MSK Flashcards

Question

Steroid Injection Contraindications

Answer 1

* joint infection * overlying skin infection * systemic bacteremia * thrombocytopenia/bleeding disorders * prosthetic joints * osteonectrosis or fracture * uncontrolled DM * psoriatric plaques * steroid allergy

Answer 2

hyaluronate preparation * hyaluronic acid is in synovial fluid- provides shock absorption * brand names: * Synvisc, Orhovisc, Euflexxa * C/I * infection * overlying skin disease * chicken/egg allergy

Answer 3

* joint * infection, hemorrhage, flare, steroid arthropathy (joint breakdown w/ too much steroid use) * systemic * facial flush * worstening diabetic control * supression of HPA axis * iatrogenic Cushing syndrome * local * leakage along steroid tract * atrophy of subcutaneous fat, depigmentation * misplaced injections * tendon rupture, nerve damage, cartilage injury, abscess * rare * pancreatitis * hypersensitivity rxns * uterine bleeding * osteonecrosis

Answer 4

* conservative * RICE- rest, ice, compression, elevation * rehab * meds * Rx: NSAIDs, corticosteroids, pain relievers * herbal: glucosamine and conjointin * topical (except over surgical sites!) * aspiration/injection * bracing * activity modification * surgical

Answer 5

shoulder impingement * s/s * insidious onset or mild trauma * deltoid/upper arm aching; dull at rest or sleeping * rc pain referred to deltoid * normal/near normal ROM * full strength or mild weakness d/t inflammation * tests * Neer sign * Hawkins-Kennedy sign * x-ray (+/- bone spur), MRI (r/o tears, tendinosis) * diagnosis: clinical

Answer 6

bicipital tendinitis * role of bicep: supination * unknown cause * s/s * pain in bicep through bicipital groove * rupture causes "Popeye muscle" deformity * tests * Speed's sign * Yerganson's test * tx * conservative: PT, ice, subacromial/bicep injection, activity modification, NSAIDs * surgical: arthroscopy w/ 6-8w recovery

Answer 7

rotator cuff tear * supraspinatus muscle torn typically- cuff arthropathy: humeral head rides up superiorly * s/s * gradually worsening pain, NIGHT PAIN * +/- weakness * tests * drop arm * empty can * x-ray (+/- spur, cuff arthropathy) * MRI * possible US * tx * based on size, acuity, dysfunction, activity level * no symptoms = no tx * conservative * rest, ice, NSAIDs, +/- injection, PT * NO SLING- will get frozen shoulder * surgery * arthroscopic or open repair

Answer 8

glenohumeral instability/dislocation * s/s * dislocation/subluxation vs. generalized- doesn't affect just the shoulder * may be trauma or genetic (adolescent) * may have numbness or tingling * check axillary n. (CN XI) - feel for deltiod contraction * ALWAYS do neurovascular check before reduction/procedure * **Bankart Lesion**- labrum torn w/ dislocation * tests * x-ray pre/post reduction to check for fractures- MUST HAVE AXILLARY VIEW * for recurrent instability * apprehension test (anterior/posterior) * sulcus sign (inferior) * load and shift test (anterior/posterior) * tx * traction/counter traction * Stimpson hanging arm technique * 1st- immobilize 2-3w, PT \>4w, maybe surgery * recurrent- arthroscopy vs. open surgery

Answer 9

SLAP tear (Superior Labrum Anterior to Posterior) * s/s * pain anterior and deep * +/- clicking * weakness/pain w/ overhead activity * normal ROM and strength * tests * O'Brien test * Crank test * GIRD: glenohumeral internal rotation deficit- lose ROM * MR arthrogram (gold standard)- plain films will be normal * tx * grade 1-2: rest, ice, PT w/ scapular stabilizers, throwing protocol, core strengthening * grade 3+: SLAP repair if \<30-35; tenotomy or tenodesis if \>35

Answer 10

AC joint sprain/dislocation, OA/osteolysis * sprain * always lateral shoulder trauma (AC joint +/- CC ligs) * tx: * immobilize w/ sling ~2d, rest, ice, NSAIDs, PT * surgery rare (grade 4+ only) * OA/osteolysis * conservative vs. open or arthroscopic excision/resection

Answer 11

adhesive capulitis * s/s * freezing -\> plateau -\> thawing * trauma, immobilization, thyroid disease, diabetics, women * adhesions and thickening of joint capsule * tests * x-ray to r/o other causes * NO MRI * tx * conservative: rest, ice/heat, PT, GH injection, NSAIDs, pain meds * surgery: * manipulation under anesthesia * arthroscopy for lysis of adhesions

Answer 12

* subacromial space * seated w/ forearm on lap * inject **~1cm** below posterior border of acromion * directed medially, anteriorly, slightly superiorly 2-3cm * glenohumeral joint * posterior **2 fingers** medial and posterior acromion border * directed anteriomedial toward coracoid process * bicipital tendon sheath * sitting or supine * externally rotate arm and mark point of max tenderness * insert 30-45 deg into sheath AVOIDING tendon * AC (acromioclavicular) joint * seated w/ forearm in lap * superior approach insert ~.5cm * SC (sternoclavicular) joint * sitting or supine * anterior approach ~0.5cm

Answer 13

thoracic outlet syndrome * s/s: * women 20-50 * trauma or mechanical stress, conginital: cervial rib, long C7 transverse process, fibrous tissue in thoracic outlet * vague: neck, trapezious, shoulder/arm, supraclavicular pain or aching * parasthesia (ulnar nerve commonly) * color changes in arm * fatigue * WORSENING w/ ARM OVERHEAD * bruits * tests * Adson's maneuver * elevated arm stress * tx * conservative * rest, meds: NSAIDs, muscle relaxers, PT w/ postural awareness * surgery- rare

Answer 14

* inspection * edema, deformity, ecchymosis, atrophy * palpation * bony landmarks * ROM at elbow * flexion, extension, supination, pronation * strength testing * special tests

Answer 15

medial/lateral epicondylitis * s/s * overuse injury * +/- weakness * lateral pain- tennis elbow (common extensor) * medial pain- golfer's elbow (common flexor) * tx * conservative * rest, ice, NSAIDs, +/- cortisone, injection bracing * surgery (not common) * drill holes in bone to advance healing

Answer 16

collateral ligament injury * radial collateral ligament (LCL) * rare, usually associated w/ fracture or dislocation * ulnar collateral ligament (MCL) * repeated valgus stress (pitching), injuries rare * s/s * acute- pop then medial elbow pain * chronic- no specific injury, just progressing pain * **ulnar paresthesia** (ring/little finger) * pain w/ ecchymosis * tests * valgus stress test * MR arthrogram * tx * conservative: rest, NSAIDs, PT, throwing mechanics * surgery- "Tommy John" UCL repair

Answer 17

olecranon bursitis * s/s * acute or gradual * direct blow, gout or crystalline deposits (gritty on palpation), infection (septic) bursitis requires surgery * swollen, painful, sometimes red posterior elbow * warm to touch * remainder of exam benign * tests * aspirate and analyze WBC, crystals, gram stain/culture * tx * I&D and Abx * NSAIDs, elbow pad, cortisone injection if no infection * surgical excision (not common)

Answer 18

cubital tunnel syndrome (ulnar neuritis) * s/s * medial elbow aching * atrophy of hand * direct blow vs. leaning on elbows or holding flex position * check for deformity/carrying angle * tests * elbow flex test * positive Tinel's sign * vibration and light touch perception- 2pt discrimination * manual muscle testing * finger abduction and adduction * x-rays * EMG/NCS * tx * conservative * rest, avoid flexion, night extension splint * surgery * ulnar nerve decompression * transposition- move nerve out of cubital tunnel

Answer 19

distal bicep tendon rupture * s/s * pain and palpable defect in antecubutal fossa * musce belly retracts w/ elbow flexion * weakness w/ supination * tests * x-ray * MRI * tx * **surgery w/in 2 weeks of injury** * consider conservative if elderly, nondominant, partial

Answer 20

elbow dislocation * s/s * FOOSH * terrible triad- dislocation w/ fracture of coronoid and radial head * 80% posterior * LCL always disrupted * brachial a., median and ulnar nn. injured * tests * neurovascular check * x-ray * +/- CT scan * tx * reduction and splint under conscious sedation * ROM start in 5-7d

Answer 21

* olecranon bursa * elbow flexed, poserior 1cm distal to olecranon bursa * 18g needle w/ 10ml syringe * grasp bursa w/ other hand * elbow joint * seated w/ 45 degree elbow flex * palpate center of lateral epicondyle, radial head, tip of olecranon triangle * lateral epicondylitis * seated w/ elbow flexed 90 degrees * 1cm distal to epicondyle, point of max tenderness * 22g needle * medial epicondylitis * seated w/ elbow extended 20 degrees

Answer 22

* inspection * scars, atrophy, edema, erythema, deformity * palpate * bony and soft tissue * ROM- active and passive * especially if suspect tendon injury * strength * special testing

Answer 23

carpal tunnel syndrome * s/s * female, repetition, DM, thyroid, RA, pregnancy * 1st, 2nd, 3rd finger numbness and tingling * worse at night * muscle weakness- loss of grip and motor dexterity * tests * Tinel's sign * Phalen's sign (\*most useful) * 2pt discrimination loss * muscle atrophy * EMG and nerve conduction studies * tx * conservative * NSAIDs, activity modification, bracing, injection * surgery * open vs endoscopic

Answer 24

DeQuervain's Tenosynovitis * s/s * pain +/- mild edema * tests * Finkelstein test * tx * injection, +/- bracing, PT * rarely surgical release

Answer 25

ganglion cyst * s/s * fluid leaks from joint capsule/tendon synovial sheath * vary in size +/- pain * transilluminate * can compress medial nerve and radial artery * tx * conservative * NSAIDs, rest, wrist splint * aspiration- WATCH radial artery * surgical * if recurrent painful cyst or N/V compromise

Answer 26

thumb/finger dislocations * s/s * tearing of collateral ligament/volar capsular ligament * check for joint stability 1-2w later * tests * x-ray to r/o fracture * tx * conservative- taping

Answer 27

gamekeeper's (skier's) thumb * s/s * tear of ulnar collateral ligament (UCL) of MC joint * pain, swelling, ecchymosis * tests * valgus stress test * x-ray to r/o fracture * +/- MRI if suspect rupture * tx * conservative vs. surgical if UCL ruptured

Answer 28

trigger finger * s/s * pain and catching * thickening of flexor tendon sheath- a1 pulley * mostly long and ring finger * female, RA/DM * worse after inactivity * tx * conservative vs. surgical

Answer 29

flexor tendon injuries flexor digitorum profundus (FDP) & digitorum sublimis (FDS) * s/s * "Jersey finger"- ring finger most common * swelling, ecchymosis * TTP at distal phalanx * associated w/ RA/OA * tests * test flexion at PIP and DIP * tx * surgical repair * \*\*\* DOCUMENT evaluation with every finger/hand cut \*\*\*

Answer 30

boutonniere deformity * s/s * rupture extensor central slip * tests * x-ray to r/o fracture * tx * extension splint to PIP * 6w if youger, 3w if older

Answer 31

mallet finger * s/s * rupture to extensor tendon at DIP * tests * x-ray to r/o fracture * tx * RICE * extensor splint all times for healing * surgery for large avulsion

Answer 32

swan neck deformity * s/s * weakening of volar plate * RA/nerve disorders * pain and swelling * tests * x-ray * tx * conservative vs. surgical

Answer 33

paronychia * s/s * pain and swelling around nail * tx * digital block and drainage * oral abx * cephalexin (Keflex) 500mg po q6h 10d * tmp/smx (Bactrim DS) 1 po q12h 10d * clindamycin (Cleocin) 300mg 1 po q8h 10d

Answer 34

felon * s/s * puncture wound (usually thumb or index) * sever pain and swelling * tense, red, swollen, very tender * tests * S. aureus pathogen * tx * digital block w/ surgical drainage * abx: Keflex or Bactrim

Answer 35

septic flexor tenosynovitis * s/s * puncture wound * **Kanavel's 4 cardinal signs** 1. intense pain w/ extension 2. flexion posture 3. fusiform swelling 4. tenderness along flexor tendon sheath * tests * CBC, ESR, sed rate * x-ray * tx * call hand service * SURGICAL EMERGENCY \*\*DO NOT MISS * Abx * poor prognosis- usually residual stiffness, loss of ROM

Answer 36

herpetic whitlow * s/s * pain, swelling * tests * herpes simples 1 or 2 * tx * conservative- DO NOT DRAIN these * +/- antivirals

Answer 37

* inspection * LL length/alignment, deformity, muscle atrophy, pelvic obliquity, Q-angle * Q-angle: * female 17 deg, male 14 deg * angle of ASIS to middle patella to mid tibia * stresses medial side of knee + foot pronation * gait analysis * palpation * bony prominences, soft tissue, joint line * ROM * manual muscle testing (MMT) * special tests

Answer 38

* ischial tuberosity * anterior tilt- downward tilt w/ hip extension * posterior tilt- hip flexion * lateral tilt * pelvic rotation w/ walking * diarthroidal- movement in 3 planes * hip pain- anterior to seam line of pants * back pain- posterior to seam line of pants * femoral neck angle * anteversion- smaller angle than normal (foot in) * retroversion- larger angle than normal (foot out) * coxa vara- inclination \<125 degrees * coxa valga- inclination \>125 degrees

Answer 39

* Trendelenburg Test/Sign * hip drop opposite affected gluteus medius/minimus * Thomas test * hip flexor contracture/psoas tightness (knee to chest) * log roll test * pain w/ internal leg rotation- acetabular/femoral neckpathology * FABER (Patrick) test * flexion-abduction-external rotation (cross leg while lying) * SI joint or hip problem * Hamstring flexibility * passive SLR 80 degrees * knee extension should be 5-15 degrees of straight

Answer 40

hip strain * s/s * TTP * pain with stretching or resistance to MMT * tx * RICE, NSAIDs, pain relievers, PT * surgery- avulsion injuries

Answer 41

hip bursitis - trochanteric bursitis * s/s * most common hip bursitis * lumbar spine OA/scoliosis, length discrepancy, trauma * runner, female, middle age to elderly * pain at rest and activity * difficulty ambulating * TTP greater trochanter * pain w/ abduction * tx * RICE * cortisone injection * NSAIDs, pain reliever * weight loss * rehab: stretch/strengthen gluteus medius and IT band

Answer 42

piriformis syndrome * s/s * pain w/ sitting or getting out of bed * pain w/ hip adduction * difficulty sitting * absent neurological signs * TTP SI joint, gluteal muscles, greater sciatic notch * tests * piriformis test * Lasegue sign- leg lifted and straight, flex knee and cross * x-ray, MRI, CT to r/o other causes * EMG to differentiate btw piriformis and herniated disk * tx * NSAIDs, PT, +/- injection * surgery?

Answer 43

femoral acetabular impingement * s/s * osseous deformity of acetabular rim, femoral head/neck junction * causes labral tear and articular cartilage microtrauma * from overuse * tests * decreased flex and IR * +FIDDIR * x-ray (AP and lateral) * MR arthrogram * tx * conservative vs. surgical

Answer 44

hip dislocation * s/s * obvious deformity * tests * check distal pulses and nerve status, knee * x-rays (AP and lateral) * CT if fracture suspected * tx * reduction ASAP * if no fracture w/ PWB and advance as tolerated

Answer 45

osteonecrosis * s/s * bone death- collapse of femoral head * risks: corticosteroid use, alcohol abuse, trauma, sickle cell, RA, lupus * Trendelenburg gait * decreased/painful ROM * tests * pain w/ straight leg raise * +log roll * x-ray, MRI or CT * tx * w/out collapse * core decompression * vascularized fibular grafting * w/ collapse * arthroplasty (replacement)

Answer 46

hip osteoarthritis * s/s * childhood disease, trauma, osteonecrosis, infection * anterior groin/thigh pain (worse at night) * pain w/ activity and progresses to constant pain * popping, catching grinding * fixed external rotation and flexion contracture * tests * x-rays * tx * conservative * pain control, activity modification, assistive devices * surgery * osteotomy * total hip arthroplasty

Answer 47

lateral femoral cutaneous nerve entrapment * s/s * pain and dysethesia of lateral thigh * decreased sensation but pressure or tapping over nerve increases symptoms * no muscle or abnormal reflexes * tests * plain films- r/o abnormalities * CT/MRI- r/o pelvic or abdominal masses * tx * weight loss, loosening tigh clothing * meds * cortisone injection * surgical release of nerve rarely done

Answer 48

* inspection * gait, alignment, feet, discoloration, effusion, atrophy * palpation * quad/patellar tendon, joint line, MCL/LCL, bursa, popliteal fossa * ROM * knee flexion 0-130 degrees (up to 10 percent of hyperextension) * manual muscle testing * grading scale * special test

Answer 49

* apprehension test * move patella laterally: +if pain, apprehension, quad contraction * J sign * excessive lateral patellar shift in terminal extension (up and out) * McMurray's test- meniscus * leg lifted w/ knee at 90 degree angle then...knee out/foot in to knee in/foot out * try to catch popping or catching * anterior drawer/Lachman's test- ACL * ACL prevents anterior translation of tibia and posterior translation of femur * posterior drawer/posterior sag sign- PCL * valgus stress test- tests MCL * knee pressed in, ankle pressed out * varus stress test- tests LCL * knee pressed out, ankle pressed in

Answer 50

bursitis * s/s * **pre-patellar-** inflamed (trauma related) or septic * **pes anserine-** early medial compartment OA * overuse, injury, break in skin * tx * aspirate to r/o infection * NSAIDs, activity modification, compression * surgery rarely to resect (normally resolves on own)

Answer 51

tendinitis * quadriceps tendon- above patella * patellar tendon- "jumper's knee", inferior patella * s/s * TTP on bony prominences/tendon * pain w/ resisted knee extension * full ROM * +/- swelling * tests * plain films * tx * RICE, NSAIDs, activity modification, PT (hamstring stretches), knee strap/sleeve

Answer 52

tendon ruptures (quad, patella fracture, patellar) * s/s * fall on partially flexed knee * pain, swelling, inability to ambulate * discoloration * tests * plain films to r/o fracture * MRI * tx * surgery

Answer 53

patellofemoral syndrome * s/s * overuse of overloading of joint * worse w/ activities the load front of joint * **chondromalacia**- pathologic changes of articular cartilage (softening of cartilage) * observe alignment while weight bearing- foot pronation, femoral anteversion, genu valgum, vastus medialis oblique atrophy * tests * Q-angle, J sign, patellar apprehension sign * assess hamstring tightness and quad strength- weak quads put more sheer force across patellofemoral joint * plain films * tx * activity modification, NSAIDs, bracing * PT- flexibility and strengthening

Answer 54

lateral patellofemoral instability * s/s * direct contact or sudden change in position * usually spontaneously relocates * deformity, swelling * tests * + apprehension sign * TTP medial patella * plain films * MRI to r/o soft tissue damage * tx * conservative * RICE * +/- aspiration * braced in extension * NSAIDs, pain meds * PT- quad strengthening, flexibility * surgery * if recurrent dislocation or conservative failure * MPFL repair

Answer 55

meniscus tears * s/s * acute w/ twisting, squatting, change in position * swelling * joint effusion and joint line tenderness * decreased ROM- **EMERGENCY IF CANNOT EXTEND** * +/- quad atrophy (quad shuts down w/ knee injury) * +/- locked knee * tests * + McMurray test * plain films- weight bearing * MRI * tx * conservative * RICE, pain control, PT * surgery * meniscectomy vs. meniscal repair * inner cut out (no circulation) while outer stitched

Answer 56

baker's cyst * s/s * most common cyst in knee * **associated w/ degenerative meniscal tears** * popliteal swelling/fullness and pain * calf pain and swelling if ruptures (may think DVT) * tests * plain films * MRI other pathlology suspected * tx * conservative * rarely surgery for fear of transecting popliteal nerve

Answer 57

ACL tear * s/s * effusion * decreased muscle strength * antalgic gait * +/- "pop" * tests * +Lachman's exam * pivot shift test * anterior drawer * plain films, MRI * tx * RICE, ROM * surgical reconstruction if younger, active (need full ROM before surgery)

Answer 58

PCL tear * s/s * pain, joint effusion, +/- instability * decreased ROM * tests * + posterior drawer test * posterior sag * x-ray/MRI * tx * depends upon degree of instability

Answer 59

collateral ligament sprain * s/s * pain, swelling, stiffness, +/- instability or mechanical symptoms * TTP over ligament/attachment * tests * plain films, MRI * tx * MCL- conservative if isolated or grade 1-3 * LCL- conservative grade 1-2, surgical grade 3

Answer 60

chondral/osteochondral defect (OCD) * s/s * direct trauma, articular cartilage injuries * tests * plain films to check for loose bodies, MRI * tx * conservative * surgical * microfracture- punch holes in bone * OATS- punches of outer articular cartilage place on points of greater weigth bearing * autologous chondrocyte implantation

Answer 61

* inspection * gait analysis, hindfoot analysis * palpation * anterior joint line, malleoli, sinus tarsi, achilles tendon, metatarsals, peroneal tendons, posterior tibial tendon * ROM * manual muscle testing * special tests * anterior drawer test * draw foot anteriorly * Thompson test * feet hanging off bed, calf squeezed, foot should move if achilles intact, torn if no movement * inversion stress test * foot inverted while holding ankle * eversion stress test * foot everted while holding ankle * interdigitation neuroma test * foot squeeze test * web space compression tenderness test

Answer 62

ankel sprain * s/s * inversion: anterior/posterior talofibular lig, calcaneofibular lig, tibiofubular lig, subtalar lig * eversion: deltoid lig * TTP * **palpate/assess 5th MT ALWAYS**- don't miss Jones fx * **palpate/assess achilles tendon ALWAYS** * tests * anterior drawer * squeeze test * external rotation test * x-ray, MRI, MR arthrogram (looking for uniformity around talus) * tx * goal: prevent chronic instability and pain * conservative- rehab * surgical- rare

Answer 63

achilles tendon rupture * s/s * swelling, ecchymosis, difficulty ambulating * **palpable tendon defect** * tests * Thompson's test (most reliable w/in 48 hrs) * plain films, ?MRI * tx * non-surgical: serial casting * surgical * tendon retraction- based on activity level, age, risk

Answer 64

tarsal tunnel syndrome * s/s * worse after walking/exercise * relieved w/ rest * night pain * TTP over tarsal tunnel (posterior to medial malleolus) * decreased sensation * tests * + Tinel sign * plain films * MRI to r/o other patho/space occupying lesions * EMG/NCS not accurate at ankle and below * tx * conservative * injection, orthotics * surgical- poor outcomes

Answer 65

plantar fasciitis * s/s * increased pain w/ standing and walking * TTP medial calcaneal tuberosity * toe dorsiflexion increases pain * tests * plain films * entheseophyte- heel spur (but not source of pain) * tx * conservative * orthotics, night splint, PT, NSAIDs, injections, acupuncture * rarely surgical

Answer 66

pes planus - flat foot * s/s * classic presentation- mid 50, female, overweight * RF: corticosteroid injections, DM, HTN, prev foot injuries * insidious onset pain and swelling in media ankle * ankle rolls and lost arch * sinus tarsi pain * hindfoot valgus- **"too many toes"** * unable to toe raise * tests * plain films, ?MRI - thickening of tendon * tx * conservative * casting, orthotics, PT * surgical * tendon transfer / osteotomy

Answer 67

metatarsalgia * s/s * abnormal metatarsal lengths, toe deformities: claw/hammer * pain w/ activity * callus formation- intractable plantar keratosis * pain, swelling, MTP joint stability * digital nerve function * ddx * plantar wart: anywhere on sole, punctate hemorrhage, fibrillated texture * tests * plain films * tx * conservative * metatarsal pad, removal of callus, orthotics, PT, shoe wear * surgical * realign toes and/or metatarsal heads

Answer 68

interdigital (Morton) neuroma * s/s * 3rd-4th toe webspace * plantar forefoot pain * dysesthesias of 2 affected toes * rarely at night * "feels like walking on marble" * tests * + squeeze test * assess MTs * sensory exam (ANYTIME a nerve is involved) * plain films, MRI/US to r/o other causes * tx * conservative * metatarsal pad, shoe change, corticosteroid injection * surgical * excision

Answer 69

hallux valgus ("bunion") * s/s * pain, swelling, numbness or tingling * tests * plain films * tx * conservative * shoe wear, orthotics, PT- biomechanical evaluation * surgery

Answer 70

turf toe * s/s * pain, swelling, ecchymosis * +/- ligamentous * common in athletes * hyperextension of MTP * tests * plain films * MRI to r/o other causes * tx * conservative * orthotic devices, stiff soled shoes * surgical (rare) * only if displaced intra-articular or avulsion fracture

Answer 71

* hammer toe * PIP flexion deformity (no DIP or MTP deformities) * claw toe * MTP extension w/ PIP flexion * mallet toe * DIP flextion * s/s * swelling, pain, deformity, shoe calluses * tests * evaluate sensory and motor of lower extremity * tx * conservative * shoe wear, splints * surgical * fix deformities

Answer 72

spurling test * narrows neural foramen * increases/reproduces redicular symptoms

Answer 73

cervical sprain / strain * PE * +/- swelling, tenderness, limited ROM * neurologic exam usually normal * tests * x-rays * Tx * meds: NSAIDs, pain meds, muscle relaxers, steroids * +/- cervical collar or neck roll * massage, stretching, PT * DISCUSS tx options (time off, rest, ice/heat, chiro) * self limited (4-6w) * whiplash (6-12m)

Answer 74

* straight-leg raise * check for herniated disk * pain w/ lifting **asymtomatic** leg * seated straight leg raise * creates sciatic tension * patient will lean back to reduce pain (+) * __FABER test * flexion-abduction-external rotation (figure 4 postion) * hip and SI joint pathology

Answer 75

Waddell signs * non-organic tenderness * axial simulation/torso rotation * seated straight-leg raise * sensory examination

Answer 76

cervical spondylosis * PE * tenderness, decreased ROM w/ pain, gait/sensory analysis * tests * Spurling, Babinski, Brudzinski-Kernig, ankle clonus * x-ray, MRI, CT myelogram * Tx * degeneration will continue w/ time * conservative vs. surgical * decompression and fusion

Answer 77

cauda equina syndrome (compression of n. roots distal to conus medullaris) * PE * **unable to heel toe walk** * anal sphincter tone * tests * MRI, CT myelogram * Tx * IMMEDIATE decompression surgery

Answer 78

cervical rediculopathy * can be caused by disc herniation or degenerative changes

Answer 79

lumbar herniated disk * PE * list/trunk shift * **sciatica** * + seated asymptomatic leg raise (specific to herniated disk) * tests * plain films - degenerative changes * MRI if neurologic changes/intolerable pain * Tx * conservative * NSAIDs, rest, PT * epidural steroid injections * manipulative therapy, traction, acupuncture * surgical * microdiscectomy, laminectomy

Answer 80

myelopathy * tests * Babinski sign * Brudzinski-Kernig test (head lift - leg lift/abduct) * ankle clonus (foot dorsiflex) * x-ray, MRI, CT myelogram, EMG/NCS (neuropathy vs compression) * PE * TTP, decreased ROM, decreased lordosis, +/- Spurling * **shoulder pain does not radiate past elbow** (cervical) * Tx * delayed leads to paralysis, weakness, chronic pain * conservative * spontaneous resolution in 2-8w * NSAIDs * cervical traction * **NO SPINAL MANIPULATION** (no chiropractor)

Answer 81

lumbar sprain/strain * PE * decreased ROM, motor/sensory exam (L4-S1), special tests to r/o other structures * tests * +/- plain films * MRI not indicated * Tx * conservative * pain control, PT/HEP, pt education * provide options for shared decision * get them back to work

Answer 82

chronic low back pain * PE * TTP lumbar and/or SI joint, decreased ROM, normal motor/sensory exam, positive SLR * tests * plain films (look for degenerative changes) * MRI (evaluate structural changes) * Tx * pt education * pain management (watch narco abuse) * psychological testing * injections * biofeedback * cognitive/behavior conditioning * psychotherapy * detoxification programs

Answer 83

* Jefferson fracture / C1 burst fracture * Hangman's fracture (C2 pedicles) * Clay-shoveler's fracture * C7 \> C6 \> T1 * Avulsion fracture * PE * MOI specific: severe neck/back pain, paraspinous muscle spasm, bony tenderness, +/- neurologic * tests * plain images: AP, lateral, odontoid * Tx * **immobilization** * Methylprednisone 30mg/kg bolus, then 5.4mg/kg/h drip 23h * conservative vs. surgical intervention

Answer 84

spinal stenosis * PE * +/- proprioception, reflexes, urine/bowel (spincter tone rarely affected) * tests * **Romberg test** (balance lost w/ eyes closed) * x-rays to T10 * MRI * EMG/NCS * Tx * conservative * pain control, PT, water therapy, body mechanics * surgical * quality of life * decompression and spinal fusion

Answer 85

SI joint dysfunction * PE * TTP * normal motor/sensory findings * tests * FABER test * compression test (push on ASIS and rock patient) * plain films * CT scan * Tx * conservative

Answer 86

coccydynia * PE * TTP rectally * GI/gynocological exams * tests * plain films * MRI to r/o other * Tx * conservative * PT, change activity, nerve block, 6m-1y recovery * surgical * coccygectomy

Answer 87

spondylolysis / spondylolisthesis * PE * loss or lordosis * decreased strength after walking * + SLR * tests * x-ray * Tx * conservative * weight loss * surgical * stabilize defect if skeletally immature

Answer 88

scoliosis * PE * neuro exam for reflexes, motor, sensory function * gain analysis * tests * full-length PA and lateral films * EMG (radiculopathy vs. neuropathy) * Tx * skeletally immature * observation, bracing (25-45 deg), fusion (\>45 deg) * Milwaukee or Boston brace * mature * conservative tx, surgical if curve \>50-60 deg

Answer 89

metastatic disease * PE * inspect for deformity * TTP * neuro exam * tests * AP/lateral plain films * bone scan to ID other areas of mets * Tx * dependent on tumor * decompression and stabilization w/ postop radiation

Answer 90

thoracic vertebral fractures

Answer 91

* goal - prevent neurologic injury, restore stability/normal fx * types * avulsion * compression * fracture/dislocation * tx * spinal fusion * cervical * soft collar, Philadelphia collar, rigid orthosis, halo * thoracic * corset, 3-point orthosis, clamshell * lumbar * elastic belt, corset, rigid orthosis

Answer 92

* sudden onset of severe joint pain and swelling * usually 1 joint * crystals found in synovium, cartilage, surrounding tissue * types * gout - monosodium urate crystals (MSU) * calcium pyrophosphate dehydrate crystals (CPPD) * pseudogout - synovitis * chondrocalcinosis - deposits in soft tissue

Answer 93

hyperuricemia * phases 1. asymptomatic (\>7mg/dL) 2. acute gouty flare 3. intercritical gout (intervals between attacks) 4. chronic tophaceous gout * causes * underexcretion (90%) * kidney, HTN, obesity, lead, drugs * overproduction * diet, obesity, psoriasis, nicotinic acid (B3)

Answer 94

* s/s * sudden onset, cardinal signs inflammation, +/- constitutional * 1st metatarsophalangeal joint (Podagra), ankle, midfoot, knee * subcutaneous tophus: fingers, wrists, ears, olecranon bursa, achilles tendon * tests * synovial fluid analysis: crystal **negative birefringement** * rod-shaped crystals * +/- serum urate level * x-ray (r/o fracture), US to look for crystals * Tx * lifestyle modifications * acute: RICE, NSAIDs, **Colchicine**, corticosteroids * meds * xanthine oxidase inhibitor (overproduce/underexcr) * **Allopurinol** 100mg PO daily * Febuxostat 40mg po daily * increase renal excretion (underexcr) * Probenecid 250mg po daily * Pegloticase 8mg IV q2w (warn: anaphylaxis, $$$)

Answer 95

* types (more common in women, gout in men) * pseudogout - acute synovitis * knee most common * chondrocalcinosis - calcification in hyaline cartilage * asymptomatic, incidental finding * pyrophosphate arthropathy - OA w/ CPPD * tests * x-ray * synovial fluid analysis * postitive **bifringement** (square crystals) * Tx (if symptomatic) * RICE, NSAIDs, corticosteroids, +/- Colchicine

Answer 96

1. calicific tendinitis * sudden shoulder pain w/out MOI * pain-\>plateaus-\>pain when resolving-\>no pain * tx conservative or surgical (usually resolves on own) 2. Milwaukee shoulder * crystals destroy RC and shoulder joint 3. DISH (diffuse idiopathic skeletal hyperostosis) * bridging in cervical spine

Answer 97

septic bursitis * PE * aspirate to r/o infection * acute: S. aureus, B hemolytic strep, psuedomonas * chronic (think systemic): B abortus, M. tuberculosis * tests * x-ray to r/o other, look for foreign body * Tx * outpatient * PCN or 1st gen cephalosporin * tri/sulfa (Bactrim) if MRSA * Clindamycin or Linezolid if PCN allergy * inpatient * Nafcillin, oxacillin, cefazolin IV * Vanco, daptomycin, linezolid if MRSA

Answer 98

septic arthiritis (infection to joint) * PE * tests * x-rays: ususally normal, soft tissue swelling * radiolucent lines if prosthetic infection * MRIs * identify osteomyelitis * bone scan for associated osteomyelitis * labs * synovial fluid analysis * WBC \> 50,000, low glucose, high protein * ESR & CRP * cervical/urethral cultures if +gonococcal * Tx * **surgery** * IV antibiotics (4-6w)

Answer 99

osteomyelitis * PE * trauma, surgery, immuno, systemic disease * localized bone pain * +/- sinus tract, swelling, abscess, constitutional * tests * biopsy/culture of affected area (GOLD standard) * CBC - leukocytosis * elevated CRP/Sed rate * plain films * MRI - marrow changes * CT - early cortical erosions * bone scan (highly sensitive, low specificity) * Tx * debridement and excision of infected bone * abx spacer * IV abx * Abx impregnated methylmethacrylate beads

Answer 100

osteoarthritis * PE * joint effusion, crepitus, antalgic gait, decreased ROM, muscle atrophy * +/- deformity * knees: genu varum (bow) vs. valgum (knock) * hands: * Bourchard nodes (PIP) * Heberden nodes (DIP) * tests * x-ray: joint space narrowing, osteophytes, sclerosis * MRI: r/o other sources of pain (not routinely used in OA) * no US * no specific labs * Tx * conservative as long as possible * RICE, bracing, corticosteroid injections * meds * NSAIDs, tramadol, glucosamine/chondroitin * NO opiates * PT * patient education- activity, occupation, weight loss * CAM: accupuncture, Tai Chi, supplements * surgical * NO arthroscopy * joint replacement

Answer 101

rheumatoid arthritis * PE * **symmetric polyarthritis, deformities** * **morning stiffness** * isidious onset w/ distal joints first - **MCP, PIP** (spares DIPs, toe IPs) * swelling, tenderness, fever, malaise, weakness * nodules anywhere * improves with pregnancy then flares after * C1-C2 articulation can affect surgery * swan-neck; boutonniere deformity; hammer toes * **Felty's syndrome**: RA, splenomegaly, neutropenia * tests * Rheumatoid factor * anti-CCP (anti-cyclic citrulinated peptide antibody) * Tx * lifelong - no cure, just management/remission * NSAIDs, low-dose prednisone, steroid injections * disease modifying antirheumatic drugs (target inflammation/antibodies) * Sulfasalazine, hydryoxychloroquine * Methotrexate/Leflunamide * Cyclophosphamide * anti-TNF drugs * inflixamab, entanercept * adalimumab, golimamab * surgery - joint replacement

Answer 102

1. cellular callus * mesenchymoid cell proliferation 2. mineralized callus * collagen to cartilage 3. bony callus * lamellar bone replaces mineralized callus 4. remodeling

Answer 103

* acute respiratory distress syndrome (ARDS) * fat embolism to lungs * atelectasis (partial or complete collapse of lung) * DVT, PE * compartment syndrome (5 P's) * nerve/blood vessel injury * failure of normal healing

Answer 104

1. pain out of proportion 2. paresthesia 3. pallor 4. paralysis 5. pulselessness

Answer 105

* bone side and name, position * proximal, mid, distal * line: transverse, spiral, oblique * type of fracture * open (no skin break) / closed (bone protruding) * complete / incomplete * greenstick, buckle (Torus) - "squished can" * simple / comminuted (w/ or w/out butterfly fragment) * angulation (bent- change in anatomical position) * direction apex is pointing, location of distal fragment * ex.: angulated 45 deg apex dorsal * displacement (distance apart) * anterior, posterior, lateral, medial * 100% = no contact at fracture site * other: * distraction- amount of separation * shortening- overriding, impacted * # of pieces * fragments * joint disruption- intra-articular * % subluxation- dislocation laterally, medially...

Answer 106

clavical fracture * mechanism * direct blow, fall on outstretched arm * presentation * pain, deformity, grinding at fx site, sagging shoulder * CHECK SKIN for necrosis * tx * based on displacement * conservative * immobilize: sling, brace 4-6w * surgery * ORIF: open reduction w/ internal fixation * IM nail (intermedulary)

Answer 107

proximal humerus fracture (axillary nerve) * high energy injury: fall, MVA * Neer classification: 2, 3, 4-part (head, shaft, greater/lesser tuberosity) * tx * conservative: sling 6w, passive ROM after 3w * surgery * ORIF * hemiarthroplasty

Answer 108

humeral shaft fracture (radial nerve) * mechanism: trauma, fall * tx * varies by severity * malunion common

Answer 109

supracondylar fracture (brachial artery) * mechanism: fall w/ elbow extended * tx * surgery

Answer 110

epicondyle/condylar fractures (medial/lateral condyle) * mechanism * fall on outstreatched arm (valgus/varus force) * tx * conservative * rest, splint, delayed, ROM * surgical * percutaneous pinning * ORIF

Answer 111

radial head/neck fracture * mechanism * fall w/ elbow extended * most common elbow fx in adults * tx * long arm splint 2-3w (must go beyond wrist) * rarely surgery * DO NOT immobilize too long * PT

Answer 112

olecranon fracture * mechanism * fall onto posterior elbow * active tricep avulsion * tx * displacement & triceps guide treatment

Answer 113

MUGR "gruesome murder" * Galeazzi * radial fracture w/ distal radioulnar joint dislocation * fall on outstreatched arm w/ elbow flexed * surgical fixation * Monteggia * ulnar fracture w/ radial head dislocation * fall on outstretched arm * surgery

Answer 114

radial shaft fracture * mechanism * high energy injury, MVA * usually w/ ulnar fracture/dislocation * tx * surgery

Answer 115

ulnar shaft fracture * mechanism * usually direct blow * tx * spint * rarely surgery

Answer 116

distal radius fracture * mechanism * **Colles**: low energy FOOSH * **Smith**: fall on _flexed_ wristh (reverse Colles) * most common fx of upper extremity * presentation * deformity, swelling, ecchymosis * tenderness over fracture site * tx * buckle/minimal displacement - immobilize * colles/smith/angulation/displacement - reduction or surgery (6w: 2 splint, 4 cast)

Answer 117

chauffeur fracture (radial styloid fracture) * mechanism * direct blow to back of wrist * forced ulnar deviation and supination * tx * surgery

Answer 118

scaphoid fracture * mechanism * FOOSH * often misdiagnosed as sprain * "snuff box pain" * most common carpal fx * tx * when in doubt- tx as fx: thumb SPICA splint * splint 12w * surgery rarely

Answer 119

metacarpal fracture - boxer's fracture * mechanism * hitting object with closed fist * neck, shaft, or base fx * 5th metacarpal neck most common * presentation * pain, swelling, **rotational deformity**, depressed knuckle * CHECK for open wounds * tx * acceptable angulation: 10-20-30-40 rule from 1st digit * rotational deformity NOT acceptable * conservative * ulnar gutter splint/cast * 4-6w immobilization * referral * unstable fractures/rotational deformity * closed reduction vs. surgeryd

Answer 120

fracture at base of 1st metacarpal * types: * **Bennett** fracture: intra-articular avulsion fx - CMC joint * sublux/dislocation * **Rolando** fracture: "Y" or "T" shaped comminuted, intra-articular fx * same mechanism, less commom

Answer 121

* malunion * incomplete or faulty healing that affects function * delayed union * slower than normal healing * non-union * lack of bony reconstituion - bone remains at callus stage

Answer 122

phalange fractures * mechanism * most common MSK injury * presentation * pain, swelling, deformity * CHECK open wounds, nail bed injury - ortho referral * tx * budding taping * surgery: angulation, displacement, open fracture * complications: * loss of motion, malunion, nonunion

Answer 123

pelvic fracture * mechanism * high energy, MVAs * presentation * check for GU injuries: bladder, prostate * fall - unable to bear weight * leg shortened and externally rotated * tx * stabilize * most need surgery

Answer 124

1. femoral neck * types: * subcapital, transcervical, basicervical * intracapsular * blood flow to femoral head disrupted * tx * femoral neck w/ no/minimal displacement - pinning * w/ displacement - arthroplasty (replacement) 2. intertrochanteric * tx * intramedullary nail/gamma nail * dynamic hip screw (DHS) 3. subtrochanteric * tx: screws

Answer 125

femur shaft fracture * mechanism * high energy, MVA * tx * nonsurgical * non-displaced or multiple comorbidities * surgical * displaced/unstable

Answer 126

supracondylar fracture * mechanism * load to flexed knee * presentation * assess **popliteal artery**, ACL * pain, swelling, inability to flex/extend knee, +/- deformity * tx * conservative vs. surgical

Answer 127

tibial plateau fracture * mechanism * extreme load or fall * 60% lateral * tx * non-operative * nwb w/ close follow-up * surgery * cannulated screw fixation or plate/screw, NWB

Answer 128

patella fracture * mechanism * direct trauma * forceful quadriceps contraction * presentation * deformity, swelling, can't SLR * tx * non-operative: * nwb 6w, gradually increase PROM * surgery if displacement \>3mm

Answer 129

tibial shaft fracture * mechanism * high energy, often open, twisting mechanism * most common long bone fracture * presentation * pain, deformity, wounds, fracture blisters * **compartment syndrome** - 5 P's, fasciotomy * assess n/v status * tx * conservative - LLC w/ progressive weight bearing * surgical * unstable, open fracture * presentation after reduction * IM nail

Answer 130

Maisonneuve fracture * mechanism * eversion injury - **Mortise widening** * proximal 1/3 fibula fracture * w/ fibular neck - think **peroneal nerve** palsy * tx * surgery * ORIF

Answer 131

ankle fracture * mechanism * twisting (inversion/eversion), MVA * most common bone + joint injury * smoking and habitus * presentation * pain, swelling, deformity, inability to ambulate * tx * conservative * avulsion: treat like ankle sprain * posterior splint vs. walking cast vs. walking boot * surgical * if any mortise widening/suspicion

Answer 132

medial malleolus fracture * mechanism * usually high impact: MVA, fall, tackled * considerations: * displacement (\<2mm in joint acceptable) * joint involvement (\<25% joint surface acceptable) * tenderness elsewhere * tx * referral * non-operative * nwb short leg splint vs. wbat short leg cast

Answer 133

bi/tri-malleolar frature * unstable, refer for surgery

Answer 134

Stress, Jones, Avulsion * mechanism * IMPORTANT: sudden vs. aching over time * inversion - Jones * eversion - other fracture * tx * stress - nwb cast 6-8w * Jones - surgery vs. short-leg walking cast vs nwb cast 6-8 * avulsion - most common, short-leg walking cast/boot 4-6

Answer 135

stress fractures * mechanism * overuse * presentation * insidious pain that progressively gets worse * MRI for inflammatory stress * tx * eliminate the stress - REST * nwb 6-12w, immobilize, PT, pain control

Answer 136

SALTER * Type I: S- straight across * Type II: A- above * Type III: L- lower * Type IV: T- through/transverse * Type V: R- ruined (cRushed)

Answer 137

* loss of grip strength * residual dorsal deformity * loss of knuckle prominence

Answer 138

fibula fracture * mechanism * direct blow, inversion/eversion injury * presentation * limping or uable to bear weight due to pain, edema, ecchymosis * tx * non-weightbearing * dependent on location, ankle stability

Answer 139

* ankylosing spondylitis * reactive athritis * psoriatric arthritis * enteropathic arthritis

Answer 140

* spine/joint pain * chronic inflammation -\> new bone formation (joint ankyloses) * asymetrical peripheral arthritis * **ocular inflammation (acute anterior uveitis** * **HLA-B27 gene** * **sacroiliitis in imaging** * Tx * pt education * exercise * NSAIDs, corticosteroids, sulfasalazine, methotrexate, anti-TNF therapy

Answer 141

Ankylosing Spondylitis * PE * stooped posture (advanced) * chest expansion * tests * **Schober test** - measure points on back (lumbar mobility) * +/- FABER test (for SI joint) * RF/ANA negative * HLA-B27 * x-rays: "bamboo spine" * MRI: inflammatory changes

Answer 142

Reactive Arthritis * PE * mucocutaneous lesions * papulosquamous eruptions on palms and soles * diarrhea * tests * x-rays, MRI * HLA-B27 * **synovial fluid analysis to dx septic vs. aseptic** * Tx * NO CURE - self limited * NSAIDs * +/- intra-articular injection

Answer 143

Psoriatric Arthritis * PE * spondylitis - inflammation of vertabrae * mimics RA but no nodules or RF * tests * x-rays * Tx * pain control * anti-TNF

Answer 144

Enteropathic Arthritis * PE * lower extremeties- peripheral arthritis not assoc. w/ HLA-B27 * spondylitis/sacroiliitis- assoc. w/ HLA-B27 * tests * HLA-B27 * Tx * control GI -\> controlled joint inflammation

Answer 145

Scleroderma (systemic sclerosis) 1. autoimmunity and inflammation 2. vascular injury and obliteration * capillary loss 3. fibrosis and matrix deposition * deposition of connective tissue matrix

Answer 146

* Systemic * Diffuse * all over, rapid progression * swelling, erythema, pruritis, fatigue, stiffnesss, malaise, Raynaud later * early pulmonary fibrosis and acute renal failure * Limited * peripheral (spares trunk) * CREST * Calcinosis cutis * Raynaud's: * primary cause: cold/stress = episodic vasoconstriction * secondary: disease, B-blockers, chemotherapy * Esophageal dysmotility (thickening) * Sclerdactyly * Telangiectasia * Mixed Connective Tissue Disorder * overlap of SLE, scleroderma, myositis * Raynaud w/ hand edema, renal crisis later * autoantibody against U1-RNP * Localized * more common in children * **Morphea** - reddish/purple lesion of skin * skin induration (hardening) spares digits, common on LE * NO Raynaud, NO systemic involvement

Answer 147

* skin * thickening, symmetrical/bilateral, starts @ fingers and works proximal, masklike facies, hyperpigmentation/vitiligo in dark skinned, calcium deposits * GI tract * periodontal disease; GERD; stomach-gastroparesis; small intestine-impaired mobility, malabsorption; colon-constipation, rectal prolapse * lungs * **honeycomb x-ray**; RF: AA, male, difuse skin, severe GERD, topoisomerase-I antibodies * pulmonary HTN; RF: limited cutaneous, late disease onset, many telangiectasias, anticentromere autoantibodies * kidneys * life threatening; CKD; RF: AA, tendon rubs, RNA plymerase I & II autoantibodies * cardiac * diffuse disease; tachychardia; conduction abnormalities; regurgitation; diastolic HF; pericardial effusion * MSK * CTS; decreased joint mobility; tendon friction rubs (rupture) * other * dry eyes/mouth; hypothyroid; CNS spared

Answer 148

* tests * labs * CBC /w diff - anemia * Sed rate/CRP/RA normal * Vit deficiencies: folate, B12, D * nailfold capillaroscopy * Dx * skin induration, Raynaud's, organ manifestations * Tx * No known regime to alter course * immunosuppressants * corticosteroids (sparingly in low doses) * cyclophosphamide (slow lung disease) * methotrexate (for skin manifestations) * antifibrotic therapy * D-penicillamine (prev. new organ involvement, improved survival) * ACE inhibitors (for renal crisis) * treat specific organ complications

Answer 149

* osteoblasts - build * osteoclasts - break down * ostecytes - mature cells * secrete and calcifies bone matrix material * regulate bone reabsorption and formation * release cytokines * osteoprotogerin (OPG) * receptor activator of nuclear factor kB ligand (RNAKL) * regulate osteoclast production and rate of bone reabsorption

Answer 150

bone mineral density (BMD) * peak bone mass * 18-20 - proximal femur * 25-30 - spine * more loss than formation after this

Answer 151

* primary (idiopathic) * juvenile (8-14 y/o) * Stage I * post-menopausal women (51-75) * trabecular bone loss * common fx: vertebral body, distal forearm * Stage II (senile) * men and women 70+ * trabecular and cortical bone loss * common fx: wrist, vertebra, hip * secondary * men \> women * environmental factors * nutrition, Ca/Vit D deficiency, inactivity, meds (PPI, chemo), tobacco, alcohol, caffeine, trauma * disease * RA, cushings, DM, hyperthyroid

Answer 152

DEXA - bone density scan * 70+ y/o * 50-70 postmenopausal * 50-59 w/ wrist fracture * 70's w/ vertebral fracture * 50+ w/ hip fracture

Answer 153

* S/s * NO s/s - must screen at risk * PE * measure height loss: \>4cm since young adult max suggests vertebral fx * BMI * kyphosis: **Dowager hump** (wedge shaped compression fx) * +/- spinal TTP and percussion * tests * FRAX - fracture risk assessment tool: demographics, prev fx, parent fx, smoking, glucocorticoids, RA, alcohol, DEXA BMD # * workup * labs to assess secondary causes * x-rays to check for fractures * **duel energy x-ray absorptiometry (DEXA) for bone mineral density** * T-score: value of control peak BMD * within 1 SD = normal * -1.0 to -2.5 SD = osteopenia * -2.5 SD and below = osteoporosis * -2.5 and below + fragility fx = severe/established osteoporosis * Z-score: value of age/sex match * -2.0 and above = normal * -2.0 and below = below expected * Repeat testing * normal - mild osteopenia: 10-15y * moderate osteopenia: 3-5y * advanced osteopenia: annually * undergoing tx: annual to monitor response * Not recommended * premenopausal, men \< 70, women \< 65 w/out risk factors

Answer 154

* QCT-quantitiative CT (spine) * pQCT (wrist and tibia) * Finger DXA * US of calcaneous or wrist * 3D CT of bone biopsy microarchitecture

Answer 155

osteomalacia * PE * asymtomatic * deformity over time * muscle weakness * fracture * antalgic gait/difficulty ambulating * tests * Chvostek's sign: tap on facial nerve elicits twitch * labs for underlying disorders: CMP, LFT, calcium, Vit D * x-rays * bone biopsy * Tx * Vit D replacement (\>18 6,000 IU qd or 50,000 qw x 8w, 1500-2000 qd maint.) * patient education: dietary changes, fall risk

Answer 156

Paget Disease * PE * asymptomatic or specific bone pain * increased hat size, hearing loss, tinitis (if skull) * deformities: bowing, kyphosis, abnormal gait * tests * x-rays, +/- bone scan, No MRI/CT * labs * **alkaline phosphatase** (bone specific) - high sensitivity for diagnosis * NOT a calcium/Vit D issue (osteoclast problem) * urine: hydroxyproline, dexypyridinoline, C-telopeptide * Tx * goal: control activity, treat complications * Bisphosphonates * Zoledronate acid (Reclast) 5mg IV * Alendronate (Fosamax) 40mg x 6m * Risedronate (Actonel) 30mg qd x 2m * neoplasm - refer for amputation, chemo * joint disease (OA or fracture) - replacement/ORIF

Answer 157

* supplemental calcium (1000/1200 W\>50 & M\>70) and vitamin D (600/800 W/M\>70) * Bisphosphonates * inhibit osteoclasts to decrease turnover and bone loss * oral * **Alendronate** (Fosamax) * Alendronate/cholecalciferol (Fosamax + D) * Risedronate (Actonel) * Iandronate (Boniva) * Parenteral * Zoledronic acid (Reclast) * Ibandronate (Boniva) * Expensive: * Selective Estrogen REceptor Modulators (SERMs) * decrease cytokines that activate osteopblasts - vertebral fx only * **Raloxifene** (Evista) 60mg po qd * Recombinant human parathyroid hormone * **Teriparatide** (Forteo) 20mcg SQ qd (thigh or abdominal wall) * high risk vertebral fractures, stimulates bone formation, no more than 2y, black box: osteosarcoma * Human monoclonal antibody * **Denosumab** (Prolia) 60mg SQ q6m * Abx to RANKLE - inhibits osteoclast formation/activity * Calcitrol * nasal spray, inhibits osteoclasts * Estrogen/progestin * decreases bone turnover/loss * Fracture treatment (total hip, hemiarthroplasty, vertebroplasty, kyphoplasty)

Answer 158

* ABC - aneurysmal bone cyst * CMF - chondromyxoid fibroma * EG - eosinophilic granuloma * GCT - giant cell tumor * FD - fibrous dysplasia * NOF - non ossifying fibroma * SBC - simple bone cyst

Answer 159

benign typically have well defined borders * bone forming (osteo-) * osteoid osteoma, osteoblastoma, osteoma * cartilage forming (chondro-) * chondroma, osteochondroma, chondroblastoma * fibrous bone lesions (fibro-) * fibrous dysplasia, nonossifying fibroma * radiolucent bone lesions * giant cell tumor, unicameral bone cyst, aneurysmal bone cyst

Answer 160

osteoid osteoma * tests * \<1cm **lytic nidus** w/ surrounding sclerosis * HOT on bone scan, use CT to localize * "cherry red" nidus histology * Tx * NSAIDs for pain * curettage/burring * radiofrequency ablation

Answer 161

osteoma * PE * firm mass w/ little to no pain * tests * xray: dense cortical bone, not contiguous w/ intramedullary canal * Tx * observation vs. marginal resection

Answer 162

osteoblastoma * tests * x-ray: no sclerotic rim, NO **nidus** * Tx * biopsy * surgical * curettage and bone grafting * tumor excision w/ bone reconstruction vs internal fixation

Answer 163

osteochondroma * PE * often asymptomatic * pain or painful mass * away from growth plate * tests * xrays * Tx * asymptomatic * monitor * symptomatic * surgical excision

Answer 164

enchondroma * PE * asymptomatic - usually incidental finding * pain w/ pathologic fracture * tests * plain films: stippled calcification * Tx * no tx if asymptomatic * symptoms * biopsy * currettage w/ bone grafting

Answer 165

periosteal chondroma * PE * painful, sometimes palpable mass * tests * xray: saucerization w/ sclerosis * Tx * excision * need to r/o chondrosarcoma

Answer 166

fibrous dysplasia * PE * pain * tests * xray: ground glass appearance * Tx * Bisphosphonates * surgical management * rigid fixation

Answer 167

unicameral bone cyst * PE * incidental finding -or- * mild pain, swelling, stiffness in joint * sudding pain d/t pathologic fracture * tests * xray * Tx * r/o sarcoma! * intralesional aspiration and corticosteroid injection * surgery * curettage w/ bone grafting

Answer 168

aneurysmal bone cyst * tests * MRI (instead of CT) to image fluid levels * Tx * surgery * curettage and bone grafting

Answer 169

metastatic disease

Answer 170

multiple myeloma * PE * bone pain, pathologic fractures, weakness/malaise * neuro complaints - spinal cord compression * tests * plain films * Tx * surgical fixation of pathologic fractures * chemotherapy * radiation

Answer 171

osteosarcoma * PE * variable: pain, swelling, night pain, no hx trauma * palpable mass * decreased ROM * lymphandenopathy * +/- respiratory mets * primary (surface) vs. secondary (intramedulary) - variants * tests * labs: LDH, ALP, CBC w/ diff, CMP, urinalysis * open biopsy * plain xrays * CXR to check for mets to lungs * bone scan (evaluate metastatic disease) * CT (location and staging) * MRI (eval soft tissue involvement) * Tx * wide resection - limb sparing * rotationplasty * **amputation** * chemo

Answer 172

chondrosarcoma * PE * **pain over time** * night pain * +/- mass * symptoms near location of tumor

Answer 173

secondary chondrosarcoma * tests * plain films: scattered, irregular calcification

Answer 174

Ewing sarcoma (boards question - know osteo vs. ewing sarcomas) * PE * **progressively worse pain** * night pain * localized swelling/mass * increased warmth over area, fever, incr sed rate/WBCs, anemia, malaise (mimics infection) * tests * plain films: destructive lesion w/ poor border, periosteal bone formation * MRI for soft tissue involvement * CT scan for staging * Tx * dependent on location and size * chemo/radiation * surgery * limb sparing vs. amputation (rare)

Answer 175

chondroblasoma * PE * pain, tenderness, swelling, limp (if in LE) * tests * xray: well circumscribed/defined lytic lesion w/ surrounding sclerosis; +/- stippled calcification * histology: "**chickenwire** calcification" * Tx * curettage (scrapping) and bone graft * increased risk of osteoarthritis when joint involved

Answer 176

nonossifying fibroma * PE * asymptomatic to painful * test * xray: geographic, thick sclerotic rim, well circumscribed * Tx * usually heals spontaneously by 20's * oberservation vs. surgical * curettage and bone graft

Answer 177

giant cell tumor * PE * pain, swelling, deformity w/ increasing size * pathologic fractures * **can metastasize to lung** * tests * xray: lucent, sometimes see bony destruction, can enter soft tissue * Tx * surgery * curettage, ablation, bone grafting, fixation

Answer 178

systemic lupus erythematosus (SLE) * epidemiology * unknown: genetics, environment (UV, drugs: procainamide, hydralazine, quinidine, isoniazid), viruses, diet (a.a.), hormonal * Hx * sunlight, hair loss, Raynaud's, FH * systems * fever, malaise, wt loss; skin; MSK: pain, stiffness out of proportion, non-erosive; kidneys; CNS: seizures, psychosis; cardio; GI; hematologic: anemia, thrombocytopenia; ocular * tests * CBC w/ diff, CMP, ESR, CRP, PT, PTT, ANA, urinalysis * **anti-dsDNA** * **anti-Smith** * **anithistone** (drug induced SLE) * plain films to r/o other * CXR, ECG, echocardiogram to eval other systems * Tx * conservative vs. medicinal based on severity * counseling/lifestyle - smoking cessation, sun, fatigue, sleep * PT/OT * meds * antimalarials: hydroxycholoroquine (Plaquenil) * NSAIDs * corticosteroids: Prednisone (not w/ NSAIDs) * supplement CA+Vit D if long-term * DMARDs (immunosuppressants) * Methotrexate (Trexall) * Azathioprine (Imuran) * Cyclophosphamide * Mycophenolate

Answer 179

Sjorgren's Syndrome * etiology * unknown: genetics, environment: viruses, hormones * systems * fatigue, fever; skin; pulmonary; MSK; renal; neuro: neuropathy, myelopathy; neoplasia: lymphandenopathy * tests * ocular/oral exams * **Schirmer** test (strip from eye) * Rose Bengal staining * labs: CBC w/ diff, CMP, +RF, +ANA, +ESR * **anti-Ro/SSA** * **anti-La/SSB** * Tx * no cure - treat symptoms/systems * fluid replacement, skin lotion, humidifiers, eye & dental exams * rheumatology referral

Answer 180

Polymyalgia Rheumatica * tests * HLA-DR4 * ESR \>40, CRP, CBC w/ dif, -RF, -antiCCP, CPK * **GCA (temporal artery biopsy) - gold standard** * ****Tx * Prednisone 12.5-25mg/d * PPI to protect GI * Ca+/Vit d * giant cell arteritis * Prednisone 40-60mg 4w then decrease 10mg q2w until at 20mg, then reduce by 2.5mg q2-4w to 10mg then decrease 1mg q1-2m as long as no relapse

Answer 181

Polyarteritis Nodosa * etiology * unknown: HBV/HCV, CECR1 gene mutation * systems * fever, fatigue, anorexia/weight loss, myalgia * nervous system, cutaneous: Raynaud's, rash, purpura, **livido reticularis**; GI, renal failure, testicular tenderness * tests * CBC w/ diff, CRP, ESR, liver function, HBV/HCV, -RF, -ANA * biopsy skin * abdominal CT for ischemic/affected organs * Tx * refer to rheumatologist * meds: * Prednisone 1-2mg/kg/d * antivirals for HBV * tx HTN

Answer 182

Dermatomyositis * S/s * **Gottron's papules**: raised scaly lesions on MCP, PIP, elbows, eyelids * rash in V neck distribution * arthralgias in knees, wrists, hands; fatigue, weight loss, fever; Raynaud's; GI; pulmonary; cardiac * **proximal muscle weakness** - standing climbing, walking, lifting * tests * CBC, ESR, CK, AST/LDH * +ANA (non specific) * **anti-Mi2 & anti-MDA5** (specific) * MRI, EMG * **muscle biopsy** - definitive * Tx * non-med: high protein, exercise, consult system specialists * skin: avoid UV, topical corticosteroids, hydroxychloroquine * oral meds: * corticosteroids - Prednisone 1mg/kg/d 4-8w; d/c when CK level normal * Methotrexate 7.5mg po weekly, increase as needed; take w/ folic acid

Answer 183

Polymyositis * S/s * arthralgias in knees, wrists, hands; fatigue, weight loss, fever; Raynaud's; GI; pulmonary; cardiac * **proximal muscle weakness** - standing climbing, walking, lifting * tests * CBC, ESR, **elevated CK**, AST/LDH * +ANA (non specific) * **anti-Jo-1** (specific) * MRI, EMG * **muscle biopsy** - definitive * Tx * non-med: high protein, exercise, consult system specialists * skin: avoid UV, topical corticosteroids, hydroxychloroquine * oral meds: * corticosteroids - Prednisone 1mg/kg/d 4-8w; d/c when CK level normal * Methotrexate 7.5mg po weekly, increase as needed; take w/ folic acid

Answer 184

Fibromyalgia * S/s * widespread pain and stiffness (neck, shoulder, low back, hips) * fatigue, disordered sleep, cognitive function, depression, HA, IBS, TMJ, overactive bladder * tests * labs to r/o other diseases: CBC w/ diff, BMP, TSH, ESR, CRP, ANA, RF, CPK * imaging for underlying pathology * Tx * focus on non-pharm: education, counseling, eliminate stressors, PT/OT * meds (low dose, short term) * acetaminophen, Tramadol 50mg q6-8h PRN * muscle relaxers: Cyclobenzaprine (Flexeril) 5mg po q8h * NO OPIOIDS * anxiety and insomnia * Alprazolam (Xanax) * Zolpidem (Ambien) * antidepressants * Amitriptyline, Duloxetine (Cymbalta), Venlafaxine (Effexor) * anticonvulsants for neuropathic pain * Gabapentin (Neurontin), Pregabalin (Lyrica)

Answer 185

Complex Regional Pain Syndrome * S/s * pain out of proportion to event * color changes * skin dry, shiny, wrinkles w/ temp changes * joint fibrosis: flexion contractures, frozen shoulder * muscle weakness/tremors * 3 stages: acute (3m), subacute (9m), chronic (1+y) * tests * no specific labs * plain films for bone demineralization (DEXA scan) * triple phase bone scan - increased uptake in articular structures * Tx * conservative * education - screen for depression and suicide * NSAIDs, corticosteroids * sympathetic nerve block * PT/OT * surgical * upper thoracic/lumbar sympathectomy * chemical sympathectomy * spinal cord stimulator implant

Answer 186

Chronic Fatigue Syndrome * S/s * sudden onset of abrupt, debilitating fatigue - impacts ADLs * +/- flulike prodrome * similar to fibromyalgia * test * r/o heart disease, thyroid, anemia, liver and renal disease, psych * Tx * supportive and symptomatic

Answer 187

Marfan Syndrome * S/s * eye: lens displacement, retinal detachment; msk: ligament laxity, increased limb and finger length; mouth: arched palate, crowded detention; spontaneous pneumothorax; striae atrophy; cystic organs * tests * genetic testing * opthalmic exam * skeletal testing * Tx * education, tx of pathology

Answer 188

Ehlers-Danlos Syndrome * S/s * velvety skin/atrophy * medium and large vessel rupture * easily bruises * organ rupture, premature rupture of fetal membranes * Tx * treat manifestations * care w/ suturing * B-blocker to protect vessels

Answer 189

Osteogenesis Imperfecta * S/s * recurrent fx w/ bony deformity, impaired mobility * short stature * restrictive lung disease, compression of brain stem * abnormal teeth * **blue sclera** * Tx * fracture management * **Risedronate** - increase bone mineral density

MSK Flashcards

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