due to malabs of vit. D and resultant secondary hyperparathyroidism
Pain is worse w/ exercise, relieved by rest
What is patellar dislocation?
Occurs after quick, lateral movements on a flexed knee
Most common in young athletes
RF: <20y, jt laxity, LE malalignment, patellar subluxation (excess lateral movement w/in trochlea), tight iliotibial band
Presentation: feeling of knee giving way, severe pain, popping noise; lateral displacement of patella out of trochlea w/assoc. tear of medial patellofemoral ligament
Exam: flexed knee w/ reduced ROM and lateral displacement of patella
What is patellofemoral syndrome?
Poorly localized anterior knee pain, related to chronic overuse; worse during wt bearing w/ knee flexed (eg squatting, ascending/descending stairs); pain w/ isometric contraction of quads
Common in young women
Initial mgmt: activity modification (eg reduced intensity of exercise) and NSAIDs; stretching and strengthening exercises w/ emphasis on quadriceps and hip abductors
What is plantar fasciitis?
Inflammation and degeneration of plantar aponeurosis (deep plantar fascia); repetitive microtrauma to aponeurosis
RF: middle aged adults, who are obese; Pes planus, obesity, working or standing/ exercising on hard surfaces for long periods
Sxs: pain at plantar aspect of heel and hindfoot; worse with wt bearing (esp after prolonged rest); first steps of the day are the worst
Dx: Tenderness at insertion of plantar fascia; pain w/ dorsiflexion of toes; presence of heel spurs on XR (low sensitivity)
Tx: activity modification, stretching exercises, heel pads/orthotics
What is rotator cuff impingement/tendinopathy?
Pain w/ abduction, external rotation; subacromial tenderness; normal ROM w/ positive impingement tests (Neer- upside down beer cans, Hawkins)
Results from repetitive activity above shoulder ht (eg painting ceilings)
RCT most common in pt who perform repetitive arm movement above shoulder ht; persists w/ subacute pain on abduction
Impingement syndrome: compression of soft tissue structures b/n humeral head and acromion, characteristic feature of RCT
What is adhesive capsulitis?
Decreased passive and active ROM; stiffness +/- pain
What is biceps tendinopathy/rupture?
Anterior shoulder pain; pain w/ lifting, carrying, or overhead reaching; weakness less common
What is glenohumeral osteoarthritis?
Uncommon and usually caused by trauma; gradual onset of anterior or deep shoulder pain; decreased active and passive abduction and external rotation
What is a rotator cuff tear?
Common in pts over 40, often after fall on outstretched arm
Causes pain and weakness w/ abduction and external rotation of the humerus
Complete supraspinatus tear appreciated in drop arm test
Dx: MRI
Tx: surgery
What is a stress fracture?
RF: repetitive activities (eg running, gymnastics), abrupt increase in physical activity, inadequate Ca and vit D intake, decreased caloric intake, female athlete triad - low caloric intake, hypomenorrhea/amenohrrhea, low bone density
Presentation: 2nd metatarsal most commonly injured; insidious localized pain, pt tenderness at fracture site, possible neg XR in first 6w
XR: may initially be normal, but can show hairline lucency or local periosteal thickening
Mgmt: reduced weight bearing for 4-6weeks, referral to orthopedic surgeon for fracture at high risk for malunion (eg anterior tibial complex, 5th metatarsal)
