Week 5 Orthopedics Flashcards
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
C
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?
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.
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?
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.
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?
Salter-Harris classification
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?
Rotator cuff injury
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?
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.
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?
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.
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?
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.
shoulder flexion/extension
external/internal rotation, arm in 90 degrees of abduction
posterior reach, internal rotation
wrist flexion and extension
ulnar and radial deviation
forearm rotation supination/pronation
tendon
Tough band of fibrous connective tissue that connects muscle to bone
Bursa
a sac lined with a membrane that produces and contains synovial fluid
Ligament
a short band of tough, flexible fibrous connective tissue that connects two bones or cartialges or hold together a joint
Joint
point at which two or more bones meet
Tough band of fibrous connective tissue that connects muscle to bone
tendon
a sac lined with a membrane that produces and contains synovial fluid
Bursa
a short band of tough, flexible fibrous connective tissue that connects two bones or cartialges or hold together a joint
Ligament
point at which two or more bones meet
Joint
external rotation, arm at side
When would you xray an ankle?
Signs of joint instability or fracture suspected
Grade 1 ankle sprain
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
Grade 2 Ankle Sprain
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
Grade 3 ankle sprain
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
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
Achilles Tendonopathy
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
Achilles Tendonopathy
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
Achilles Tendon Rupture
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
What is the Thompson test?
Evaluates Achilles Tendon Rupture
- 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
Achilles Tendon Rupture
Management
Complications
Education
Management
- Immediate Referral; soft tissue emergency
Complications
- weak/atrophy muscles = gait disorders
Education
- Prevention
Plantar Fasciitis
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
Plantar Fasciitis
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
Morton Neuroma
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
What is the Mulder sign?
Tests for fibrotic neuroma
Squeeze medial and lateral sides of foot
+ Sign = reproducible pain or audible click
Morton Neuroma
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
Bursitis
Population at risk
- acute trauma
- repetitive injury
- infection
- gout
- pseudogout
- uremia
- RA
- Tb
- DM
- Immunosuppressed
Where is septic bursitis seen most often?
elbow and Knee
Olecranon and prepatellar since they are close to skin surface
Shoulder Bursitis
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
how to perform the Neers Impingement Sign?
How to perform the Hawkin’s impingement sign
how to perform the Neers Impingement Sign?
How to perform the Hawkin’s impingement sign
Elbow (Olecranon) Bursitis
risk factors
Clinical Presentation
Risk Factors
- Male
- Manual Labor
- Sports
- Military
Clinical Presentation
- Posterior elbow swelling
Hip Bursitis
Clinical Presentation
Clinical Presentation
- Sudden or gradual
- Possible radiation to lateral thigh
- Worse at night
- Pain on palpation
- Hip flexion & rotation exacerbates pain
Knee Bursitis AKA??
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)
What is the Balottment test?
Tests for knee effusion
apply downward pressure to patella
click felt = effusion
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
What is US useful for identifying?
Rotator cuff
Baker’s cyst
Achilles Tendon pathology
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
Septic Arthritis
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
Gonococcal Arthritis
Clinical Presentation
most common cause of septic arthritis in sexually active
2 distinct presentations
Arthritis-dermatitis Syndrome = disseminated bacteremic stage
- dermatitis = skin lesions in multi stages
- Tenosynovitis
- Migratory Polyarthritis
Localized septic arthritis
- arthritis now settled in just 1 joint
- synovial fluid more purulent
Triad
1.
Septic Arthritis
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
Septic Arthritis Management
Medical Emergency
Refer to ED
- strict non weight-bearing
- ID, rheumatology, Orthopedic surgery
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
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
What are two causes of low back pain?
Medical: inflammatory, infectious, neoplastic and visceral…rare but need time sensitive treatment
mechanical
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
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
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
Cauda Equina symptoms
- urinary retention/incontinence
- lower extremity weakness
- recent onset erectile dysfx
- hyporeflexia
What does the straight leg test assess damage in?
Nerve root tension sign
L5 to S1
tests radicular pain
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
What is the femoral nerve stretch test?
root tension sign
looks at upper lumbar radiculopathy L2 - L4
+ if pain in anterior thigh
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
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
What is Antalgic gait?
walking with a limp
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
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
Varus Stress test look for?
LCL laxity at 30 degrees flexion
What does the Valgus Stress test look for?
MCL laxity
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
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
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
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
Clinical presentation of a meniscus tear?
How to test?
- Joint effusion
- tenderness along joint line
- instability
Thessaly test
McMurray test
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
What is the McMurray Test
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
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
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
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
What is the Spurling maneuver?
Provocative test for cervical spinal root involvement
+ test = reproduction of symptoms down arm
What is the Lhermitte sign?
electric shock sensation down the spine into limbs;
+ response = cervical cord disorders like compression, tumor or MS
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
Osteoarthritis
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
Acute vs chronic osteomyelitis
Acute: < 2 weeks
Chronic: >3months
In a diabetic patient, an ulcer larger than ________ cm is highly suspicious of _______
2x2 cm
osteomyelitis
Diagnostics for osteomyelitis
CBC
CRP
BC (if febrile or evidence of vertebral osteomyelitis)
Plain xray for bone changes
if x-ray normal, then mri
Phamacologic management osteoarthritis
Stable patient = wait for culture
or
Empiric antibiotics to include MRSA =
- Vanco & Ceftriaxone (3rd gen cephalo )
- 2nd line: flouroquinolone
Cervical radiculopathies feel better when the shoulder is in the ___ position
Cervical radiculopathies feel better when the shoulder is in the elevated position
Pain during active but not passive ROM is suggestive of….
adhesive capsulitis/frozen shoulder
Marked weakness in shoulder abduction and external rotation suggests…
rotator cuff tear
What are the common causes of chronic shoulder pain?
rotator cuff disorders
adhesive capsulitis
shoulder instability
teninitis
arthritis
__________ manifests as activity related shoulder pain.
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
Pain in the should at night that makes sleeping on the affected arm impossible is ______ until proven other wise……..
rotator cuff disease
Pain in the shoulder with repetitive overhead activity suggests _____
Pain in the shoulder with repetitive overhead activity suggests rotator cuff disease
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
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
What does the Adams test measure?
Scoliosis
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
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
Define
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.
An inability to weight bear immediately after trauma is suspicious of?
fracture
What does the Shuck test assess?
watson test?
carpal instability
scaphoid ligament instability
What does the empty can or Jobe test evaluate the strength of what muscle?
supraspinatus
What does the drop arm test signify?
inability to lower arm in controlled motion = rotator cuff injury
What is used to assess ACL injury?
anterior drawer test
Lachman test
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
What movements indicate lateral epicondylitis?
lateral elbow pain with passive wrist flexion and active wrist extension
“tennis elbow”
What movements indicate medial epicondylitis?
pain with resisted wrist flexion and forearm pronation and passive wrist extension
“golfer’s elbow”
epicondylitis
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
Elbow sprains
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
RADIAL HEAD FRACTURES
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
RADIAL HEAD FRACTURE
DDx
Management
DDx
- epicondylitis
- capsular tear
- cartilage injury
Management
- PRICE
- immobilization with arm flexed at 90 degees
- Orthopedic referral
ULNAR NEURITIS
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
Olecranon Burisitis
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
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)
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
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
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
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
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
which of the following elements on physical exam would indicate the possibility of ankle fracture and should be evaluated by x-ray?
- ability to bear weight on affected ankle
- tenderness over medial malleolus
- swelling of affected ankle
- bruising of affected ankle
- tenderness over medial malleolus
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?
- sprained anterior talofibular ligament
- sprained deltoid ligament
- muscle strain
- fracture of the growth plate at distal fibula
fracture of the growth plate at distal fibula
which of the following knee injuries is least likely to cause acute swelling in the first 48 hours after injury?
- meniscus tear
- ACL rupture
- PCL rupture
- MCL sprain
MCL sprain
Fractures of the ____ bone occurs during a fall from an outstretched hand
scaphoid
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
ACL
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”
PCL
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
Meniscus
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
MCL
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
- Grade 1 = pain, no laxity = 3 weeks rest
- Grade 2 = pain, laxity but end feel = 8 weeks rest
- Grade 3 = laxity no end feel possible pain = 12 weeks rehab; 6 weeks brace
may need surgery
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
