Clin Med Exam 3 Flashcards
(212 cards)
1
Q
FAI- Femoroacetabular Impingement
A
Groin and/or lateral hip pain
Bone overgrowth/abnormality tears labrum or destroys cartilage
2
Q
FADIR and FABER tests are best for checking for
A
FAI- Femoroacetabular Impingement
3
Q
Labral Tear of Hip
A
Groin pain, often radiates to lateral hip, anterior thigh, and buttocks
Catching and Clicking
MR ARthrogram best form of dx
4
Q
Snapping Hip Syndrome
A
Snapping or popping with walking/ getting up from chair, or swinging leg
Muscle/tendon is sliding over bony prominence
External (IT band) vs Internal (Iliopsoas tendon)
5
Q
Tx of Snapping Hip Syndrome
A
NSAIDs, avoid painful activity, Steroid Injection
PT, stretching, US, heat/ice, myofascial release
Iontophoresis- voltage current
6
Q
Greater Trochanteric Pain Syndrome
“Trochanteric Bursitis”
A
most common cause lateral hip pain in adults
Repetitive overload tendinopathy, bursa inflamed
Pain worse when lying on side
7
Q
Greater Trochanteric Pain Syndrome
A
Worse w lying on side, walking, staris, incline, prolonged standing
Trendelenburg Sign
8
Q
Tx for Greater Trochanteric Pain Syndrome
A
Self limiting but can do NSAIDs, heating pad, sit differently, Steroid injection
9
Q
MCL sprain
A
Often part of unhappy triad: MCL, ACL, and Medial meniscus
10
Q
MOI for MCL Sprain
A
knee flexion, foot planted, and Lateral Impact causing valGUM stress and rotation
11
Q
ACL injury
A
most common knee ligament to be injured
ACL prevents anterior movement of the tibia
12
Q
MOI for ACL injury
A
Noncontact: quick change w pivoting
Contact: direct blow causing hyperextension and again valGUM stress w lateral impact
Feel a “POP” then pain and swelling
Pt reports feeling very unstable
13
Q
ACL presentation
A
Joint effusion, guarding, able to bear wait w/laxity and feel very unstable
14
Q
Test for ACL injury
A
Lachman, Anterior Drawer, Pivot shift
15
Q
Imaging for ACL
A
MRI preferred
16
Q
PCL
A
largest and strongest ligament of knee
MOI: high force trauma (MVA) vs low force (soccer)
least likely to be injured during sports
17
Q
PCL injury
A
presentation varies. may be subtle or very unstable
General knee pain, pt says “something just isn’t right”
Limp
18
Q
PCL tests
A
Posterior drawer sign and Posterior sag sign
19
Q
Meniscus injury
A
Excessive rotational force
Medial meniscus is most vulnerable to injury
Joint line pain, unable to fully extend
knee “locking” or “catching”
20
Q
Meniscus tests
A
McMurray, Apley Grind
21
Q
Patellofemoral Pain Syndrome
A
“Runner’s knee”
22
Q
Patellofemoral Pain Syndrome/ Runner’s Knee
A
Most common knee complaint
Malalignment!!
Anterior pain under patella, worse w stairs
Crepitus, popping, feeling unstable
23
Q
Patellofemoral/Runner’s knee
Jenn
A
+theater or long car ride sign
Test: Patellar glide and Apprehension
Tx: Ice, NSAIDs, strengthen hip aBductors and quads, stretch hamstrings, core, taping, stabilizing brace
24
Q
Baker’s/Popliteal cyst
A
often asymptomatic
foundon accident
pain/swelling w prolonged activity or standing
NSAIDs, Aspirate, Injection, Compressive neoprene brace
25
Patellar Tendonitis "jumper's knee"
patellar tendon inflammation
repetitive trauma
Running, jumping, kicking sports
Worse w excessive foot pronation and running on hills
Ice, NSAIDs, brace, strap, modify activity, rest, PT
26
IT Band syndrome
overuse injury
Runners, cyclists
gradual onset of localized pain
localized tenderness that is reproducible with ROM and compression to ITB region
*Evaluate for LLD
27
Knee Bursitis
Prepatellar and Pes Ansarine regions are most common
Trauma vs Overuse
*Rule out infection!
NSAIDs, avoid irritating factors, Aspirate/steroid injection, padding/bracing
28
Osteochondritis Dissecans
Necrosis of subchondral bone
10-20 YO, Young
Repetitive loading in wt bearing joints- elbows, knees
Gymnasts, Throwing sports
29
Osteochondritis Dissecans
Trauma --> focal hypovascularity --> necrosis --> Chondromalacia --> Articular fragment
30
Osteochondritis Dissecans
intermittent swelling, popping, locking, catching in advanced disease
Pain, guarding possible
X Ray shows flattening of articular surface (Crater)
31
Tx of Osteochondritis Dissecans
Stage I-III: Conservative, avoid running/jumping, Immobilize for months and maybe PT
Stage IV: Surgery. Drill to promote new bone growth. Fixation if there is an unstable lesion and remove loose bony fragment
32
Lateral Ankle Sprain
Most commonly injured
Lateral Ligament Complex:
Anterior talofibular ligament
Calcaneofibular ligament
Posterior talofibular ligament
Inversion injury
Anterior drawer test
33
Medial ankle sprain
Deltoid ligament
Eversion injury
34
Syndesmotic ankle sprain
High ankle sprain:
Anterior and Posterior Talofibular, Transverse Tibiofibular, Interosseous membrane
Dosiflex/rotational injury
35
Test for Syndesmotic Ankle Sprain
Squeeze test
36
Tx for Ankle Sprains
RICE, NSAIDs, +/- short immobilizer for grade II-III to prevent repeat injury, brace/tape
37
Achilles tendon
Acute: tendinopathy, rupture
Peds: Calcaneal Apophysitis "Sever's Disease"
38
Achilles tendon rupture
Sensation of violent hit or pop, maybe painless
Palpate in plantar and dorsiflexion
39
Test for Achilles Tendon
Thompson test- there should be plantar flexion movement when calf squeezed
40
Tx for Achilles Tendon
Equinus splinting, boot allowing for constant plantar flexion
Constant PLANTAR FLEXION
41
Plantar Fasciitis
First step in morning painful
can be d/t activity, heel spurs, pes planus, ankle pronation, poor shoe wear
Worse w/ROM that places fascia under sprain
Ortho or podiatry referral only for severe: Steroid injection, Splinting, Casting
42
Gout
Monosodium Urate Cyrstals
>6.8 is Hyperuricemia
1st MTP Joint "Podagra"
X Ray: "punched out" "rat bite erosions"
43
Gout
Negatively birefringement and Needle shaped
44
Tx of Gout
Allopurinol: DOC
(Febuxostat is another option but has FDA cardiovascular warning)
Acute flare: NSAIDs (48hrs), Glucocorticoids, Colchicine (24hrs)
When starting meds, use NSAIDs or Colchicine to reduce risk of acute flare
45
Pseudogout
Calcium Pyrophosphate Crystal Disease
Older ages
Associated w/ Hemochromatosis and Hyperparathyroidism
Knee
Chondrocalcinosis
Positively bifringent and Rhomboid shaped
46
Tx for Pseudogout
Steroid, NSAIDs, or Colchicine
Prophlyactic if 3 or more attacks/year: Colchicine daily
47
Reactive Arthritis
1-4 wks after GI or GU infection
Young adults
"Cant see, cant pee, cant climb a tree"
HLA B27 Positive, RF negative
2/3 cases self-limiting, refer to Rheumo if needed
Treat arthritis: NSAIDs, then Steroids, then DMARDs (only progress to the next one if first doesn't work)
48
Ankylosing Spondylitis
Axial
Starts at SI joints and progresses proximally
Young adults, <40
Ossification "Bambo Spine"
Labs show ESR, CRP elevated
X Ray shows Hallmark Sacroilliitis
Improves w/exercise
GREAT RESPONSE TO NSAIDs
49
Lupus SLE
Genetic, immunologic, hormonal, environmental factors --> Antinuclear Antibodies
Malar butterfly rash, Discoid rash
Increased risk MI
+ Anti- DNA, Anti-Sm Ab, and ANA
Daily Hydroychloro/ Plaquenil!!!! Optho f/u always
Based on severity, can add: NSAIDs, steroids, immunosupp
50
Drug induced Lupus
Procainamide, Isoniazid, Hydralazine
Will have + Antihistone antibody, but negative anti-dsDNA and anti-Sm Ab
51
Polymyositis/ Dermatomyositis
Proximal muscle weakness (groceries and getting up from chair is difficult)
Gradual
LUNG STUFF- interstitial lung disease and scarring of lung tissue
Cutaneous addition: Heliotrope rash, Gottron's papules, Shawl sign
Tx: Glucocorticoids
may add immunosupp (MTX or Azathio)
52
Sjogrens Syndrome
Sicca comples -dry eyes and mouth
Schirmer test
Anti-Ro and Anti-La
53
Polyarteritis Nodosa PAN
only arteries affected-narrowing
Thrombosis, Ischemia, Infarct
Skin biopsy: Leukocytoclastic Vasculitis
Renal manifestation (kidney) most common!
ANCA negative lab
Steroids, may add Immunosupp if severe
54
Systemic Sclerosis
narrowing of small vessels
Limited Cutaneous vs Diffuse Fibrosis
limited: CREST
diffuse: rapid tightening of skin, organ damage risk
tx: none really, pt education and symptomatic
55
RA
```
synovial joints
boggy
periphery--> proximal
Morning stiff >1hr
better w exercice
SPARES DIP
Trigger finger, Swan neck, Boutonniere, Ular drift
```
Cervical --> cervical myelopathy if sublux
X Ray: arrowhead, joint space narrowing, bony erosion
Anti CPP is more specific for RA
EARLY USE OF DMARDs
56
Felty's syndrome is a triad of RA
Anemia
Splenomegaly
Neutropenia
57
Tx for RA
EARLY USE OF DMARDs
58
DMARDs
Traditional/synthetic
Biologic (TNF vs non)
JAK inhibitor
59
OA
Involves all joint tissues
OLD AGE
joint space narrows leading to bony changes
OSTEOPHYTES (bone spurs)
Relieved by rest- ZzzZzZ
Herberden's, Bouchard's nodes
First MCP joint "Squared Off"
NSAIDs, Cymbalta, Tramadol, Acetaminophen, Steroid
60
Polymyalgia Rheumatica
Old man
Proximal stiffness and aching
Assoc w/ Giant Cell Temporaritis
Rapid Improvement with LOW DOSE GLUCOCORTICOIDS!!!
61
Fibro
3 months or greater of sx
Female, 20-50s most common
Often occurs w Lupus or RA
Tricyclic antidepressants, Seretonin and NE reuptake inibitors (SNRIs)
Cymbalta
Savella
Anticonvulsants- Lyrica, Neurontin
62
Tests for Impingement
Neers, Hawkins
Tx: NO ARM SLING, Do physical therapy and f/u in 2-3 weeks
Possible steroid injection
63
Labral Tear of shoulder
can be acute or repetitive
Acute: FOOSH, sudden pull
Often accompanied by another shoulder issue
Bankar lesion- inferior tear assoc w dislocation
SLAP lesion- around the top rim
Biceps tendon pain, restricted rotation, scapula motion dysfx
64
Tests for Labral Tear
Anterior glide
Speed's
O'Brien's
Imaging: MRArthrography preferred
65
Frozen Shoulder
May develop adhesions
Reduced ROM in 2 OR MORE planes
Mechanical restriction
Apley Scratch Test
Physical Therapy ASAP rocky
66
AC Sprain/Separation
assoc w/ classic Football Fall
Fall onto tip of shoulder w/arm tucked
Worse @ bedtime
3 degrees depending on how many ligaments involved
67
Ligaments of AC Sprain/Separation
Coracoclavicular x2 (Trapezoid & Conoid)
Acromioclavicular
Coracoacromial
68
Test for AC injury
Cross Over (cross-body adduction)
69
AC injury tx
Reduce pressure and traction to allow ligaments to reform and strengthen
Shoulder immobilizer 3-4 wks
Steroid injections if not improving 2-4 wks, Surgery for grade 3
70
Clavicular fracture
Tenting of skin, Decreased ROM
Conservative for minimally displaced, non displaced, and ALL PEDS
Try Sling, Swathe vs Figure 8 Harness
Analgesics, Sleep upright, cosmetic
71
When to refer to Ortho for Clavicle fracture
All distal 1/3, All proximal 1/3, or displaced
72
Subacromial Bursitis (shoulder)
Inflammation or degeneration of bursa
Repetitive movement
May results from systemic disease- RA, gout, sepsis
R/o sepsis!! Fluid aspirate if needed
Can inject steroids if infection is ruled out
73
Biceps Tendonitis
inflammation of long head biceps tendon
Repetitive lifting
Pain on anterior shoulder w/aBduction and external rotation
Yergasons and Speeds
Reduce inflamm, swelling, and prevent rupture
Ice, NSAIDs, PT, steroid injection?, surgery
If rupture: POPEYE deformity
74
Myelopathy
damage to Spinal Cord
75
Radiculopathy
damage to Nerve Root
R & R
76
Myelopathy sx
BELOW THE LESION
Spasticity, up going plantar reflex (Babinski sign), Clonus (sustained), "Lhermitte sign" pain down spine/extremities with neck flexion
77
Radiculopathy sx
DERMATOMAL PATTERN
Hypotonia
Muscle atrophy, fasciculation
78
sTrain
muscle, tendon
79
sPrain
ligament (bone-bone)
80
Nexus Criteria: if all 5 are met, no need to image before assessing ROM or manipulation
```
No posterior midline tenderness
Normal alertness
No intoxication
No abn neuro findings
No other painful inj
```
81
Reasons to get AP, lateral, AND Odontoid X Ray for Cervical
if Trauma or pt is OLDER
82
Opoids
No longer than 1-2 weeks
83
Resolution of Cervical sprain/strain
4-6 weeks
| Whiplash may take longer
84
Cervical and Lumbar Radiculopathy
Onset can be abrupt or occur and worsen
85
Radiculopathy
follow nerve pattern!!!
86
Cervical Radiculopathy
can include radicular pain/paresthesia with neck flexion
87
Cervical Radiculopathy
Typically Unilateral
unless stenosis
88
How to relieve Lumbar Radiculopathy
Lie on back with knees elevated or in fetal position
89
Impingement b/w L1 and L4 can cause:
Anterior thigh pain
90
Impingement from L4 and below:
Pain radiates down to foot
91
Physical Exam for Radiculopathy
Motor, Sensory, and DTR dysfx should follow nerve distribution
92
Cervical Radiculopathy
DROM, loss of cervical lordosis
93
Lumbar Radiculopathy
Positive straight leg
Reverse straight leg raise for lesion above L4 (L1-L4)
Typically + low back pain/spasms
94
What is the cutoff for whether radiculopathy pain is on anterior thigh or on the shin?
at about L4
L1-L4
L4 and below
95
Order MRI for Radiculopathy IF:
- Sx >4 weeks
| - Immediately IF significant neuro deficit or if myelopathy is identified
96
Tx of Radiculopathy
If nonprogressive Neuro sx:
| NSAIDs, steroids, PT
97
Tx of Radiculopathy
If confirmed and severee pain with worsening Neuro deficits:
Epidural Injections
Surgery Referral if no improvement after injections or concern for myelopathy
(2-3 injections then refer)
98
Spinal Stenosis
can be Acquired or Congenital
99
Acquired Spinal Stenosis
D/t: spondylosis (fracture), spondylolisthesis (anterior slippage), Herniated disc and lig flavum thickened, traumatic and post op fibrosis, skeletal disease (RA, ankylosing spondylitis)
100
Congenital Spinal Stenosis
Dwarfism, Congenitally small spinal canal, Spina Bifida
101
Lumbar Spinal Stenosis
Most common cause of neuro leg pain in Elderly
Neurogenic claudication: progressive leg pain worse w/ standing or walking
relieved by leaning forward "Shopping cart sign"
Radicular sx can be present without actual back pain
102
Most common cause of Lumbar Stenosis
Spondylosis (fracture)
| +/- Ligamentum Flavum Hypertrophy
103
Cervical Stenosis
most common cause of myelopathy in elderly
d/t progressive spondylosis with Bone spur formation, disc herniate, and lig flavum hypertrophy
varying signs
104
Cervical and Lumbar Stenosis Imaging
MRI preferred!!
CT myelogram is good but invasive
EMG/NCS if unclear to r/o other dx
105
Stenosis tx
NSAIDs initially for pain
Cervical brace and activity restriction
Consider PT and Core strengthen for Lumbar Stenosis (aerobics for elderly)
Epidural steroid injections
Surgical decompression or fusion if sig stenosis or neuro changes/severe pain
106
Cauda Equina
EMERGENCY
Compression of lumbar, sacral, coccygeal nerve roots
sx vary greatly
Hx very important, esp malignancy
107
Causes of Cauda Equina
Intervertebral disc herniation, epidural abscess, tumor, lumbar stenosis, metastatic, infectious, autoimmune
108
Cauda equina sx
LBP w radiation into 1 or both legs
Leg weakness multiple distributions L3-S1
Weak plantar flexion, loss of ankle reflex S1-2
Perineal sensory loss
"Saddle anesthesia" , urinary retention, incontinence fecal and urinary, sexual dysfx
109
Tx of Cauda Equina
Dexamethasone 10 mg IV immediately!!
Emergent MRI WITH CONTRAST
if not avail, CT myelogram
110
Tx Cauda Equina
Scan entire spine if concern for metastasis or unsure of cause
Tx depends on cause of cord compression
Surgical consult for decompression/radiation therapy if CA
Prognosis variable
111
Red Flags for Malignancy
```
Unexplained weight loss
Failure of pain to improve with tx
Pain > 1 month
Pain at night-wake frm sleep
PMHx CA
>50 YO
New onset spine pain w known malignancy is metastatic until proven otherwise
```
112
Red Flags for Infection
```
Pain at rest
BP with FEVER
Immunocomp
IV drug user
Recent hx of infection, i.e.: UTI, PNA, Cellulitis
```
113
Thoracic Outlet Syndrome
compression of neurovascular bundle above 1st rib and behind the clavicle
Repetitive: pitching athletes
Cervical rib anomaly
Muscular anomaly
Injury (Trauma, fracture)
114
Three types of Thoracic Outlet Syndrome:
Neurogenic (nTOS)- 95% brachial plexus compression
Arteriol (aTOS)- subclavian artery compression
Venous (vTOS)- subclavian vein compression
115
nTOS presentation
compression in the scalene triangle
reproducible w elevation of arm
upper ext pain, dysesthesia, weakness/numbness
may not be specific nerve distribution
116
nTOS presentation
progressive, unilateral weakness of Hypothenar muscle
Numbness in Ulnar OR Medial nerve distrib
Tenderness over Scalene Muscles
117
aTOS presentation
sx develop spontaneously (not related to work/trauma)
almost always assoc with CERVICAL RIB
Thromboembolism to hand or arm
Arm/hand ischemia: pain, paresthesia, pallor, coolness
Pulse @ wrist may be diminished or absent
118
vTOS
typically related to vigorous, repetitive UE activity
Upper ext venous thrombosis
SWELLING OF EXTREMITY- hallmark (paresthesia is secondary to swelling)
Cyanosis, ext pain, fatigue in forearm within minutes of use
119
Dx of TOS
Electrodiagnostic testing - particularly with nTOS
Brachial Plexus Block- nTOS
US- initial for artery or vein
CXR- bony anomaly, good for artery one bc artery one is 90% assoc w bony anomaly
CT angiography/venography to appreciate UE vasculature
MRI w contract
120
tx of nTOS
PT 4-6 wks
Steroid, Botulinim toxin type A
Decompression surgery for worsening sx, or if failed conservative
121
tx of vTOS
Catheter directed thrombolysis (best w/in 2 wks of sx onset)
| Decompressive surgery
122
tx of aTOS
Decompressive surgery
| Surgical Embolectomy- very dangerous and can result in further injury
123
Elbow epicondylitis
medial- golf. wrist flexors
lateral- tennis. wrist extensors
sling, WRIST brace (even though prob is at elbow), ice (only right after activity), Anti-inflammatory
124
Prevent elbow epicondylitis
Forearm strap, stop activity, correct technique
125
Treat recurrent elbow epicondylitis
Steroid injection, surgery
| usually do NOT inject on medial side d/t Ulnar nerve location
126
Olecranon Bursitis
trauma, prolonged pressure
| can become infected: warmth adn redness
127
Treat olecranon bursitis
Ice, NSAIDs, Aspirate- gram stain and culture
| Abx, +/- surgical intervention
128
Cubital Tunnel
compression of ULNAR nerve
4th and 5th finger sx
decreased grip strength
chronic: muscle wasting
129
Cubital tunnel tx
NSAIDs (if repetitive cause), brace, PT
| Surgery- cubital tunnel release +/- ulnar nerve transposition (move the nerve)
130
Carpal Tunnel Syndrome
1/2 loaf fingers
MEDIAN nerve compression
Swelling of synovium or thickening of transverse carpal ligament
131
Carpal Tunnel synd
```
Pregnant, typers, women: male 2:1
Usually gradual onset
early: dull ache
late: burning, numbness, tingling
Worse @ night bc wrist position during sleeping- often flexed
```
Thenar muscle atrophy
132
Carpal Tunnel Syndrome
Tinel's and Phalen's test
X Ray, grip strength
Nerve Conduction study, Electromyogram
133
Carpal Tunnel tx
Acute: immediate decompression
Chronic: NSAIDs, steroid injection, Brace, PT
Surgical release: endoscopic or open
134
Ganglion cyst
```
collection of synovial fluid
dorsal and volar wrist most common
Soft, mobile, can change often
often change size after activity
Size doesnt necessarily coorelate with pain
```
135
Ganglion cyst tx
NSAIDs, Aspirate and Steroid, Surgery
| "bible bump" not rec
136
De Quervain Tenosynovitis
+Finkelstein test
Inflammation of 1st Dorsal Compartment
Sheath of aBductor pollicus LONGUS and extensor pollicis BREVIS
Overuse/repetitive gripping
Postpartum F>M
pain/sw along dorsal radial wrist
137
De quervain tenosynovitis tx
Stop painful activity, Thumb spica splint, immobilization brace, NSAIDs, Steroid, Surgical referral to decompress 1st dorsal compartment
138
Boutonniere
Flexion of PIP
| Hyperextension of DIP
139
Trigger Finger
```
A1 Pulley
Nodule forms @ volar MCP joint
Mechanical impingement
Benign, idiopathic, spontaneous
Inflammatory nodule- PAINFUL
```
Will often come in for "catching, locking" of finger and pt has to pull open
Nodule is under sheath- palm of hand
140
Tx of Trigger finger
NSAIDs, Steroid injection, Surgery to release A1 pulley (contracture will never come back after surgery)
141
Concerning features on an X ray
```
Indistinct margin
Abnormal Periosteal rxn
Soft tissue mass/invasion
Rapid growth
Pathologic fracture
```
142
Unicameral Bone Cyst
```
Simple bone cyst
fluid filled cavity in bone
Easily fractured
Younger pts
Long bones
Tx: "NO TOUCH LESION"
these can spontaneously improve
```
143
Aneurysmal Bone Cyst
```
Same as other but blood filled
Spine and extremities
Benign but AGGRESSIVE and RAPID GROWTH
Often treated since aggressive
Refer to Ortho (surgery)
```
will not improve on own
144
Non-ossifying Fibroma
"MES" Metaphyseal (end of bone), Eccentric (on side of bone), Sclerotic border (bright white)
Tx: Observe, Ortho referral if lesion greater than 50% diameter of bone
145
Giant Cell Tumor
Benign but aggressive
***Only one that CROSSES METAPHYSEAL/EPI region
Not good bc can affect joint space now
Localized pain and weakness
X Ray, *Usually followed by MRI
Need to r/o CA
146
Giant Cell Tumor tx
Refer to Ortho, Radiation, Surgery, high recurrence rate
147
Osteoid Osteoma
Small benign
Can see the reaction to the bone around it more than the tumor itself
NIDUS- dot in middle, releases other cells that cause pain
148
Osteoid Osteoma
Dull aching pain, SEVERE at night
RELIEVED BY NSAIDs
149
Osteoid Osteoma imaging
X Ray, CT, labs to r/o infection
Refer to ortho OR
Interventional Radiology
CT guided radiofrequency ablation- tx w/o big surgery!!
150
Osteochondroma (exostosis)
Abnormal bone/cartilage growth along surface of bone
Pedunculated (stalk) or sessile
Grows in proportion with the patient!
May be painful w activity, depends on location
151
Osteochondroma (exostosis) tx:
Observe, may have to treat for other secondary complications
152
Osteosarcoma and Ewings Sarcoma
Malignant primary bone tumor
Asymptomatic becomes painful and swollen
X Ray, MRI, CT
Ortho and Oncology
153
Chondrosarcoma
Males 60-80
Bone tumor made of cartilage producing cells
Hips, shoulder, pelvis (Radiates to hip/knee)
X Ray, MRI, Biopsy
Ortho, Radiation, Chemo
154
Multiple Myeloma
Most common primary bone tumor in adulthood
Of the marrow
Entire skeleton
Radiation, Pesticide, HIV
Fatigue, fever, night sweats, DIFFUSE BONE TENDERNESS
155
Multiple Myeloma
Labs, UA-Bence Jones Proteins
X Ray: Punched Out appearance
Radiation, Chemo, Supportive care
156
Metastatic Bone CA
Prostate, Breast, Kidney, Thyroid, Lung
LUNGS most common spread
157
Risk factors for Low BP
Poor ab muscles, Obesity, Pregnant
158
Swimmer's view X Ray
C7-T1
159
Odontoid view
C1 and C2
160
Cervical Spine Imaging Indications
Trauma, Infection, Atypical pain, Extremity pain, Osteoporosis, Degenerative change
161
Lumbar Spine Imaging Indications
Fall from > 3 meters, Fall from standing if >60YO or frail, Ejection MVA, Sig trauma, Acute and severe BP, Neuro deficits, AMS, Postop fibrosis, Chronic condition and back pain, Hx of CA with back pain, BP at night or resting
162
Oblique view Lumbar X Ray
to see Articular facets and Pars interarticularis
163
Nerve Conduction Study
Can determine SPECIFIC SITE of nerve injury
164
Lhermitte sign
Shock like sensation radiating into spine or arms with forward flexion of the neck
165
NEXUS not applicable for
Direct blow to neck
Penetrate trauma to neck
Adults >60 YO
166
Lumbar strain/sprain
usually axial, but can radiate to buttocks
may spasm
may not be able to stand without frequent change in position
167
Lumbar strain/sprain treatment
No bedrest
NSAIDs, PT, TENS unit, trigger point injections
Core strength after pain improves
168
Spondylosis
"Spinal Arthritis"
Osteophytes/ Bone spurs
Non spec degenerative changes
Can lead to spinal stenosis and/or neuroforaminal narrowing
169
Spondylosis
ARTHRITIS
170
Cervical Spondylosis
Osteophytes form
Thickening of ligamentum flavum
May cause stenosis or foraminal narrowing--> radiculopathy and/or myelopathy
171
Most common cervical spondylosis (arthritis) sx
Decreased Cervical ROM
also: chronic neck pain, worse w/upright activity, may cause paraspinous muscle spasm, Occipital HA, radicular sx, advanced stenosis --> myelopathy
172
Cervical Spondylosis (arthritis) physical exam
TTP along paraspinal muscles and posterior spinous process
Pain with "Facet loading" Spurling test
Extend and rotate to side of pain, downward pressure on head, postiive if pt has PAIN OR PARESTHESIA
pain alone is not positive test
173
Cervical Spondlyosis (arthritis) tx
NSAIDs, PT, Surgery, Pain mgmt referral
174
Lumbar Spondylosis (arthritis) sx
Hallmark: pain that radiates to one or both buttocks
other mechanical pain worsened by movement, pain releived by lying down, difficulty being in one position for too long,
175
Lumbar Spondylosis imaging
Osteohpyte, disc space narrowing, MRI if warranted
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Tx of Lumbar Spondylosis (arthritis)
NSAIDs, PT, consider pain mgmt referral
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Spondylolisthesis
Anterior displacement
more common in LUMBAR spine
typically d/t Spondylolysis (Fracture) of pars interarticularis
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Listhesis sx
pain usually rotates whether in cervical or lumbar
cervical: shoulders, occipital HA
lumbar: posterior to knees worse w standing (spasms in hamstrings making it hard to bend forward)
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Findings for Spondyolisthesis
Diminished lumbar lordosis
180
Spondylolisthesis
refer to Ortho Spine or Neurosurgeon
| May require surgical fixation
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Spondylolysis (Fracture)
Scotty dog
90% time at L5
Rep. forced back extension- football player/gymnast
can be degenerative in older
often asymptomatic finding
Tx: bracing/ PT/ restrict activity
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Radiculopathy (ROOT)
Young ppl
lifting and twisting can increase spinal pressure resulting in herniation of intervertebral disc
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Radiculopathy (ROOT)
Older ppl
Degenerative changes can tear the annulus with disc prolapse and press on nerve ROOT
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Lumbar spine radiculopathy
L4-5, L5-S1
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Cervical spine radiculopathy
C6-7
186
Radiculopathy sx
can be abrupt or worsen over time
SEVERE and worsened by activity
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Cervical Spine radiculopathy sx
Neck pain/possible occipital HA
Weakness, reduced grip strength
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Lumbar spine radiculoapthy
follow nerve pattern
L4 distinguishes
lying on back with knees elevated or in fetal position relieves pain
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Imaging for Radiculopathy
if sx persist >4 weeks
| Immediately if significant neuro damage or myelopathy is identified
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Radiculopathy tx
If nonprogressive neuro deficits
NSAIDs, Steroids, PT
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Radiculopathy tx
If worsening or SEVERE PAIn
```
Epidural injections (no more than 2-3)
Then surgery referral
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Spinal Stenosis
Narrowing
can be acquired or congenital
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Lumbar spinal stenosis
Most common neuro leg pain in elderly
progressive bilateral leg pain aggravated by standing or walking
relieved by leaning forward - shopping cart sign
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Neurogenic vs Claudication
Neurogenic pain:
Relieved walking flexed with cart YES
Takes a few minutes to relieve once sitting down
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Vascular/Claudication pain
Relieved by standing erect
| Immediately relieved by sitting/lying
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Most common cause of Lumbar Spinal Stenosis
Spondylosis (Arthritis)
197
Most common cause of myelopathy in elderly
Cervical Spinal Stenosis
d/t progressive spondylosis with osteophyte formation, disc herniation, and ligamentum flavum hypertrophy
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Test of choice for Cervical and Lumbar STENOSIS
MRI !!!
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Spinal STENOSIS treatment
NSAIDs, Cervical brace and activity restriction, PT for core strengthening - aquatics in elderly
Epidural steroid injections
Surgical decompression or fusion if significant stenosis
200
Cauda equina
Surgical emergency
Compression of lumbar, sacral, coccygeal nerve ROOTS
201
Tx for Cauda Equina syndrome
Dexamethasone 10 mg IV x 1 immediately
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Imaging for Cauda Equina
EMERGENT MRI w contrast
if not available : CT Myelogram
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Malignancy Red Flags with Back Pain
Unexplained wt loss, no imp with tx, pain >1 month, pain at night wake from sleep, PMHx of CA, older than 50YO
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Red Flags for Infection with Back Pain
Pain @ rest, fever, Immunocomp, IV drug use, recent hx of infection
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Causes of Thoracic Outlet Syndrome
Repetitive injury or athletic arm movement (pitching)
Cervical rib anomoly
Muscular anomoly
Fracture
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Neurogenic Thoracic outlet syndrome
Brachial plexus 95% of cases!!!
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Neurogenic Thorac outlet synd
Progressive unilateral weakness of Hypothenar muscle
numbness in Ulnar or Median distribution
Tenderness over scalene muscle
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Arterial Thoracic outlet synd
almost ALWAYS assoc with CERVICAL RIB 90%
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Venous Thorac outlet synd
related to vigorous, repetitive UE activities
HALLMARK: swelling of extremity
cyanosis, fatigue after short use
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Tx for nTOS
PT 4-6 wks
Steroid injection, Botulinum toxin type A
Decompression surgery if worsening sx or failed treatment
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vTOS
Catheter directed thrombolysis, decompressive surgery
212
aTOS
Decompressive surgery
| Surgical embolectomy- but very dangerous!!! can result in further injury
