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NURP532 > Week 5 Orthopedics > Flashcards

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

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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.

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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.

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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

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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

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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.

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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.

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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.

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9
Q

A

shoulder flexion/extension

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10
Q
A

external/internal rotation, arm in 90 degrees of abduction

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11
Q
A

posterior reach, internal rotation

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12
Q
A

wrist flexion and extension

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13
Q
A

ulnar and radial deviation

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14
Q
A

forearm rotation supination/pronation

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15
Q

tendon

A

Tough band of fibrous connective tissue that connects muscle to bone

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16
Q

Bursa

A

a sac lined with a membrane that produces and contains synovial fluid

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17
Q

Ligament

A

a short band of tough, flexible fibrous connective tissue that connects two bones or cartialges or hold together a joint

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18
Q

Joint

A

point at which two or more bones meet

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19
Q
A
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20
Q

Tough band of fibrous connective tissue that connects muscle to bone

A

tendon

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21
Q

a sac lined with a membrane that produces and contains synovial fluid

A

Bursa

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22
Q

a short band of tough, flexible fibrous connective tissue that connects two bones or cartialges or hold together a joint

A

Ligament

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23
Q

point at which two or more bones meet

A

Joint

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24
Q
A

external rotation, arm at side

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25
Q

When would you xray an ankle?

A

Signs of joint instability or fracture suspected

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26
Q

Grade 1 ankle sprain

Pathology

Findings

Treatment

Sequelae

A

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
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27
Q

Grade 2 Ankle Sprain

Pathology

Findings

Treatment

Sequelae

A

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
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28
Q

Grade 3 ankle sprain

Pathology

Findings

Treatment

Sequelae

A

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

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29
Q

Where is the Achilles tendon?

What are some disorders of the Achilles?

A

Where: posterior to ankle joint & flexes/extends ankle

tendinosis, paratendonitis, insertional tendinosis, and frank rupture

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30
Q

Achilles Tendonopathy

Clinical Presentation

Physical Examination

Diagnostics

A

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
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31
Q

Achilles Tendonopathy

DDx

Management

Complications

A

DDx

  • plantar fasciitis
  • Partial tendon rupture

Management

  • Immobilization
  • NSAID
  • Shoe inserts
  • 8 weeks to resolve

Complications

  • rupture
  • chronic pain
  • chronic foot drop
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32
Q

Achilles Tendon Rupture

Pathophysiology

Clinical Presentation

Physical Exam

Diagnosis

A

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
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33
Q

What is the Thompson test?

A

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

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34
Q

Achilles Tendon Rupture

Management

Complications

Education

A

Management

  • Immediate Referral; soft tissue emergency

Complications

  • weak/atrophy muscles = gait disorders

Education

  • Prevention
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35
Q

Plantar Fasciitis

Clinical Presentation

Physical Exam

Diagnostics

A

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
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36
Q

Plantar Fasciitis

DDx

Management

Complications

A

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
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37
Q
A
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38
Q

Morton Neuroma

Pathophysiology

Population Affected

Clinical Presentation

Physical Exam

A

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
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39
Q

What is the Mulder sign?

A

Tests for fibrotic neuroma

Squeeze medial and lateral sides of foot

+ Sign = reproducible pain or audible click

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40
Q

Morton Neuroma

Diagnostic

DDx

Management

A

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
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41
Q

Bursitis

Population at risk

A
  • acute trauma
  • repetitive injury
  • infection
  • gout
  • pseudogout
  • uremia
  • RA
  • Tb
  • DM
  • Immunosuppressed
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42
Q

Where is septic bursitis seen most often?

A

elbow and Knee

Olecranon and prepatellar since they are close to skin surface

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43
Q

Shoulder Bursitis

Clinical Presentation

Exam findings

A

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
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44
Q

how to perform the Neers Impingement Sign?

A
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45
Q

How to perform the Hawkin’s impingement sign

A
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46
Q
A

how to perform the Neers Impingement Sign?

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47
Q
A

How to perform the Hawkin’s impingement sign

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48
Q

Elbow (Olecranon) Bursitis

risk factors

Clinical Presentation

A

Risk Factors

  • Male
  • Manual Labor
  • Sports
  • Military

Clinical Presentation

  • Posterior elbow swelling
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49
Q

Hip Bursitis

Clinical Presentation

A

Clinical Presentation

  • Sudden or gradual
  • Possible radiation to lateral thigh
  • Worse at night
  • Pain on palpation
  • Hip flexion & rotation exacerbates pain
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50
Q

Knee Bursitis AKA??

Clinical Presentation EX what makes it worse or better?

Physical Exam #3

A

“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)
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51
Q

What is the Balottment test?

A

Tests for knee effusion

apply downward pressure to patella

click felt = effusion

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52
Q

What diagnostic tests would you order for bursitis and why?

A

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

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53
Q

What is US useful for identifying?

A

Rotator cuff

Baker’s cyst

Achilles Tendon pathology

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54
Q

When do you need to rule Septic Arthritis even if a noninfectious type of arthritis has already been diagnosed?

A
  • Acute or subacute presentation
  • Monoarticular
  • Not responding to anti-inflammatory treatment
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55
Q

Septic Arthritis

Pathophysiology

Clinical Presentation

A

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
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56
Q

Gonococcal Arthritis

Clinical Presentation

A

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
Q

Septic Arthritis

Diagnostics

A

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
Q

Septic Arthritis Management

A

Medical Emergency

Refer to ED

  • strict non weight-bearing
  • ID, rheumatology, Orthopedic surgery
59
Q

What are red flags with lower back pain?

A
  • >50 years
  • recent unexplained weight loss
  • failure to improve after 1 month conservative management
  • Fever
  • New lower extremity weakness
  • bowel/bladder dysfunction
60
Q

Difference in symptoms duration for low back pain

Acute

Subacute

Chronic

A

Acute: <6 weeks

Subacute: 6weeks - 3 months

Chronic: >3 months; symptoms >half of the days in the last 6 months

61
Q

What are two causes of low back pain?

A

Medical: inflammatory, infectious, neoplastic and visceral…rare but need time sensitive treatment

mechanical

62
Q

Describe axial low back pain

A

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
Q

Describe radicular low back pain

A

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
Q

Difference between neurogenic claudication vs vascular claudication r/t lower back pain

A

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
Q

Cauda Equina symptoms

A
  • urinary retention/incontinence
  • lower extremity weakness
  • recent onset erectile dysfx
  • hyporeflexia
66
Q

What does the straight leg test assess damage in?

A

Nerve root tension sign

L5 to S1

tests radicular pain

67
Q

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?

A

positive crossed straight leg raise

Increased specificity for disc herniation

68
Q

What is the femoral nerve stretch test?

A

root tension sign

looks at upper lumbar radiculopathy L2 - L4

+ if pain in anterior thigh

69
Q

When would you order imaging for someone with low back pain? What would be your first tool?

A

Red Flags

No improvement after 4-6 weeks

Plain xray

70
Q

What is a Trendelberg gait?

A

r/t defective hip abductor mechanism

Trunk shifts over the affected him while standing

shifts away affected hip during swing motion

71
Q

What is Antalgic gait?

A

walking with a limp

72
Q

What is the typical presentation of a medial collateral ligament (MCL) tear?

What do you perform to determine MCL laxity?

A
  • PAIN
  • (usually no instability or swelling)
  • tender at medial joint line at insertion point

Valgus Stress

73
Q

What is the typical presentation of a lateral collateral ligament (LCL) tear?

What do you perform to determine LCL laxity?

A
  • acute lateral knee pain
  • instability “knee gives way”

Varus Stress test

74
Q

Varus Stress test look for?

A

LCL laxity at 30 degrees flexion

75
Q

What does the Valgus Stress test look for?

A

MCL laxity

76
Q

Signs of an ACL injury

Tests to examine

A
  • “pop”
  • autonomic s/s: dizzy/sweaty/faint
  • Acute swelling within 2 hours
  • Unstable knee

Tests

  • “Lachman test”
  • Anterior drawer test
77
Q

What is the anterior drawer test? how to perform?

A

ACL assessment

Knee flexed 90 degrees with foot flat on surface.

Pull tibia forward

“soft” or absent end point = ACL tear

78
Q

What is the Lachman test?

A

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
Q

How is the knee meniscus usually injured?

A

the weight-bearing knee is twisted while it is partially flexed

Once torn the inner meniscus cannot heal d/t limited blood flow

80
Q

Clinical presentation of a meniscus tear?

How to test?

A
  • Joint effusion
  • tenderness along joint line
  • instability

Thessaly test

McMurray test

81
Q

What is the Thessaly test?

A

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
Q

What is the McMurray Test

A

Assess tear in knee cartilage

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
Q

What is patellofemoral pain syndrome?

Clinical presentation

A

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
Q

Prepatellar bursitis

Cause

S/S

Treatment

A

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
Q

Clinical presentation of cervical radiculopathy

Common causes

A
  • Neck pain extending to arm
  • Pain worse in am than neck
  • Neurologic findings: weak/numb/tingle

Common causes:

  • Herniated disk
  • Disc degeneration
86
Q

What is the Spurling maneuver?

A

Provocative test for cervical spinal root involvement

+ test = reproduction of symptoms down arm

87
Q

What is the Lhermitte sign?

A

electric shock sensation down the spine into limbs;

+ response = cervical cord disorders like compression, tumor or MS

88
Q

What are the Canadian Cervical Spine Rules? 6

A

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
Q

Osteoarthritis

Symptoms

Diagnostics

Management

A

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
Q

Acute vs chronic osteomyelitis

A

Acute: < 2 weeks

Chronic: >3months

91
Q

In a diabetic patient, an ulcer larger than ________ cm is highly suspicious of _______

A

2x2 cm

osteomyelitis

92
Q

Diagnostics for osteomyelitis

A

CBC

CRP

BC (if febrile or evidence of vertebral osteomyelitis)

Plain xray for bone changes

if x-ray normal, then mri

93
Q

Phamacologic management osteoarthritis

A

Stable patient = wait for culture

or

Empiric antibiotics to include MRSA =

  • Vanco & Ceftriaxone (3rd gen cephalo )
  • 2nd line: flouroquinolone
94
Q

Cervical radiculopathies feel better when the shoulder is in the ___ position

A

Cervical radiculopathies feel better when the shoulder is in the elevated position

95
Q

Pain during active but not passive ROM is suggestive of….

A

adhesive capsulitis/frozen shoulder

96
Q

Marked weakness in shoulder abduction and external rotation suggests…

A

rotator cuff tear

97
Q

What are the common causes of chronic shoulder pain?

A

rotator cuff disorders

adhesive capsulitis

shoulder instability

teninitis

arthritis

98
Q

__________ manifests as activity related shoulder pain.

A
99
Q
A
100
Q

Severe acute activity-related shoulder pain with restricted movement is likely ________

A

Severe acute activity-related shoulder pain with restricted movement is likely acute calcific tendonitis

101
Q

Pain in the should at night that makes sleeping on the affected arm impossible is ______ until proven other wise……..

A

rotator cuff disease

102
Q

Pain in the shoulder with repetitive overhead activity suggests _____

A

Pain in the shoulder with repetitive overhead activity suggests rotator cuff disease

103
Q

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 _______

A

RA

polymyalgia rheumatica

pseudogout

104
Q

Shoulder bursitis symptoms

A
  • 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
Q

What does the Adams test measure?

A

Scoliosis

106
Q

Define:

Angulated fracture

Transverse fracture

Oblique fracture

A

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
Q

What type of fracture is commonly seen in children?

A

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
Q
A
109
Q

Define

Comminuted fracture

avulsion fracture

A

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
Q

An inability to weight bear immediately after trauma is suspicious of?

A

fracture

111
Q

What does the Shuck test assess?

watson test?

A

carpal instability

scaphoid ligament instability

112
Q

What does the empty can or Jobe test evaluate the strength of what muscle?

A

supraspinatus

113
Q

What does the drop arm test signify?

A

inability to lower arm in controlled motion = rotator cuff injury

114
Q

What is used to assess ACL injury?

A

anterior drawer test

Lachman test

115
Q

What are the Ottawa Ankle rules?

A

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
Q

What movements indicate lateral epicondylitis?

A

lateral elbow pain with passive wrist flexion and active wrist extension

“tennis elbow”

117
Q

What movements indicate medial epicondylitis?

A

pain with resisted wrist flexion and forearm pronation and passive wrist extension

“golfer’s elbow”

118
Q

epicondylitis

What is it?

Presentation

Examination

DDx

Management

A

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
Q

Elbow sprains

Presentation

Examination

DDx

Management

A

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
Q

RADIAL HEAD FRACTURES

What is it?

Presentation

Examination

A

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
Q

RADIAL HEAD FRACTURE

DDx

Management

A

DDx

  • epicondylitis
  • capsular tear
  • cartilage injury

Management

  • PRICE
  • immobilization with arm flexed at 90 degees
  • Orthopedic referral
122
Q

ULNAR NEURITIS

What

Presentation

Examination

A

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
Q

Olecranon Burisitis

What

Presentation

Exam

A

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
Q

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

A

Anterior cruciate ligament tear (ACL)

125
Q

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

A

d. Conservative treatment with splinting and ice

126
Q

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

A

b. When the outcome of the imaging study will impact the management plan

127
Q

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

A

c. Discuss conservative therapy with ice/heat, NSAIDS and physical therapy

128
Q

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

A

c. Morton neuroma

129
Q

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

A

b. Asymmetry of the posterior chest wall

130
Q

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
A
  1. tenderness over medial malleolus
131
Q

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
A

fracture of the growth plate at distal fibula

132
Q

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
A

MCL sprain

133
Q

Fractures of the ____ bone occurs during a fall from an outstretched hand

A

scaphoid

134
Q

What are the Ottowa knee rules?

A

■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
Q

ACL

Typical Mechanism of injury

S/S

Characteristics

Diagnostic tests

Management

A

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
Q

PCL

Typical Mechanism of injury

S/S

Characteristics

Diagnostic tests

Management

A

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
Q

Meniscus

Typical Mechanism of injury

S/S

Characteristics

Diagnostic tests

Management

A

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
Q

MCL

Typical Mechanism of injury

Characteristics

Diagnostic test

Management

A

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
Q

What are the Ottowa ankle rules

A

–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

NURP532 (11 decks)

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