MSK Flashcards

Question

Osteoarthritis of 1st CMC Joint

Answer 1

d/t overuse Sxs: - pain, fullness, limited function Complication: thumb in palm deformity, hyperextension at MCP joint Dx: Xray Tx: - splinting, APAP, NSAIDs, cortisone Surgery: - remove trapezium +/_ ligament reconstruction, tendon interposition (anchovy procedure),cast for months, splint, therapy

Answer 2

Inflammation of 1st doral compartment (APL, EPB) Sx: pain, swelling of radial aspect of wrist Dx: + Finkelstein test Tx: - rest - tendon glides - splinting - NSAIDs, cortisone injection - surgery: release 1st dorsal compartment

Answer 3

MC soft tissue tumor of wrist and hand - joint = mucus cyst - tendon sheath = retinacular cyst - may be dorsal or volar D/t insult to joint, often don't remember initiating injury Tx: - avoid aspiration of volar ganglion to avoid injury to radial artery - recurrence up to 30% with or without surgery - can scar after surgery

Answer 4

Need plain lidocaine w/out epinephrine R/o EPL rupture w/the injury +/- surgery (can't lift thumb off table) Dx: Xray Tx: - nondisplaced: short arm cast - displaced: reduce using hematoma block (w/lidocaine) and traction w/finger traps w/application of Sugar Tong Splint** (prevents forearm rotation) surgery: failed conservative mgmt, open fracture, younger age, significant displacement

Answer 5

MC fracture wrist bone d/t FOOSH - commonly results in nonunion if displaced, d/t poor blood supply to proximal aspect Sxs: anatomical snuffbox pain Dx: may not be evident on initial film Tx: - thumb spica cast* - hand in position like you're going to shake their hand - surgery

Answer 6

DJD; irreversible loss of articular cartilage RF: Fhx, obesity, age, trauma Sxs: - stiffness, pain - Herberden's = DIP nodes - Bouchard = PIP nodes - Osteophytes (bone spurs) = can wear on the extensors - Mucous cysts = DIP, ganglion cyst Dx: Xray to r/o other pathology Mgmt: - exercise in pain free range to maintain motion/strength - wt loss - pain mgmt: APAP, NSAIDs, topicals, intraarticular injections - surgery

Answer 7

Systemic, disabling polyarthritis resulting in chronic synovitis w/erosive articular changes Sxs: - ulnar deviation at MCP, caput ulnar Dx: RF, CBC Mgmt: - Salicylates, NSAIDs, corticosteroids - DMARDs: methotrexate, hydroxychloroquine - splinting, assistive devices - surgery

Answer 8

D/t - congenital d/t widened FPL - acquired: age>40, diabetes, RA Sxs: - inflammation of flexor tendon sheath - form nodule along flexor, does not glide - pain, locking, catching - tenderness at A1 pulley, can lock in flexion or can hear clicking* Mgmt: - A1 pulley release: NSAIDs, cortisone injections, surgery - splint to keep pt from going all the way into flexion (+ cortisone injection)

Answer 9

A/w avulsion of base of distal phalanx - injury of distal extensor mechanism Sxs: cannot extend DIP Mgmt: - reduce into extension; if not, pin - splint or serial casting in slight hyperextension for 6wk followed by prn splinting until week 8 vs. surgical pinning

Answer 10

common athletic injury (football, wrestling) Rupture of distal flexor digitorum profundus (FDP) Mgmt: surgical repair to reattach FDP to distal phalanx

Answer 11

A/w ski pole injury (forceful radial deviation) Rupture of ulnar collateral ligament (UCL) of thumb +/- avulsion injury [main stabilizer of MCP joint] Dx: confirm w/clinical exam and stress views under fluoroscopy of the thumb - valgus stress and see if it opens up Complication: long term instability may lead to arthritis Mgmt: - nonsurgical: cast, splint - surgical: required for large avulsion fracture

Answer 12

Scandinavian >50 a/w DM, alcohol, epilepsy, pulmonary disease Sxs: - thickening and contraction of palmar fascia - painless palmar nodule and progress to flexion deformity - 4th or 5th digit Dx: - >30deg = intervention Mgmt: - invasive fasciectomy - CCH or PNF - high risk of recurrence

Answer 13

D/t sporting injury Document neurovascular pre/post Dx: Xray to r/o fracture Mgmt: - reduce by applying longitudinal traction distally, and gentle pressure over dorsal deformity to guide reduction - if unable to reduce with or without digital block, may require open reduction - immobilize w/splinting or casting

Answer 14

Mgmt: - ice, elevation, pain mgmt, mobilization of unaffected joints - immobilization w/splinting or casting - closed reduction +/- percutaneous pinning - open reduction internal fixation w/pin, screw, plate

Answer 15

Punching w/fist Sxs: - fracture of metacarpal neck Complication: may end up with a little palmar deformity Mgmt: - non surgical treatment unless severe

Answer 16

E.g. industrial, snow blower, nail bed crush common in children Sxs: - bleed a lot Consider open fracture if nail bed involved and must cover w/abx Tuft fracture: injury to distal pharynx, swollen, tender, nail involvement, splint Mgmt: - remove nail and inspect nail bed - use nail or foil to split eponychial fold = best chance for nail regrowth - might require revision amputation

Answer 17

Compression/entrapment of LFCN - compression where it exits pelvis medial to ASIS under inguinal ligament Et: thin female w/heavy workmans belt - other RF: obesity, tight clothing, scar tissue from previou surgery/trauma Sxs: SENSORY only - pain, burning, hypoesthesia; anterolateral or lateral thigh - joggers: "electrical jab" w/hip extension - strength/DTR unaffected Dx: clinical - abd/pelvic exam to r/o intraabdominal pathology - AP pelvis, AP/lateral hip; r/o bony pathology - CT/MRI if intrapelvic mass suspected Mgmt: - remove compression - wt loss - cortison injection - surgical release rarely required Red flags: - intolerable sxs failing conservative treatment warrant referral for further eval

Answer 18

Bone death in femoral head d/t disruption of vascular supply to femoral head from trauma - progresses to bone structure fragment, collapse resulting in articular surface collapse and progressive arthritis - MC 3-5th decades; often bilaterally - RF: trauma, corticosteroids, ETOH, SCD, RA, SLE, HIV Sxs: gradual dull ache or throbbing in groin* or lateral hip* - severe pain w/bone death - limited ROM, antalgic limp PE: - pain w/active SLR - pain w/active/passive ROM of hip Dx: AP pelvis, AP/frog-lateral * *crescent sign: well-defined sclerotic area just beneath articular surface representing a subchondral fracture - MRI if indicated Mgmt: - limit weight bearing - intraarticular corticosteroid injection - surgical: refer to ortho [core decompression, vascularized fibular grafting, osteochondral allografting, total hip arthroplasty]

Answer 19

Snapping/popping sensation occurring as tendons move over bony prominences - MC: IT band snapping over greater trochanter Sxs: - pain if trochanteric bursitis (often coexist) - iliopsoas tendon involved: felt in groin as hip extends from flexed position (rising from chair) Limitation in IR, a limp, or shortening of limb suggests problems w/in joint and not IT band Dx: clinical - AP pelvis, lateral hip Xray - MRI r/o acetabular labrum tear Mgmt: PT, NSAIDs, corticosteroid injection - surgery (rare) Refer: - unclear diagnosis - intraarticular pathology - failure of conservative measures

Answer 20

Inflammation/hypertrophy of greater trochanteric bursa - may be secondary to lumbar spine disease, intraarticular hip pathology, leg length discrepancy, inflammatory arthritis, prior hip surgery Sxs: - pain/tenderness over greater trochanter; pain w/hip abduction; worse rising from seated position - night pain - may radiate distally to knee or proximally into butt - Trendelenburg sign* Dx: clinical - AP pelvis, lateral hip Xray Refer: failure of tx, uncertain dx, suspected fracture Mgmt: - PT - corticosteroid/local injection into greater trochanteric bursitis - NSAIDs, ice/heat - activity modification - use of cane - surgery rare

Answer 21

Loss of articular cartilage of hip joint - idiopathic; secondary to hip problems Sxs: gradual onset groin/anterior thigh pain - butt or lateral thigh pain; may be referred to knee - initially pain w/activity but progress to pain at rest/night - antalgic gait - loss of ROM - abductor lurch (sway trunk over affected hip) to compensate for pain and abductor weakness - pain w/active SLR Dx: AP pelvis/hip, lateral - joint space narrowing - osteophyte formation - subchondral cyst formation - subchondral sclerosis Mgmt: NSAIDs/APAP, activity mod, PT, corticosteroid injection (fluoroscopic or US guided) - surgery: THA (replace femoral neck, head, acetabulum) Referral/Red Flag: - persistent pain despite conservative treatments - all young patients

Answer 22

Pelvic Ring: different fracture patterns that occur based off applied forces to the pelvis Pubic symphysis = surgery Rami fracture can be managed with protected wt bearing and not surgery Dx: - pelvic ring: AP (standard) & inlet/outlet views - acetabular: AP (standard) & Judet (45deg oblique) - CT scan Mgmt: - protected weight bearing (6-12wk) - certain patterns are stable and patients can wt bear as tolerated Surgical stabilization: - widened pubic symphysis - SI joint widening or dislocation - extended sacral fractures Refer ALL to ortho

Answer 23

Fracture pattern depends on position of femoral head at time of injury, magnitude of force, and age MC: trauma when femoral head takes out superior part of acetabulum Dx: Xray - check pulse/sensation after traction - if you lose pulse, get vascular surgeon involved Tx: - distal femoral traction: preserve soft tissue, maintain length, maintain femoral head reduction if dislocated - non-op tx: minimally displaced, joint maintained, no intraarticular fragments, poor surgical candidate - surgical tx: min posttraumatic arthritis, repair acetabulum, toe-touch weight bearing up to 3mo postop Complications: - posttraumatic arthritis - neurovascular injury - heterotopic ossification - avascular necrosis

Answer 24

Almost all a/w hip dislocation Look for intraarticular fragments a/w fracture Dx: Xray Mgmt: <1mm step off = closed treatment >1mm step off = surgery (ORIF)

Answer 25

MC older women r/t osteopenia/osteoporosis - other: falls in elderly, high energy trauma in younger pt Sxs: affected leg is shorted and ER** Garden Classification system 1. impacted - femoral neck shortened 2. non-displaced 3. partially displaced 4. completely displaced w/vertical fx line Dx: xray - intraoperative imaging Mgmt: - nondisplaced: pinning; usually younger pt - displaced: hemi or total hip arthroplasty Percutaneous pinning: restricted weight bearing Hemi arthroplasty: WBAT

Answer 26

Area between greater/lesser trochanter - F 60-70yo, r/t osteopenia/osteoporosis - h/o fall, direct trauma to greater trochanter Sxs: leg shortened, ER** Mgmt: - most need surgical stabilization (sliding/dynamic hip screw; intramedullary nail) - non-op: high-risk pt or demented nonambulator

Answer 27

Greater: obtain MRI - operative mgmt Lesser: elderly, look for evidence of pathologic process (tumor, osteoporosis) - tx sxs

Answer 28

Point between lesser trochanter and point 5cm distal - high energy (GSW in young pt) - falls in elderly Dx: xray Mgmt: - placed initially into bucks traction if going to OR w/in 24hr - non-op mgmt for very poor surgical candidate only - surgical stabilization** - restricted WB 6-10wk, PT, short-term nursing home

Answer 29

Good healing rate d/t large blood supply Mgmt: - typically placed in some type of traction prior to proceeding to the OR - intramedullary nailing

Answer 30

- any fracture involving the distal 9cm of the femur - usually d/t high energy trauma; elderly may be d/t osteoporosis and low-energy injury A: supracondylar B: condylar C: combination Mgmt: - non-op: nondisplaced or incomplete fracture - operative [intramedullary nailing or ORI w/surgical plating]: intraarticular, displacement, ipsilateral LE fracture MC Complication* - loss of knee motion, results if you don't maintain articular surface of the knee

Answer 31

MC knee tear - d/t twisting of hyperextension injury - MCL/meniscus may be involved Sxs: - sudden onset pain; unable to return to activity following injury - audible pop - development of hemarthrosis in the following 24hr - chronic instability if not treated PE: + Lachman + Anterior Drawer Dx: - AP, lateral, tunnel views of the knee: usually only positive for effusion, possibly avulsion fracture of lateral capsular margin of tibia - fall injury = Xray to r/o other fracture - Knee MRI: if ACL suspected but not confirmed w/PE Mgmt: Refer all to ortho* - RICE, crutches, WB if tolerated in knee immobilizer - PT Surgical options - young, active pt: ACL reconstruction - older, less active pt: PT +/- ACL functional bracing

Answer 32

Isolated injury is less common than combination injury w/ACL Cause: dashboard injury*, fall onto flexed knee, pure hyperflexion injury (usually ACL/PCL) Sxs: - pain, joint effusion w/in 24hr; limited ROM - instability w/weight bearing - may not have tenderness to palpation PE: + posterior drawer + sulcus sign (hold tibia up) Dx: MRI** - AP, lateral Xray to identify bony pathology Mgmt: RICE, knee immobilizer - PT, early ROM; functional bracing - surgery: less common to repair

Answer 33

D/t valgus force w/out rotation Sxs: - usually able to ambulate after injury - localized swelling (less than ACL/PCL) - limited motion - mechanical symptoms or instability infrequent - ecchymosis/effusion 24-48hr PE: - tenderness along MCL - Valgus stress test Dx: MRI* - AP, lateral Xray may show avulsion fracture Mgmt: - RICE, crutches, NSAIDs, PT - Grade II: refer, protective bracing, WBAT [5-10mm laxity] - Grade III: refer, 3-4mo protective bracing w/gradual return to WBAT over 4-6wk [>10mm laxity]

Answer 34

D/t varus force w/out rotation - less common than MCL Sxs: - usually able to ambulate following injury - localized swelling - mechanical sxs or instability infrequent - ecchymosis/effusion after 24-48hr - limited motion PE - tenderness along LCL - varus stress test Dx: MRI** - AP, lateral Xray may show avulsion fracture Mgmt: - RICE, crutches, NSAIDs, PT - Grade II: refer, protective bracing, WBAT [5-10mm laxity] - Grade III: refer, 3-4mo protective bracing w/gradual return to WBAT over 4-6wk [>10mm laxity]

Answer 35

Acute injury - traumatic twisting of knee Older pt - degenerative May be a/w injury of another knee ligament Sxs: - sudden onset pain, swelling, stiffness over 2-3d - joint effusion w/acute injury - mechanical sxs** : locking, catching, popping - large fragment, knee may become "locked" - medial or lateral pain, with twisting or squatting - pain waxes and wanes PE: - tenderness over medial/lateral joint line - limited ROM - + McMurray test - + Apley's test Red Flags: - traumatic effusion - mechanical symptoms - ligamentous instability - no response to conservative treatment - persistent joint line tenderness or effusion

Answer 36

Dx: - AP, lateral, sunrise Xray if trauma or effusion - chronic: AP, lateral should be weight-bearing - MRI if not responding to conservative treatment or if ligament injury suspected - Aspiration if crystal disease or joint infection suspected Mgmt: Conservative: no mechanical sxs; degenerative - RICE, PT, NSAIDs, APAP Surgery: acute injury, locking or catching*, younger pt - meniscectomy vs. repair - red: vascular - white: non-vascular

Answer 37

Sxs: - pain w/activity or direct pressure - often worse if sedentary for long period, limp - localized swelling and tenderness - numbness below patella if saphenous nerve and infrapatellar branch compressed by pes and anserine bursa Dx: - aspiration of prepatellar bursa for fluid analysis to r/o infection - purulent or seropurulent material - gram stain, culture, crystal analysis, synovial fluid analysis - AP, lateral Xray of knee Mgmt: - NSAIDs, ice, activity modification, PT - aspiration, corticosteroid injection - IV/PO abx if infection - surgery to resect bursa (rare) Red Flags: - symptoms not responding to conservative tx - signs of ligament or tendon problems - infected bursa not responding to conservative treatment

Answer 38

- bursa lies between skin and patella to anterior aspect of knee - MC caused by direct trauma* or chronic kneeling* - may be infected w/Staph aureus or streptococcus

Answer 39

- bursa lies under sartorius, gracilis, semitendinosus on medial aspect of tibia just below tibia plateau - MC cause by OA of medial compartment

Answer 40

Osteonecrosis of subchondral bone - MC medial femoral condyle - d/t repetitive small stresses to subchondral bone that disrupt blood supply - osteonecrotic bone becomes separated from surrounding bone, weakens, and gradual fracture of articular cartilage surface occurs becoming loose bodies in joint Sxs: - gradual onset of knee pain, knee effusions, catching or locking - walking w/foot externally rotated may relieve pain - tenderness to palpation PE: + Wilson Test - supine, flex hip and knee to 90deg, internally rotate tibia and slowly extend knee + = pain at 20-30deg and pain relieved w/ER of tibia Dx: AP, lateral, tunnel Xray - necrotic area of bone or FB in joint - MRI assess overlying articular cartilage and stage lesion Mgmt: goal is heal lesion Nonsurgical: - child prior to skeletal maturation (overlying cartilage still intact) - activity modification, crutch use Surgical: - adults, articular cartilage that has been separated from bone - intact lesion - drill to promote vascular growth - unstable lesion - temporary internal fixation - remove loose fragment, debride articular surface defect

Answer 41

D/t overuse or overload syndrome; common in younger pt (<40y) but may occur in older pt after lifting strain Sxs: anterior knee - pain following exercise or w/prolonged sitting, squatting, kneeling - increased pain w/stairs, running, jumping, squatting - tenderness over tendon or attachments - warmth, swelling, soft-tissue crepitus - normal ROM but pain w/resisted knee extension or hyperflexion Dx: AP, lateral Xray (-) but may see osteophyte or heterotopic ossification - MRI for surgical cases or when partial rupture suspected Mgmt: rest (days-wks) + NSAIDs, analgesics, ice after/heat before activity - avoid corticosteroid injection into tendon (may increase r/o tendon rupture) - PT, knee sleeve Red Flags: - possible or confirmed rupture of the extensor mechanism - failure of conservative treatment

Answer 42

Diffuse anterior knee pain increased w/activity - usually r/t overuse or overloading of patellofemoral joint - chondromalacia not always present Sxs: - sense of instability or catching; no swelling or prior trauma - worse after prolonged sitting, stairs, jumping, squatting - knee angulation; increased Q angle - J sign: active knee flexion then extension - patella moves laterally >1cm - pain w/patellar compression - crepitus w/knee flexion --> extension - patellar apprehension sign* (instability) Dx: AP, lateral, sunrise view Mgmt: activity modification, PT, NSAIDs, APAP, wt loss - surgery Red flag: - persistent symptoms, recurrent effusions - findings of patellar instability

Answer 43

MC >55yo; gradual onset pain especially w/weight-bearing activity Sxs: - may have mechanical symptoms of buckling or giving away - stiffness, intermittent swelling - progresses to pain at rest or w/sleeping - tenderness to joint lines - valgus or varus deformity - mild effusion - crepitus to patellofemoral joint - decreased ROM w/progressive disease Dx: - weight-bearing* AP Xray, lateral, sunrise - joint space narrowing, osteophyte formation, sclerosis, periarticular cysts ``` Mgmt: Conservative - NSAIDs/APAP; PT; intraarticular corticosteroid injection - Ice, heat, topical analgesics - ambulatory device ``` Surgical: indicated when pt cannot stand the pain anymore - TKA Red flags: - failure of conservative tx - pain at rest, decreased ROM, significant functional limitations

Answer 44

MC synovial cyst/bursa in the knee - communicates w/knee joint and becomes more prominent when trauma creates excess joint fluid - a/w degenerative meniscal tears or systemic inflammatory conditions (RA)** Sxs - swelling or fullness to popliteal fossa w/pain and tenderness; mechanical symptoms - severe pain and swelling in calf if rupture occurs - mass seen and/or palpated at popliteal fossa - effusion and mechanical symptoms usually indicate intraarticular irritation Dx: (-) Xray, but may show DJD or calcification of cyst - U/S to differentiate cyst/vascular* - do NOT aspirate pulsatile mass Mgmt: - RICE - aspiration only transient and fluid often reaccumulates - treat cause of increased fluid and cyst usually resolves spontaneously [meniscectomy, TKA] - cyst excision

Answer 45

Gradual onset pain to posteromedial aspect of distal third of leg - develops w/exercise; a/w prolonged walking or running - may be inflammation of tibial periosteum secondary to repetitive muscle contraction Sxs: gradual onset; pain to distal third of medial tibia, site of origin of posterior tibialis - tenderness to distal third of medial tibia - pes planus, overpronation Dx: AP, lateral views of tibia to r/o stress fracture Mgmt: - activity modification, NSAIDs, ice massage, analgesic, shoe inserts Red flags: - r/o stress fracture and exertional compartment syndrome w/neurovascular checks, pain out of proportion to injury

Answer 46

Mechanism: direct or indirect - quad tendon attaches superiorly, patellar tendon attaches distally Dx: - important to assess active knee extension: ability to perform active extension must be assessed w/SLR* - Xray Complications: - loss of knee motion - loss of extensor strength - posttraumatic arthritis Mgmt: Nonoperative: - <3mm displacement, minimal articular disruption, intact extensor mechanism - WBAT in knee immobilizer - Knee ROM 4-6wk once callus begins to form Operative: - 3mm of displacement, >2mm articular disruption, disrupted extensor mechanism - WBAT in knee immobolizer postop - repair tendon - patellectomy vs. ORIF

Answer 47

Mechanism: forceful varus/valgus stress - elderly: fall - involves articular surface; more serious when involving joint - MC = lateral plateau - may be a/w ligament injury Dx: CT Mgmt: Initial: long leg cast Nonop: nondisplaced, comorbid conditions, preexisting arthritis Op: perform when soft tissue swelling improved (10-14d s/p injury) - ORIF + NWB x 3mo

Answer 48

Usually occurs 5-7cm proximal to calcaneus Med: ciprofloxacin Sxs: sudden, severe calf pain, rapidily achy - partial: calf strain or pull w/maintainence of function - complete: weakness, loss of function PE: + thompson test - check palpable deficit, tenderness, achilles swelling Dx: MRI Mgmt: Nonsurgical: partial tear or poor surgical candidate - splint in plantarflexion, then subsequent casting is less and less flexion Surgical: complete tear - treatment must not be delayed as deficit widens as muscle belly retracts end of tendon* - refer all suspected partial or complete tears

Answer 49

Posterior heel "start up" pain Tenderness w/palpation of Achilles Dx: imaging not requires; may show calcification if chronic Mgmt: PT, NSAIDs - refer if conservative failure after 1wk - NO steroid injections

Answer 50

MC: ATFL MC inversion injury High ankle sprain: tibiofibular syndesmosis injury Sxs: - pain over anterolateral ankle; swelling and loss of function common - inability to walk - ecchymosis and swelling - tenderness over affected ligament PE: - anterior drawer: laxity suggesting higher grade ligament tear - squeeze test: high ankle sprain Dx: AP, lateral Xray IF [Ottawa rules] - tenderness at tip of malleolus - inability to weight bear immediately after injury or take four steps in the ER - pain at the base of 5th metatarsal (may pull off part of the bone) MRI rarely indicated; if you think it is required = refer Mgmt: Goal - prevent chronic instability and pain - RICE, NSAIDs, PT - severe: 2-3wk NWB boot Refer: - high ankle sprain, fracture - significant instability - failure of conservative measures

Answer 51

Cause: idiopathic, inflammatory, posttraumatic 90% of ankle DJD = prior injury* Sxs: pain w/activity, swelling, stiffness, rest pain - decreased ROM - pain w/palpation, creptius - swelling, fullness, warmth Dx: Xray Mgmt: - NSAIDs, immobilization, bracing, shoe modification; temporary steroid injections Refer: - pain and ambulation problems - worsening sxs - failure of conservative treatment Surgical: - fusion = remove arthritis - fix w/plate, screw

Answer 52

Entrapment of tibial nerve in tarsal tunnel Sxs: pain, swelling in posterior medial ankle w/associated radiating neuritis sxs in the tibial nerve distribution PE: + tinel Dx: EMG - MRI preop, r/o tarsal tunnel mass Mgmt: - immobilization for acute inflammation - PT for nerve glide exercises - Gabapentin (Neurontin) or Pregabalin (Lyrica) for neuropathic pain Surgical: fail conservative; tarsal tunnel mass

Answer 53

H/o increased physical activity or obesity Sxs: start-up pain - pain over plantar fascia origin or throughout fascia +/- Baxter's nerve Dx: radiograph may show heel spur Mgmt: - 1yr of conservative treatment: NSAIDs, heel cord stretches, night splint, PT - cortisone injection from medial aspect (NOT plantar) Surgical: plantar fasciotomy + stretching

Answer 54

Females Symptomatic in shoes "Pump bump" - posterior lateral prominence - soft tissue changes first, then bony Dx: Xray Mgmt: gel sleeve, heel lift, surgery

Answer 55

+/- h/o trauma Worse in barefoot or hard floor; only w/weight bearing activity Comparable to plantar fasciitis - but NO startup pain Sxs: pain over central heel on exam +/- palpable bone indicating fat pad atrophy - adequate fat pad but + pain w/palpation = maybe bruised fat pad Dx: Xray r/o stress fracture Mgmt: - orthotic pads help cushion - no injections, no replacement therapy

Answer 56

Military recruit, marathon runner PE: provocative test = + pain w/squeezing of calcaneal body Dx: Xray; but MRI confirms* Mgmt: - NWB boot x 4-6wk, then PT to stretch area that tightened up in boot - gradual return to activity

Answer 57

D/t forced plantar flexion; easily missed as ankle or foot sprain Sxs: pain over dorsal midfoot, usually mild to significant swelling - swelling, pain over tarsal-metatarsal joint - stabilization of ankle and hindfoot w/sagittal stress of the midfoot will create pain and occasionally instability is felt Dx: - Fleck sign: metatarsals and bones of foot don't line up - Xray Mgmt: - immobilization - urgent surgery* to stabilize medial column - posterior splint at 90deg from base of foot to base of knee

Answer 58

D/t trauma or fatigue (stress) Sxs: swelling, pain w/weight bearing - new or INC training regimen is common for stress fracture Dx: Xray Mgmt: - NWB x 4-6wk then WBAT - refer to Ortho Surgery: - significant shortening, displacement, angulation, subluxation - painful non-union at 8wk

Answer 59

5th metatarsal fracture - classic: zone 2 [NWB cast 6-8wk, surgery In athlete or sxs non union at 3mo] - pseudo jones: zone 1 [NWB cast x 4-6wk] - zone 3: stress induced [usually need surgery as delayed union is common] Dx: Xray

Answer 60

Sxs: pain, swelling, erythema Dx: Xray often negative Mgmt: NWB in post op shoe - followed by gradual increase in WB, activity

Answer 61

Lateral deviation of hallux d/t hereditary, acquired, traumatic - more common in females d/t shoe wear Sxs: prominent medial eminence, pain w/activity, problems in shoe wear Mgmt: shoe modification - surgery: deformities w/sxs on regular basis

Answer 62

Cause: shoe, trauma, high arches, pressure from bunion Hammer toe: flexion at PIP, extension DIP Claw toe: flexion at both PIP, DIP Mallet toe: neutral PIP, flexion DIP pain over deformity prominence can cause corns or distal tip of toe rubbing Dx: Xray Mgmt: reduce w/pencil, buddy tape - reassure that it may be tender for a while - surgery: percutaneous fixation for significant angulation fracture or cannot be reduced

Answer 63

Direct trauma - stubbed toe, kicked something Permanent deformity is uncommon unless significantly displaced Sxs: swelling, pain, ecchymosis Dx: Xray Mgmt: reduce w/pencil, buddy tape - reassure that it may be tender for a while - surgery: percutaneous fixation for significant angulation fracture or cannot be reduced

Answer 64

Common in walkers or d/t overuse, poor shoes Sxs: - pain in ball of foot: worse in barefoot or hard floors ("walking on stones") - pain with palpation of metatarsal heads: callous, fat pad atrophy, hammer toe, bunion Dx: normal Xray Mgmt: orthotics w/metatarsal pad - refer if no improvement in a few weeks

Answer 65

Hard to differentiate w/metatarsalgia Pain worse in tight shoes* and better barefoot Neuritic symptoms radiate into affected toes Pain w/compression in web space (2nd, 3rd, webspace) Dx: - negative radiograph - U/S - diagnostic lidocaine* : dec pain in Morton's but not metatarsalgia Mgmt: - orthotics w/MT pad - Neurontin - sclerosing agent? - Surgical excision if conservative measures fail

Answer 66

Anatomy - 2 sesamoid bones surround by FHB and plantar plate fibers - tibial (medial) and fibular (lateral) Causes: inflammation from overuse/direct trauma; fracture; AVN Sxs: pain under 1st MT head +/- h/o forced DF injury (Turf Toe) - may fracture sesamoids Dx: best visualized on AP Xrary - presence of sesamoids alone not indicative Mgmt: - if overuse, orthotics w/sesamoid protection - refer to ortho if fail orthotic treatment or if fracture or AVN are present

Answer 67

Hereditary neuromuscular disorder w/multiple variants Sxs: weakness of tibialis anterior and peroneal - neuropathy symptoms - Cavovarus deformity: ankle instability; 5th MT stress fractures Mgmt: - bracing for weak tibialis anterior (foot drop) - reconstructive surgery (refer to ortho)

Answer 68

DM pt d/t breakdown of bone from trauma or DM neuropathy Sxs: acute erythema, warmth, edema - improves w/elevation and off-loading* - chronic: bone destruction leaves a rocker bottom deformity - at risk of ulcer, infection, or loss of limb Dx: initial Xray may be negative - classic sign: fragmentation of bone and subsequent collapse Tx: manage DM

Answer 69

D/t high energy trauma (fall) - fracture of distal tibia w/extension into ankle joint Sxs: pain, severe swelling quickly* ``` Dx: CT Weber class (based on fibular involvement) ``` Weber A: below tibial plafond = stable; NWB cast 4-6wk Weber B: at tibial plafond - w/out displacement, tx nonop - + deltoid tenderness of medial clear space widening: ORIF - stress test if unclear - may have syndesmotic injury Weber C: above tibial plafold - indicates syndesmotic injury - requires ORIF Mgmt: call ortho immediately - external fixation until definitive fixation can be performed

Answer 70

Isolated Check proximal fibula Xray if malleolus tender Mgmt: - nondisplaced: cast - displaced: ORIF

Answer 71

Lateral + medial Xray Mgmt: - unstable: ORIF surgery - no displacement and multiple comorbidities: consider casting

Answer 72

high rate of associated dislocation Lateral + medial + posterior Xray Mgmt: - very unstable and requires ORIF - usually 7-10d after injury to allow soft tissue to settle down - initially splint in stirrup + posterior rigid splint - call ortho*

Answer 73

External rotation injury - medial deltoid ligament tear + syndesmotic tear + proximal fibular fracture Xray Unstable = ORIF

Answer 74

Talus, calcaneus d/t very high energy trauma - MVA, fall from height Dx: check spine for concomitant injury** - Hawkins classification - Xray

Answer 75

Nondisplaced: cast immobilization 6-8wk Displaced: ORIF

Answer 76

Mgmt: - immediate reduction & fixation - complications: AVN

Answer 77

MC complication from fracture Hawkins sign: subchondral lucency of talar body; occurs 6-8wk postop - confirm w/MRI Mgmt: - NWB in boot w/bone stimulator - more diffuse alteration in blood supply compared to OLT

Answer 78

D/t high impact trauma Sxs: pain/swelling around heel Dx: Xray, CT if needed Complications: - high rate of posttraumatic subtalar DJD - chronic heel pain d/t fat pad injury - treat w/orthotics Mgmt: - refer all to ortho* - short leg splint ASAP - 10d NWB for both surgical and nonop pt Woudn dehiscence MC postsurgical complication

Answer 79

Inflammatory back pain (lumbar, SI, hip) Manifestations: - acute anterior uveitis (MC) - bowel disease - enthesitis - peripheral arthritis - psoriasis Dx: - Schober test <4cm - Occiput to wall - cervical mobility - Labs: HLA-B27*, inc ESR/CRP Imaging - lags behind presentation 7-10y - Bamboo spine** - bone building disease, dec ROM - Sacroilitis = radiograph hallmark** Mgmt: tx current manifestations of dz - NSAIDs for pain, stiffness - pt ed, exercise, PT - NO DMARDs - corticosteroid injections may be helpful - may consider surgery

Answer 80

Strain: paravertebral muscles Sprain: facet joints, disc, spinal ligament Most injuries thought to be a combo of both* PE: neck, back, PV Red flags: - h/o CA - unexplained weight loss - urinary retention, incontinence - progressive motor or sensory loss - loss of anal sphincter tone - saddle anesthesia* - trauma, fever, UTI, infection

Answer 81

* imaging does NOT improve outcomes in pt w/o sxs of serious underlying condition, therefore not indicated for most significant trauma: plain film*, may need CT or MRI - concern for serious neurologic cause = MRI (r/o cauda equina syndrome) * even w/minor red flags, 4-6wk of conservative treatment reasonable prior to imaging Mgmt: - pt ed; avoid bedrest; NSAIDs/APAP; muscle relaxants; warm compress; PT - oral steroids; lumbar supports; massage; spinal manipulation

Answer 82

Anterior compression (>5deg) in at least three adjacent vertebral bodies, as measured on lateral spine radiograph - MC in tall boys; a/w w/back pain in adulthood - affects thoracic or thoracolumbar spine Sxs: subacute pain w/out precipitant - pain worse after activity and at end of day - pain improved w/rest and age PE: curvature does not flatten w/forward bending, extension, or lying supine* Dx: - standing lateral spine radiograph** criteria: - anterior wedging >5deg in three adjacent vertebral bodies Mgmt: - conservative: strengthening, stretching, analgesics, avoidance of precipitants - bracing or surgery may be warranted w/persistent pain or kyphosis >60deg

Answer 83

Lateral curvature of spine Sxs: generally painless* MC R thoracic curvature - asymmetry of shoulder heights, scapular prominence or position - waistline or pelvic height discrepancy - rib hump when pt bends over and comes back up slowly Dx: * females screened twice at ages 10/12 and boys once at 13 or 14 - standing AP spine radiograph* - location of curve defined by apical vertebrae; direction of curvature defined by direction of convexity - Cobbs Angle* = degree of curvature; > 15 is abnormal Mgmt: - ortho referral - curve 20-25: monitor - curve 25-45: no bracing in skeletally mature; Milwaukee brace in growing children - curve >45: may require surgery regardless of skeletal maturity; refer regardless of age

Answer 84

Non-inflammatory DJD, MC arthritis in adults - leading cause of hip/knee replacement - progressive erosion of articular cartilage* leading to sclerosis and osteophyte formation - synovitis (cool effusions) and synovial hypertrophy - ligamentous laxity and disruption of joint capsule w/out injury Causes: - aging - congenital, obesity*, injury RF: age, female, AA, genetic, obesity, joint stress Sxs: - joint pain INC w/activity, relieved w/rest; worse in evening - stiffness <30min, restricted ROM - asymmetric sxs - weakness, atrophy - no systemic sxs - Herberden's, Bouchard's nodes

Answer 85

Dx: - normal ESR/CRP - neg rheum tests - noninflammatory synovial fluid (WBC <2k) xray: joint space narrowing, osteophytes, sclerosis, subchondral cysts, nodes Mgmt: - limited to sx control; wt loss!! - joint protection - APAP - NSAIDs + PPI - can't tolerate NSAIDs: capsaicin cream, methylsalicylate cream, diclonfenac sodium gel - intraarticular steroid injection (or hyaluronic acid) Surgical indications: - pain affecting work, sleep, walking, leisure

Answer 86

Skeletal fragility w/compromised bone strength predisposing to an INC r/o fracture - primary: reduced bone mass/fractures in postmenopausal women or older men d/t age related factors - secondary: bone loss from clinical disorder bone mass peaks by 18-25yo RF: female, white, petite, Fhx, early menopause, immobilization, ETOH, cigarette, Ca/Vit D def, meds, gastrectomy, intestinal surgery - meds: steroids, heparin, AEDs Sxs: - fractures, complications - MC: vertebral, proximal femur, distal forearm - no pain prior to fracture - fracture can result in chronic pain and disability Osteopenia Pt - T-score -1 to -2.5 - FRAX: calculate 10y risk of hip and major osteoporotic fracture (based on femoral neck BMD + RFs) - only applies before treatment

Answer 87

Dx: BMD, hp/vertebral fx w/o trauma - all postmenopausal women, men >50yo eval for need of BMD BMD testing - women >65 - men >70 - adult w/fracture over age 50 - adult w/condition (RA) or taking medication (glucocorticoid) associated w/low bone mass or bone loss Osteoporosis: T-score at or below -2.5 Mgmt: - Calcium [men 1000mg/d female 1200mg/d]: Ca carbonate take w/food; citrate for pt on PPIs or if they have constipation - Vit D 600-800 IU/day - PT/OT, smoking cessation, dec ETOH Prevention: - estrogen - raloxifene - alendronate, risedronate, ibandronate Treatment: - raloxifene (SERM) - bisphosphonates** - calcitonin, teriparatide, IV zoledronic acid, denosunab Treat 4-5y w/bisphosphonates then drug holiday 1-2y R/o osteonecrosis of jaw, atypical fremur fracture

MSK Flashcards

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