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Emergency Medicine EOR > Orthopedics/Rheumatology > Flashcards

Orthopedics/Rheumatology Flashcards

1
Q

What is a sprain?

A

involves a ligament

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2
Q

What is a strain?

A

involves muscles and tendons

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3
Q

What is cervical sprain?

A

(whiplash) - can last 18+ months

- stiffness/pain in the neck; presents with paraspinal muscle tenderness and spasm and + Spurling test

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4
Q

What is the tx of cervical sprain?

A

treat with a soft cervical collar (2-3 days), application of ice/heat, analgesics, gentle active ROM soon after injury

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5
Q

What is a back strain (thoracic and lumbar strain)?

A

MC cause of back pain usually due to lifting, twisting, or strenuous activity

  • stiffness, difficulty breathing, axial back pain, and no radicular symptoms
  • no neurological changes (no pain below the knees)
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6
Q

What is the tx of back strain?

A

in the absence of “red-flag symptoms treat conservatively with NSAIDs, heat, ice, PT, home-based exercise

  • bed rest < 2 days, + NSAIDs +/- muscle relaxants (cyclobenzaprine) or short term benzodiazepine
  • resume activity as tolerated, re-eval if not improved in 4 weeks
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7
Q

What is bursitis?

A

inflammation of the bursa (thin-walled sac lined with synovial tissue); caused by trauma/overuse

  • pain, swelling, tenderness - may persist weeks
  • Tx: prevention of precipitating factors, rest, brace/support, NSAIDs, steroid injections
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8
Q

What is prepatellar bursitis (housemaid’s knee)?

A
  • pain with direct pressure on the knee (kneeling)
  • swelling over the patella
  • common in wrestlers: concern for septic bursitis in wrestlers - aspiration with gram stain and culture
  • treatment: compressive wrap, NSAIDs, +/- aspiration and immobilization
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9
Q

What is subacromial bursitis?

A
  • a condition caused by inflammation of the bursa that separates the superior surface of the supraspinatus tendon from the overlying coracromipal ligament, acromion, and coracoid (the acromial arch) and from the deep surface of the deltoid muscle
  • pain often not associated with trauma
  • pain on motion and at rest can cause fluid to accumulate
  • the presentation is very similar to what you would see with subacromial impingement
  • aspirate if fever, diabetic, or immunocompromised
  • treatment includes prevention of the precipitation factors, rest, and NSAIDs, cortisone injections can be helpful
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10
Q

What is tendonitis?

A
  • inflammation of the tendon commonly due to overuse injuries and systemic disease (arthritis)
  • features: pain with movement, swelling, impaired function, resolves over several weeks but recurrence common
  • Tx: ice, rest, stretching for inflammation
  • NSAIDs help but don’t penetrate tendon circulation; steroid injection + anesthesia may be beneficial
  • surgery for excision for scar tissue/necrotic debris if conservative measures fail
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11
Q

What is patellar tendinitis?

A
  • activity- related anterior knee pain associated with focal patellar tendon tenderness, also known as “jumper’s knee” (up to 20% of jumping athletes)
  • may present with swelling over tendon and tenderness at the inferior border of the patella
  • Basset’s sign: tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at the distal pole of the patella in full flexion
  • Radiographs. - AP, lateral, skyline views of the knee - usually normal - may show inferior traction spur (enthesophyte) in chronic cases
  • ultrasound - thickening of the tendon and hypo echoic areas
  • MRI in chronic cases - demonstrates tendon thickening
  • Ice, rest, activity modification, followed by physical therapy, surgical excision and suture repair as needed
  • cortisone injections are contraindicated due to the risk of patellar tendon rupture
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12
Q

What is biceps tendonitis?

A
  • patient will present with - pain at the biceps groove
  • anterior shoulder pain - may have pain radiating down the region of the biceps, symptoms may be similar in nature and location to the rotator cuff or subacromial impingement pain
  • pain with resisted supination of the elbow
  • x-ray to r/o fracture, ultrasound: can show thickened tendon within the bicipital groove
  • MRI: can show thickening and tenosynovitis of proximal biceps tendon - increased T2 signal around the biceps tendon
  • “Popeye” deformity - indicates a rupture
  • treat with NSAIDs, PT strengthening, and steroid injections
  • surgical release reserved for refractory cases for bicep pathology seen during arthroscopy
  • Special tests:
  • speed test: pain elicited in the bicipital groove when the patient attempts to forward elevate shoulder against examiner resistance while the elbow extended and forearm supinated, positive if the pain is reproduced, may also be positive in patients with SLAP lesions
  • Yergason’s test: elbow flexed 90 degrees, wrist supination against resistance, positive if the pain is reproduced
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13
Q

What is Cauda equina?

A

a rare condition usually involving a large midline disk herniation that compresses several nerve roots, usually at L4-L5 level

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14
Q

What are the signs and symptoms of Cauda equina?

A

leg pain, numbness, saddle anesthesia, bowel/bladder dysfunction and/or paralysis

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15
Q

How is Cauda equina dx?

A

MRI - new-onset urinary symptoms with associated back pain/sciatica need and MRI

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16
Q

What is the tx of Cauda equina?

A

this is a surgical emergency requiring immediate referral

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17
Q

What is Costochondritis?

A

inflammation of the cartilage that connect a rib to the breastbone

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18
Q

What are the characteristics of Costochondritis?

A
  • causes pain and tenderness on the breastbone, pain in more than one rib or pain that gets worse with deep breaths or coughing
  • risk factors: age > 40, high-impact sports, manual labor, allergies, rheumatoid arthritis, ankylosing spondylitis, reactive arthritis
  • Inflammation of the costochondral joints that causes localized pain and tenderness
  • overuse of chest wall muscles (painters, gardeners, etc.)
  • usually at multiple levels and lacking swelling
  • can affect children as well as adults
  • history of a URI with coughing, strenuous exercise, or physical activities
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19
Q

What is the presentation of Costochondritis?

A
  • chest wall pain described as sharp, aching, or pressure-like
  • exacerbated by upper body movements, deep breathing
  • can be noted at more than one location, but most often is unilateral
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20
Q

What is the diagnosis and exam of Costochondritis?

A
  • pain is reproduced with palpation of the chest wall area
  • x-ray, bone scan, vitamin D level, biopsy, ECG (rule out other things)
  • the diagnosis should be reconsidered in the absence of local tenderness to palpation
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21
Q

What is the tx of Costochondritis?

A
  • anti-inflammatories acetaminophen, non steroidal ibuprofen
  • applying heat with compresses such as heating pads
  • physical therapy, local steroid injection
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22
Q

What are the pearls of Costochondritis?

A
  • patients older than 35 years must be worked up for CAD such as EKG and troponin
  • pulmonary embolism can sometimes mimic like Costochondritis
  • tietze syndrome is an inflammatory process causing visible enlargement of the costochondral area “slipping rib syndrome”
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23
Q

What are the ddx of ecchymosis/erythema?

A

deep vein thrombosis, sprain/strain, cellulitis, rheumatoid arthritis, ulcers, ligament sprain, abuse and neglect, bruised ribs, DIC, fractures, septic joint

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24
Q

What are the causes of ecchymosis?

A
  • blood leaks form a broken capillary into surrounding tissue under the skin and causes a flat subcutaneous spot of bleeding
  • subcutaneous discoloration resulting form this seepage of blood within the contused tissue
  • while ecchymosis is not always a result of trauma, bruises and hematoma are typically caused by an injury
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25
Q

How is ecchymosis diagnosed and exam?

A
  • bruising and discoloration of the skin
  • can be from a dark purple color to a light tan color
  • ecchymoses also have a more diffuse border
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26
Q

What is the tx of ecchymosis?

A

ice packs and NSAIDS

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27
Q

What are the pearls of ecchymosis?

A
  • eccymosis is commonly seen in the ER after fractures because the bone is bleeding and the surrounding tissue
  • any extremity injury with ecchymosis is a fracture until proven otherwise
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28
Q

What are the causes and presentation of erythema?

A
  • characterized by the reddening of the skin, the appearance of the rash
  • erythema is caused due to injury or irritation is caused blood capillaries
  • It occurs with any skin injury, infection, or inflammation
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29
Q

What can erythema occur with?

A

inflammation, sunburn, allergic reactions to drugs (for example Erythema multiforme is an acute, immune-mediated condition characterized by the appearance of distinctive erythema-like target-like lesions on the skin

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30
Q

What is the tx of erythema?

A
  • must identify the underlying cause for treatment

- In other words, erythema is smoke, not fire

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31
Q

What is the pearl of erythema?

A

in the ER with orthopedic cases, erythema with increase temperature to the skin should alarm you to the fact that infection needs to be ruled out

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32
Q

What are the characteristics of a humerus fracture/dislocations?

A

MC site of radial nerve injury; posterior fat pad/sail sign, treat with sugar tong splint (distal) and computation splint (shaft) with ortho follows up in 24-48 hours

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33
Q

What are the characteristics of a supracondylar fracture/dislocations?

A

MC pediatric elbow fracture; usually from fall to outstretched hand; XR shows anterior fat pad (dark area on either side of the bone), check neurologic/vascular involvement (median nerve/brachial artery injury), long arm posterior splint followed by long arm casting (ORIF for displaced)

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34
Q

What are the characteristics of a radial head fracture/dislocations?

A

pain and tenderness along the lateral aspect of the elbow, limited elbow/forearm ROM, particularly pronation/supination; MC cause is falling on an outstretched arm; treat with a sling, long arm splint at 90 degrees, ORIF

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35
Q

What are the characteristics of a radial head subluxation (nursemaid) fracture/dislocations?

A

lateral elbow pain, hold the elbow in slight flexion and forearm pronated; pain and tenderness localized to the lateral aspect of the elbow; usually from pulling upward motion; the supination-flexion technique is classically used

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36
Q

What are the characteristics of a nightstick fracture (of ulna) fracture/dislocations?

A

usually from a blow; functional brace with good interosseous mold for isolated nondisplaced or distal 2/3 ulna shaft fx; ORIF if displaced

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37
Q

What are the characteristics of a Monteggia fracture/dislocations?

A

(proximal ulnar shaft fracture with radial head dislocation)
-elbow pain and swelling, tenderness to palpation along the elbow, decreased elbow ROM, the radial head may be palpable if dislocated, FOOSH, radial nerve injury, treat with ORIF

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38
Q

What are the characteristics of a Galeazzi fracture/dislocations?

A

(distal radial shaft fracture, dislocation of ulna)
-wrist pain, swelling, pain wit flexion/extension; FOOSH, falling on pronated hand, unstable fracture = ORIF, long arm splint

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39
Q

What are the characteristics of a Colles fracture/dislocations?

A

dorsally angulated extra-articular distal radius fracture; “fragility fracture “; FOOSH; causes dinner fork deformity; need lateral XR to make the diagnosis; treat with sugar tong splint/cast

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40
Q

What are the characteristics of a Smith fracture/dislocations?

A

extra-articular metaphysic fracture of the radius with solar angulation and displacement - garden space deformity; from fall with palm closed, hands flexed, blow to the back of the wrist; median nerve injury = common (can develop carpal tunnel over time); reduction/surgery or casting, PT for ROM and strengthening

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41
Q

What are the characteristics of a scaphoid fracture/dislocations?

A

FOOSH, snuffbox tenderness = treat as a fracture; pain on radial surface of the wrist at anatomical snuffbox, fracture may not be evident for up to 2 weeks; complication = avracular necrosis; treat with 10-12 weeks casting with a thumb spica splint

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42
Q

What are the characteristics of a Boxer’s fracture/dislocations?

A

fracture of the neck of the 5th/4th metacarpal; usually from a punch with a clenched fist, treat with ulnar gutter splint with joints at 60-degree flexion

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43
Q

What are the characteristics of a Bennett/Rolando of hand fracture/dislocations?

A

require ORIF

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44
Q

What are the characteristics of a should dislocation?

A

mode of injury = FOOSH (abduction and extension)

  • usually sports-related/in elderly
  • anterior: MC (arm = anterior) = arm is abducted and externally rotated (FOOSH)
  • posterior: the arm is adducted and internally rotated
  • In both: get x-ray (AP, axillary, and scapular view)
  • Tx: reduce, post reduction films, sling, and swath, PT
  • rotator cuff tear/labral tar also possible
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45
Q

What is Bankart lesion?

A

fracture of anterior inferior glenoid following impaction of the humeral head against glenoid

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46
Q

What is Hill-Sachs lesion (dent in the humeral head)?

A

compression chondral injury of the posterior superior humeral head following impaction against the glenoid

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47
Q

What is axillary nerve injury (C5-C6 fibers)?

A

transient neurpraxia present in 5% shoulder dislocations, numbness/tingling of lateral shoulder

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48
Q

What are the characteristics of a clavicular fracture?

A

usually from direct fall on the shoulder - a direct blow to the lateral aspect of shoulder/birth trauma in newborn

  • Middle third = MC
  • PE: swelling, erythema, tenderness to palpation, tenting of overlying skin, MC injured rotator cuff muscle = supraspinatus
  • X-ray: anteroposterior and clavicle view
  • tx: simple arm sling or figure of eight sling: 4-6 weeks adults, ortho consult if proximal 1.3; begin PT after 4 weeks with light strengthening after 6 weeks
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49
Q

What are the characteristics of a hip fracture?

A

sever hip, groin, thigh pain often with a history of recent trauma/fall; hip tender with pain on active and passive ROM

  • femoral neck = main blood supply to femoral head = medical circumflex femoral artery
  • log roll maneuver (internal and external rotation of leg elicits hip pain) which suggests femoral neck fracture
  • get AP x-ray of the pelvis; high incidence of avracular necrosis with femoral neck fractures
  • Tx: manage with ORIF; hip arthroplasty, DVT, prophylaxis until ambulatory
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50
Q

What are the characteristics of hip dislocation?

A

hip pain with leg shortened and internally rotated/adducted after trauma = MC cause (fall from height, MVA)

  • posterior dislocation in 90% = adducted, flexed, internally rotates; anterior dislocation = abducted, flexed, externally rotated
  • R/O sciatic nerve injury, prevent DVT
  • X-ray: posterior - femoral head superior to acetabulum; anterior - femoral head inferior to the acetabulum
  • tx: closed reduction under conscious sediation, open reduction if failure of closed reduction; repeat XR and neuromuscular exam after reduction
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51
Q

What are the Ottawa Knee Rules?

A

sensitive

  • age > 55
  • tenderness to the head of the fibular
  • Isolated tenderness to the patella
  • Inability to flex the knee to 90 degrees
  • Inability to bear weight for 4 steps both immediately and in examination room regardless of limp
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52
Q

What are the Pittsburgh Knee Rules?

A

greater specificity

  • recent fall or blunt trauma
  • age < 12 y/o or > 50 y/o
  • unable to take 4 steps unaided steps
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53
Q

What are the characteristics of knee dislocation?

A

usually after high impact trauma and pt can’t extend knee; worry about popliteal artery injury - diagnose with CT angiogram, get pre and post-reduction reduction X-ray; MRI required to eval soft tissue injury for surgical planning; orthopedic emergency à early reduction essential (check distal pulses and perineal nerve function)

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54
Q

What are the characteristics of tibial plateau fracture?

A

usually in children in MVA, get ap lateral oblique XR, if displace check perineal nerve (foot drop) - may need to confirm with CT/MRI, tx: non displace = cast 6-8 weeks; displaced= ORIF

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55
Q

What are the characteristics of patella fracture?

A

patella Alta (pulled quad muscles cause fracture displacement; tx = 6-8 weeks immobilization, may bear partial weight; displaced need ORIF

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56
Q

What are the characteristics of knee osteoarthritis?

A

degenerative disease of synovial joints that cause progressive loss of articular cartilage; pain worse with activities, swelling, stiffness, palpable crepitus on exam; XR shows joint space narrowing, osteophytes, subchondral sclerosis; tx = weight reduction, moderate activity, NSAIDs, intra-articular steroid injection, bracing, canes, muscle strengthening, PT; acetaminophen = first line, NSAIDs = second lines; total joint replacement indicated in advanced cases

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57
Q

What are the x-ray Ottawa ankle rules?

A
  • pain long lateral malleolus, medial malleolus
  • midfoot pain, 5’th metatarsal or navicular pain
  • unable to walk more than four steps in the ER or exam room
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58
Q

What are the characteristics of jones fracture?

A

proximal 5’th metatarsal diaphysis fracture; pain over the lateral border of foot; not benign (poor blood supply to that area); radiographs: AP later, oblique; tx: walking boot/cast, RICE, surgery for displaced, 6 weeks non-weight bearing

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59
Q

What are the characteristics of stress fracture?

A

common in athletes, military (overuse), most common in 3’rd metatarsal; dx: XR 50% negative, bone scan/MRI may show, tx: rest, splint, post-op shoe

60
Q

What are the characteristics of talus fracture?

A

high force impact (falling/snowboarding), x-ray demonstrates talus fracture, non-weight bearing cast for non-displaced, surgery for displaced

61
Q

What are the Weber Ankle Fracture Classification?

A

level of fibular fracture relative to the syndesmosis

  • fibular fracture below mortise, tibiofibular syndesmosis intact or mild tear, deltoid ligament intact or may be torn, stable or unstable
  • fibular fx above Mortise, tibiofibular syndesmosis torn with a widening of talofibular joint, deltoid ligament damage or medial malleolar fracture, unstable = ORIF
62
Q

What are the characteristics of ankle dislocation?

A

usually from fall, MVA, sports injury; can be damage to blood vessels/nerves/skin; tx = reduction +/- ORIF

63
Q

What is gout?

A

involves the accumulation of uric acid in the soft tissue of joints and bone

  • altered purine metabolism and sodium urate crystal precipitation into the synovial fluid, M>W (9:1) until menopause (1:1)
  • usually young, > 30 yo, asymmetric, great toe; tophi
64
Q

What are the signs and symptoms of gout?

A

MC = podagra (attack of MTP of the great toe) (70% of cases); pain, swelling, redness, exquisite tenderness, in chronic gout = tophi

65
Q

How is gout dx?

A

arthrocentesis - rod-shape negatively birefringent

  • serum uric acid level > 8 (not diagnostic)
  • Imaging: small, punched out lesions on XR = high likelihood diagnosis
66
Q

What is the tx of gout?

A

lifestyle: elevation, rest, decrease purines (meats, beer, seafood, alcohol), weight loss, increase protein, limit alcohol
- pharm: NSAIDs = drug of choice (indomethacin tid); colchicine = effective but bad GI s/e; steroid injections for those who can’t take NSAIDs, oral pred if other meds not tolerated
- thiazide diuretics and aspirin should be avoided
- the management between acute attacks: colchicine, allopurinol
- don’t start someone on allopurinol in an acute attack

67
Q

What is pseudo gout?

A

usually > 60 yo; large joints, lower extremity; no tophi

-similar gout symptoms

68
Q

How is pseudogout dx?

A

rhomboid-shaped calcium pyrophosphate crystals - positively birefringent
-XR shows fine, linear calcification in cartilage

69
Q

What is the tx of pseudo gout?

A

NSAIDs, colchicine, intra-articular steroid injections

-colchicine = prophylaxis, NSAIDs = acute attacks

70
Q

What is a herniated cervical disc?

A

usually posterolateral at C5-C6/C6-C7; pain into arm/shoulder, numbness/tinging pain into the arm with pain at rest until there’s movement; confirmed with MRI

71
Q

What are the signs and symptoms of C4 herniation?

A

weakness in shoulder elevation

72
Q

What are the signs and symptoms of C5 herniation?

A

weakness of shoulder abduction and external rotation; bicep reflex may be diminished

73
Q

What are the signs and symptoms of C5-C6 herniation?

A

pain at shoulder tip with radiation to the anterior upper arm, radial forearm, thumb; weakness with elbow flexion or shoulder external rotation

74
Q

What are the signs and symptoms of C6-C7 herniation?

A

affects C7 nerve root - pain at the shoulder blade, pectoral area, medial axilla, posterolateral upper arm, dorsal elbow and forearm, index, and medial digits or all of the fingers; diminished triceps reflex

75
Q

What are the signs and symptoms of C7-T1 herniation?

A

cause T8 radiculopathy - opponens pollicis and hand intrinsic muscles; weakness of finger abductors and grip strength

76
Q

What is a lumbar disc herniation?

A

pain in a dermatomal pattern - increases with coughing, straining, bending, and sitting (L5-S1 is most common)

77
Q

What is sciatica?

A

back pain radiating through thigh/buttocks (lower leg below the knee down L5-S1) - do straight leg raise, crossover test; dx = noncon MRI; tx: NSAIDs, rest, steroids, PT, epidural steroid injection, surgery if warranted

78
Q

What are red-flag symptoms of lumbar disc herniation?

A

fecal/urinary incontinence, saddle anesthesia, urinary retention, immunosuppresion, IVDU, fevers, chronic steroid use, focal neurological deficit, fracture/infection, trauma, >50 with mild trauma, neoplasm or fracture, history of CA, unexplained weight loss, no improvement after 6 weeks of conservative management

79
Q

What are the symptoms of L1 disc herniation?

A

inguinal region (rare)

80
Q

What are the symptoms of L12-L4 disc herniation?

A

spinal stenosis; anterior aspect of the thigh

81
Q

What are the symptoms of L5 disc herniation?

A

Mc radiculopathy: lateral aspect of the leg into the foot; strength can be reduced in foot dorsilfexion, toe extension, foot inversion, and foot eversion

82
Q

What are the symptoms of S1 disc herniation?

A

pain down the posterior aspect of the leg into the foot from the back; reduced strength with plantar flexion, ankle reflex loss

83
Q

What are the symptoms of S2-S4 disc herniation?

A

sacral/buttock pain that radiates down the posterior aspect of the leg into perineum = urinary/fecal incontinence and sexual dysfunction

84
Q

What is low back pain?

A

the most common causes of low back pain = prolapsed intervertebral disk and low back strain
-usually occurs within 24 hours of injury/overuse

85
Q

What are the features of low back pain?

A
  • pain originating in the back and radiating down the leg = nerve irritation
  • musculoskeletal usually located to one region/point tenderness
  • sciatica felt in buttock, posterior thigh, posterolateral aspect of leg around lateral malleolus to the lateral dorsum of the foot
  • unilateral low back and butt pain that gets worse with standing = SI joint involvement
  • pain in the elderly increased by walking and relieved by leaning forward = spinal stenosis
86
Q

How is low back pain dx?

A

x-ray usually not required if history and physical is benign/normal neuro exam

  • red flags: fever, weight loss, morning stiffness, IVDu/steroid history, trauma, cancer, saddles anesthesia, loss of anal sphincter tone, motor weakness = emergent x-ray
  • CT helpful in demonstrating bony stenosis and identifying lateral nerve root entrapment
  • MRI helpful for cord pathology, neural tumors, stenosis, herniated disks, and infections
  • get x-ray if pain persists
87
Q

What is the tx of low back pain?

A

short term rest (max 2 days), with support under knees and neck + NSAIDs

  • progressive walking to normal activities if pain subsides
  • postural exercises/back rehab
  • no improvement in 6 weeks = imaging to r/o spinal tumor/infection (if normal = rehab)
  • surgery if conservative tx fails (-5%)
88
Q

What is osteomyelitis?

A

acute or chronic infection and inflammation of bone and bone marrow - can occur as a result of hematogenous seeding, the contiguous spread of infection or direct inoculation into intact bone (trauma/surgery)

  • fever, restriction of movement of involved extremity or refusal to bear weight
  • S. aureus is the most common organism (80%)
  • pasteurella seen in case caused by cat/dog bites; salmonella in sickle cell; mycobacterium TB seen in vertebral involvement (Potts DZ); Staph epidermidis in prosthetic joints
89
Q

How is osteomyelitis dx?

A

with bone aspiration = gold standard

  • x-ray triad: demineralization, periosteal reaction, bone destruction (lags behind symptoms 7-10 days); MRI shows changes before XR
  • labs: CRP elevated for 4-6 weeks, WBC and ESR high in most cases
  • definitive diagnosis = blood cultures or by needle aspiration/bone biopsy
90
Q

How is osteomyelitis tx?

A

empiric therapy directed toward most probable organism and tailored once culture results are available

  • all hardware removed
  • IV antibiotics = 4-6 weeks for acute OM and > 8 weeks for chronic or MRSA
  • if diabetic foot ulcer is > 2 cm x 2 cm or bone is palpable osteomyelitis is likely
91
Q

What is non-opioid tools and function related outcomes?

A
  • before treating, first, differentiate acute pain from chronic pain (or acute flare of chronic pain)
  • if chronic pain - escalations in pain medication should be made with discussion with outpatient providers
  • if acute pain - determine nociceptive or neuropathic pain
  • discuss expectations upfront including function-related goals over the absence of pain
  • NSAIDs +/- acetaminophen are 1st line meds for most acute nociceptive pain and are just as effective as opioids
  • NSAID ceiling effect for analgesia:
  • naproxen: 500 mg (1000 mg/day)
  • ibuprofen: 400 mg (1200 mg/day)
  • diclofenac: 50 mg (150 mg/day)
  • scheduling NSAIDs and acetaminophen provide continuous pain control that avoids many of the challenges of PRN medications
  • Nonpharmacologic treatments include mobility with PT and heat/cold packs, OMT, acupuncture, massage, and others
  • consider topical analgesic patches (lidocaine 5%)
  • consider cymbalta for a combination of pain and depression
  • consider COX 2 inhibitors such as celebrex or mobic
  • consider muscle relaxants such as baclofen, cyclobenzaprine (flexeril), tizanidine (Zanaflex), etc.
  • consider gabapentin or TCAs (nortripytline) for neuropathic pain
  • consider referral to pain management
92
Q

What are the characteristics of NSAIDs in special populations?

A
  • in general, NSAIDs are not absolutely contraindicated in patients with chronic kidney disease, hepatobiliary/gastrointestinal disease, and cardiovascular disease
  • however - they should be used with caution and, in many cases, with oversight and assistance from subspecialists
  • to reduce risk of harm use less potent NSAIDs like naproxen and ibuprofen
  • Using NSAIDs at low doses and for short duration helps mitigate risk for kidney, cardiovascular, and GI disease
  • risk factors for GI toxicity:
  • history of a previously complicated ulcer
  • age > 65
  • high doe NSAID therapy
  • concurrent use of aspirin/corticosteroids/anticoagulants
  • low risk for GI toxicity = no risk factors, moderate risk = 1-2 risk factors, high risk > 2 or h/o previously complicated ulcer
  • consider a PPI while on NSAID therapy for moderate and high-risk patients
  • due to the risks of impairing prostaglandin-mediated renal perfusion, NSAIDs should be avoided in decompensated cirrhosis, bleeding risk is also significant in this population
93
Q

What is safe opioid prescribing?

A
  • it starts with a discussion of treatment goals and duration upfront
  • use low dose, oral, short-acting opioids for the shortest duration possible
  • combining opioids with non-opioid adjuvants like acetaminophen and NSAIDs creates an opioid-sparing and synergistic effect
  • it helps improve pain control at lower opioid doses
  • lower doses and shorter courses of opioids expose the patient to less risk of opioid related adverse effects
  • oral preferred over IV because there are less extreme peaks and troughs
  • immediate release preferred over controlled release formulations for better titration
94
Q

What is septic arthritis?

A

direct bacterial invasion of joint space - most dangerous form of acute arthritis = medical emergency

95
Q

What are the characteristics of septic arthritis?

A
  • a single, swollen, warm, painful joint that is tender to palpation + constitutional symptoms (fever, sweats, myalgia, malaise, pain)
  • MC = knee and hip
  • caused by: hematogenous spread, direct inoculation, contiguous spread
  • S. aureus is most common (40-50%); N. gonorrhea in sexually active young adults, streptococci; psudodomonas in IVDU
  • diagnose with arthrocentesis: joint fluid aspirate for definitive diagnosis (WBC > 50,000 primarily PMNs)
96
Q

What is the tx for septic arthritis?

A

based on gram stain - 2-4 week course of antibiotics + arthrotomy with joint drainage

  • staph aureus = vanco/nafcillin (Vanco or clindamycin if PCN allergic)
  • gonorrhea = ceftriaxone
  • IVDU = cipro/levaquin
97
Q

What is medial epicondylitis?

A

(golfer’s/pitchers elbow): overuse syndrome, pain with resisted wrist flexion and pronation, pain at the medial elbow may radiate to the wrist
-tx: activity modification, PT, steroid injection, surgery for a patient who failed PT for 4-6 mo

98
Q

What is lateral epicondylitis?

A

(tennis elbow): overuse syndrome; pain with wrist extension and forearm supination
-tx: activity modifcation, counterforce bracing, PT, steroid injection, surgery for failed PT 4-6 mo

99
Q

What is olecranon bursitis?

A

(scholar’s elbow) elbow swelling - nonseptic = acute trauma/repetitive trauma; septic = pain/fever (r/o septic/gout with aspirate)
-tx: PT, rest, ice, systemic antibiotic based on culture if septic, NSAIDs, injected steroids, operative

100
Q

What is cubital/ulnar tunnel syndrome?

A

caused by ulnar nerve compression at wrist

  • sx = paresthesias over small finger and ulnar half of 4th finger and ulnar dorsum of hand; worse with cell phone use, nigh sx caused by sleeping with arm in flexion , tinnel sign positive
  • tx: NSAIDs, activity medication, nighttime bracing, operative = ulnar nerve decompression
101
Q

What is carpal tunnel?

A

pain/paresthesia in median nerve distribution (first 3 digits and radial half of 4th digit; sx worse at night); Phalen (pushing backs of hands together) and + Tinel test (tapping over nerve); clinical dx; confirmed by nerve conduction studies
-tx = splint at night, steroid injection/oral, surgical decompression for severe

102
Q

What is De Quervain’s Tenosynovitis?

A

pain and swelling at base of thumb that radiates into the radial aspect of forearm + Finkelstein
-tx = thumb spica splint x 3 weeks, NSAIDs 10-14 days, steroid injections, PT

103
Q

What is thumb collateral ligament injury?

A

(gamekeeper/skier): ulnar collateral ligament injury from fall on an abducted thumb

  • gamekeeper = chronic; skier = acute
  • laxity and pain with valgus stretch; XR to evaluate for avulsion injury
  • tx: thumb spica splint 4-6 weeks
104
Q

What is Dupuytren contracture?

A

AKA claw hand (MC 4th and 5th digit): benign fibroproliferative disorder characterized by contracture of palms and palmar nodules - associated with alcoholic cirrhosis - painless nodules on palms, may limit function; tabletop test positive (lie flat on tabletop)

  • diagnosis = clinical
  • tx: injected collagenase or steroid, faciotomy or fasciectomy if patient is refractory to 1st line therapy
105
Q

What is mallet finger?

A

(baseball - tear at DIP joint): avulsion of extensor tendon = forced flexion; can’t straighten distal finger

  • XR = bony avulsion of the distal phalanx
  • tx: splint DIP uninterrupted extension x 6 weeks or surgical pinning
106
Q

What is boutonniere deformity?

A

(tear at PIP joint - jammed finger): PIP flexion and DIP hyperextension; usually from jammed finger, Elson test = bend PIP 90 degrees over edge of table and extend middle phalanx against resistance = weak PIP extension and DIP will be rigid; XR not required
-tx: splint PIP in extension x 4-6 weeks

107
Q

What is cellulitis caused by?

A

usually staph/strep

108
Q

What is paronychia caused by?

A

infection next to fingernail; acute = bacterial; chronic = fungal

109
Q

What is a felon?

A

abscess in the tip of the finger

110
Q

What is herpetic whitlow?

A

herpes virus infection around the fingernail (thumb sucking)

111
Q

What is a ganglion cyst?

A

noncancerous mucin - filled synovial cyst caused by trauma, mucoid degeneration, synovial herniation usually on the dorsal aspect of the wrist; usually asymptomatic, do Allen’s test to ensure radial and ulnar artery flow; U/S can differentiate a cyst from a vascular aneurysm; most ganglia don’t require treatment - observe
-aspirate (avoid on the volar aspect of wrist d/t radial artery - effective on only 50% of pt. Excision (severe sx or neurovascular manifestations)

112
Q

What is AC joint separation?

A

fall directly on shoulder or FOOSH, may have an elevation of clavicle (step off deformit) and point tenderness and pain with cross-chest testing; XR taken with pt holding weight to assess the level of injury to joint
-tx: conservative management can be sling/analgesia; more severe = operative repair

113
Q

What is biceps tendonitis?

A

pain at biceps groove, anterior shoulder pain, pain with resisted supination of elbow

  • dx: XR to r/o fx, U/S can show thickened tendon within bicipital groove; MRI shows increased T2 signal around biceps tendon; “popeye deformity” a rupture
  • tx: NSAIDs, PT, steroid injection; surgical release for refractory cases
  • speed’s: pt attempts to forward elevate shoulder against examiner resistance while the elbow extended and forearm supinated; positive with pain (SLAP lesion)
  • Yergason’s elbow flexed at 90, wrist supination against resistance
114
Q

What is rotator cuff tear/tendinopathy?

A

supraspinatus = MC injury; shoulder pain with overhead activity or at night when lying on arm/weakness and immobility after acute injury; shoulder pain with overhead activity or at night when lying o arm/weakness and immobility after acute injury; XR= initial imaging (loss of subacromial space due to upward migration of humeral head)

  • MRI = most accurate
  • tx = NSAIDs, steroid injection and surgical repair if you fail 3- mo of conservative
  • supraspinatus: empty can test, full can test, arm drop
  • subscapularis: lift-off test (elbow at 90, rotate medially against resistance)
  • teres minor/infraspinatus: elbow at 90, rotate laterally against resistance
115
Q

What is adhesive capsulitis?

A

insidious onset shoulder stiffness and pain at rest, decreased active and passive ROM, post-fracture looks like rotator cuff injury, apley scratch test
-tx = NSAIDs, PT, steroid injection

116
Q

What is subacromial impingement?

A

pain with reaching/lifting and pain with overhead motion

  • Neer test: arm fully protonated with pain during forward flexion while shoulder held
  • Hawkins: elbow/shoulder flexed at 90 with sharp anterior shoulder pain with internal rotation
  • Drop arm: pain with inability to lift the arm above shoulder or hold it
  • XR may show a subacromial spur
  • Tx: rest, ice, activity modification, NSAIDs, steroid injection, arthroscopic surgery if refractory to conservative
117
Q

What is subacromial bursitis?

A

inflammation of bursa from trauma/overuse; pain on motion and at rest a fluid accumulation; aspirate if fever, diabetic, immunocompromised
-tx: prevention of precipitation factors, rest, NSAIDs, steroid injections sometimes

118
Q

What is glenohumeral joint osteoarthritis?

A

more common in elderly; pain with activities

  • XR = subchondral clerosis and osteophytes at the inferior aspect of humeral head
  • MRI indicated to evaluate rotator cuff tendon
  • tx = NSAIDs, PT, steroid injections, total shoulder arthroplasty if unresponsive to conservative tx
119
Q

What is prepatellar bursitis?

A

pain with direct pressure on the knee, swelling over the patella, concern for septic bursitis in wrestlers
-tx: compressive wrap, NSAIDs, +/- aspiration and immobilization for 1 week; steroid use = controversial

120
Q

What is patellar tendinitis?

A

activity-related, “jumper’s knee”, swelling over tendon and tenderness at inferior border of patella; XR may show inferior traction spur in chronic cases (enthesophyte)

  • U/S = thickening tendon and hypoechoic areas
  • MRI shows tendon thickening
  • tx = ice, rest, activity modification, PT; surgical excision and suture repair as needed; steriod injection = CI d/t risk or tendon rupture
121
Q

What is an ACL tear?

A

pop and swelling along with instability or “giving out” the knee after plant and twist injury; quickly stopping movement and changing direction while running/landing jump = rotation or valgus stress = ACL injury; anterior drawer test, Lachman’s = most sensitive, MRI confirms diagnosis; PT and lifestyle modification for low demand pt; surgery for young/active

122
Q

What is a MCL injury?

A

valgus stress injury (hit in football); “pop” along with medial joint line pain, MRI = definitive, conservative tx with bracing and therapy = effective, surgery for grade III injury; Valgus stress test

123
Q

What is a LCL injury?

A

trauma to the inside of the knee; rare; MRI = definitive study; conservative treatment with bracing and therapy usually effective, surgery for grade III injury; Varus stress test

124
Q

What is a PCL injury?

A

blow to the knee while flexed or bend like landing hard during sports fall; test = posterior drawer sing, sag sign, MRI = confirms; protected weight-bearing and rehab for isolated grade I and II; surgical repair for PCL + ACL or PCL and PCL + grade III MCL or LCL

125
Q

What is a meniscal tear?

A

after twist injury with locking, feeling of knee giving away, a triad of joint line pain, effusion, locking; effusion usually 6-24 hours after injury; McMurray test/apley test

126
Q

What is an ankle sprain?

A

85% are in collateral ligaments a anterior talofibular ligament during inversion; deltoid affected by eversion

  • anterior drawer test, talar tilt test
  • Xray depends on Ottawa ankle rules: malleolar zone pain and bone tenderness at lateral or medial malleolus; can’t bear weight/take a few steps
  • Tx: rest, ice, NSAIDs, crutches , bracing, splinting, f/u with ortho based on Xray and dx
127
Q

What is an achilles tendon rupture?

A

“pop” then weakness, palpable gap + increased resting ankle dorsiflexion in a prone position with knees bend, + thompson test

  • MRI shows acute rupture with retracted tendon edges
  • tx: surgical repair for early ROM, splint with the ankle in some plantar flexion
128
Q

What is plantar fasciitis?

A

pain on the plantar surface usually at calcaneal insertion of plantar fascia upon weight bearing especially in morning/initiation of walking after prolonged rest (dancers, runners)
-tx: stretching, ice, calf strengthening, shoe inserts, NSAIDs

129
Q

What is tarsal tunnel?

A

posterior tibial nerve compression from overuse, restrictive footwear, +tinel’s sign

  • dx: nerve conduction test/electromyography
  • tx: avoid exacerbating activities, NSAIDs, steroid injection if no improvement, surgery
130
Q

What is a bunion (hallux valgus)?

A

deformity of the bursa over 1st metatarsal; hx of poorly fitted shoes/flate feet (pes planus) or RA; pain over prominence at MTP joint/pain with shoes

  • dx = XR
  • tx = comfortable wide toed shoes; surgical when sx present despite shoe modification
131
Q

What is morton’s neuroma?

A

painful mass near tarsal heads, MC in women with tight-fitting shoes, high heels; sharp pain with ambulation at 3rd metatarsal head; associated with numbess/paresthesia

  • MRI may be needed for diagnosis
  • tx = wide shoes, steroid injections, surgical resection if conservative management fails
132
Q

What is a sprain?

A

involves ligaments and a strain involves muscles and tendons

  • the symptoms of a sprain and a strain are very similar, that’s because the injuries themselves are very similar
  • remember a strain has the letter “t” for tendon
133
Q

What is a sprain?

A

a joint sprain is the overstretching or tearing of ligaments
-ligaments connect two bones together

134
Q

What are the characteristics of a sprain?

A
  • symptoms include pain, bruising, swelling, limited flexibility, decreased ROM
  • the most common location for a sprain is the ankle joint
  • caused by trauma or the joint being taken beyond its functional range of motion
  • ranges from a minor injury resolve in a few days
  • major rupture of one or more ligaments requiring surgical fixation
  • can occur at any joint but are most common in wrist and ankle
135
Q

What are the classifications of a sprain?

A
  • first degree sprain (ild) the fibers of the ligament are stretched but intact
  • second-degree sprain (moderate) is a tear of a ligament, from a third to almost all its fibers
  • third-degree sprain (severe) is a complete rupture of the ligament, sometimes avulsing a piece of bone
136
Q

How is a sprain dx?

A

often clinical = X-ray or MRI

137
Q

What is the treatment for a sprain?

A

RICE include

  • Rest: the sprain should be rested, no additional force should be applied on the site of the sprain
  • Ice: ice should be applied immediately to the sprain to reduce swelling and pain, it can be applied for 10-15 minutes at a time, 3-4 times a day, ice can be combined with wrapping to minimize swelling and provide support
  • Compression: dressings, bandages, or ace-wraps should be used to immobilize the sprain and provide support
  • Elevation: keeping the sprained joint elevated
138
Q

What are the pearls of sprain?

A

in the ER with orthopedic cases sprains deal with ligament and RICE and anti-inflammatories are 1st line therapy

139
Q

What is a strain?

A

a joint strain is the overstretching or tearing of muscles or tendons
-tendons connect bones to muscles

140
Q

What are the characteristics of a strain?

A
  • muscles or tendon fiber tear as a result of an acute or chronic injury
  • the muscle fibers tear as a result of chronic overstretching or an acute injury
  • the most common locations for a muscle strain are the hamstring muscle and the lower back
  • symptoms include pain, muscles spasms, swelling, limited flexibility, decreased ROM
  • acute strains are more closely associated with recent mechanical trauma or injury
  • chronic strains typically result from repetitive movement of the muscles and tendons over a long period of time
141
Q

What is the classification and diagnosis of strain?

A

Degrees of injury (as classified by the American College of Sports Medicine)

  • first degree (mildest) - little tissue tearing; mild tenderness; pain with a full range of motion
  • second degree - torn muscle or tendon tissues; painful, limited motion; possibly some swelling or depression at the spot of the injury
  • third-degree (most severe) - limited or no movement; severe acute pain, though sometimes painless straight after the initial injury
142
Q

What is the tx of a strain?

A

RICE include:

  • Rest: The strain area should be rested, no additional force should be applied on the site of the strain
  • Ice: ice should be applied immediately to the strain to reduce swelling and pain, it can be applied for 10-15 minutes at a time, 3-4 times a day, ice can be combined with wrapping to minimize swelling and provide support
  • Compression: dressings, bandages, or ace-wraps should be used to immobilize the strain area and provide support
  • Elevation: Keeping the strained muscle elevated
  • Physical therapy for the strained muscle or tendon can be schedules after at least 7 days of rest
143
Q

What are the pearls of a strain?

A

strains deal with injuries to muscles and tendons while sprains deal with ligaments

144
Q

What are the causes and presentation of swelling/deformity?

A
  • in the emergency room swelling and deformity after an acute injury can be either be a fracture and/or dislocation of a specific joint or area
  • it is imperative to make sure that the vascular area distal to the swelling and/or the deformity is intact
  • any type of vascular compromise distal to a deformity must be treated immediately
  • for example, in an elbow supracondylar fracture, the median nerve can be compromised distal to the fracture
  • another example is during a knee dislocation the popliteal artery can be compromised and the knee dislocation needs to be reduced immediately afterward usually a CT angiogram of the knee is done to rule out any type of vessel injury
145
Q

What is the tx for swelling/deformity?

A
  • x-ray imaging and sometimes a CT scan of the area of deformity and swelling area needs to be done to rule out a fracture and/or dislocation
  • if dislocation is present reduction is next management
  • if a fracture is present reduction is the next in management or possible surgery depending on the severity of the fracture
146
Q

What are the pearls of a strain?

A

Any type of ER orthopedic injury with swelling or deformity needs to be immediately evaluated for neurovascular compromise if it is present the deformity whether it be a fracture or dislocation needs to be reduced immediately

Emergency Medicine EOR (12 decks)

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