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Clin Med 1 - MSK/ HEENT exam 2 > MSK Lower Extremity Injuries and Infections > Flashcards

MSK Lower Extremity Injuries and Infections Flashcards

1
Q

Approx. 25% of pts with hip fx do not survive past ____ year.

A

1 :(

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2
Q

What classifcation system is used when identifying femoral neck fx?

A

Garden classification I-IV

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3
Q

How would we tx Stage I and II: stable hip fractures?

A

•Treated with internal fixation (head-preservation)

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4
Q

How would we tx stage III and VI: unstable fractures

A
  • Treated with arthroplasty
  • Hemi vs. total arthroplasty
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5
Q

Explain the difference b/w Garden Stage I vs Stage II femoral neck fx?

A

Garden stage I: non-displaced incomplete, including valgus impacted fracture

• Medial femoral neck trabeculae may reveal greenstick fracture

Garden stage II: non-displaced complete

•No disturbance of medial trabeculae

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6
Q

Explain the difference b/w Garden Stage III vs Stage IV femoral neck fx?

A
  • Garden stage III: complete fracture, incompletely displaced
  • Femoral head tilts into varus position
  • Garden stage IV: complete fracture, completely displaced
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7
Q

Define the location of an Intertrochanteric Fracture.

Are they intra or extra caspsular?

A

•Fracture between greater and less trochanters

extracapsular

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8
Q

How would we tx an intertrochanteric fx?

A
  • IM Nailing
  • DHS Compression Screw
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9
Q

Intertrochanteric Fx occurs thru ______ bone with excellent blood supply-thus heals well.

A

cancellous

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10
Q

When assessing a hip fx that you believe is an intertrochanteric it is not always possible to distinguish b/w IT and _________ fx?

A

•basilar femoral neck fx

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11
Q

How would we tx a subtrochanteric fx?

A

IM Nailing

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12
Q

Pt presents to clinic complaining of “achy” pain in her hip. She tells you she feels very stiff in the morning or after prolonged sitting with “loosening up” after approx. 30 min of activity.

Dx?

Tx (pharmacologic?)

A

hip arthritis

NSAIDS/Tylenol

•Intra-articular cortisone injection (done under fluoroscopy)

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13
Q

Pt arrives to clinic c/o aching, intense lateral-sided hip pain. She says she can no longer sleep on her dise or apply pressure to the area.

After taking a hx she tells you that a few weeks ago she walked into the side of her counter-top and had a bruise over her lateral hip.

Dx?

is surgery necessary?

A

Greater Trochanteric Bursitis

No- NSAIDS/ tylenol ice.

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14
Q

Pt complains of pain in groin; that sometimes radiate to lateral hip. she Describes it as dull ache which waxes/wanes with activity/rest.

DX?

A

FAI

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15
Q

Explain 2 types of bone spurs seen in Femoral Acetabular Impingement.

A
  • Cam bone spur
  • Abnormal Femoral Head/Neck junction; increased radius at waist
  • Impingement occurs primarily during flexion, adduction, IR
  • Pincer bone spur
  • Excessive Acetabular Coverage
  • Linear Contact between the labrum and femoral head/neck junction
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16
Q

What is the area affected in FAI?

A

•Femoroacetabular joint

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17
Q

What type of spur is pictured?

A

pincer

  • Excessive Acetabular Coverage
  • Linear Contact between the labrum and femoral head/neck junction
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18
Q

Pt complains of sharp stabbing pain may occur with turning, twisting, and squatting.

Upon x-ray you notice:

Dx?

what type of spur?

A

FAI

CAM

  • Abnormal Femoral Head/Neck junction; increased radius at waist
  • Impingement occurs primarily during flexion, adduction, IR
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19
Q

When assessing a hip fx on physical exam you note sensitivity on active and passive ______ rotation

A

Internal rotation.

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20
Q

Pt arrives to clinic complaining of leg pain after a fall (high-energy deceleration injury).

you X-ray the knee:

Dx?

Tx for stable fx?

A

Tibial Plateau Fracture

•hinged-knee brace, crutches. Pt NWB but can do active ROM exercises from seated/lying position

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21
Q

What is the name for an avulsion fracture involving lateral aspect of tibial plateau.

What ligament is most likely to be disrupted?

A

Segond Fracture

ACL (75%)

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22
Q

Pt arrives to clinic after a skiing injury.

She presents with knee pain and swelling. She appears to be holding her knee in approx. 20 degree flexed position for comfort.

When examining she resist full extension and is not be able to flex past 90 degrees due to secondary to hemarthrosis.

Dx?

A

Segond Fracture

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23
Q

When taking an x-ray of a suspected Segond fx, what may appear on the film?

A

•May show curvilinear fracture- elliptic bone fragment parallel to lateral aspect of tibial plateau

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24
Q

Pt arrives to clinic after falling due to a sports injur (basketball). They complain of knee pain.

You notice hemarthrosis and swelling of the affected knee.

You initally take an x-ray to see whats going on and note a curvilinear fracture- elliptic bone fragment parallel to lateral aspect of tibial plateau.

Is this a tibeal plateau fx or should you continue to investiagte and order an MRI?

A

YES - MRI essential to identify internal derangement (MCL/ACL) usually ACL

this is a segond fx due to hemarthrosis, sports injury fall and the curcilinear fx!!!!

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25
Q

2 MOI that cause patellar fx?

A
  • Direct trauma to anterior patella, i.e. dashboard injury
  • Sudden forceful contraction of quad muscles in context of sport injury
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26
Q

how do we tx a patellar fx?

A
  • ORIF with tension band wiring
  • NWB in hinged knee brace locked in extension
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27
Q

Pt arrives to clinic after a severe fall.

she c/o not being able to extend their leg (absent extensor mechanism) and you also note swelling in the affected knee and a defect in the distal quad tendon.

Dx? (this is a fracture)

A

patellar fx

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28
Q

Do quad tendon rupture or patella tendon rupture occur in pts <40 y/o??

A
  • Patellar tendon ruptures usually occur in pts < 40 y/o
  • Quad tendon ruptures in pts > 40 y/o
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29
Q

A heavy set 45 y/o male presents to clinic complaining of leg pain. He just returned from a boating trip w/ friends where he tells you the EXACT moment he heard a “pop” when jumping onto his friends boat from the dock.

On assessment you notice swelling, and he has an inability to extend his knee.

Dx?

Tx

A

Quad Tendon Rupture - usually heavy set male, forced flexion against resistance/extension and can tell you exact moment they heard “popping” sound.

surgically repaired

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30
Q

Pt arrives to clinic complaining of knee pain. On examinination you notice a Patella alta.

He is partially able to extend his knee?

Dx? (full/partial)

A

Partial Patellar tendon tear - complete tear pt would be unable to extend at all.

•can be treated w/ immobilization in hinged knee brace for 4-6 weeks

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31
Q

what type of tear is this?

A

quad tendon rupture

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32
Q

what type of tear is this?

A

patellar tendon

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33
Q

Complete Patellar tendon ruptures are rare in young athlete unless assoc w/ _____?

A

steroids

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34
Q

Identify the Fx?

NOTE: also a spiral fracture of proximal fibula not shown

A

Maisonneuve Fracture

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35
Q

what is a Maisonneuve Fracture

A
  • Combination of spiral fracture of proximal fibula with ankle injury of one or more:
  • Widening of ankle joint due to rupture of distal tibiofibular syndesmosis
  • Deltoid ligament disruption
  • +/- fracture of medial malleolus
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36
Q

______ is one of strongest predictors of knee OA progression

A

malalignment

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37
Q

_______ progression of knee OA 4X more likely in individuals with _______ alignment

_______progression 5X more likely in individuals with ___________ alignment

A

Medial / varus

Lateral / Valgus

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38
Q

When looking for knee arthritis how should you order your x-ray?

A

WEIGHT baring arthritis series (with 30 deg PA flexed view)

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39
Q

What injection other then cortisone is helpful is managing knee arthritis

A

Viscosupplement - used after failing other therapy options.

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40
Q

what is a characterisitic finding of OA on xray?

A

narrowing of joint space

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41
Q

Pt presents to clinic after a sports injury that occured 3 hrs ago. Upon immediate examination you notice massive effusion. The patient also complains of a “looseness” in the knee. You were not able to witness the fall but the PT wrote in the chart that:

“the fall resulted in valgus stress to knee with ipsilateral foot planted”

Dx?

Why would we also order an x-ray?

A

ACL tear

X-Rays to R/O Segond fx

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42
Q

What test would you perform during a physical exam to help support an ACL tear dx?

A
  • Lachman (superior) – move tibia anteriorly
  • A positive test reveals increased laxity – often without a definite end-point.
  • Anterior Drawer
  • Hip 45 deg – move tibia anteriorly
  • (+) tibia translates anteriorly more then 6mm
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43
Q

When watching sunday night football, you notice this injury occur. The fall was caused by valgus-type force directed to lateral knee. The doc on the field forgot to turn his mic off and you hear him ask the pt if he is experiencing any “locking” the pt replies no. He also asks if there was a “pop” sound when the injury occured. Pt says no.

Just upon witnessing the fall what is your suspected dx?

A

MCL tear

differentiate from meniscus as “locking” sensation is key finding for meniscus tears!

Also “pop” is usually heard w meniscus tear

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44
Q

what is the “Unhappy Triad”

A

an injury to the anterior cruciate ligament, medial collateral ligament, and meniscus.

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45
Q

what runs with the MCL

A

medial meniscus

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46
Q

What is the cause of the lateral mal-tracking in patella femoral syndrome?

A

•The relative weakness of the vastus medialis obliques (VMO) and tightness of IT Band and other quad muscles

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47
Q

What x-ray view is most important when evaluating patella femoral syndrome?

A

•Sunrise (Merchant) view is most important

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48
Q

Pt comes to clinic complaining of diffuse pain around the knee and a “stiff” feeling when getting up. They report no pain with activities but usually become “achy” afterward.

Upon exam you note there is no effusion and the vastus medialis obliques (VMO) are atrophied compared to the rest of the quad. The IT band is also tender.

Dx?

A

Patella Femoral Syndrome

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49
Q

Are medial or lateral meniscus tears more common?

A

medial

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50
Q

what type of tear is a McMurray test useful in dx?

what is a + McMurry test?

A

Meniscus Tears

  • rotates the leg internally while extending the knee to 90 degrees of flexion.
  • (+) If a “thud” or “click” is felt along with pain
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51
Q

When would we choose a Meniscal repair vs Meniscectomy?

A
  • Meniscal repair in younger pts
  • Requires protected WB, gentle ROM x 6weeks as tissue heals
  • Meniscectomy in older less active pts
  • WBAT post-op and quicker return to sports/employment
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52
Q

Key finding in meniscus tears

A

•“locking” is key finding.

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53
Q

what is the most common sports injuries seen in outpatient clinics?

A

ankle sprain

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54
Q

How do we tx a midshaft tibia fx?

(remember these are mostly unstable)

A

IM nail fixation

•If multi-trauma pt., may need to temporize with Ex-Fix (Damage Control Ortho)

55
Q

When looking at ankle fx _____ rotation causes spiral fx of fibula and greater force will also lead to _____ _______ fx.

A

external rotation

medial malleolus fx

56
Q

Pt presents with ankle pain: more specifically

pain/ tenderness over ATF ligament, also calcaneofibular and PTF ligaments.

dx?

A

lateral ankle sprain

57
Q

pt presents with ankle pain more specifically

pain /tenderness over deltoid ligament also posterior tibial tendon.

Dx?

A

Medial Ankle Sprain

58
Q

most common MOI in an ankle sprain

A

an inversion and plantarflexion sprain, which injures ATF ligament (lateral ankle sprain)

59
Q

younger pt comes to clinic complaining of moderate foot psin. Upon taking a detailed history they tell you they were playing with friends and jumped off their parents van onto the pavement.

on examination you see severe swelling.

Dx?

where else in their body should you ask them if they are noticing pain?

A

Calcaneus Fracture

Lower back!!! - secondary to associated lumbar compression fx

60
Q

how do we tx a calcaneous fx? (what type of splint?)

A
  • Well padded posterior splint to LE
  • Jones Wrap

(NWB!!)

61
Q

When examining xrays of feet you notice a transverse fracture at base of 5th metatarsal, 1.5 to 3 cm distal to the proximal tuberosity at the metadiaphyseal junction.

what is the dx?

what are these fx prone to?

A

Jones Fx

non-union - bone doesnt heal

62
Q

Identify where we would see these fx:

Jones fx?

Avulsion fx?

A

green - Jones

avulsion - pink

stress fx- blue

63
Q

5th metatarsal fx are usually due to forcible inversion of foot in plantar flexion, as may occur while stepping on a curb or climbing steps. The force pulls at insertion of _______ ______ .

A

peroneus brevis

64
Q

when looking at 5th metatarsal fx where do 90% of them occur?

A

•base of the 5th metatarsal

65
Q

The fracture is believed to occur as a result of significant adduction force to the forefoot with the ankle in plantar flexion.

A

jones fx

66
Q

The base of the 5th metatarsal is the is insertion point of _____ ____ and is affected in a jones fx.

A

peroneus tertius

67
Q

T/F

Jones fx in general, can be treated conservatively and heal well.

A

FALSE
jones fx prone to non-union

•Immobilization is important as part of the initial therapy, with a non-weight bearing cast for 6-8 weeks

this is TRUE for –> 5th metatarsal avulsion fx

68
Q

Pt comes to clinic reporting sharp volar sided heel pain of moderate to severe intensity. He reports that pain is worst “first thing in the morning when I get out of bed” and the “first few steps” are brutal but the pain resides with ambulation.

Upon examination you note Pes planovalgus orientation.

Dx?

Tx?

A

Plantar Fasciitis

  • Night Splint
  • Ice, NSAIDs
  • Physical therapy
  • +/- Corticosteroid injection
  • (inform of potential fascial rupture)
  • Surgery rarely indicated/necessary
69
Q

Risk factors for plantar fascitis:

A
  • Obesity
  • Pes planovalgus orientation (flat feet)
  • Reduced dorsiflexion (tight heel cords)
70
Q

risk factors for achilles tendon rupture

A
  • “weekend warrior”
  • Fluoroquinolones-> Reported in literature
  • Steroid injections
71
Q

Pt arrives to clinic complaining of weakness and difficulty walking along w/ heel pain.

When you ask about the onset of the pain they tell you there was no severely traumatic injury but while running on the bleachers at their local football field they heard a “pop” and a sudden sharp pain that “felt like someone kicked me”.

Upon examination you notice weak plantarflexion.

Dx?

what PE test could you use to support dx?

A

Achilles tendon Rupture

Thompson test

72
Q

Explain a positive thompson test?

A

A positive test occurs when the calf is squeezed and no plantar movement occurs at the foot.

This indicates an Achilles’ rupture

73
Q

How would we surgucall tx an achilles tendon rupture

A

“end to end”

boot post op

74
Q

Most common organisms that result in ortho infections

A

staph

strep

MRSA

75
Q

what labs should you order if you suspect an ortho infection?

A

CBC

cultures

Renal function, liver function

inflammatory markers (ESR, CRP)

76
Q

Periosteal thickening coupled with bone erosion in setting of clinical infection may indicate _______?

A

osteomyelitis

77
Q

When you are suspicious of an orthopedic infection, when is it appriopriate to use ultrasound?

A

If deep abscess is suspected

78
Q

Osteomyelitis approach to imaging:

A
  • *X-rays
  • *US if appropriate
  • **MRI
  • *3-Phase Bone Scan
79
Q

what is the common pathogen responsible for osetomyelitis

A

S. aureus in bone tissue.

80
Q

How is osteomyelitis dx? (3 things)

A

blood tests

bone biospy

imaging

81
Q

Kanavel’s 4 cardinal signs indicate infective flexor tenosynovitis:

A
  • Fusiform swelling of an entire finger
  • Partially flexed posture of the finger
  • Tenderness limited to course of flexor tendon sheath
  • Disproportionate pain on passive extension of the finger
82
Q

Usual bacteria responsible for hand infections? (4)

A

staph

  • Strep
  • Pasteurella
  • Oral anaerobes
83
Q

pt arrives to clinic w/ an erythematous, swollen, warm area. They are a known IVDU.

You suspect a hand infection as a result of a puncture wound.

what must you ALWAYS do in this pts case?

A

•Always x-ray Heroin users

84
Q

what are hand infections often from

A
  • Cat bite
  • Human bite
  • Puncture wounds
  • Always x-ray Heroin users
85
Q

Pt arrives to clinic complaining of paresthesia and pain in their hand. You note they have on a cast.

When you ask about their injury they tell you they had a minor fracture to their radius that has been healing for 3 weeks.

When you ask about their pain level out of 10 they report a 12.

what are you HIGHLY suspicious of?

A

compartment syndrome - presents w a cast and pain out of proportion to injury.

86
Q

tx for compartment syndrome

A

Fasciotomy

87
Q

what type of fractures most commonly cause compartment syndrome?

A

leg and forearm (fx of radius and ulna)

88
Q

what are the early signs of compartment syndrome?

A
  • Pain out of proportion to injury
  • Paresthesia – pins & needles sensation
89
Q

During Compartment syndrome muscle fascia prevents expansion of tissue. Venous outflow _______, as arterial flow is ____.

A

•Venous outflow decreases, as arterial flow is greater

90
Q

what are the late signs of compartment syndrome?

A

5 P’s •

•Pain • Pallor • Pulselessness • Paresthesia • Paralysis

91
Q

what are the 5 presenting sx of OA

A

Joint-line tenderness

Decreased range of motion (ROM)

Swelling

Joint deformity

Instability

92
Q

Non-modifiable systemic risk factors for OA

A

Age / gender (women)

Genetics (60% hip and hand, 40% knee)

93
Q

what is the modifiable systemic risk factor for OA

A

Obesity

Dose–response relationship exists between obesity and risk of knee OA

For every 5-unit increase in body mass index (BMI), there is an associated 35% increased risk of knee OA

94
Q

What are the 4 modifiable local risk factors of OA

A

muscle strength

physical activity / occupation

joint injuries

alignment

95
Q

when looking at modifiable risk factors for a pt with knee OA what muscle should you look to strengthen?

A

quad femoris

•Improvement in strength, through exercise, associated with reduced pain and improved function in people with knee OA

96
Q

what is the most important joint / knee injury in the context of OA

A

ACL

Large percentage will show changes within 10 yrs. after initial injury

97
Q

first line tx for pain management of OA / DJD

A

acetaminophin

•325 to 650 mg q 6 hours on a scheduled basis (maximum dose 4 g/day;

maximum 2 g/day if chronic alcohol intake or underlying liver disease

98
Q

what is prescribed to pts with OA if acetaminophen proves ineffective

A

NSAIDS

Topicals

99
Q

what topical analgesic is used to manage pain in OA

A

•Diclofenac Gel (Voltaren)

100
Q

When a pt is dx with OA it is important to educate them on weight management as, for each kg weight loss, knee experiences _______ reduction in load during daily activities.

A

fourfold

101
Q

what is the tx algoirthm (1st and 2nd line) for pain management of OA?

A
  • Mild-moderate pain
  • Acetaminophen used first line
  • Add topical analgesics prn
  • If measures fail
  • NSAIDs, Viscosupplementation
102
Q

what is the hallmark of Complex Regional Pain Syndrome

A

•Hallmark: Pain presentation is disproportionate in degree to what is typically expected from injury

103
Q

what are the 2 types of Complex Regional Pain Syndrome?

A

type I: reflex sympathetic dystrophy (90% of cases, no peripheral nerve injury)

Type II: causalga (+ peripheral nerve injury)

104
Q

pt arrives to clinic experiencing spontaneous pain, swelling and different skin temperatures with NO precipitating event. Upon examination you notice bone atrophy.

what type of complex regional pain syndrome is this?

A

Type I: not always a precipitating event (Type II there ALWAYS is a precipitating event)

Type I (+) for bone atrophy (Type II will be -)

105
Q

what are the 3 cardinal signs of type 2 complex regional pain synd?

A

burning pain

allodynia

hyperalgesia

106
Q

what are the 3 cardinal signs of type 1 complex regional pain synd?

A

spontaneous pain

swelling

different skin temps

107
Q

3 most common MSK lesions

A
  • Undifferentiated pleomorphic sarcoma
  • Liposarcoma
  • Leiomyosarcoma
108
Q

Upon physical exam of a MSK lesion what size is concerning?

A

>5cm

109
Q

when working up an MSK lesion what should you always start with ?

A

X-ray!

110
Q

when working up an MSK lesion what are bone scans used to detect??

A
  • Metastatic lesions
  • Stress fractures
  • Insufficiency fractures
111
Q

what imaging technique is best indicated for smaller MSK lesions involving cortical structures of bone or spine?

A

CT scan

112
Q

when working up a soft tissue MSK lesion what is the imaging technique of choice?

A

MRI

  • Modality of choice for evaluating:
  • Bone marrow involvement
  • Non-calcific soft-tissue lesions
113
Q

what is ALWAYS needed to dx MSK lesion?

A

tissue biopsy

114
Q

When preforming a biopsy on an MSK lesion where is hightest quality diagnostic tissue found?

A

Highest-quality diagnostic tissue usu. found at periphery of lesion, at interfaces of normal surrounding tissue

115
Q

when preforming a biopsy of an MSK lesion what are the 3 types for musculoskeletal neoplasia:

A

Excisional- discouraged unless

Lesion 2–3 cm

In location where a section of healthy tissue can be resected as a margin without significantly increased morbidity

Incisional

Needle

116
Q

what are the goals of MSK cancer staging

A
  • treatment guidance
  • prognostic stratification
  • investigation continuity
117
Q

How are Benign Orthopedic Lesions classified

A
  • matrix which the tumor cells produce:
  • Bone
  • Cartilage
  • Fibrous tissue
  • Fat
  • Blood vessel
118
Q

why would a Benign Orthopedic Lesion be classified as “aggresive”

A

they may recur locally after removal (resection)

119
Q

name a Benign Orthopedic Lesion that rarely metastasize

A

giant cell tumor

120
Q

In the context of malignant ortho lesions what is the most common site of mets

A

lungs

121
Q

Term “malignant” indicates

A

moderate to high probability that the tumor will metastasize

122
Q

most common type that originates in bone

A

Osteosarcoma

123
Q

cancer of cartilage cells

A

Chondrosarcoma

2nd most common form of malignant bone tumor

124
Q

MSK malignant cancer that often arises in diaphysis of long bones of legs & arms

A

•Ewing’s Sarcoma

125
Q

where are we most likely to find osteosarcome?

A

arms

legs

pelvis

126
Q

cancer that is uncommon in < 20 y/o and those > 75

A

Chondrosarcoma

127
Q

in what type of cancer would you find a periosteal reaction?

what does this look like?

and what does it indicate?

A

Ewing’s Sarcoma

sun burst appearance - indicates an aggressive process

128
Q

where are you most likely to see Chondrosarcoma

A

Arms

Legs

Pelvis

Ribs (sometimes)

129
Q

what is this lesion called?

dx?

A

codmans triangle

ewings sarcoma

130
Q

what age group does osteosarcoma most frequently present in

A

between 10-30 y/o

131
Q

Chondrosarcoma may also form within prior benign tumors of cartilage and bone called _____ and normall develops from (normal / abnormal) cartilage.

A

Osteochondromas

normal

132
Q

identify the lesion

A

Chondrosarcoma

133
Q

identify the lesion

A

Osteosarcoma

134
Q

identify the lesion

A

ewing sarcoma

Clin Med 1 - MSK/ HEENT exam 2 (4 decks)

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