Exam 3 Flashcards by Brittni Coppola

monosodium urate crystals
hyperuricemia (purine metabolism = uric acid)
95% underexcreters (mostly decrease renal function)

stage I - asymptomatic, no treatment needed
stage II - acute, severe attack of 1 joint
stage III - after 10+ years of acute attacks, chronic swelling and tophi

rapid onset pain, redness, warmth
PODAGRA - MTP joint of great toe
often recurrent

Gout

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Gout diagnostics and treatment

radiography = joint erosion
arthrocentesis = (-) BIREFRINGENT

Treatment: analgesia, NSAIDs (indomethacin or Naproxen)
Colchicine (diarrhea side effect)
glucocorticoids if can’t take NSAID or colchicine - sugar can rise in DM pts

*Urate-Lowering Therapy - goal to maintain serum uric acid of 6.0 or less
Probenecid - uricosuric agent
–> underexcreters only and avoid in pt with ASA (aspirin) use or nephrolithiasis (kidney stones)
Allopurinol (Zyloprim) and Febuxostat (Uloric) - xanthine oxidase inhibitors

Agent of Choice - Allopurinol - good for both over and underexcreters

Prophylaxis with colchicine or NSAID first, then initiate urate-lowering therapy
–> may precipitate an acute attack

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calcium pyrophosphate dihydrate (CPP) crystals
comorbidities

acute, typically mono-articular - 50% knees
may mimic RA, OA or septic arthritis
self-limited

Pseudogout (chondrocalcinosis or CPPD deposition disease)

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Pseudogout diagnostics and treatment

synovial fluid aspiration - (+) BIREFRINGENT

Treatment: NSAIDs or cholchicine
glucocorticoids (oral or systemic) if above doesn't work
remove crystals via joint aspiration
ice
joint immobilization

considered chronic if 3+ attacks in a year

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autoantibodies to nuclear antigens (inflammatory autoimmune disorder)
multi system disease
more common in blacks and females

fever, fatigue, weight change
malar rash
photosensitivity
symmetric nonerosive arthritis
Raynaud's phenomenon (white - blue - red episodic vasospastic disease)
serositis (cardiopulmonary inflammation)

Systemic Lupus Erythematous (SLE)

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Systemic Lupus Erythematous (SLE) diagnostics and treatment

ANA –> anti-dsDNA and anti-Sm subtypes
C3 and C4 - complement system
CBC, ESR (erythrocyte sedimentation rate/sed rate)
imaging if needed

Treatment: sun protection, diet, exercise, etc.
NSAIDs and rest for mild sxs
cytotoxic/immunosuppressive agents (ie. methotrexate) for severe sxs
systemic corticosteroids
antimalarials - hydroxychloroquine (Plaquenil) with ophthalmology f/u

drug-induced SLE (HIP drugs among others - hydralazine, isoniazid, procainamide)
–> (+) antihistone antibody

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chronic, systemic autoimmune disorder
diminished exocrine gland function (salivary & lacrimal)
more common in females
common association with SLE, RA and systemic sclerosis

SICCA complex - dry eyes, dry mouth
--> keratoconjunctivitis, xerostomia
arthritis/arthralgia
parotid gland enlargement
fatigue
Raynaud's

Sjogren Syndrome (SS)

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Sjogren Syndrome (SS) diagnostics and treatment

ANA –> anti-Ro.SSA and anti-La/SSB subtypes
Schemer’s test - tear production
salivary gland biopsy

Treatment: regular f/u with dentist and ophthalmologist
dry eyes –> artificial tears, cyclosporine drops
xerostomia - biotene OTC (saliva substitute)
steroids

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rare, chronic autoimmune disorder
diffuse FIBROSIS of skin and internal organs
skin appears taut and shiny
2 forms: limited (80%) diffuse (20%)
more common in females

arthralgia/arthritis
pericarditis
renal and pulmonary HTN

limited:
CREST syndrome
calcinosis cutis (calcification of subQ tissues)
Raynaud's
esophageal dysmotility
sclerodactyly (puffy hands)
telangiectasia

diffuse (worse prognosis):
rapid development of symmetric skin thickening on trunk and proximal extremities
more likely to have significant internal organ damage

Systemic Sclerosis (Scleroderma)

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Systemic Sclerosis (Scleroderma) diagnostics and treatment

ANA –> anti-SCL-70
proteinuria (renal involvement)

Treatment: symptomatic and supportive
Raynaud’s - Nifedipine (Ca2+ channel blocker)
Esophageal - H2 blockers, H+ pump inhibitors, small more frequent meals

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inflammatory arthritis triggered by antecedent GI/GU infection
HLA-B27 + (85%)
“can’t see, can’t pee, can’t climb a tree”
more common in men (post-GU infection)

acute, asymmetric oligoarthritis - often lower extremities
1-4 weeks post-GI/GU infection
diarrhea (GI) or urethritis (GI - “can’t pee”)
conjunctivitis (“can’t see”)
keratoderma blennorrhagicum on palms and soles

Reactive Arthritis (“Reiter’s Syndrome”)

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Reactive Arthritis (“Reiter’s Syndrome”) treatment

NSAIDs - indomethacin
intra-articular/systemic glucocorticoids
methotrexate (MTX) or anti-TNF (cytotoxic/immunosuppressive) if above doesn’t work
sxs resolve 6-12 months

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chronic, systemic, inflammatory autoimmune disorder
thickening of synovial membrane = inflammation (synovitis)
–> can lead to carpal tunnel over time
destruction of cartilage and bone
joint deformity and loss of fctn if not treated

gradual onset
symmetric polyarthritis
*morning stiffness for at least 1 hour
distal sites affected early - MCP and PIP joints

phys exam: ulnar deviation of MCP joints
Boutonniere deformity (PIP)
Swan neck deformity (DIP) - more severe disease
tenderness/swelling
*rheumatoid nodules = unfavorable sign (elbows)

Rheumatoid Arthritis (RA)

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Rheumatoid Arthritis (RA) diagnostics and treatment

radiography - preferred initial
--> soft tissue swelling around joint
--> periarticular osteopenia (thinning bones around joint)
--> narrowing joint space
--> subluxation/dislocation
--> bone erosion and joint obliteration
MRI and U/S to check for synovitis
joint aspiration if unsure

Lab: CBC/ESR
rheumatoid factor (RF) –> (+) early in course = more severe
anti-CCP antibodies (newer and more specific)
ANA (non-specific)

Treatment: control synovitis, prevent joint injury, preserve ADLs
NSAIDs + glucocorticoids
DMARDs (disease modifying anti-rheumatic drugs)
–> slows/halts disease progression
–> refer to Rheumatology
ex. methotrexate, sulfasalazine (synthetic)
ex. TNF inhibitors Enbrel, Remicaid, Humira (biologic) - risky
*CVD most common cause of death

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degenerative joint/disk disease
risks: age, female, obesity, genetic, general wear/tear

pain exacerbated by activity and relieved by rest
morning stiffness typically resolves in less than 30 min
typically hands, knee, hip, pine

crepitus
bony enlargement
decreased ROM and malalignment
tenderness
Bouchard's nodes (PIP)
Heberden's nodes (DIP)
1st carpometacarpal joint (CMC)
osteophytes
effusions
pain around hip/groin referred to knee
cervical and lumbar spondylosis

Osteoarthritis (OA)

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Osteoarthritis (OA) diagnostics and treatment

radiological: joint space narrowing
osteophytes
subchondral sclerosis and cysts

(-) RF and anti-CCP
no joint obliteration like RA

Treatment: pain control
minimize disability and pt education
NSAIDs (ie. diclofenac)
narcotics - sparingly if at all
intra-articular glucocorticoids
–> no more than 2-3 times per year - atrophy to cartilage
surgical = joint replacement or resurfacing

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chronic inflammatory rheumatic condition
*association with giant cell (temporal) arteritis

gradual onset symmetric stiffness at least 30min
shoulder pain > hip and neck (proximal regions)
synovitis and bursitis
edema
decreased ROM
“gel” phenomenon = stiffness after periods of rest

Polymyalgia Rheumatica (PMR)

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Polymyalgia Rheumatica (PMR) diagnostics and treatment

elevated ESR (>40)
(-) ANA, RF, anti-CCP
imaging - x-ray, MRI, U/S

*general rule of thumb:
male = age/2 = ESR
female = (age + 10)/2 = ESR

Treatment: RAPID RESOLUTION with low dose glucocorticoids (ie. prednisone)
MTX or TNF inhibitors for select pts
PT
NSAIDs

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soft tissue pain disorder - muscles, tendons, ligaments
widespread, chronic
women 20-55yo = common complaint
no tissue inflammation

aching stiffness
fatigue
paresthesia
hard time explaining what hurts
headaches
insomnia
superficial pain in 11/18 tender points

Fibromyalgia

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Fibromyalgia treatment

cyclobenzaprine - muscle relaxer
antidepressant - amitriptyline, cymbalta (SNRIs)
anticonvulsants - Lyrica, Neurontin (gabapentin)
psych referral
*avoid narcotics - addiction

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non-displaced

fragments in anatomic alignment

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displaced

fragments no longer in usual alignment

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angulated

fragments maligned and angular

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bayonetted

distal fragment longitudinally overlaps proximal fragment

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distracted

distal fragment separated from proximal fragment by a gap

closed

skin over and near fracture intact

open

skin over and near fracture lacerated or abraded by the injury --> REFER

transverse

perpendicular to shaft of bone

comminuted

2+ fragments of fracture

oblique

angulated fracture line

segmental

type of comminuted fx in which a completely separate segment of bone is bordered by fx lines

spiral

multiplanar and complex fx line (common in ski injuries)

intra-articular

fx line crosses articular cartilage and enters the joint

torus

incomplete buckle fx of one cortex often seen in children

greenstick

incomplete fx with angular deformity seen in children | almost like it bends and one side breaks but the other doesn't

impaction

one bone hits or "impacts" an adjacent bone

compression

type of impaction fx that occurs in vertebrae resulting in depression of end plates often in older people with osteoporosis

depression

type of impaction fx that occurs in the knee when the femoral condyle strikes softer tibial plateau

stress (fatigue)

fx in normal bone that has been subjected to repeated or cyclical loads that in and of themselves are not sufficient to cause a fx

stress (insufficiency)

fx in weakened bone that has been subjected to a load insufficient to fx a normal bone

pathologic

fx through bone weaker by tumor, metabolic bone disease or osteoporosis

SITS muscles (SIT = ext rot & ABd, S = int rot) pain over anterior and lateral aspects of shoulder that radiates to deltoid and progressively worsens decreased ROM (inability to ABduct above shoulder) shoulder may catch/click subacromial tenderness Drop arm and empty can tests acute tear = often labral pathology chronic tear = pain usually worse at night, gradual weakness does NOT improve with analgesics

Rotator Cuff Tear

Rotator Cuff Tear diagnostics and treatment

lidocaine injection test radiograph - elevation of humeral head 1+cm *MR ARTHROGRAM (good for labral pathology too) Treatment: ice and NSAIDs weighted pendulum stretching with some shoulder immobilization PT if persistent, subacromial steroid injection or surgery

*principle cause of rotator cuff tendonitis subacromial (pinpoint) tenderness gradual pain in lateral shoulder that radiates to deltoid normal glenohumeral joint ROM *preserved strength Neer's and Hawkin's tests (flexion, int rot maneuvers)

Shoulder Impingement Syndrome

Shoulder Impingement Syndrome diagnostics and treatment

radiography - normal in 1st episode pts MRI useful for chronic sxs Treatment: ice, NSAIDs, activity modification *NO arm sling recommended PT referral with f/u if persistent, corticosteroid injections or surgery

stiffened glenohumeral joint secondary to injury, trauma, overuse, sling use, bursitis may develop adhesions chronic pain with limited ROM due to mechanical restriction Apley Scratch test --> comparison is key ABduction and ext rot

Adhesive Capsulitis ("frozen shoulder")

Adhesive Capsulitis ("frozen shoulder") treatment

imaging isn't helpful Treatment: PT consult - stretch lining of joint treat underlying process

complains of bump on shoulder that is worse at bedtime AC joint swelling, tenderness and possible deformity pain aggravated by downward traction Cross-Over test --> pain with passive cross-body ADduction sprain, partial or complete tear

Acromioclavicular (AC) Injury

Acromioclavicular (AC) Injury grading

Grade I - AC joint intact, point tender SPRAIN without separation, normal radiographs Grade II - separation of superior and inferior AC ligaments, decreased ROM, instability with stress testing of AC joint, radiographic evidence (PARTIAL TEAR) Grade III - separation of superior and inferior AC ligaments AND coracoclavicular ligament, severe pain, decreased ROM and instability radiograph shows inferior margin of distal clavicle at or above superior margin of acromion (COMPLETE TEAR)

Acromioclavicular (AC) Injury treatment

shoulder immobilizer 3-4 weeks for comfort ice, rest, NSAIDs corticosteroid injection if not improving surgical for Grade III (recent studies do not support)

``` tenderness to palpation over clavicle visual deformity seen decrease ROM apprehension and guarding single AP radiograph of clavicle ``` 70-80% middle 1/3 - typically displaces superiorly

Clavicle Fracture

Clavicle Fracture treatment

sling/swathe or figure 8 harness analgesics and muscle relaxers sleep upright ortho referral for all displace and proximal or distal fxs --> surgery

inflammation or degeneration of sack-like structure repetitive movement injury pain to shoulder with ROM and rest localized tenderness to palpation warm, red, fever, malaise *not often isolated and may cause impingement

Subacromial Bursitis

Subacromial Bursitis treatment

fluid aspiration if suspected sepsis, otherwise imaging provides little benefit ice and NSAIDs restriction of overuse aspiration and corticosteroid injection

pain to anterior shoulder with ABduction and ext rot popping sensation weakness Yergason's and Speed's tests inflammation of long head of biceps tendon as it passes through bicipital groove

Biceps Tendonitis

Biceps Tendonitis treatment

U/S beneficial NSAIDs and rest PT surgery

arm held in position of protection --> SULCUS SIGN apprehension and relocation tests 95% anterior --> SPECIAL CONSIDERATIONS 1. Bankart lesion detachment of anterior inferior labrum from glenoid rim 2. Hill Sachs lesion cortical depression of posterolateral humeral head when humeral head is impacted by anterior rim of glenoid 3. axillary n. decreased sensation of lateral aspect of shoulder and decreased deltoid function

Glenohumeral Subluxation/Dislocation

Glenohumeral Subluxation/Dislocation treatment

PT ice, rest, NSAIDs shoulder immobilizer --> sling and swathe 2-4wks surgery for repeat dislocations

localized pain and swelling reproducible pain with wrist flexion (medial) or wrist extension (lateral) against resistance overuse syndrome Medial = Golfer's elbow --> wrist flexor, pronator Lateral = Tennis elbow --> wrist extensor, supinator

Elbow Epicondylitis

Elbow Epicondylitis treatment

``` acute = sling, wrist brace, ice and NSAIDs recurrent = steroid injections and surgery for debridement preventative = forearm strap and decreased repetitive activities ```

swelling of the elbow +/- pain +/- ROM infection = erythema and warmth cause: trauma, infection, rheumatologic condition

Olecranon Bursitis

Olecranon Bursitis treatment

ice and NSAIDs aspiration antibiotics +/- surgical intervention if infected

decreased grip strength RF and SF tingling and numbness chronic = muscle wasting ulnar n. compression

Cubital Tunnel

Cubital Tunnel treatment

radiographs and nerve conduction studies NSAIDs bracing PT surgery

``` gradual, progressive pain --> early = intermittent, late = burning, numbness, tingling sxs worse at night *thenar muscle atrophy decreased grip strength decreased sensory to thumb, IF, LF ``` Tinel's and Phalen's tests swelling of synovium or thickening of transverse carpal ligament causing compression of median n.

Carpal Tunnel Syndrome

Carpal Tunnel Syndrome diagnostics and treatment

nerve conduction study = delayed because demyelination EMG = denervated muscle spontaneously fires Treatment: acute = immediate decompression chronic = NSAIDs, corticosteroid injection, brace, PT, surgery

soft mobile mass commonly on dorsal radial and solar aspects of wrist fluctuates in size often with activity may decrease ROM and become painful collection of synovial fluid within a joint or tendon sheath

Ganglion Cyst

Ganglion Cyst treatment

NSAIDs aspiration and steroid injection surgery for recurrence (50% come back) may resolve spontaneously

pain and swelling along dorsal radial wrist pain aggravated by thumb and wrist motion Finkelstein test inflammation of 1st dorsal compartment due to overuse

De Quervain's Tenosynovitis

De Quervain's Tenosynovitis treatment

``` decreased repetitive activity thumb spica immobilization NSAIDs steroid injections surgery for decompression ```

painless nodules that turn into palpable cords extension loss of fingers (usually RF & SF) Hueston Table Top test - ability to flatten hand on table progressive fibrosis of palmar fascia connective tissue disorder

Dupuytren's Contracture

Dupuytren's Contracture treatment

observation refer for surgery if progressive glucocorticoid injection for pain or rapid growth of nodules

nodule forms at solar aspect of MCP causing mechanical impingement and inflammation digit snaps/catches/locks with passive and active ROM at IP/PIP joints progressively painful nodule unable to slide through A1 pulley

Trigger Thumb/Finger (Stenosing Flexor Tenosynovitis)

Trigger Thumb/Finger (Stenosing Flexor Tenosynovitis) treatment

NSAIDs local corticosteroid injection surgery to release A1 pulley

``` gradual neck stiffness and soreness muscle tightness HA (tension) starting at base of skill shoulder pain decreased ROM due to pain neuro exam normal tenderness to palpation ``` usually 2-24 hrs post-injury (adrenaline)

Cervical Strain/Sprain

Cervical Strain/Sprain treatment

radiograph - AP/ lateral/odontoid with flexion/extension views MRI only if neuro deficit "therapeutic trial" for 48 hours - rest, ice/heat, massage NSAIDs, muscle relaxants - 48-72hrs around the clock, not PRN narcotics for limited course if necessary PT - TENS unit application anti-depressants if chronic majority recover in 4 wks

ACUTE onset pain secondary to identifiable precipitating event pain worsens with activity and radiates to butt decreased ROM due to pain neuro exam normal tenderness to palpation 30-60% have had prior episodes

Lumbar Strain/Sprain

Lumbar Strain/Sprain treatment

variable clinical presentation 1 level with unilateral, radicular sxs multiple levels with bilateral sxs may see signs consistent with myelopathy if central disc herniation causes cord compression neck tenderness or muscle spasm correlate plain films with MRI --> narrowing disc space and bone spurs (osteophytes) combo degenerative disc disease and hypertrophy of ligamentum flavum and facets

Cervical Spondylosis

Myelopathy

``` upper motor neuron (UMN) hyperactive reflexes --> clonus spasticity upgoing toes (Babinski's sign) late muscle atrophy weakness in affected distribution ```

Radiculopathy

``` lower motor neuron (LMN) hypoactive reflexes flaccidity fasciculations muscle atrophy weakness in affected distribution ```

acute to severe pain radiates from low back to legs ("sciatica") in 95% of cases pain aggravated by sitting, coughing, sneezing may see trunk shift to one side Straight Leg Raise test (SLR) Achilles Tendon reflex if L5-S1 herniation (S1 nerve root) most common at L4-5 and L5-S1 most posterolateral because posterior longitudinal ligament (PLL) is weakest

Herniated Lumbar Disk Disease

Herniated Lumbar Disk Disease diagnostics and treatment

radiographs - decreased height of disc space and osteophytes MRI = diagnostic NSAIDs/analgesics (ibuprofen or naproxen) muscle relaxants (cyclobenzaprine/flexeril) NO narcotics heat/cold PT urgent referral if neuro deficits --> surgery

urinary retention in 90% bilateral lower extremity muscle weakness acute LBP with sciatica due to massive midline herniation "SADDLE" anesthesia - numb wherever you sit decreased anal sphincter tone --> rectal exam *neurologic emergency = REFER

Cauda Equina Syndrome

Cauda Equina Syndrome treatment

MRI is diagnostic disc herniation or trauma = urgent surgical decompression metastatic disease = urgent oncology consult for radiation

back pain aggravated by bending, lifting, twisting may have "step off" of spinal processes on exam associated with degenerative disc disease anterior displacement of one vertebrae on another *graded by % --> less than 50% = asymptomatic

Spondylolithesis

Spondylolithesis treatment

50% = spinal fusion to stabilize | any neuro impairment = REFER

neurogenic claudication = progressive LBP and bilateral leg pain aggravated by standing and/or walking relieved by leaning forward congenital or acquired condition that narrows neural foramen causing compression

Lumbar Spinal Stenosis

Lumbar Spinal Stenosis diagnostics and treatment

decreased height of intervertebral discs facet hypertrophy hypertrophy of ligamentum flavum narrowing of intervertebral foramina NSAIDs PT epidural steroid injections for pain

Spinal Tumors

new onset LBP in patient with known malignancy is metastasis until proven otherwise

``` back pain malaise fever sepsis wound drainage ``` osteomyelitis (infection of bone) - rare and commonly associated with invasive procedures

Spinal Infections

Spinal Infections treatment

antibiotics | surgical drainage

aching LBP around SI joint that progresses proximally persistent morning back stiffness 1+hr --> exacerbated by inactivity and improves with activity low grade fever, fatigue, weight loss, night sweats *acute anterior uveitis/iritis (circumcorneal flush) *limited spinal motion tenderness over joint loss of lumbar lordosis accentuation of thoracic kyphosis Shober test --> mark 10cm above an 5cm below intersection of iliac crest and spine ask pt to forward flex as much as possible re-measure distance --> should be 20+cm (5cm change)

Ankylosing Spondylitis

Ankylosing Spondylitis diagnostics and treatment

radiograph = BAMBOO SPINE - fusion of vertebral bodies 1st line - NSAIDs - indomethacin, celecoxib (Celebrex) 2nd line - refer to Rheumatology - TNF antagonists (i.e. sulfasalazine) intra-articular steroids no more than every 3-4mo anti-depressants refer to ophthalmology if uveitis surgery PT - supportive measures

groin or lateral hip pain sharp stabbing or dull ache aggravated by turning, twisting, prolonged standing and squatting ``` *FADIR test (flexion, ADduction, internal rotation of hip) FABER test (flexion, ABduction, external rotation of hip) ``` bone overgrowth or abnormality in bone development can change the function of the hip joint 2 types: pincer = acetabular involvement Cam = femoral head involvement could be combo of pincer and Cam lesions

Femoroacetabular Impingement (FAI)

Femoroacetabular Impingement (FAI) diagnostics and treatment

x-rays initially CT/MRI if needed NSAIDs PT decrease aggravating activities surgical eval if conservative tx fails

``` dull or sharp groin pain catching/clicking radiates to lateral hip, anterior thigh or butt insidious onset vs. acute trauma FADIR/FABER tests ROM and strength testing ```

Labral Tear of the Hip

Labral Tear of the Hip diagnostics and treatment

*MR Arthrogram (test of choice for labral tears) x-rays MRI conservative vs. referral for surgical consultation

painful or painless snapping/popping aggravated by activity pseudosubluxation external = passive internal/external rotation of hip while laying on side (IT band over g greater trochanter) internal = FABER test then extend hip to check snapping (iliopsoas tendon over iliopectineal eminence or femoral head) increased risk in adolescents and dancers

Snapping Hip Syndrome

Snapping Hip Syndrome treatment

NSAIDs +/- corticosteroid injection PT - stretching and heat/ice surgery rarely indicated

``` lateral hip pain localized to greater trochanter pain with resisted abduction Trendelenburg sign (hip drop on contralateral side) ``` repetitive overload tendinopathy (gluteus medius and minimus)

Greater Trochanteric Pain Syndrome (Trochanteric Bursitis)

Greater Trochanteric Pain Syndrome (Trochanteric Bursitis) treatment

``` self-limiting NSAIDs ice (acute) or heat (chronic) adjust positioning steroid injection into bursa ```

most common MOI: knee flexion with foot planted lateral impact with valgus stress and rotation Valgus stress test = MCL Varus stress test = LCL Unhappy Triad (Triad of O'Donoghue) ACL MCL Medial Meniscus

Medial Collateral Ligament (MCL) Sprain

joint effusion (hemarthosis) guarding laxity pt hears/feels a "pop" followed by immediate pain, swelling and instability *Lachman's test - stabilize distal femur and pull on tibia anteriorly Anterior Drawer test Pivot Shift test more common in females (increased Q angle = increased values stress) *prevents anterior translation of the tibia >50% associated with meniscus injury

Anterior Cruciate Ligament (ACL) Injury

Anterior Cruciate Ligament (ACL) Injury treatment

``` RICE (rest, ice, compression, elevation) refer to ortho surgery for young patients and athletes brace PT - rehab ```

mild to moderate knee effusion and hemarthrosis generalized knee pain limp often missed because subtle or associate with high energy trauma Posterior Drawer test Posterior Sag sign prevents posterior translation of tibia largest and strongest ligament of the knee

Posterior Cruciate Ligament (PCL) Injury

joint line pain inability to fully extend knee - locking/catching walking up and down stairs and squatting is painful McMurray's test - external rotation of heel, flex maximally, then slowly provide values stress while extending Apley's compression/distraction test C-shaped cartilage that increases contact area for articulation --> aids in joint stability and shock absorption can often result in arthritis later because bone on bone

Meniscus Injury

Meniscus Injury treatment

consider location and extent of teat conservative vs. surgical MRI may help

Knee "Sprains" Grading and Treatment

Grade I - mild stretch RICE, WB as tol Grade II - partial tear RICE, brace immobilization, +/- crutches, PT, possible surgery Grade III - complete tear REFER --> surgical repair, crutches, brace, aggressive PT

anterior pain under patella pain worsens when going up and down stairs + theater/long car ride sign crepitus, popping and instability Patellar glide test apprehension test *most common knee complaint in primary care malalignment, patellar tracking concerns

Patellofemoral Pain Syndrome

Patellofemoral Pain Syndrome treatment

ice and NSAIDs PT brace PRN no imaging needed

often asymptomatic pain/swelling may occur behind knee accumulation of joint fluid in popliteal fossa

Baker's Cyst (Popliteal Cyst)

Baker's Cyst (Popliteal Cyst) treatment

NSAID aspiration/injection compression brace

pinpoint tenderness inferior to patella inflammation from repetitive trauma

Patellar Tendonitis ("Jumper's Knee")

Patellar Tendonitis ("Jumper's Knee") treatment

ice, NSAIDs, bracing/strapping rest PT

gradual onset localized pain initial sharp/burning during activity develops into constant deep ache overuse injury evaluate for limb length discrepancy

Iliotibial Band Syndrome (ITBS)

Iliotibial Band Syndrome (ITBS) treatment

RICE NSAIDs PT

pain, swelling, tenderness to the knee r/o infection pre-patellar and pes anserine are most common site of inflammation

Knee Bursitis

Knee Bursitis treatment

NSAIDs aspiration/steroid injections padding/bracing

chronic pain usually in knee, ankle or elbow catching.clicking if something is caught there lesion of cartilage and underlying bone that results in necrosis and possible displacement

Osteochondritis Dissecans (OCD)

Osteochondritis Dissecans (OCD) treatment

*MRI will pick it up long term bracing activity restrictions PT surgery

swelling/pain at the ankle ecchymosis difficulty WB eval for bone pain ``` lateral ligament complex (most commonly injured) INVERSION with plantar flexion Anterior Drawer test medial = deltoid ligament complex EVERSION syndesmotic = high ankle sprain Squeeze test ```

Ankle Sprains

Ankle Sprains treatment

radiograph only to r/o fx RICE NSAIDs +/- short immobilization for grade 2-3 PT

recent increase in training resulting in burning pain or sudden pivoting or rapid acceleration palpate along tendon for pain, edema or defect have pt do active ROM first - plantar and dorsiflexion Thompson test peds = Sever's disease (inflammation at growth plate)

Achilles Tendon

Achilles Tendon treatment

ortho referral - conservative vs. surgery | immobilization - boot allowing for continuous plantar flex position

pain with onset of walking (first step in the morning) unilateral or bilateral point tenderness aggravated by ROM r/o S1 radiculopathy (SLR and achilles tendon reflex tests) inflammation of fascia from activity, poor shoe wear, ankle pronation, heel spurs, etc.

Plantar Fasciitis

Plantar Fasciitis treatment

ice, rest, NSAIDs PT improve shoe wear if severe = steroid injection, splinting, casting

progressive bone loss with increased risk of fx prevent with Ca2+/Vitamin D and exercise evaluate with DEXA scan for bone densitometry

Osteoporosis

Osteoporosis treatment

estrogen replacement therapy - Raloxifine (Evista) calcitonin bisphosphates - alendronate (fosamax), risedronate (actonel), ibandronate (boniva)

``` increased pain in the joints redness warmth inflammation *Surgical emergency ```

Septic Arthritis

Septic Arthritis diagnostics and treatment

joint aspiration - gram stain, fungi, crystals, etc. CBC, ESR, CRP, cultures IV antibiotics

most common benign tumor fluid-filled cavity in bone cortex still intact radiographs, MRI/CT if needed, bone scan Treatment: may resolve spontaneously consider surgery for recurrent pathologic fxs

Unicameral Bone Cyst (UBC)

blood filled cyst in bone spine and extremities most often affected benign but aggressive radiography, MRI, biopsy Treatment: refer to ortho for surgery

Aneurysmal Bone Cyst (ABC)

benign lesion metaphyseal, eccentric (edge of bone), sclerotic borders looks like bubbles asymptomatic and typically incidental finding Treatment: observe with serial radiographs ortho referral is lesion is >50% diameter of bone

Non-ossifying Fibroma (NOF)

benign aggressive tumor may develop as growth plate closes localized pain and weakness radiographs, MRI, bone scan (hot spot) Treatment: refer to ortho for radiation and surgery

Giant Cell Tumor (GCT)

small benign tumor *nidus-center of growing cells surrounded by thickening bone severe pinpoint pain at night resolved immediately from taking NSAIDs Treatment: refer to ortho or interventional radiology for radio frequency ablation

Osteoid Osteoma

fixed, non-mobile mass near joints pain with activity tingling/numbness if near nerve benign, abnormal growth of bone and cartilage along surface of bone Treatment: observation and refer if painful

Osteochondroma (Exostosis)

asymptomatic vs. pain/swelling pathologic fx malignant primary bone tumor - rapidly growing *most common bone tumor in children radiographs, MRI/CT Treatment: refer to ortho and oncology

Osteosarcoma and Ewing's Sarcoma

pain and weakness pelvic masses radiate pain to hip and bone bone tumor of CARTILAGE-PRODUCING cells Treatment: refer to ortho +/- radiation and chemo

Chondrosarcoma

fatigue, fever, sweats diffuse bone tenderness pathologic fxs most common primary bone tumor --> malignant bone marrow involves entire skeleton *Bence-Jones proteins in UA punched-out appearance on imaging Treatment: chemo, radiation, supportive

Multiple Myeloma

asymptomatic anemia (labs) bone scans ``` Lead Kettle (PB-KTL) prostate, breast, kidney, thyroid, lungs men = P and L woman = B ``` *REFER

Metastatic Bone Cancer

Exam 3 Flashcards

(141 cards)