Week 5 Orthopedics Flashcards
1
Q
A patient with elbow pain without localized erythema or warmth is diagnosed with bursitis of the elbow and serum laboratory results are pending. What is the initial treatment while waiting for these results A Aspiration of the bursal sac for cultureAspiration of the bursal sac for culture B Corticosteroid injection into the bursal sacCorticosteroid injection into the bursal sac C Elbow pads, NSAIDs, rest, and ice, , Elbow pads, NSAIDs, rest, and ice D Physical and occupational therapy
A
C
2
Q
A patient injures an ankle while playing soccer and reports rolling the foot inward while falling, with immediate pain and swelling of the lateral part of the joint. The patient is able to bear weight and denies hearing an audible sound at the time of injury. What does this history indicate?
A
Likely ankle sprain, with a possible fracture Immediate swelling of the joint raises the index of suspicion for a fracture or a substantial amount of joint involvement. Without radiographs, none of these possibilities can be confirmed.
3
Q
A 14-year-old boy who is overweight develops a unilateral limp with pain in the hip and knee on the affected side. An exam reveals external rotation of the hip when flexed and pain associated with attempts to internally rotate the hip. What is most important initially when managing this child’s condition?
A
Place the child on crutches or in a wheelchair to prevent weight bearing This child’s age, history, and symptoms are consistent with slipped capital femoral epiphysis. The child should be placed on crutches or in a wheelchair to prevent weight bearing. Obesity is often part of the history and should be managed, but the immediate need is to prevent further damage to the hip. Referral to orthopedics should immediately follow prevention of weight bearing. Physical therapy may be part of treatment after the epiphysis is stabilized.
4
Q
A school-age child falls off a swing and fractures the humerus close to the elbow joint. What is the most important assessment for this patient to evaluate possible complications of this injury?
A
Salter-Harris classification
5
Q
A 45-year-old patient reports a recent onset of unilateral shoulder pain, which is described as diffuse and is associated with weakness of the shoulder but no loss of passive range of motion. What does the provider suspect as the cause of these symptoms?
A
Rotator cuff injury
6
Q
A patient has recurrent lumbar pain, which is sometimes severe. The patient reports that prescription of nonsteroidal, anti-inflammatory drugs (NSAIDs) is no longer effective for pain relief. What will the provider recommend?
A
Referral to an interventional spine physician Patients with recurrent or chronic lower back pain may benefit from lumbar epidural corticosteroid injection performed by an interventional spine physician. Physical therapy is often used for acute injury if no improvement in 4 to 6 weeks. Opioid analgesics are not usually effective.
7
Q
A 3-year-old child is brought to the clinic by a parent who reports that the child refuses to use the right arm after being swung by both arms while playing. The child is sitting with the right arm held slightly flexed and close to the body. There is no swelling or ecchymosis present. What will the primary care pediatric nurse practitioner do?
A
Gently attempt a supination and flexion technique This is most likely an annular ligament displacement injury, or “nursemaid’s elbow.” The primary provider can attempt to reduce the elbow using either a supination/flexion technique or a pronation technique. Consider maltreatment if recurrent dislocations or other symptoms or signs are present. If this fails after three attempts, immobilization and referral are indicated. Radiologic studies are rarely necessary.
8
Q
A high school soccer player sustains a knee injury when kicked on the lateral side of the knee by another player. The provider notes significant swelling of the knee, with pain at the joint line on the medial aspect of the knee. What will the provider do to treat this injury?
A
Refer for a same-day orthopedic consultation This patient has an injury caused by a traumatic event associated with swelling and should have a same-day orthopedic consultation. Simple sprains may be managed with RICE. MRI may be ordered by the orthopedist.
9
Q
A
shoulder flexion/extension
10
Q
A
external/internal rotation, arm in 90 degrees of abduction
11
Q
A
posterior reach, internal rotation
12
Q
A
wrist flexion and extension
13
Q
A
ulnar and radial deviation
14
Q
A
forearm rotation supination/pronation
15
Q
tendon
A
Tough band of fibrous connective tissue that connects muscle to bone
16
Q
Bursa
A
a sac lined with a membrane that produces and contains synovial fluid
17
Q
Ligament
A
a short band of tough, flexible fibrous connective tissue that connects two bones or cartialges or hold together a joint
18
Q
Joint
A
point at which two or more bones meet
19
Q
A
20
Q
Tough band of fibrous connective tissue that connects muscle to bone
A
tendon
21
Q
a sac lined with a membrane that produces and contains synovial fluid
A
Bursa
22
Q
a short band of tough, flexible fibrous connective tissue that connects two bones or cartialges or hold together a joint
A
Ligament
23
Q
point at which two or more bones meet
A
Joint
24
Q
A
external rotation, arm at side
25
When would you xray an ankle?
Signs of joint instability or fracture suspected
26
Grade 1 ankle sprain
## Footnote
**Pathology**
**Findings**
**Treatment**
**Sequelae**
**Pathology**
* stretching/minor tearing ligament fibers
**Findings**
* min pain/swelling/ecchymosis
* full ROM
* Mild point tenderness
* Stable joint
* Able to bear weight
**Treatment**
* RICE & Active ROM
* Non-weight bearing activity like bike
* Return to sports 2-3 weeks
**Sequelae**
* recurs in 1st month if not rehabilitated
27
Grade 2 Ankle Sprain
## Footnote
**Pathology**
**Findings**
**Treatment**
**Sequelae**
**Pathology**
* partial tearing of ligament fibers
**Findings**
* mod pain/swell/ecchy
* painful, slightly limited motion & stability
* point tenderness over joint
* mild joint laxity w/stress
* painful to bear weight
**Treatment**
* RICE/active rom
* partial weight-bearing (crutches/cane)
* sports return 4-8 weeks
**Sequelae**
* recurrent sprains, joint instability, traumatic arthritis
28
Grade 3 ankle sprain
## Footnote
Pathology
Findings
Treatment
Sequelae
**Pathology**
* Complete tearing of ligament fibers
**Findings**
* Severe pain/swelling/ecchy
* Loss of motion & stability
* Severe pain/difficult examination
* Abnormal joint movement
* inability to bear weight
**Treatment**
* Immediate referral to orthopedic surgeon
* Cast 10-14 days
* Non-weight bearing activity
* Rehab before returning to sports with semirigid ankle
**Sequelae**
persistent instability (nonsurgical treatment), traumatic arthritis
29
Where is the Achilles tendon?
What are some disorders of the Achilles?
Where: posterior to ankle joint & flexes/extends ankle
tendinosis, paratendonitis, insertional tendinosis, and frank rupture
30
**Achilles Tendonopathy**
## Footnote
**Clinical Presentation**
**Physical Examination**
**Diagnostics**
**Clinical Presentation**
* joint pain that subsides during exercise but increases at rest
* Located in heel (insertional) OR along tendon length (tendinosis)
* AM stiffness
* Abnormal gait/toe walking
**Physical Exam**
* Localized swelling
* Haglund deformity (bony prominence)
* Chronic = nodules, inflame signs, crepitus
**Diagnostics**
* Unnecessary for mild cases
* US can r/o tendon rupture
* MRI only for surgery
31
Achilles Tendonopathy
## Footnote
DDx
Management
Complications
**DDx**
* plantar fasciitis
* Partial tendon rupture
**Management**
* Immobilization
* NSAID
* Shoe inserts
* 8 weeks to resolve
**Complications**
* rupture
* chronic pain
* chronic foot drop
32
**Achilles Tendon Rupture**
## Footnote
**Pathophysiology**
**Clinical Presentation**
**Physical Exam**
**Diagnosis**
**Pathophysiology**
* decreased blood supply to area and ruptures usually d/t sudden change in direction
**Clinical Presentation**
* "i thought i was shot in the calf" & audible to nearby people
* sudden ankle weakness
* can't rise toes
* limp
* NO PAIN
**Physical Exam**
* visible/palpable gap usually 4cm above calcaneal prominence
* Thompson test
**Diagnosis**
* US or MRI
33
What is the Thompson test?
Evaluates Achilles Tendon Rupture
1. pt kneels on char or prone with knee in flexed position
- Test =Tendon intact = foot plantar flexes when calf is squeezed; can be negative with only partial tear
+ Test = Calf squeezed and no movement
34
Achilles Tendon Rupture
## Footnote
**Management**
**Complications**
**Education**
**Management**
* Immediate Referral; soft tissue emergency
**Complications**
* weak/atrophy muscles = gait disorders
**Education**
* Prevention
35
Plantar Fasciitis
## Footnote
**Clinical Presentation**
**Physical Exam**
**Diagnostics**
**Clinical Presentation**
* pain w/ weight bearing in AM
**Physical Exam**
* Point tenderness at insertion site
* Arch fullness
* fascia pain at fascia body, lateral, and medial heel aspects
**Diagnostics**
* AM heel discomfort and resolves after several mins but returns later in day
* weight-bearing x-ray r/o bone abnormality or bone spur
36
Plantar Fasciitis
## Footnote
**DDx**
**Management**
**Complications**
**DDx**
* other causes of heel pain
* calcaneal fx w/ trauma history
* gout
* bursitis
**Management**
* Conservative: rest, no barefoot, heel pad, NSAID, ice
* PT
* Corticosteroid injection
**Complications**
* Lingering problem
* gait alteration = hip & back pain
37
38
Morton Neuroma
## Footnote
**Pathophysiology**
**Population Affected**
**Clinical Presentation**
**Physical Exam**
**Pathophysiology**
* repeat trauma causing inflammation & fibrosis of plantar nerve where medial and lateral branches converge
Population
* middle aged, narrow shoes that cause entrapment
* Claw toed or bunions
**Clinical Presentation**
* Severe burning/pain at third web space
* Relieved by going barefoot/massages
* Aggravation from foot elevation
**Physical Exam**
* Point tenderness & edema over third space (between 3rd n 4th toe)
* + Mulder sign
* Paresthesia
39
What is the Mulder sign?
Tests for fibrotic neuroma
Squeeze medial and lateral sides of foot
+ Sign = reproducible pain or audible click
40
Morton Neuroma
## Footnote
**Diagnostic**
**DDx**
**Management**
**Diagnostic**
* US or MRI if absence of clinical findings
**DDx**
* Calluses
* Warts
* Ganglia/cysts
* Ledderhose syndrome: plantar fibromatosis
**Management**
* Conservative stepwise treatment
* wider toes, insoles, separate toes w/pad
* NSAIDs
* Steroids
41
**Bursitis**
## Footnote
**Population at risk**
* acute trauma
* repetitive injury
* infection
* gout
* pseudogout
* uremia
* RA
* Tb
* DM
* Immunosuppressed
42
Where is septic bursitis seen most often?
elbow and Knee
Olecranon and prepatellar since they are close to skin surface
43
**Shoulder Bursitis**
## Footnote
**Clinical Presentation**
**Exam findings**
subacromial bursitis most common
**Clinical Presentation**
* Anterior or lateral shoulder pain
* Acute or insidious onset/ interrupts sleep
* Exacerbated by overhead activities; active abduction and internal rotation of the arm
* Tenderness below acromion
* Weakness with internal rotation
**Exam findings**
* +Neer Impingement Sign
* +Hawkins Impingement sign
44
how to perform the Neers Impingement Sign?
45
How to perform the Hawkin's impingement sign
46
how to perform the Neers Impingement Sign?
47
How to perform the Hawkin's impingement sign
48
**Elbow (Olecranon) Bursitis**
**risk factors**
**Clinical Presentation**
**Risk Factors**
* Male
* Manual Labor
* Sports
* Military
**Clinical Presentation**
* Posterior elbow swelling
49
Hip Bursitis
## Footnote
**Clinical Presentation**
**Clinical Presentation**
* Sudden or gradual
* Possible radiation to lateral thigh
* Worse at night
* Pain on palpation
* Hip flexion & rotation exacerbates pain
50
**Knee Bursitis AKA??**
## Footnote
**Clinical Presentation EX what makes it worse or better?**
**Physical Exam #3**
"housemaid's knee" = prepatellar bursitis
**Clinical Presentation**
* pain worse going from sitting to standing
* going up stairs
* Pain at night
* Tenderness
**Physical Exam**
* Pain with active resisted knee flexion
* Thickening that feels like nodules
* Negative Ballottment test (+ = effusion)
51
What is the Balottment test?
Tests for knee effusion
## Footnote
apply downward pressure to patella
click felt = effusion
52
What diagnostic tests would you order for bursitis and why?
**Plain xray** = r/o arthritis, foreign body, soft tissue, bone pathology, effusion or crystal presence
Bursal fluid aspiration = Systemic symptoms & bursitis suspected
Inflammatory markers = r/t autoimmune condition
US = r/o bursa involvement with significant swelling...r/o rotator cuff, Achilles tendon pathology & Baker's cyst
53
What is US useful for identifying?
Rotator cuff
Baker's cyst
Achilles Tendon pathology
54
**When do you need to rule Septic Arthritis even if a noninfectious type of arthritis has already been diagnosed?**
* Acute or subacute presentation
* Monoarticular
* Not responding to anti-inflammatory treatment
55
**Septic Arthritis**
## Footnote
**Pathophysiology**
**Clinical Presentation**
**Pathophysiology**
* S. aureus
* N. gonorrhea (sti origin)
**Clinical Presentation**
* Acute Onset
* Pain, red, swollen, warm
* Painful at rest AND motion AND weight bearing
* Synovial effusion
* muscle spasm
* Proximal lymph node involvement
56
**Gonococcal Arthritis**
## Footnote
**Clinical Presentation**
most common cause of septic arthritis in sexually active
_2 distinct presentations_
**Arthritis-dermatitis Syndrome** = disseminated bacteremic stage
1. dermatitis = skin lesions in multi stages
2. Tenosynovitis
3. Migratory Polyarthritis
**Localized septic arthritis**
1. arthritis now settled in just 1 joint
2. synovial fluid more purulent
**Triad**
1.
57
Septic Arthritis
## Footnote
Diagnostics
**Diagnostics**
* CBC = Elevated WBC
* Inflammatory Markers
* Blood culture
* Synovial fluid culture
\*\*send blood and culture specimens before antibiotics are started!!!
Xrays are not helpful unless r/o arthritis or osteomyelitis
US = identify small amount fluid and inflammatory changes
58
Septic Arthritis Management
Medical Emergency
Refer to ED
* strict non weight-bearing
* ID, rheumatology, Orthopedic surgery
59
What are red flags with lower back pain?
* \>50 years
* recent unexplained weight loss
* failure to improve after 1 month conservative management
* Fever
* New lower extremity weakness
* bowel/bladder dysfunction
60
Difference in symptoms duration for low back pain
Acute
Subacute
Chronic
Acute: \<6 weeks
Subacute: 6weeks - 3 months
Chronic: \>3 months; symptoms \>half of the days in the last 6 months
61
What are two causes of low back pain?
Medical: inflammatory, infectious, neoplastic and visceral...rare but need time sensitive treatment
mechanical
62
Describe axial low back pain
usually in lumbar spine with gluteal symptoms
New, acute
Severe disrupts sleep & ADLs
exacerbated by prolonged positions
usually forward flexion, Valsalva, and seated position make it worse
63
Describe radicular low back pain
Leg & thigh pain greater than back pain...radiates beyond knee usually radicular
Neurologic symptoms: numb/tingle/weak/reflex changes/root tension signs
Improved by walking and changing positions
64
Difference between neurogenic claudication vs vascular claudication r/t lower back pain
**Neurogenic**
* thigh/calf pain worsened with standing or walking
* alleviated with sitting
* symptoms vary day to day
Vascular
* altered peripheral pulses
* no symptoms with standing
* steady symptoms daily
65
Cauda Equina symptoms
* urinary retention/incontinence
* lower extremity weakness
* recent onset erectile dysfx
* hyporeflexia
66
What does the straight leg test assess damage in?
Nerve root tension sign
L5 to S1
tests radicular pain
67
If a straight leg raise is performed on an unaffected leg and it reproduces symptoms in the unaffected leg....What is this called and what does it mean?
positive crossed straight leg raise
Increased specificity for disc herniation
68
What is the femoral nerve stretch test?
root tension sign
looks at upper lumbar radiculopathy L2 - L4
+ if pain in anterior thigh
69
When would you order imaging for someone with low back pain? What would be your first tool?
Red Flags
No improvement after 4-6 weeks
Plain xray
70
What is a Trendelberg gait?
r/t defective hip abductor mechanism
Trunk shifts over the affected him while standing
shifts away affected hip during swing motion
71
What is Antalgic gait?
walking with a limp
72
What is the typical presentation of a medial collateral ligament (MCL) tear?
What do you perform to determine MCL laxity?
* PAIN
* (usually no instability or swelling)
* tender at medial joint line at insertion point
Valgus Stress
73
What is the typical presentation of a lateral collateral ligament (LCL) tear?
What do you perform to determine LCL laxity?
* acute lateral knee pain
* instability "knee gives way"
Varus Stress test
74
Varus Stress test look for?
LCL laxity at 30 degrees flexion
75
What does the Valgus Stress test look for?
MCL laxity
76
Signs of an ACL injury
Tests to examine
* "pop"
* autonomic s/s: dizzy/sweaty/faint
* Acute swelling within 2 hours
* Unstable knee
Tests
* "Lachman test"
* Anterior drawer test
77
What is the anterior drawer test? how to perform?
**ACL assessment**
Knee flexed 90 degrees with foot flat on surface.
Pull tibia forward
"soft" or absent end point = ACL tear
78
What is the Lachman test?
ACL assessment
* knee flexed 15-30 degrees
* Stabilize femur above joint with 1 hand
* other hand lifts lower leg while pushing on femur
"knock" or firm stop = ACL intact
absence of firm end point = ACL tear
79
How is the knee meniscus usually injured?
the weight-bearing knee is twisted while it is partially flexed
Once torn the inner meniscus cannot heal d/t limited blood flow
80
Clinical presentation of a meniscus tear?
How to test?
* Joint effusion
* tenderness along joint line
* instability
Thessaly test
McMurray test
81
What is the Thessaly test?
Tests for Meniscal integrity
Provider holds outstretched hands while patient stands on one leg
Patient twists weight-bearing knee 3x
joint pain & locking sensation = meniscal tear
82
What is the McMurray Test
Assess tear in knee cartilage
## Footnote
Patient lies supine with leg straight
Provider Rotates tibia internally/externally while applying pressure "stress" to knee while simultaneously flexing
"click" or "pop" = torn meniscus
83
What is patellofemoral pain syndrome?
Clinical presentation
most common overuse injury of knee; Knee pain localized to anterior portion of knee
"runner's knee" "jumper's knee"
Presentation
* bilateral pain limited to ant portion of knee
* knee is "giving out"
* Pain with prolonged sitting
* may have an effusion
84
Prepatellar bursitis
Cause
S/S
Treatment
**Cause**: trauma such as frequent kneeling EX floorer
**S/S:**
* swelling superficial to the patella
* pain is mild unless under direct pressure
* no pain with weight-bearing or knee ROM
**Treat**:
* RICE
* NSAIDs
* protect knee
85
Clinical presentation of cervical radiculopathy
Common causes
* Neck pain extending to arm
* Pain worse in am than neck
* Neurologic findings: weak/numb/tingle
Common causes:
* Herniated disk
* Disc degeneration
86
What is the Spurling maneuver?
Provocative test for cervical spinal root involvement
+ test = reproduction of symptoms down arm
87
What is the Lhermitte sign?
electric shock sensation down the spine into limbs;
+ response = cervical cord disorders like compression, tumor or MS
88
What are the Canadian Cervical Spine Rules? 6
**Identifies people that are at high risk for cervical fracture and need Xray**
■Age 65 or above
■Fall from more than 1 meter or 5 stairs
■Motor vehicle collision (MVC) at greater than 60 mph
■Bicycle collision
■Any type of diving accident
■Paresthesias in extremities
89
**Osteoarthritis**
## Footnote
**Symptoms**
**Diagnostics**
**Management**
**Symptoms**
* prevalent upon rising
* after prolonged activity and relieved by rest
* Gradual loss of joint motion
* Trendelenburg gait
* Joint effusions
* painful palpation at joint line
* Heberden & Bouchard nodes
**Diagnostics**
* possibly joint aspirate for crystals/Infectious or inflame
**Management**
* Acetaminophen
* Tramadol
* NSAID
90
Acute vs chronic osteomyelitis
Acute: \< 2 weeks
Chronic: \>3months
91
In a diabetic patient, an ulcer larger than ________ cm is highly suspicious of \_\_\_\_\_\_\_
2x2 cm
osteomyelitis
92
Diagnostics for osteomyelitis
CBC
CRP
BC (if febrile or evidence of vertebral osteomyelitis)
Plain xray for bone changes
if x-ray normal, then mri
93
Phamacologic management osteoarthritis
Stable patient = wait for culture
or
Empiric antibiotics to include MRSA =
* Vanco & Ceftriaxone (3rd gen cephalo )
* 2nd line: flouroquinolone
94
Cervical radiculopathies feel better when the shoulder is in the ___ position
Cervical radiculopathies feel better when the shoulder is in the **elevated** position
95
Pain during active but not passive ROM is suggestive of....
adhesive capsulitis/frozen shoulder
96
Marked weakness in shoulder abduction and external rotation suggests...
rotator cuff tear
97
What are the common causes of chronic shoulder pain?
rotator cuff disorders
adhesive capsulitis
shoulder instability
teninitis
arthritis
98
\_\_\_\_\_\_\_\_\_\_ manifests as activity related shoulder pain.
99
100
Severe acute activity-related shoulder pain with restricted movement is likely \_\_\_\_\_\_\_\_
Severe acute activity-related shoulder pain with restricted movement is likely **acute calcific tendonitis**
101
Pain in the should at night that makes sleeping on the affected arm impossible is ______ until proven other wise........
**rotator cuff disease**
102
Pain in the shoulder with repetitive overhead activity suggests \_\_\_\_\_
Pain in the shoulder with repetitive overhead activity suggests **rotator cuff disease**
103
Morning stiffness lasting more than 1 hour
Rest pain that improves as the day wears on
and
bilateral shoulder pain in an older adult of symptoms of \_\_\_\_\_\_\_
RA
polymyalgia rheumatica
pseudogout
104
Shoulder bursitis symptoms
* Abrupt onset
* pain felt at tip of shoulder or along upper third of humerus
* Pain referred down deltoid muscle into upper arm
* Occurs when pain is lifted overhead or twisted
105
What does the Adams test measure?
Scoliosis
106
# Define:
Angulated fracture
Transverse fracture
Oblique fracture
Angulated fracture: open or closed greater than 30 degrees
Transverse fracture: break in bone cortex that goes straight across
Oblique fracture: diagonally on x-ray films
107
What type of fracture is commonly seen in children?
greenstick fracture because children have a more porous cortex that makes the on more flexible.
Bone looks like a fresh twig were being bent in two
108
109
Define
## Footnote
Comminuted fracture
avulsion fracture
comminuted = bone ends shatter with multiple fragments
avulsion = bone chip fracture when the ligament pulls away from the bone. Usually after a forceful injury like inversion ankle injury.
110
An inability to weight bear immediately after trauma is suspicious of?
fracture
111
What does the Shuck test assess?
watson test?
carpal instability
scaphoid ligament instability
112
What does the empty can or Jobe test evaluate the strength of what muscle?
supraspinatus
113
What does the drop arm test signify?
inability to lower arm in controlled motion = rotator cuff injury
114
What is used to assess ACL injury?
anterior drawer test
Lachman test
115
What are the Ottawa Ankle rules?
Xray if there is pain in the malleolar area **AND**.....1 of
* point tenderness of the posterior edge or tip of the lateral malleolus
* " medial malleolus
* inability to weight bear for 4 steps immediately after injury and exam
Xray if there is pain in the mid foot AND....1 of
* Bone tenderness at the base of 5th metatarsal
* Bone tenderness at the navicular
116
What movements indicate lateral epicondylitis?
lateral elbow pain with passive wrist flexion and active wrist extension
"tennis elbow"
117
What movements indicate medial epicondylitis?
pain with resisted wrist flexion and forearm pronation and passive wrist extension
"golfer's elbow"
118
epicondylitis
## Footnote
What is it?
Presentation
Examination
DDx
Management
What
* inflammatory condition
* pain at tendon origin
* takes several months fo recovery
Presentation
* Gradual OR acute onset pain along epicondyle
* with or without radiation
* Hx lifting, hammering, screwing, gripping
Examination
* local tenderness over affected epicondyle
* ROM & distal neurovascular components WNL
DDx
* Cubital tunnel syndrome
* Cervical radiculopathy
* rotator cuff tendonitis
* osteoarthritis
Management
* NSAIDs, elbow splint,
* Steroid injection
* Surgery
119
Elbow sprains
## Footnote
Presentation
Examination
DDx
Management
**Presentation**
* Pain after throwing, overhead
* or weight bearing activity (medial)
* or fall onto extended elbow (lateral)
**Examination**
* Tender over affected ligaments
* Medial
* tender MAX 2cm distal to epicondyle
* Pain/instability w/ valgus stretch
* Lateral
* vague lateral tenderness
* pain reproduced only with arm extended and supinated
**DDx**
* Epicondylitis
* Nerve irritation
* Fracture/tear
**Management**
* "PRICE"
* sling for 48 hours
* NSAIDS
120
RADIAL HEAD FRACTURES
## Footnote
What is it?
Presentation
Examination
What
* caused by fall onto outstretched hand
* involves superior portion of radial bone
Presentation
* Arm cradled at 90 degrees
* Pain decreases after 30 mins injury then recurrs several hours later
* bleeding in joint
Examination
* Edema
* Tenderness over radial head
* limited ROM
* Painful rotation
* Normal neurologic examination
121
RADIAL HEAD FRACTURE
## Footnote
DDx
Management
**DDx**
* epicondylitis
* capsular tear
* cartilage injury
**Management**
* PRICE
* immobilization with arm flexed at 90 degees
* Orthopedic referral
122
ULNAR NEURITIS
## Footnote
What
Presentation
Examination
**What**
* "cubital tunnel syndrome"
* Compression of ulnar nerve
**Presentation**
* pain localized to medial elbow
* radiate to forearm
* cause hand clumsiness
**Exam**
* tender ulnar groove
* 5th digit sensory loss
* dim motor strength 4th and 5th digits
* + Tinel sign
\*\*diagnosis w/ EMG studies
123
Olecranon Burisitis
## Footnote
What
Presentation
Exam
**What**
* Swelling bursa sac
* history of trauma, RA, crystal
**Presentation**
* After acute injury= painful edema elbow
* Chronic = soft, edema non tender
* ROM intact
**Exam**
* edema
* tender
* Full ROM
* normal neuro
* Chronic bursitis = rough nodes
124
An 18-year-old soccer player presents to primary care with a knee injury that occurred during practice 3 hours ago. The patient reports that they were running for the ball and quickly changed directions and felt a pop and immediate pain. On exam, the knee is swollen and range of motion is limited due to the pain and swelling. What is the most likely diagnosis based on this information?
Select one:
a. Patellar fracture
b. Anterior cruciate ligament tear (ACL)
c. Meniscus tear
d. Ruptured Baker cyst
Anterior cruciate ligament tear (ACL)
125
A 27-year-old patient who works in information technology presents for a tender nodule in the right wrist for 3 weeks. The patient denies any numbness, tingling or weakness. On exam, the nurse practitioner notes a 2 cm smooth, rubbery mass that is slightly tender on the dorsal aspect of the wrist with full range of motion. How should the nurse practitioner manage this patient?
Select one:
a. Refer to physical therapy for therapeutic ultrasound
b. Refer to a hand specialist for immediate excision
c. Perform a corticosteriod injection
d. Conservative treatment with splinting and ice
d. Conservative treatment with splinting and ice
126
When should the nurse practitioner consider ordering an MRI for shoulder pain?
Select one:
a. When there is an acute injury as the initial imaging modality
b. When the outcome of the imaging study will impact the management plan
c. MRI should be performed on all patients presenting with shoulder pain
d. MRI is not a sensitive diagnostic test for the shoulder
b. When the outcome of the imaging study will impact the management plan
127
A 33-year-old patient with no past medical history complains of left lower back pain after lifting a heavy piece of furniture 5 days ago. The pain is intermittent and radiates down the posterior aspect of the leg into the foot and is associated with tingling in the left foot. The patient denies fever, chills, nocturnal pain, bowel or bladder problems, or weakness in the leg. On exam, he has limited flexion reflexes in the lower extremities. Straight leg raise is positive at 30 degrees on the left. The nurse practitioner should do which of the following as the next step?
Select one:
a. Order an x-ray of the lumbosacral spine
b. Order an MRI of the lumbosacral spine without contrast
c. Discuss conservative therapy with ice/heat, NSAIDS and physical therapy
d. Treat with oral corticosteriods for 1 week
c. Discuss conservative therapy with ice/heat, NSAIDS and physical therapy
128
A 42-year-old female runner presents with burning pain in the right foot between the 3rd and 4th metatarsals that is worse when elevating her foot. The nurse practitioner should suspect which of the following?
Select one:
a. Metatarsalgia
b. Bunion
c. Morton neuroma
d. Plantar fasciitis
c. Morton neuroma
129
The nurse practitioner is completing a sports physical on a 14-year-old patient and performs the Adams test. What does the nurse practitioner assess for during this test?
Select one:
a. Pectus deformity of the anterior chest
b. Asymmetry of the posterior chest wall
c. Unequal or increased arm span
d. Strength and range of motion of the spine
b. Asymmetry of the posterior chest wall
130
which of the following elements on physical exam would indicate the possibility of ankle fracture and should be evaluated by x-ray?
1. ability to bear weight on affected ankle
2. tenderness over medial malleolus
3. swelling of affected ankle
4. bruising of affected ankle
1. tenderness over medial malleolus
131
A school age child with an acute ankle inversion injury resulting in lateral ankle. pain and swelling is most likely to have which of the following injuries?
1. sprained anterior talofibular ligament
2. sprained deltoid ligament
3. muscle strain
4. fracture of the growth plate at distal fibula
fracture of the growth plate at distal fibula
132
which of the following knee injuries is least likely to cause acute swelling in the first 48 hours after injury?
1. meniscus tear
2. ACL rupture
3. PCL rupture
4. MCL sprain
MCL sprain
133
Fractures of the ____ bone occurs during a fall from an outstretched hand
scaphoid
134
What are the Ottowa knee rules?
■Injury due to trauma and any one of the following:
–Age older than 55 years
–Tenderness at the head of the fibular or the patella
–Inability to bear weight for 4 steps
–Inability to flex the knee to 90 degrees
135
ACL
## Footnote
**Typical Mechanism of injury**
**S/S**
**Characteristics**
**Diagnostic tests**
**Management**
**Typical Mechanism of injury**
* sports related: jumping/rapid turning/deceleration
**S/S**
* Heamrthrosis
* Rapid Onset
* 0-2 hours
**Characteristics**
* "pop"
* Pain poorly defined
* Restricted ROM or hyperextension
**Diagnostic tests**
* Lachmann
* Anterior Drawer test
* Pivot shift
**Management**
* Surgery if "giving way"
136
PCL
## Footnote
**Typical Mechanism of injury**
**S/S**
**Characteristics**
**Diagnostic tests**
**Management**
**Typical Mechanism of injury**
* Less common
* sudden violent hyperextension
**S/S**
* minimal
**Characteristics**
* Diffuse pain
* Assoc w/ PLC injury
**Diagnostic tests**
* Reverse lachmann
* Posterior sag
**Management**
* Rehab
* Good outcomes
137
Meniscus
## Footnote
**Typical Mechanism of injury**
**S/S**
**Characteristics**
**Diagnostic tests**
**Management**
**Typical Mechanism of injury**
* contact sports; twisting on fixed foot
**S/S**
* Haemarthrosis = severe tear
* slow onset = minor tear
**Characteristics**
* "clicking" and "locking"
* Reduced ROM
**Diagnostic tests**
* McMurray
* Apley
* Joint line tenderness
**Management**
* 3 weeks conservative
* Surgical repair
138
MCL
## Footnote
**Typical Mechanism of injury**
**Characteristics**
**Diagnostic test**
**Management**
**Typical Mechanism of injury**
* common contact injury
* Below flexed knee from lateral side
* Usually injured with ACL
**Characteristics**
* Local pain
* Tender on palpation
* ROM full in grade I & II tears
**Diagnostic tests**
* Valgus stress
1. Grade 1 = pain, no laxity = 3 weeks rest
2. Grade 2 = pain, laxity but end feel = 8 weeks rest
3. Grade 3 = laxity no end feel possible pain = 12 weeks rehab; 6 weeks brace
may need surgery
139
What are the Ottowa ankle rules
–Pain in the malleolar region (medial or lateral)
–Patient cannot bear weight immediately after the injury and in your office for 4 steps
–Pain at the base of the 5th metatarsal
–Pain at the navicular bone
