Rheumatology and Orthopaedics (Musculoskeletal System) Flashcards
1
Q
What are common sites of osteoarthritis?
A
DIP joint (Heberden nodes), PIP joints (Bouchard nodes), wrist, hip, knee, and spine
2
Q
What do radiographs show in OA?
A
Asymmetric narrowing, subchondral sclerosis, bony cysts, and marginal osteophytes
3
Q
What are the 4 categories for the diagnostic criteria for RA?
A
- Joint involvement (0-5 points)
- Serology (0-3 points)
- Duration of symptoms (0-1 point)
- Acute phase reactants (0-1 point)
4
Q
To make a diagnosis of RA, what score must be achieved from the diagnostic criteria?
A
6 out of 10
5
Q
Joint involvement (0-5 points)
A
- 1 medium or large joint (0 point)
- 2-10 medium or large joints (1 point)
- 1-3 small joints (2 points)
- 4-10 small joints (3 points)
- Greater than 10 joints (at least 1 small) (5 points)
6
Q
Serology (0-3 points)
A
- RF and ACPA negative (0 point)
- RF or ACPA low positive (2 points)
- RF or ACPA high positive (3 points)
7
Q
Duration of symptoms (0-1 point)
A
-6 weeks (1 point)
8
Q
Acute phase reactants (0-1 point)
A
- CRP and ESR not elevated (0 point)
- Increased CRP or ESR (1 point)
9
Q
What some extra-articular manifestations of RA?
A
Changes in the skin, lungs, kidneys, eyes, liver, blood system, and heart. Osteoporosis is frequently diagnosed
10
Q
What is seen on radiography in RA patients?
A
Soft-tissue swelling and juxta-articular demineralization
11
Q
Pharmacologic treatment for RA
A
- NSAIDs, which may be used in conjunction with DMARDs
2. DMARDs are begun as soon as the diagnosis is made
12
Q
What is the frequently prescribed initial DMARD in RA?
A
Methotrexate
13
Q
What are some other synthetic DMARDs that can be used in RA?
A
Corticosteroids, sulfasalazine, antimalarials, and leflunomide
14
Q
What are some new biologic DMARDs that can be used in RA?
A
Etanercept, abatacept, rituximab, infliximab, and adalimumab
15
Q
What is a common combination therapy for RA?
A
Methotrexate plus a biologic DMARD
16
Q
What are some forms of juvenile arthritis?
A
Systemic; pauciarticular, four or fewer joints; and polyarticular, five or more joints
17
Q
Systemic juvenile arthritis (Still disease; JIA)
A
- This type is characterized by spiking fevers (102-104) myalgia, polyarthralgias, and a typical salmon-pink maculopapular rash appearing in the evening and with the fever
- There are minimal articular findings, but hepatosplenomegaly, lymphadenopathy, leukocytosis, pericarditis, or myocarditis may occur
18
Q
What is Koebner phenomenon?
A
It is a rash that is elicited by scratching the skin in susceptible areas; commonly found in systemic juvenile arthritis
19
Q
Pauciarticular juvenile arthritis
A
- This type is characterized by involvement of four or fewer medium to large joints
- Patients are also at risk for development of asymptomatic uveitis that may lead to blindness if they have a positive ANA test
20
Q
Polyarticular juvenile arthritis
A
- This type resembles adult RA with its systemic involvement and involves five or more of the small and large joints
- Systemic symptoms include low-grade fever, fatigue, rheumatoid nodules, and anemia
21
Q
Treatment of juvenile arthritis
A
- NSAIDs and PT and OT are most beneficial. Methotrexate or leflunomide may be used as second-line agents, early on, if there is no improvement with NSAIDs
- 75-80% of patients remit
22
Q
What is the most common pathogen in joint infections?
A
Staphylococcus aureus
23
Q
Treatment of septic arthritis
A
- IV abx for 2 weeks. Ceftriaxone is recommended for empiric treatment; adjustment is made post culture and sensitivity
- Arthrotomy and arthrocentesis often are required
- Oral abx should follow the IV abx for up to an additional 4 weeks
24
Q
Psoriatic arthritis general characteristics
A
This is an inflammatory arthritis with skin involvement usually preceding joint disease by months to years
25
Clinical features of psoriatic arthritis
1. The course is usually mild and intermittent, affecting a few joints
2. Symmetric arthritis resembles RA and may involve the hands and feet. Pitting of the nails and onycholysis are seen
3. Sausage-finger appearance is a common feature
26
Psoriatic arthritis diagnostic studies
1. ESR is elevated; normocytic normochromic anemia is seen
2. Hyperuricemia may occur when skin involvement is severe
3. RF is normal
4. "Pencil in cup" deformities of the proximal phalanx re demonstrated on radiography
27
Psoriatic arthritis treatment
1. NSAIDs are sufficient for mild cases
2. Methotrexate is beneficial. Biologic DMARDs, TNF inhibitors are recommended for severe cases. Corticosteroids and antimalarials should be avoided
28
When is reconstructive surgery indicated in psoriatic arthritis?
For painful end-stage arthropathy
29
Reactive arthritis (Reiter syndrome) general characteristics
1. It is a seronegative arthritis that presents with a tetrad of urethritis, conjunctivitis, oligoarthritis, and mucosal ulcers
2. It is often seen as a sequelae to STIs or gastroenteritis
30
What are the clinical features of reactive arthritis?
Patients may have asymmetric arthritis that involves large joints below the waist; mucocutaneous lesions (balanitis, stomatitis), urethritis, and conjunctivitis
31
Reactive arthritis diagnostic studies
1. 50-80% of patients are HLA-B27 positive
2. Synovial fluid is usually culture negative
3. Evidence of permanent and progressive joint disease may be present on radiography
32
Reactive arthritis treatment
1. Physical therapy and NSAIDs are the mainstay of treatment
2. Antibiotics given at the time of infection will reduce the chance of developing the disorder but do not alleviate the symptoms of the reactive arthritis.
33
Gout diagnostic studies
1. Joint fluid analysis is diagnostic if rod-shaped, negatively birefringent urate crystals are seen. The diagnosis of gout also may be inferred by clinical examination
2. Serum uric acid level of greater than 8 mg/dL is suspcious, but not diagnostic
34
What does imaging show in gout?
Characteristic erosions (small, punched out lesions and interosseous tophi) on plain radiographs make the diagnosis of gout highly suspect
35
Patient education with gout
Elevation and rest may alleviate the symptoms. Dietary modifications stressing decreased ingestions of purines and alcohol can reduce elevated urate levels
36
Gout pharmacotherapy
1. NSAIDs are generally the initial drug of choice (i.e., indomethacin, 25-50mg PO TID until symptoms resolve)
2. Colchicine is also very effective. Use is limited due the pervasive GI side effects
3. Corticosteroid injections are recommended for accessible joints; oral prednisone (or ACTH) may be used if other medicines are not tolerated and septic arthritis have been ruled out
37
Management between acute attacks of gout can be achieved with what medications?
Colchicine, probenecid, sulfapyrazine, allopurinol, or febuxostat. Allopurinol should be started during an acute attack although should not be discontinued in a patient already on maintenance
38
What are the most commonly affected joints in pseudogout?
Knee, wrist, and elbow
39
What does joint aspiration show in pseudogout?
Rhomboid-shaped calcium pyrophosphate crystals that are positively birefringent
40
What do radiographs show in pseudogout?
Fine, linear calcifications in cartilage (chondrocalcinosis)
41
Treatment of pseudogout
NSAIDs, colchicine, and intra-articular steroid injections
42
Diagnosis of SLE requires at least how many of the criteria to be met?
At least four, including a significantly high-titer ANA
43
Diagnostic criteria for SLE
1. Malar rash
2. Discoid rash
3. Photosensitivity
4. Oral ulcers
5. Arthritis
6. Serositis (heart, lungs, or peritoneal)
7. Renal disease (proteinuria, cellular casts)
8. ANA
9. Hematologic disorders (hemolytic anemia, leukopenia, leukocytosis, thrombocytopenia)
10. Immunologic disorders (LE cell, anti-DNA, anti-Sm, false-positive serologic test for syphilis)
11. Neurologic disorders (seizures or psychosis in absence of any other cause)
44
Drugs that may cause a lupus-like syndrome
Procainamide, hydralazine, isoniazid, methyldopa, quinidine, and chlorpromazine
45
What can be used as markers for progression of SLE?
Antibodies to Smith antigen, double-stranded DNA, or depressed levels of serum complement (C3 or C4)
46
Antimalarias (hydroxychloroquine or quinacrine) may be used in SLE for what?
Musculoskeletal complaints and cutaneous manifestations
47
Corticosteroids in SLE
1. Topical or intralesional preparations are often used for cutaneous manifestations
2. Low- or high-dose oral corticosteroids are used for disease flares and tapered as symptoms resolve
48
Methotrexate in SLE is used in low doses for what?
Arthritis, rashes, serositis, and constitutional symptoms
49
What is polymyositis?
It is an inflammatory disease of striated muscle affecting the proximal limbs, neck, and pharynx. The skin can also be affected (dermatomyositis)
50
What is the cause of polymyositis?
It is unknown, but there is a strong association with an occult malignancy
51
Polymyositis clinical features
Insidious, painless, proximal muscle weakness; dysphagia; skin rash (malaria or heliotrope); polyarthralgias; and muscle atrophy
52
Polymyositis diagnostic studies
1. The muscle enzymes creatinine phosphokinase (CPK) and aldolase will be elevated
2. Muscle biopsy should be performed and will show myopathic inflammatory changes
53
Polymyositis treatment
High-dose steroids, methotrexate, or azathioprine until symptoms resolve
54
Polymyalgia rheumatica is characterized by what?
Pain and stiffness in the neck, shoulder, and pelvic girdles and is accompanied by constitutional symptoms (e.g., fever, fatigue, weight loss, depression)
55
Polymyalgia rheumatica cause
The cause is unknown. It is associated with giant cell (temporal) arteritis in up to 30% of the cases
56
Polymyalgia rheumatica diagnostic studies
ESR is markedly elevated (>50 mm/hr). Temporal arteritis is confirmed by biopsy (minimum length 2.5 cm)
57
Polymyalgia rheumatica treatment
Patients respond quickly to low-dose corticosteroid therapy, which may be require for up to 2 years and slowly tapered. Higher doses are required if giant cell arteritis is present; treatment should not be delayed while awaiting biopsy
58
What is polyarteritis nodosa?
Small and medium artery inflammation involving the skin, kidney, peripheral nerves, muscle, and gut
59
What is the cause of polyarteritis nodosa?
It is unknown, but association with hepatitis B is seen in up to 30% of patients
60
What type of skin lesions may be in polyarteritis nodosa?
Palpable purpura and livedo reticularis
61
Polyarteritis nodosa diagnostic studies
1. The diagnosis is usually established by vessel biopsy or angiography
2. Elevated ESR and CRP and proteinuria may be present as well as a positive hepatitis B surface antigen (HBsAg)
3. Presence of ANCA is suggestive but not diagnostic of polyarteritis nodosa
62
Treatment of polyarteritis nodosa
1. Initial management is with high doses of corticosteroids
2. Cytotoxic drugs and immunotherapy also may be used. Concomitant treatment of hepatitis B may be required
3. Hypertension should be treated if present
63
What is the cause of scleroderma?
Unknown
64
Scleroderma characteristics
- Characterized by deposition of collagen in the skin and, less commonly, in the kidney, heart, lungs, and stomach
- The peak age of onset is between 30-50 years
65
What are the two types of scleroderma?
Diffuse and limited
66
Diffuse scleroderma
Affects the skin as well as the heart, lungs, GI tract, and kidneys
67
Limited scleroderma
Affects the skin of the face, neck, and distal elbows and knees and late in the disease causes isolated pulmonary HTN
68
CREST syndrome
- Calcinosis cutis
- Raynaud phenomenon
- Esophageal dysfunction
- Sclerodactyly
- Telangiectasias
- Associated with limited scleroderma
69
Scleroderma diagnostic studies
1. ANA is present in 90% of patients with diffuse scleroderma
2. Anticentromere antibody is associated with CREST syndrome and anti-SCL-70 antibody is associated with diffuse disease and portends a poor prognosis
3. Patients should be monitored for development of HTN, heralding kidney involvement
70
Scleroderma treatment
1. There is no cure
2. Treatment is aimed at organ-specific disease processes (PPIs, ACEI, avoidance of triggers and CCB for Raynaud, and immunosuppressive drugs for pulmonary HTN)
71
Sjögren's syndrome general characteristics
1. It is an autoimmune disorder that destroys the salivary and lacrimal glands (exocrine glands)
2. It may also be a secondary complication to a preexisting connective tissue disorder such as RA, SLE, polymyositis or scleroderma
72
Sjögren's syndrome diagnostic studies
1. RF is present in 70% of the cases, ANA in 60%, anti-Ro antibodies in 60%, and anti-La antibodies in 40% of cases
2. A Schirmer test evaluates tear secretions by the lacrimal glands. Wetting of less than 5 mm of filter paper placed in the lower eyelid for 5 minutes is positive for decreased secretions
3. Biopsy of the lower lip mucosa confirms lymphocytic infiltrate and gland fibrosis
73
Sjögren's syndrome treatment
1. Management is mainly symptomatic
2. Pilocarpine may increase saliva flow
3. Cyclosporine may improve ocular symptoms
74
Fibromyalgia is characterized by what?
Pain above and below the waist that is bilateral and axial for a duration of at least 3 months
75
What is the only drug that is FDA-approved specifically for the treatment of fibromyalgia?
Pregabalin (Lyrica). Studies report reduced pain and improved sleep. Side effects, however, include fatigue, trouble concentrating, sleepiness, and edema
76
What is tendonitis?
Refers to inflammation of the tendon
77
What is tenosynovitis?
Inflammation of the enclosed tendon sheath
78
What are the common sites where tendonitis and tenosynovitis appears?
Rotator cuff, supraspinatus, biceps, flexor carpi ulnaris, flexor carpi radialis, flexor digitorum, patella, hip adductor, and Achilles
79
Why should intratendon injection be avoided?
Because of the risk of rupture. An injection of corticosteroid with anesthesia alongside the tendon may be beneficial
80
What may be tried in tendinitis and tenosynovitis if conservative treatment is unsuccessful?
Excision of scar tissue and necrotic debris. The scar tissue is caused by repetitive micro trauma to the tissue
81
What are common sites of penetration for bursitis?
Subacromial, subdeltoid, trocahnteric, ischial, iliopsoas, olecranon, and prepatellar and suprapatellar (housemaid's knee)
82
What is osteomyelitis?
It is an infection of bone caused by a pyogenic organism (most commonly S. aureus) and is described by duration, cause, site, extent, and type of patient
83
Acute hematogenous osteomyelitis most commonly affects who?
The long bones of children
84
Which patients are at risk of salmonella osteomyelitis?
Patients with sickle cell anemia
85
What is chronic hematogenous osteomyelitis?
This is when, after the original acute infection has completed appropriate treatment (antibiotics, surgery), viable colonies of bacteria harbored in necrotic and ischemic tissue cause a recurrence of infection
86
Exogenous osteomyelitis results from what?
Open fracture or surgery
87
Acute hematogenous osteomyelitis clinical features
1. Pain, loss of motion, and soft-tissue swelling occur
| 2. Drainage is rare
88
Chronic hematogenous osteomyelitis clinical features
1. Recurrent, acute flare-ups of tender, warm, sometimes swollen areas occur, and patients often complain of malaise, anorexia, fever, weight loss, and night sweats as well as pain and drainage from a sinus tract (an abnormal channel permitting escape of exudate to the surface)
2. Bone necrosis, soft-tissue damage, and bone instability can occur
89
Treatment of osteomyelitis
1. Acute osteomyelitis is treated with a 6- to 8-week course of antibiotics (typically IV; however, some bacteria respond well to oral antibiotics); rifampin is a good abx
2. Chronic osteomyelitis is treated with a minimum of 4 weeks to 24 months of IV and po antibiotics depending on the organism involved and the comorbidities of the patient
3 Immobilization and surgical drainage may be indicated. Attention to open wounds must be part of the treatment as well as removal of any hardware present
4. Surgical debridement may be required to remove sequestra, sinus tract, infected bone, and scar tissue
90
What are the most common carcinomas that commonly metastasize to the bone?
Carcinomas of the prostate, breast, lung, kidney, and thyroid
91
What is echondroma?
It is a cartilaginous tumor that is the most common primary benign bone neoplasm of the hand and is asymptomatic unless complicated by a pathologic fracture
92
What are lipomas?
Soft, nontender, moveable mass; common benign soft-tissue mass
93
What are ganglions?
Soft, nontender, transilluminant mass, usually on the dorsum of the hand or wrist
94
What are mucous cysts?
Ganglia originating from the DIP joint and often are associated with Heberden nodules
95
What are the most common types of primary sarcomas of bone?
Chondrosarcoma, Ewing sarcoma, and osteosarcoma
96
What is the most common primary malignant bone tumor?
Multiple myeloma
97
Ewing sarcoma
Found in patients between 5-25 years of age, usually in the diaphyses of long bones, ribs, and flat bones.
98
Osteosarcomas
Most common in individuals 10-20 years of age, arising in the metaphyseal area of long bones
99
What are common bone lesions in patients over 60 years old?
Metastatic carcinoma is the most common source of bone lesion. Chondrosarcomas also increase in incidence in adults older than 60 years of age and can present within the central metaphyseal area
100
What levels are elevated when the bone is broken down and remodeled?
Alkaline phosphatase and lactate dehydrogenase
101
If multiple myeloma is suspected, what type of test is best to document lytic lesions?
Bone scan
102
Bone scans uses
They can evaluate distant osseous metastasis and noncontiguous tumor or skip lesions. They are not diagnostic in multiple myeloma
103
For benign tumors of bone neoplasm, what is the treatment?
Simple excision
104
Malignant bone neoplasms treatment
1. Wide surgical resection is used when feasible
2. The success of chemotherapy, either alone or in conjunction with radiation therapy, depends on the type of tumor, its location, and whether metastasis has been found
3. Limb salvage is part of definitive treatment
4. Radiation therapy followed by local resection is the common treatment for soft-tissue sarcoma
105
Type I primary osteoporosis
Postmenopausal; this occurs primarily in women but can occur in men. It is the most prevalent form of primary osteoporosis
106
Type II primary osteoporosis
Senile; occurs in both men and women. Patients older than 75 with poor calcium absorption are at risk
107
Secondary osteoporosis
Recognized by conditions in which bone is lost because of the presence of other diseases (malignancies, corticosteroid use, GI disorders, or hormonal imbalances)
108
With type I primary osteoporosis, what bone is primarily affected?
Trabecular bone
109
With type I primary osteoporosis, what are the most common fracture sites?
The vertebrae, hip, and distal radius
110
With type II primary osteoporosis, what bone is affected?
Both trabecular and cortical bone
111
With type II primary osteoporosis, what are the most common fracture sites?
Hip and pelvis
112
DEXA scan is recommended in which groups?
1. Postmenopausal women younger than 65 years of age who have one or more additional risk factor
2. All postmenopausal women older than 65 years of age
3. Postmenopausal women who present with fractures
4. All women considering therapy for other conditions in which the bone mineral density will affect that decision
5. Women who have been on hormone replacement therapy for prolonged periods
6. Patients who experience fractures after minimal trauma
7. Patients with evidence of osteopenia on radiography or a disease known to increase risk for osteoporosis
8. Patients with RA
113
Bisphosphonate drugs (aledronate) are considered to be the first-line treatment for osteoporosis. What are the instructions for this medication as well as potential side effects?
These drugs must be taken on an empty stomach, and the patient must be able to sit upright for 30-60 minutes after ingestion. Long-term use may be associated with weakened bones or complications such as jaw necrosis; close monitoring is recommended
114
Hormone replacement therapy (HRT) may be used for osteoporosis. What are the risks associated with this?
It carries a risk for MI, stroke, breast CA, and thromboembolic events
115
Selective estrogen receptor modulators (SERMs) may also be used in the treatment of osteoporosis. The risk of what is increased with this medication?
DVT
116
Teriparatide (a PTH analog) has shown great promise in the treatment of osteoporosis, but why is it not recommended to be used for longer than 2 years?
Risk of osteosarcoma
117
Examples of direction fractures
1. Transverse (at a right angle to the axis of the bone)
2. Spiral (bone has a twisted appearance; also called torsion)
3. Oblique (fracture line between horizontal and vertical direction)
4. Comminuted (splintered or crushed)
5. Segmental (double)
118
Examples of alignment fractures
1. Angulation (deviation from straight line)
| 2. Displacement (abnormal position of fracture fragments)
119
Open fractures treatment
1. Any bleeding fracture should be considered an open fracture until proven otherwise
2. Ideally, open fractures must be derided and irrigated within 4-8 hours of injury
3. IV abx (1st and 2nd generation cephalosporins and aminoglycosides) should be administered for 48 hours after fracture and for 48 hours after surgical procedures
4. Immobilization and fixation should be performed to preserve function
120
Intra-articular fractures (the fracture line enters a joint cavity) treatment
1. Open treatment may be indicated to restore and maintain articular congruity
2. When stable, consider active ROM
121
Femur fracture treatment
1. Treat femoral neck fractures with percutaneous screws or hemiarthroplasty, femoral shaft fractures with intramedullary rods or plates, and intertrochanteric fractures with sliding hip screw fixation or a long gamma nail
There is significant potential for hemorrhage
122
Fractures of the tibia and fibula treatment (in adults)
1. Fractures of the tibia and fibula are associated with ligamental, meniscal, and vascular injuries
2. For simple fractures, closed reduction with cast placement is appropriate; for complicated or unstable fractures, open reduction combined with internal fixation is required
123
Salter-Harris Classification I
Fracture through epiphyseal plate
124
Salter-Harris Classification II
Epiphyseal fracture with associated metaphyseal fragment
125
Salter-Harris Classification III
Fracture through the epiphysis into the articular surface
126
Salter-Harris Classification IV
Fracture through the distal metaphysis, epiphyseal plate, and epiphysis
127
Salter-Harris Classification V
Impaction of the epiphyseal plate
128
What are the types of incomplete fractures?
Torus and Greenstick fractures
129
Torus fractures (buckle fractures)
Occur when one side of the cortex buckles as a result of a compression injury. Treatment is 4-6 weeks in a cast
130
Greenstick fracture
1. These fractures occur in long bones when bowing causes a break in one side of the cortex
2. When the angulation of the fracture is less than 15 degrees, a long arm or leg cast can be applied for 4-6 weeks
3. Fractures with angulation of greater than 15 degrees need referral to an orthopedist surgeon
131
What is a dislocation?
It is a total loss of congruity that occurs between the articular surfaces of the joint
132
What is subluxation?
Any less serious loss of congruity, or a less than complete dislocation
133
What are some common sites of dislocation?
Anterior shoulder, posterior hip (a common complication of a posterior dislocation is osteonecrosis of the femoral head) and dislocations of the posterior elbow
134
What is a Lisfranc fracture?
A dislocation of the tarsometatarsal joint complex
135
What is a strain?
It is an injury to the bone-tendon unit at the myotendinous junction or the muscle itself
136
What is a sprain?
It involves collagenous tissue, such as ligaments or tendons
137
Causes of TMJ disorder (3)
1. Neuropsychologic components, such as psychologic stress
2. Joint capsulitis from bruxism, such as grinding of teeth, clenching of teeth, and posturing of the jaw, may cause TMJ disorder
3. Hypermobility syndrome and malocclusion may lead to pain the jaw area
138
What is a common cause of rotator cuff syndrome in adults?
Impingement of the supraspinatus tendon as it passes beneath the subacromial arch
139
What treatment should be considered for patients with persistent impingement that results in rotator cuff ssyndorme?
Arthroscopic subacromial decompression
140
What is the most common cause of shoulder dislocation?
Fall on outstretched arm in abduction and extension
141
What type of views should be ordered for a shoulder dislocation?
AP view of the shoulder as well as a transthoracic "Y" view
142
What is a Hill-Sachs lesion?
Humeral head deformities
143
What is a Bankart lesion?
Tear of the glenoid labrum (may be picked up on MRI)
144
Treatment of shoulder dislocation after post reduction films and neurovascular status is assessed?
Immobilization by sling and swath (velpeau sling) is recommended for all. For patients younger than 40 years of age, therapy should begin after 3 weeks and for those older than 40 years of age, therapy should begin after 1 week
145
Adhesive capsulitis (frozen shoulder) is an inflammatory process that may follow what?
injury to the shoulder or arise on its own (increased risk in diabetes)
146
Frozen shoulder characteristics
Pain and restricted motion of the glonohumeral joint
147
What does arthroscopy show in frozen shoulder?
Decreased volume of the joint capsule and capsular contraction
148
Treatment of adhesive capsulitis
NSAIDs, passive ROM, and occasionally, manipulation under anesthesia
149
Treatment of OA of the humeral head
NSAIDs, cortisone injections, activity modification, and debridement or total joint replacement in severe cases
150
Rupture of the long head of the biceps tendon causes and treatment
1. This rupture can occur as a result of spontaneous or forced overload
2. In the elderly, this rupture can be caused by degenerative or attritional changes
3. Treatment: rupture is managed by surgical repair
151
Clavicle fracture general characteristics
1. This is the most common fracture in children and adolescents
2. It is usually caused by a fall of an outstretched arm
152
Clavicle fracture imaging studies
An AP view generally will visualize the fracture
153
Clavicle fracture treatment
1. In children, the figure-of-eight sling is used for 4-6 weeks
2. In adults, a sling for 6 weeks is generally enough to treat the fracture
154
Acromioclavicular separation general characteristics (3)
1. It is also referred to as "separated shoulder"
2. It involves a "tearing" of the acromioclavicular and/or coracoclavicular ligaments
3. It is usually caused by a fall on or impact to the tip of the shoulder
155
Acromioclavicular separation imaging studies
1. An AP view of both shoulders usually is necessary
2. Mild separations may require stress films that are obtained while the patient holds a weighted object to reveal the separation
156
Acromioclavicular separation treatment
1. conservative management is possible for midl to moderate injuries because they can be managed with a sling and analgesia
2. More severe injuries usually will require operative repair
157
Humeral head fractures general characteristics
1. Most fractures of the proximal humerus occur in older patients with osteoporosis
158
Humeral head fractures clinical features
1. Pain, swelling, and tenderness, especially in the region of the greater tuberosity, are the most common findings
2. Ecchymosis typically does not appear for 24-48 hours
3. The patient will hold the affected extremity against the chest wall
4. Look for injuries to the brachial plexus and/or axillary artery
159
What type of views are ordered for humeral head fractures?
AP, lateral, and "Y" views
160
Humeral fractures are assessed most commonly by what type of classification?
Neer classification. Displaced fractures are two part, three part, or four part based on whether or not the fracture parts (e.g., head, greater tuberosity, lesser tuberosity, shaft) are involved
161
Treatment of humeral head fractures
1. Closed reduction with the application of a sling and swath (Velpeau sling) can treat most non displaced fractures. Early mobilization with pendulum exercises is indicated to prevent frozen shoulder
2. ORIF is reserved for the management of displaced fractures
162
Humeral shaft fractures mechanism of injury
Includes MVA, fall on an outstretched hand, and penetrating injuries, such as gunshot wounds
163
What type of injury should be on the lookout with humeral shaft fractures?
Radial nerve injury
164
Treatment of humeral shaft fractures
1. Initial treatment is usually the application of a coaptation splint
2. The coaptation splint can be followed by a hanging cast, Sarmiento brace, or operative repair
165
Supracondylar humerus fractures mechanism of injury
A fall on an outstretched hand with hyperextension of the elbow
166
Supracondylar humerus fracture clinical features
Initially, patients may have pain with minimal swelling. Extension of swelling around the elbow is a delayed finding
167
What artery is the most spastic artery in the body and can lead to Volkmann ischemic contractures?
Brachial artery
168
Supracondylar humerus fracture treatment
1. Treatment involves closed reduction in the operating room with posterior splint application for displaced fractures in children
2. Adults should have ORIF
169
Complications of supracondylar humerus fracture
1. Besides Volkmann ischemic contractures, injuries to all three nerves have been described
2. Varus (gunstock) or valgus deformities of the elbow may result from arrest of the medial or the lateral growth plate, respectively
170
What is a boxer's fracture?
It is a fracture of the metacarpal neck of the fourth or fifth finger
171
Treatment for boxer's fracture with 25-30 degrees of angulation
Reduced with the application of an ulnar splint with f/u in 1-2 weeks
172
What is a Colles fracture?
It is a distal radius fracture with dorsal angulation
173
Colles fracture treatment
Cast immobilization after reduction (in most cases)
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What is gamekeeper's thumb?
Sprain or tear of the ulnar collateral ligament of the thumb
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Gamekeeper's thumb treatment
Surgical repair is indicated for a complete rupture; a partial rupture may be treated by immobilization with a thumb spica cast
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Lateral epicondylitis ("tennis elbow") involves what?
The tendinous insertion of the extensor carpi radials brevis
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Medial epicondylitis ("golfer's elbow" or "baseball's elbow") affects what?
The flexor-pronator muscles at their origin, anterior the medial epicondyle
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Treatment of scaphoid (navicular) fracture
1. A delay in diagnosis should be avoided. Suspicion of scaphoid fracture without radiologic evidence should be treated as a fracture in a long-arm thumb spica cast until bone scan or MRI can be performed
2. The initial treatment for a displaced scaphoid fracture is a long-arm thumb spica cast and then referral to an orthopedic surgeon. A short-arm thumb spica cast is used for non displaced fractures with referral to an orthopedic specialist
3. Displacement of 1mm or greater requires ORIF
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What are complications of scaphoid fracture?
Nonunion of the fracture or development of avascular necrosis
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What is de Quervain disease?
It is a stenosing tenosynovitis involving the abductor pollicis longus and extensor pollicis brevis
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Red flags that indicate the need for urgent radiography in low back pain (9)
1. Fever
2. Weight loss
3. Morning stiffness
4. History of IV drug or steroid use
5. Trauma
6. History of CA
7. Saddle anesthesia
8. Loss of anal sphincter tone
9. Major motor weakness
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Treatment of scoliosis: 10-15 degrees
6- to 12- month f/u with a clinical evaluation and possibly x-rays
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Treatment of scoliosis: 15-20 degrees
They need serial AP radiographic f/u every 3 to 4 months for larger curves and every 6 to 8 months for smaller curves or for patients near the end of growth
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Treatment of scoliosis: 20 degrees or greater
Need referral to an orthopedist for continuous monitoring and management (bracing, electrical stimulation, or surgery)
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What is juvenile kyphosis (Scheuermann disease)?
Idiopathic osteochondrosis of the thoracic spine
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What is Pott disease?
It is an extra pulmonary manifestation of TB where it can cause progressive kyphosis
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When is a Milwaukee brace indicated in kyphosis?
In curves of greater than 60 degrees or with persistent pain
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90% of white and 50% of black patients with ankylosing spondylitis have what positive?
HLA-B27
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Slipped capital femoral epiphysis (SCFE) treatment
1. Definitive treatment for chronic SCFE is pinning in situ
| 2. The child should be placed on crutches and should avoid weight bearing before and after surgery
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Treatment of aseptic necrosis of the hip
1. Protected weight bearing for early stage disease is considered to be a temporary treatment. Alendronate has been used to prevent early collapse
2. Surgical options range from core decompression to total hip replacement
3. In children, the treatment is protected weight bearing. Little benefit has been shown from bracing.
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What type of test should be done in achilles tendonitis?
Thompson test (to r/o Achilles tendon rupture)
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What type of treatment is contraindicated in achilles tendonitis?
Corticosteroid injections
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Imaging for bunions (hallux valgus)
Weight-bearing radiography of the foot will show the valgus deformity of the proximal phalanx; an angle of greater than 15 degrees is considered abnormal
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Treatment of bunions
1. Encourage patients to buy shoes with a wide toe box and to use pads on the medial eminence of the bunion deformity or between the first and second toes if they are rubbing together
2. Surgical treatment is for severe deformity or pain that is not relieved with conservative treatment
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What is morton neuroma?
It is a result of traction of the interdigital nerve against the transverse metatarsal ligament causing degeneration of the nerve and chronic inflammation. It usually affects the third web space
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Treatment of morton neuroma
1. Conservative treatment using a soft metatarsal pad and shoes with a wide toe box are helpful
2. Steroid injections into the web space can be helpful
3. Surgical removal of the neuroma is possible in cases that are not resolved with conservative treatment, but the patient should be aware that the affected toes will be chronically numb
