Musculoskeletal Flashcards

Question

Posterior Drawer Sign How to perform maneuver? What is a positive test?

Answer 1

Patient lies on examination table (supine). The hip is flexed to 45 degrees, and the knee is bent to 90 degrees. The examiner sits on the forefoot/toes to stabilize the knee joint. Then examiner grasps the lower leg by the joint line and pushes it posteriorly (like closing a drawer) A positive posterior drawer sign is indicative of a damaged or **torn posterior cruciate ligament (PCL).** Sensitivity is 90%, and specificity is 99%.

Answer 2

**De Quervain’s tenosynovitis (or tendinosis**) is caused by an inflammation of the tendon sheath, which is located at the base of the thumb Tell patient to flex thumb toward the palm, then make a fist by folding remaining fingers over the thumb, then tell patient to ulnarly deviate their wrist. Positive if there is pain and tenderness on the wrist on the thumb side (abductor pollicis longus and extensor pollicis brevis tendons).

Answer 3

Meniscus Injury or Tear *Patient supine and relaxed. The examiner grasps the patient's heel with one hand and the joint line of the knee with the other hand. The knee is flexed maximally, with external tibial rotation (medial meniscus) or internal tibial rotation (lateral meniscus).* Knee pain and a “click” sound upon manipulation of the knee are positive Gold-standard test for joint damage is the **MRI**.

Answer 4

Tests for ACL damage This test is done by **bending the hip 45 degrees and the knee 90 degrees, then pulling the knee forward with a sudden jerk to test the leg's range of motion**. If it moves 6 mm beyond its normal range of motion, then you may have an ACL tear or injury Lachman's test is more sensitive than is the anterior drawer sign

Answer 5

Positive finding is an increase in _____ of the damaged knee (ligament tear). ## Footnote * Valgus stress test of the knee:* Test for the medial collateral ligament (MCL) * Varus stress test of the knee:* Test for the lateral collateral ligament (LCL)

Answer 6

Administering intra-articular/periarticular joint injections with steroids (e.g., triamcinolone) is a controversial treatment for inflamed joints. Some expert panels suggest about four injections per joint (such as a knee) in a lifetime. If high resistance is felt when pushing syringe, do not force. Withdraw needle slightly (do not remove from joint) and redirect.

Answer 7

* Tendon rupture * nerve damage * infection * bleeding * hypothalamic–pituitary–adrenal (HPA) suppression, others. ## Footnote **Joint injections are contraindicated in patients who are on anticoagulation therapy because of the risk of hemarthrosis (bleeding into joint)**

Answer 8

Show bone fractures, osteoarthritis (OA; joint space narrowing, osteophyte formation), damaged bone (osteomyelitis, metastases), metal and other dense objects. Not recommended for soft tissue structures such as menisci, tendons, and ligaments. Usually the initial imaging modality

Answer 9

Gold standard for injuries of the cartilage, menisci, tendons, ligaments, or any joint of the body. MRI uses a magnetic field and radio waves, not radiation (compared with x-rays and CT scans). Can be done without or with contrast.

Answer 10

Metal implants, pacemakers, aneurysm clips, insulin pumps, metallic foreign body in the eye, “triggerfish” contact lens, cochlear implant, electrodes for deep brain stimulation, and metallic joints.

Answer 11

Combines x-rays (gamma radiation) that are rotating in a continuous circle around the patient with computer software to show slices of three-dimensional images. Can be done without or with contrast. Detects bleeding, aneurysms, masses, pelvic and bone trauma, fractures.

Answer 12

***MRI:*** Best for soft tissue, joints, occult fractures, and soft tissue. ***X-rays (radiographs):*** Best for bone injuries such as fractures. Some bone fractures might not be visible (e.g., stress fractures).

Answer 13

***Abduction (varus)**:* Movement going away from the body ***Adduction (valgum):*** Movement going toward the body ***Proximal**:* Body part located closer to the body (compared with distal) ***Distal**:* Body part farther away from the center of the body

Answer 14

* Metacarpals:* Bones of the hands. * Carpals*: Bones of the wrist. There are a total of eight wrist bones. * Phalanges:* Fingers and the toes; singular form of the term is *phalanx*. * Metatarsals:* Bones of the feet. * Talus:* The ankle bone. * Calcaneus:* The heel bone.

Answer 15

Medial Tibia Stress Syndrome (Shin Splints) and Medial Tibial Stress Fracture

Answer 16

More common in runners (higher incidence in females) and people with flat feet. If severe, it can progress into a stress fracture. Females are at higher risk of stress fracture, especially those with “female athlete triad” (amenorrhea, eating disorder, osteoporosis). Onset precipitated or worsened with intensification of activity (increased mileage and/or frequency of training).

Answer 17

Female runner reports that she recently increased frequency/distance running and complains of recent onset of pain on the inner edge of the tibia. Pain may be sharp and stabbing or dull and throbbing. Aggravated during and after exercise. Complains of a sore spot on the inside of the lower leg or the shin (tibia). Some patients may have pain on the anterior aspect of the shin. Focal area is tender when touched. Some may develop a stress fracture on the tibia.

Answer 18

RICE for several weeks are recommended ## Footnote Apply cold packs during acute exacerbation, for 20 minutes at a time, several times a day for first 24 to 48 hours and then as needed. Compression bandage or sleeve may help decrease swelling. Using cushioned shoes (sneakers) for daily activity helps decrease tibial stress. When pain is gone, wait about 2 weeks before resuming exercise. Avoid hills and very hard surfaces until the shin splints have resolved. If aerobic exercise is desired, recommend lower impact exercises (e.g., swimming, stationary bike, elliptical trainer). If stress fracture is suspected, advise patient to avoid exercising. Stretch before exercise and start at lower intensity. Wear supportive sneakers.

Answer 19

NSAIDs as needed If suspect stress fracture, bone scan and/or MRI. A radiograph (x-ray) does not show stress fractures. Refer to orthopedic specialist.

Answer 20

Plantar Fasciitis Acute or recurrent pain on the bottom of the feet that is aggravated by walking. Caused by microtears in the plantar fascia due to tightness of the Achilles tendon. Higher risk with obesity (body mass index [BMI] \>30), diabetes, aerobic exercise, flat feet, prolonged standing.

Answer 21

Middle-aged adult complains of plantar foot pain (either on one or on both feet) that is worsened by walking and weight bearing. Complains that foot pain is worse during the first few steps in the morning and continues to worsen with prolonged walking.

Answer 22

* NSAIDs:* Naproxen (Aleve) orally twice a day, ibuprofen (Advil) orally every 4 to 6 hours. * Topical NSAID:* Diclofenac gel (Voltaren Gel) applied to soles of feet twice a day. Consider **x-ray** to rule out fracture, heel spurs, complicated case Refer to **podiatrist** as needed

Answer 23

Use orthotic foot appliance at night for a few weeks; it will help to stretch the Achilles tendon. *Stretching and massaging of the foot:* Roll a golf ball with sole of foot several times a day. Lose weight (if overweight). Use shoes with well-padded soles and/or use a heel cup on affected foot.

Answer 24

Morton’s Neuroma

Answer 25

Middle-aged woman complains of many weeks of plantar foot pain that is worsened by walking, especially while wearing high heels or tight narrow shoes. The pain is described as burning and/or numbness, and it is located on the space between the third and fourth toes (metatarsals) on the forefoot. Physical exam of the foot may reveal a small nodule on the space between the third and fourth toes. Some patients palpate the same nodule and report it as “pebble-like.”

Answer 26

This test for Morton’s neuroma is done by grasping the first and fifth metatarsals and squeezing the forefoot Positive test is hearing a click along with a patient report of pain during compression. Pain is relieved when the compression is stopped.

Answer 27

Avoid wearing tight narrow shoes and high heels. Use forefoot pad. Wear well-padded shoes. Diagnosed by clinical presentation and history. Refer to podiatrist.

Answer 28

Degenerative Joint Disease (Osteoarthritis) Occurs when the cartilage covering the articular surface of joints becomes damaged from overuse and with age. Large weight-bearing joints (hips and knees) and the hands (Bouchard’s and Heberden’s nodes) are most commonly affected. It can affect one side or bilaterally. Risk factors include older age, overuse of joints, and positive family history.

Answer 29

Gradual onset (over years). **Early-morning joint** **stiffness** with inactivity. Shorter duration of joint stiffness (**\<15 minutes**) compared with rheumatoid arthritis (RA). Pain aggravated by overuse of joint. During exacerbations, involved joint may be swollen and tender to palpation. May be one-sided (e.g., right hip only). Absence of systemic symptoms (not a systemic inflammatory illness like RA). **Heberden’s and/or Bouchard’s nodes** may be noted

Answer 30

* Heberden’s nodes:* Bony nodules on the distal interphalangeal (DIP) joints * Bouchard’s nodes:* Bony nodules on the proximal interphalangeal (PIP) joints

Answer 31

Relieve pain. Preserve joint mobility and function. Minimize disability and protect joint.

Answer 32

Exercise (with care) at least three times a week. Lose weight. Stop smoking. Do isometric exercises to strengthen quadriceps muscles (knee OA). Engage in weight-bearing exercise (walking, lifting weights), resistance-band exercises. Avoid aggravating activities. Use cold or warm packs and ultrasound treatment. Use walking aids. Patellar taping by physical therapist will reduce load on knees. *Alternative medicine:* Use glucosamine supplements, SAM-e, tai chi exercises, acupuncture.

Answer 33

Acetaminophen 325 to 650 mg every 4 to 6 hours (maximum 4 g/day) PRN. *or* Tylenol 325 mg to 1,000 mg every 4 to 6 hours (maximum dose 4 g [4,000 mg] per 24 hours) PRN. Dehydration increases risk of hepatic adverse effects; drink a lot of water.

Answer 34

NSAIDs ## Footnote If no relief with acetaminophen, switch to a short-acting NSAID. Start with NSAIDs, such as ibuprofen (Advil), one to two tablets every 4 to 6 hours or naproxen (Aleve) BID or Anaprox DS one tablet every 12 hours PRN.

Answer 35

Add a proton-pump inhibitor (PPI; omeprazole) or misoprostol (Cytotec) = For added gastrointestinal (GI) protection (if long term) If patient is at high risk for both GI bleeding and CV side effects, avoid NSAIDs. * *GI ____ risk factors:* History of uncomplicated ulcer, aspirin, warfarin (Coumadin), peptic ulcer disease (PUD), platelet disorder * *\_\_\_\_\_ analgesics:* Avoid if possible (especially if patient is a recovering narcotic addict) Age older than 75 years: Use _____ (vs. oral) NSAIDs for treatment. Rule out (1) and order (1) density test (postmenopausal females, chronic steroid treatment males/females).

Answer 36

*NSAID:* **Diclofenac gel** (Voltaren Gel); apply to painful area and massage well into skin QID. ***Capsaicin cream:*** Apply to painful area QID. Avoid contact with eyes/mucous membranes. Capsaicin comes from chili peppers. Also used to treat neuropathic pain (e.g., post shingles). Do not use on wounds/abraded skin. Avoid bathing/showering afterward (so that it is not washed off).

Answer 37

* Highest risk of GI bleeding:* Ketorolac (Toradol) and piroxicam (Feldene) * Lowest risk of GI bleeding:* Ibuprofen and celecoxib (Celebrex) * Highest risk of CV events:* Diclofenac and celecoxib at higher doses * Lowest risk of CV events:* Naproxen

Answer 38

**Ketorolac (Toradol)** is limited to 5 days of use. The first dose is given intramuscular or intravenous (IV). Heberden’s and/or Bouchard’s nodes have appeared many times on the exam. Memorize the location of each. The following may help: * *Heberden’s vs. Bouchard's node location:* The letter B comes before the letter H. Therefore, Bouchard’s node (PIP) comes before Heberden’s nodes (DIP)

Answer 39

*Types of treatment methods used for DJD:* Analgesics, NSAIDs (by mouth and topical), steroid injection on inflamed joints (*no* systemic/oral steroids), surgery (e.g., joint replacement). Do not confuse the treatment options for OA with those for RA. Recognize signs and symptoms of a medial tibial stress fracture.

Answer 40

Systemic Lupus Erythematosus *cutaneous lupus erythematosus*

Answer 41

Typical patient is a **woman** between **20 and 35** years of age. Classic rash is the maculopapular **butterfly-shaped rash** on the middle of the face (malar rash). May have nonpruritic thick scaly red rashes on sun-exposed areas (**discoid rash**). Urinalysis (UA) is positive for **proteinuria**.

Answer 42

Refer to **rheumatologist** * NSAIDs * analgesics * steroids * antimalarial **[Plaquenil]**, * immune modulators [**methotrexate**, biologics] * **monoclonal antibodies**

Answer 43

Avoid sun between 10 a.m. and 4 p.m. (causes rashes to break out). Cover skin with high sun protection factor (SPF; UVA and UVB) sunblock. Wear sun-protective clothing, such as hats with wide brims and long-sleeved shirts. Use nonfluorescent light bulbs (more sensitive to indoor fluorescent lighting).

Answer 44

Rheumatoid Arthritis

Answer 45

Adult, commonly middle-aged, woman complains of gradual onset of symptoms over months with daily fatigue, low-grade fever, generalized body aches, and myalgia. Complains of generalized joint pain, which usually involves multiple joints bilaterally. It usually starts on the fingers/hands (**PIP and metacarpophalangeal [MCP] joints**) and the wrists. Commonly reports early-morning stiffness/pain and warm, tender, and swollen fingers in the DIP/PIP joints (also called “sausage joints”). It eventually involves the majority of joints in the body bilaterally.

Answer 46

Joint involvement is more **symmetric** with more joints involved compared with DJD ## Footnote *Most common joints affected:* Hands, wrist, elbows, ankles, feet, and shoulders “Sausage joints” **Morning stiffness occurs for at least 1 hour and has been present for \>6 weeks.** Rheumatoid nodules present (chronic disease)

Answer 47

* Swan neck deformity (50%):* Flexion of the DIP joint with hyperextension of the PIP joint ([**Figure 1A**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#)) * Boutonniere deformity:* Hyperextension of the DIP with flexion of the PIP joint ([**Figure 1B**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#))

Answer 48

* Sedimentation rate:* Elevated * CBC:* Mild microcytic or normocytic anemia common * Rheumatoid factor (RF):* Positive in 70% to 80% of patients * Radiographs:* Bony erosions, joint space narrowing, subluxations (or dislocation) * Serology/antibodies:* Anti-cyclic citrullinated peptide/protein (anti-CCP), others

Answer 49

Refer to rheumatologist for early aggressive management to minimize joint damage. * Surgery:* Joint replacement (hip, knees) ameliorates RA * Careful assessment is necessary:* Never prescribe a biologic or anti–tumor necrosis factor (anti-TNF) medication if signs and symptoms of infection (e.g., fever, sore throat) are present. Tuberculosis (TB) testing should be ordered prior to start of anti-TNF therapy.

Answer 50

NSAIDs (e.g., ibuprofen, naproxen sodium) help to relieve inflammation and pain. *Steroids:* Systemic oral doses Steroid joint injections (synovial space)

Answer 51

Disease-modifying antirheumatic drugs (DMARDs) methotrexate, sulfasalazine, cyclosporine, and hydroxychloroquine (an antimalarial drug) Anti-TNF biologics Adalimumab (Humira), etanercept (Enbrel), infliximab (Remicade)

Answer 52

Anti-TNFs increase risk of infections, squamous cell skin cancer, lymphoma.

Answer 53

Anterior Uveitis, scleritis, vasculitis, pericarditis. Malignancies such as Lymphoma

Answer 54

***Uveitis (eyes)**:* Inflammation of the uvea (middle layer eyeball). Sudden onset of eye redness, pain, blurred vision. Can cause vision loss. Refer to ophthalmologist *stat*. When prescribing Plaquenil, all patients must have an eye exam prior to starting the medication. Frequent eye-exam monitoring should be performed **every 6 months** or as recommended by the ophthalmologist to assess and prevent retinal damage, which can lead to blindness.

Answer 55

Swan neck deformity and boutonniere deformity are signs of late and/or severe RA disease. Bouchard’s nodes can occur in both OA/DJD and RA (located on PIP). Heberden’s nodes are seen only with OA/DJD (located on DIP). _Distinguish between RA and OA in terms of classic presentation._ With RA, joint stiffness lasts longer. It involves multiple joints and has a symmetric distribution. RA is accompanied by systemic symptoms such as fatigue, fever, normocytic anemia.

Answer 56

*Uveitis:* Swelling of the uvea, the middle layer of the eye that supplies blood to the retina (refer to ophthalmologist *stat*). Patient treated with high-dose steroids for several weeks. Higher risk of uveitis with inflammatory disease (e.g., ankylosing spondylitis, sarcoidosis, inflammatory bowel disease). **Plaquenil** is an antimalarial. **Methotrexate** is a DMARD. It is contraindicated for use during pregnancy. When prescribing methotrexate to childbearing women, contraception must be prescribed and adhered to while taking methotrexate.

Answer 57

Know the presentation of RA and lab findings. Distinguish between presentation of OA and RA = OA more localized, RA has systemic symptoms and bilateral joints involvement NSAIDs injure the GI tract by blocking cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2), resulting in lower levels of systemic prostaglandins. Aspirin (acetylsalicylic acid) is a type of NSAID. It affects platelets and clotting permanently, but it will resolve once the affected platelets (life span about 10 days) resolve (if not on chronic NSAIDs).

Answer 58

Aspiration of the synovial fluid of the joint Microscopy exam using a polarized light is used to identify uric acid crystals in the synovial fluid to diagnose gout. **Recurrent flares + elevated serum uric acid \>6.8 mg/dL**

Answer 59

Middle-aged man presents with painful, hot, red, and **swollen MTP joint of great toe (podagra)**. Patient is limping due to severe pain from weight bearing on affected toe. History of previous attacks at same site. Precipitated by ingestion of **alcohol, meats, or seafood.** Chronic gout has **tophi** (small white nodules full of urates on ears and joints). History of recurrent inflammatory arthritis (**gout flare**).

Answer 60

***Uric acid level:*** **Elevated \>6.8 mg/dL** ***Treatment targe*****t is \<6 mg/dL** During the acute phase, uric acid level is normal; uric acid level does not begin to rise until after the acute phase. Test uric acid level 2 weeks after acute attack. * Other conditions that increase serum uric acid:* Chemotherapy, radiation therapy * Medications that increase uric acid:* Hydrochlorothiazide, furosemide

Answer 61

* CBC:* WBC level elevated * ESR:* Elevated * CRP:* Elevated

Answer 62

1st goal = PAIN RELIEF with Oral Steroids, NSAIDs, or Colchicine During flares, if patient is taking daily urate-lowering therapy (e.g., allopurinol, probenecid, febuxostat, lesinurad, pegloticase), do not discontinue it. Can continue taking these meds with gout flare meds.

Answer 63

Prednisone or prednisolone 30 to 40 mg given once a day or divided into BID dosing; taper the dose over the next 7 to 10 days. or Medrol Dosepak Shorter duration (5 days) or tapered packs are also effective

Answer 64

NSAIDs if patient refuses steroids (and does not have renal or active GI disease). * Indomethacin BID * naproxen sodium BID * diclofenac BID * celecoxib BID * or ibuprofen (800 mg TID). Can discontinue NSAIDs after 2 to 3 days of complete resolution. Do not use narcotics (not effective for gout pain).

Answer 65

Two tablets (1.2 mg) at the onset of pain and then one tablet (0.6 mg) in 1 hour. Do not take more than three tablets per gout flare episode. Advise to avoid eating grapefruit or drinking grapefruit juice with colchicine. ## Footnote * Common side effects:* Diarrhea, abdominal pain, cramps, nausea, and vomiting * Drug interactions:* Macrolides, azole antifungals, some antivirals, calcium channel blockers (CCBs), cyclosporine, tacrolimus, others * Contraindications:* Any degree of renal or hepatic impairment * Serious and life-threatening effects:* Blood cytopenias, rhabdomyolysis, liver failure, neuropathy

Answer 66

* Xanthine oxidase inhibitors (XOI):* Allopurinol (Zyloprim), febuxostat (Uloric) * Uricosoric agents:* Probenecid, lesinurad (Zurampic) * Uricase:* Pegloticase IV can cause anaphylaxis and infusion reactions; premedicate with antihistamines and corticosteroids

Answer 67

Gout patients with heart disease have higher rate of CV death compared with CV patients with gout treated with allopurinol.

Answer 68

**Allopurinol** **(Zyloprim) initial dose is 100 mg daily; increase dose until serum uric level is \<6 mg/dL.** Check CBC (affects bone marrow), renal function, liver function at baseline, then periodically. Preferred urate-lowering agent and generally well tolerated. Wait for several weeks after acute gout flare before starting on urate-lowering therapy (ULT). *Indications for ULT:* Tophus or tophi, frequent attacks (≥2 per year)

Answer 69

If renal disease, at higher risk. Manifests as fever, rash (toxic epidermal necrolysis), and hepatitis. Stop allopurinol immediately if it occurs and refer. Consider febuxostat (Uloric) if allergic to allopurinol. Alternative med is probenecid. Lifestyle changes and dietary education important part of treatment. * Patients should be instructed to avoid/minimize alcohol (\<2 servings for males/\<1 serving for females). * If overweight or obese, lose weight. Avoid fructose- or corn syrup–sweetened beverages (increase uric acid). Remain well hydrated. * Reduce high protein/dietary purine intake (red meat, shellfish, protein shakes, high dairy, organ meats). *Alternative medicine:* Cherries or red cherry juice, vitamin C

Answer 70

Joint Destruction, Joint Deformity, Tophi

Answer 71

Ankylosing Spondylitis

Answer 72

**Young adult male complains of a chronic case of back pain (\>3 months) that started at the neck and progressed down to the spine.** Neck pain is an early symptom. Reports that the pain gradually progressed from the neck to the upper back (thoracic spine) and then the lower back. Impaired spinal mobility. Joint pain keeps him awake at night. Associated with generalized symptoms such as low-grade fever and fatigue. May have chest pain with respiration (costochondritis) and costovertebral tenderness. **Long-term stiffness improves with activity.** Some may have midbuttock pain (sciatica indicates sacroiliac spine is involved).

Answer 73

***Uveitis*** *(up to 40% patients):* Complains of eye irritation, photosensitivity, and eye pain. Scleral injection and blurred vision occur. Unilateral eye involvement is common (25%–35%). Refer to ophthalmologist as soon as possible (treated with steroids). Causes a marked loss of ROM of the spine such as forward bending, rotation, and lateral bending. Decreased respiratory excursion down to \<2.5 cm (normal 5 cm). Some have lordosis. Hyperkyphosis (hunchback) occurs after 10 years or more with disease.

Answer 74

* ESR and CRP:* Slightly elevated; RF is negative. * Spinal radiograph:* Classic **“bamboo spine”\*\*** (resembles bamboo; [**Figure 1**](https://examprepconnect.springerpub.com/app/family-nurse-practitioner-fnp#)).

Answer 75

Refer to rheumatologist. If smoker, advise smoking cessation. Screen for anxiety and depression. Refer for physical therapy for initial evaluation and training, including postural training, ROM, stretching. Exercise therapy combined with hydrotherapy is more effective than exercise alone. Advise patient to buy a mattress with good support.

Answer 76

1st line initial treatment **_NSAIDs_** such as naproxen twice a day, celecoxib twice a day, ibuprofen 800 mg three times a day, or other NSAID. Usually need the maximum dose to control pain. If high risk of bleeding, prescribe PPI with NSAIDs or COX-2 inhibitor (celecoxib twice a day). For severe cases **_TNF inhibitors, biologics (e.g., etanercept), DMARDs (methotrexate), spinal fusion._**

Answer 77

**Anterior uveitis** Aortitis (inflammation of the aorta) Fusing of the spine with significant loss of ROM Spinal stenosis, hyperkyphosis

Answer 78

Low-Back Pain

Answer 79

* Acute back pain:* Up to 4 weeks * Subacute back pain:* 4 to 12 weeks * Chronic back pain:* Persists for 12 weeks or longer

Answer 80

* Obesity * Age * Female * Smoking * Anxiety, Depression * Psychologically strenuous work, Physically strenuous or sedentary work, * Workers’ compensation insurance, job dissatisfaction

Answer 81

* History of significant trauma * Suspect cancer metastases * Suspect infection (osteomyelitis) * Suspect spinal/vertebral fracture (elderly with osteopenia/osteoporosis, chronic steroid use) * **Patient age older than 50 with new onset of back pain (rule out cancer) or pain that wakes patient from sleep** * Suspect spinal stenosis (rule out ankylosing spondylitis)

Answer 82

* Suspect cauda equina or spinal cord compression * Suspect radiculopathy (spinal nerve root inflammation such as sciatica) * Suspect ankylosing spondylitis * Fevers, night sweats, weight loss, or signs of systemic illness * Symptoms worsening despite usual treatment * *Herniated disc with symptoms:* Common site is at L5 to S1 (buttock/leg pain)

Answer 83

**MRI** ## Footnote Best method for diagnosing a herniated disc. Bone scan may be helpful in identifying occult, lytic lesions. Imaging for low-back pain without other symptoms increases risk of additional or invasive procedures.

Answer 84

Treatment depends on etiology. For uncomplicated back pain, use NSAIDs (naproxen sodium); apply warm packs if muscle spasms. Muscle relaxants if associated with muscle spasms (causes drowsiness; warn patient) Abdominal and core-strengthening exercises after acute phase Consider chiropractor for uncomplicated low-back pain **Bed rest is not recommended except in severe cases of low-back pain, because it will cause deconditioning (loss of muscle tone and endurance) and increased risk of pneumonia.**

Answer 85

*Cauda Equina Syndrome* Acute pressure on a sacral nerve root results in inflammatory and ischemic changes to the nerve. Sacral nerves innervate pelvic structures such as the sphincters (anal and bladder). Considered a surgical emergency. Needs spinal and/or nerve root decompression. Refer to ED.

Answer 86

Bladder incontinence is more common than bowel incontinence Saddle anesthesia Bilateral sciatica symptoms such as paresthesias on midbuttock radiating down back of the leg

Answer 87

**Piriformis Syndrome** The piriformis muscle is located in the buttocks, and it can compress, irritate, and entrap the sciatic nerve between its muscle layers. It is responsible for 0.3% to 6% of all cases of low-back pain.

Answer 88

Patient usually complains of **sciatica** symptoms. Sciatica symptoms may include pain and numbness of the buttocks, which may radiate down the leg. Reports that the pain is worsened by prolonged sitting, driving. Pain can be episodic. History of running, lifting heavy objects, falls, or excessive stair climbing. There are **maneuvers that can be done to irritate the piriformis muscle**, such as **_FAIR_** **(flexion, adduction, internal rotation) maneuvers.** Obtain history of injury. Perform physical examination of the hip and groin, which includes inspection, palpation, ROM testing, pulses, deep tendon reflexes, and strength testing.

Answer 89

* Radiograph (x-ray):* Consider if limited hip ROM or chronic groin pain. Can help diagnose osteoarthritis of hip. * Ultrasound:* Can help diagnose tendon and soft-tissue injury around the hip and groin. * MRI:* Can help diagnose sciatic nerve compression, stress fracture of femoral neck, cartilage tears, tendon ruptures.

Answer 90

Avoid positions that trigger pain. Follow RICE (rest, ice, compression, elevation) guide; cold packs or heat can be used. Warm up and stretch before sports or exercises. Rest, cold packs, and heat may help symptoms. *Medications:* NSAIDs and muscle relaxants are the most common method of treatment. Refer for physical therapy for stretching and exercises.

Answer 91

Centrally active skeletal muscle relaxant *Side effects:* Drowsiness, dizziness, nervousness, reddish-purple urine, hypotension; do not mix muscle relaxants with sedating drugs or alcohol 1. Cyclobenzaprine (Flexeril) 2. Metaxalone (Skelaxin) 3. Tizanidine (Zanaflex) 4. Carisoprodol (Soma) can be addicting; it is a Food and Drug Administration (FDA) schedule IV substance.

Answer 92

*Ankylosing spondylitis:* Know signs and symptoms so you are able to diagnose it on the exam. Bamboo spine is pathognomonic for ankylosing spondylitis. Name of cast for fractures of the wrist is “thumb spica cast” (also available as a splint). Learn how to treat gout flare-up = goal is pain relief with NSAIDS, steroids, or colchicine Learn signs/symptoms of cauda equina = bladder/bowel incontinence, saddle anesthesia, bilateral sciatica sx such as parasthesia on midbuttock radiating back of leg If suspected, refer to ED.

Answer 93

Naproxen is the NSAID with the fewest CV effects, but it has the same GI adverse effects as other NSAIDs. It can, however, increase BP, so this should be monitored. The innervation of the bladder and anal sphincter comes from the sacral nerves and, with cauda equina, symptoms include new-onset incontinence of urine (and/or bowel), saddle-pattern paresthesia, sciatica.

Answer 94

RICE (Rest, Ice, Compression, Elevation) * Ice is best during first 48 hours postinjury. * 15 to 20 minutes per hour several times/day (frequency varies) * Rest and elevate affected joint to help decrease swelling. * Compress joints as needed. Use elastic bandage wrap (joints most commonly compressed are knees and ankles); helps with swelling and provides stability. * Administer NSAIDs (naproxen BID, ibuprofen QID) for pain and swelling PRN.

Answer 95

Tendinitis

Answer 96

(Supraspinatus Tendinitis) Rotator cuff disease usually involves damage to the **supraspinatus muscle**, which helps move the shoulder during abduction and external rotation. Caused by microtears that cause inflammation of the supraspinatus tendon. Jobs or sports with repetitive overhead activity, such as swimming, tennis, golf, weightlifting, gymnastics, and volleyball, increase risk for rotator cuff disease.

Answer 97

Patient with history of **repetitive overhead** activity (sport or job). Complains of **shoulder pain with overhead movements such as brushing hair or putting on a shirt**. There is local **point tenderness** over the tendon located on the **anterior area** of the shoulder. May have pain at night when sleeping on the side of the affected shoulder.

Answer 98

* Painful arc test* * Jobe’s test (empty can test)*

Answer 99

Starting with both arms down at the sides, ask patient to raise both arms (abduction) up towards head in an arch *Positive:* Shoulder pain that occurs between 60 and 120 degrees of active abduction

Answer 100

This is a test for the strength of the supraspinatus muscle. Instruct patient to straighten arm at 90 degrees of abduction with 30 degrees of forward flexion, then internally rotate the shoulder. Tell patient to resist when examiner attempts to adduct the arm *Positive:* Shoulder pain without weakness (tendinopathy), shoulder pain with weakness (suggests tendon tear)

Answer 101

Musculoskeletal ultrasound is useful for initial evaluation of tendon tears. MRI can identify rotator cuff tear(s).

Answer 102

*Initial treatment:* Rest affected shoulder and apply cold packs (15 minutes cold pack, repeated about two to four times per day), especially during acute phase for 24 to 48 hours. NSAIDs for pain as needed. Physical therapy to rehabilitate shoulder. Refer to orthopedic specialist if inadequate or poor response to conservative management.

Answer 103

Epicondylitis Common cause of elbow pain. **Lateral epicondyle tendon pain (tennis elbow) or medial epicondyle tendon pain (golfer’s elbow).** Usually caused by overuse injury. Most cases not due to sports.

Answer 104

Gradual onset of pain on the outside of the elbow that sometimes radiates to the forearms. Pain worse with twisting or grasping movements (opening jars, shaking hands). Physical exam will show local tenderness over the lateral epicondyle.

Answer 105

Gradual onset of aching pain on the medial area of the elbow (the side of the elbow that is touching the body), which can last a few weeks to months. Pain can be mild to severe. More common in women age 45 to 64 years. Occurs in the part of the elbow also called the “funny bone” (ulnar nerve). Physical exam will show localized tenderness over the medial epicondyle.

Answer 106

Ulnar nerve neuropathy and/or palsy (long-term pressure/damage). Complaint of numbness/tingling on the little finger and the lateral side of the ring finger and weakness of the hand. Worst-case scenario is development of a permanent deformity called “claw hand.” Refer to neurologist if suspect ulnar nerve palsy.

Answer 107

The hamstring is composed of three muscles and is located in the posterior thigh. The hamstring muscles are used for knee flexion and hip extension. Refer patients to orthopedic specialist.

Answer 108

Most hamstring injuries are acute. The patient will report hearing a popping noise accompanied by the sudden onset of posterior thigh pain while performing activities such as running at a fast pace or sprinting. On physical exam, there may be swelling, bruising, and tenderness on the posterior thigh. A muscular mass might be palpable.

Answer 109

Musculoskeletal ultrasonography and MRI are the best methods of assessing hamstring injuries.

Answer 110

Sprains are overstretching or tearing of a ligament (can be partial or complete rupture of ligament) **Lateral ankle** sprains are the most common type. Ankle sprains are usually due to sports participation. The most common sports that cause ankle injuries are basketball, indoor volleyball, track and field, and climbing.

Answer 111

* Lateral ankle sprain:* The most common mechanism of injury is inversion of the plantar-flexed foot. * Medial ankle sprain:* The most common cause is forced eversion of the ankle * It can cause an avulsion fracture of the medial malleolus due to pulling by the ruptured deltoid ligament.

Answer 112

Ottawa rules are used to determine whether a patient needs radiographs of the injured ankle in the ED. The Ottawa ankle rules are highly sensitive (96%–99.6%) for excluding ankle fracture. ## Footnote In mild-to-moderate sprains during acute phase, use RICE and elastic bandage wrap. For pain and swelling, recommend NSAIDs for pain as needed.

Answer 113

***Grade I Sprain*** ***=*** Mild sprain (slight stretching and some damage to ligament fibers); patient is able to bear weight and ambulate. There is no joint instability present during the ankle evaluation ***Grade II Sprain*** ***=*** **partial tearing of ligament,** Moderate sprain; ecchymoses, moderate swelling, and pain are present. Joint tender to palpation. **Ambulation and weight bearing are painful**. Mild-to-moderate joint instability occurs. **Consider x-ray, referral.** ***Grade III Sprain*** ***=*** **complete rupture of ligament** Severe pain, swelling, tenderness, and ecchymosis. Significant mechanical ankle instability and significant loss of function and motion. **Unable to bear weight or ambulate. Refer to ED for ankle fracture.**

Answer 114

Ankle x-ray series is required if there is pain in the malleolar zone *and* * Inability to bear weight immediately after the injury *or* * Inability to ambulate at least four steps *or* * Bone tenderness over the posterior edge or tip of the medial malleolus *or* * Bone tenderness over the posterior edge or tip of the lateral malleolus

Answer 115

First, ask about the mechanics of the injury along with symptoms. Look for swelling and ecchymosis. Palpate the entire ankle (lateral side and medial side), Achilles tendon, and the foot. Check for weight bearing, ROM, ability to ambulate, pedal and posterior tibial pulses. Grade the sprain.

Answer 116

Grade the sprain and determine if ankle x-ray series is needed or refer to orthopedics. NSAIDs (oral) and topical NSAIDs (e.g., Voltaren gel, diclofenac patches) can be used to treat pain and swelling. Can use combination topical and PO NSAIDs. Follow the RICE guide (rest, ice, compression, elevation). Early rehabilitation important. Refer for physical therapy after initial swelling and pain have decreased so that the patient can tolerate simple exercises.

Answer 117

**Grade I** sprains (mild sprains) do not require immobilization. Use elastic wrap (ACE bandage) for a few days. **Grade III** sprains are managed by an orthopedic or sports specialist. **Grade II** sprains (moderate sprain) may need more support. Use ACE and an Aircast or similar splint for a few weeks.

Answer 118

**Meniscus** = _cartilaginous_ lining between certain joints that is shaped like a crescent, helps to cushion joints (act as shock absorbers and stabilizes the knee) Tears in the meniscus result from trauma and/or overuse. Sports with higher risk are soccer, basketball, and football.

Answer 119

Patient may complain of **clicking, locking, or buckling** of the knee(s). Some patients are **unable to fully extend** affected knee. Patient may **limp**. Complains of knee pain and difficulty walking and bending the knee. Some complain of **joint line pain.** Decreased ROM. Certain movements aggravate symptoms.

Answer 120

Assess for **joint line tenderness** and knee **ROM**. Look for **locking** or **inability to fully extend or straighten the leg.** Will be **unable** to **squat** or **kneel**. Knee may be **swollen** (joint effusion). Observe patient’s **gait**.

Answer 121

**McMurray’s Test** **Apley’s Test**

Answer 122

Pain is supine. The examiner holds the knee and palpates the joint line with one hand. The other hand holds the sole of the foot. Perform internal rotation of tibia and apply varus stress, then return the knee to maximal flexion, then extend the knee with external rotation of the tibia and apply valgus stress *Positive:* Pain, clicking, or if the knee locks

Answer 123

Patient is prone with affected knee flexed at 90 degrees. Stabilize patient’s thigh (with examiner’s knee or hand). Press the patient’s heel downward (push heel toward the floor) while the foot is internally and externally rotated. The examiner is compressing the meniscus between the tibia and femur while twisting the foot. *Positive:* Pain is elicited with the compression of the knee.

Answer 124

MRI\* Refer to orthopedic specialist for repair.

Answer 125

Follow the **RICE** (rest, ice, compression, elevation) rules. * Rest the knee and avoid or minimize positions that overstress the knees, such as squatting, kneeling, climbing stairs. Apply ice/**cold pack** for 15 minutes every 4 to 6 hours, **elevate** the limb. Many need crutches. **Quadriceps-strengthening exercises** - When the pain and swelling are resolved * The quadriceps are the largest muscles of the body; they will help to stabilize the knees. Swimming, water aerobics, and light jogging are possible exercises. **NSAIDs** or acetaminophen for pain as needed. **Locking** or unstable knees need to be referred to **orthopedist**; many need **arthroscopy** to repair menisci.

Answer 126

**Ruptured Baker’s Cyst (Popliteal Cyst)**

Answer 127

Physically active patient (jogs or runs) or older patient with history of knee pain from DJD complains of **ball-like mass behind one knee that is soft and smooth**. **Foucher’s sign** = The mass will soften when the knee is bent at 45 degrees because there is less tension. Asymptomatic or will have symptoms such as pressure sensation, posterior knee pain, and stiffness. If cyst ruptures, will complain of severe pain, erythema, and tenderness of the calf. It is an inflammatory reaction resembling cellulitis, deep vein thrombosis (DVT), popliteal artery aneurysm, ganglion cyst, tumors.

Answer 128

Diagnosed by clinical presentation and history. Ultrasound as initial testing if DVT is suspected or uncertain diagnosis, initial testing is the ultrasound, which can show the ruptured cyst or venous compression. MRI if diagnosis is uncertain. Rule out plain bursitis from bursitis with infection (“septic joint”). If imaging desired or diagnosis in question, **initial test** is **ultrasound** and **plain radiography** of the knee and calf.

Answer 129

Follow **RICE** (rest, ice, compression, elevation) procedures. Gentle **compression** with elastic bandage wrap. Administer **NSAIDs** as needed. Large bursa can be **drained** with **syringe** using **18**-**gauge needle** if causing pain. Warn patient that the cyst can recur in the future. Most popliteal cysts are asymptomatic and do not require intervention.

Answer 130

Synovial fluid is a **clear, golden color**. If cloudy synovial fluid is present and the joint is red, swollen, and hot, order a **C&S** to rule out a **septic joint infection**. After it is drained, an intraarticular injection of a **glucocorticoid (triamcinolone acetonide)** can decrease inflammation.

Answer 131

Recognize Baker’s cyst presentation = Soft, smooth mass behind knee that gets softer with bending knee (bc decreases tension) Plain radiograph of a joint (such as x-ray of knee) will show bony changes or narrowing of joint space (OA), but not soft tissue such as the meniscus or ligaments. The best imaging test for cartilage, meniscus, or tendon damage is **MRI**. The gold-standard test for assessing any joint damage is **MRI**.

Answer 132

Do not forget that NSAIDs increase **CV risk, renal damage, and GI bleeding.** The best imaging test for suspected **stress fractures** is **MRI**. Plain radiographs do not show stress fractures.

Musculoskeletal Flashcards

(159 cards)