Musculoskeletal

Question 1

Finkelstein’s Test

Answer 1

De Quervain’s tenosynovitis is caused by an inflammation of the tendon sheath, which is located at the base of the thumb. The screening test is Finkelstein’s (lesson “Figure 14.2 Finkelstein’s test”), which is positive if there is pain and tenderness on the wrist on the thumb side (abductor pollicis longus and extensor pollicis brevis tendons).

Question 2

Anterior Drawer Sign

Answer 2

A positive anterior drawer sign is indicative of a damaged or torn anterior cruciate ligament (ACL).

Question 3

Posterior Drawer Sign

Answer 3

hen examiner grasps the lower leg by the joint line and pushes it posteriorly. A positive posterior drawer sign is indicative of a damaged or torn posterior cruciate ligament (PCL).

Question 4

Lachman’s Sign

Answer 4

With the patient’s knee in 30 degrees of flexion, the femur is stabilized with one hand, and the other hand is used to apply force to the tibia to displace the tibia forward on the femur (Figure 14.4). Positive result is suggestive of a tear to the ACL.

Question 5

Collateral Ligament Tests

Answer 5

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)

Question 6

Ankylosing Spondylitis

Answer 6

Chronic inflammatory disorder (seronegative arthritis) that affects mainly the spine (axial skeleton) and the sacroiliac joints (axial spondylarthritis)

Question 7

S/S Ankylosing spondylitis

Answer 7

• neck pain that progresses down the spine
• impaired spinal mobility
• joint pain that keeps you awake at night
• fatigue
• low grade fever
• costochondritis and costovertebral tenderness
• stiffness that resolves with activity
• decreased ROM
• hyperkyphosis (hunchback)
• lordosis (exaggerated inward curve of the spine, usually in the lower back)
• bamboo spine on xray

Question 8

Treatment for ankylosing spondylitis

Answer 8

• refer to rheumatology
• exercise therapy
• NSAIDS first line (then TNF inhibitors, DMARDS)

Question 9

Lateral Epicondylitis

Answer 9

Tennis elbow.

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

Question 10

Medial Epicondylitis

Answer 10

Golfer’s elbow

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 over the medial aspect of the elbow (ulnar nerve). Physical exam will show localized tenderness over the medial epicondyle.

Question 11

Gout

Answer 11

Deposit of uric acid crystals in the joints. Can be due to overproduction or reduced excretion of purine.

Question 12

Gold standard for gout diagnosis

Answer 12

joint fluid aspiration

Question 13

S/s Gout

Answer 13

• warm, painful, tender swollen joint
• rapid onset usually at night
• precipitated by ingestion of alcohol, meats, or seafood

Chronic gout has tophi (small white nodules full of urates on ears and joints)

Question 14

uric acid levels during gout flare

Answer 14

During the acute phase, uric acid level is normal; uric acid level does not begin to rise until after the acute phase.

Elevated level may support diagnosis but is not diagnostic.

Most accurate measurement is 2 weeks after gout flare

Question 15

Labs for gout

Answer 15

WBC is often elevated.
ESR is elevated.
CRP is elevated.

Uric acid will be normal, increases 2 weeks after flare. Elevation may support diagnosis but its not diagnostic.

Question 16

Treatment for gout

Answer 16

Pain relief - NSAIDS

Inflammation - steriors, prednisone or medrol taper

Colchicine - Two tablets (1.2 mg) at the onset of pain and then one tablet (0.6 mg) in 1 hour

Patient may continue daily dose of urate lowering therapy during flares (allopurinol, febuxostat….). Or may start new 2 weeks after flare.

Question 17

Dietary modifications for patients with gout

Answer 17

Avoid/minimize alcohol (<2 servings for males/<1 serving for females).

Avoid fructose- or corn syrup–sweetened beverages, which increase uric acid.

Remain well hydrated.

(DASH) or Mediterranean diet.

Advise dietary moderation in purine intake.

Potential benefit in consumption of cherries, vitamin C, fish, and omega-3 fatty acids.

Question 18

Red flags for cauda equina syndrome

Answer 18

• Bladder and bowel incontinence
• Sensory loss in the distribution of the affected nerve roots; may cause saddle anesthesia
• Low back pain accompanied by pain radiating into one or both legs
• Bilateral leg weakness

Question 19

Tibial stress fracture s/s

Answer 19

Pain that’s more focal and in one specific area of the leg.

Pain that worsens over time and increases with impact activity.

Pain that doesn’t get better after stopping activity.

Pain that’s more noticeable when resting.

There may also be tenderness to even a light touch on or near the affected bone

Question 20

Shin splints vs. tibial stress fracture

Answer 20

Pain at affected bone with fracture, more generalized with shin splints

Question 21

Treatment for shin splints

Answer 21

RICE

Cushioned sneakers for daily use

After pain stops wait 2 weeks prior to resuming activities

Stretch before and after activity

Question 22

Treatment for suspected tibial stress fracture

Answer 22

Same as for shin splints however..

If suspect stress fracture, plain radiographs are often the first imaging study; however, they are often normal initially. MRI is highly sensitive and specific. Refer to orthopedic specialist.

Recommend lower-impact exercises (e.g., swimming, stationary bike, elliptical trainer).

Question 23

Meniscus tear

Answer 23

The two menisci are crescent-shaped pads of fibrocartilage located within the knee joint. Tears in the meniscus result from trauma and/or overuse. Sports with higher risk are soccer, basketball, and football.

Question 24

Meniscus tear s/s

Answer 24

• clicking, locking, or buckling of the knee
• may be unable to fully extend affected knee.
• Patient may limp.
• Complains of knee pain and difficulty walking and bending the knee.
• joint line pain.
• Decreased ROM.

Certain movements aggravate symptoms.

Question 25

PE findings for meniscal tear

Answer 25

- Assess for joint line tenderness and knee ROM - Look for locking or inability to fully extend or straighten the leg, squat, or kneel. - Will be unable to squat or kneel. - - Knee may be swollen (joint effusion)

Question 26

Steinman’s test

Answer 26

Flex the knee joint and palpate the joint line. Pain over the posterior joint line with flexion is positive for meniscus tear.

Question 27

Apley’s test

Answer 27

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 sign is pain elicited with compression of the knee.

Question 28

Treatment for meniscal tear

Answer 28

- RICE - may need crutches - NSAIDS for pain - When the pain and swelling are resolved, start quadriceps-strengthening exercises. 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. - Locking or unstable knees should be referred to orthopedist; many need arthroscopy to repair menisci. - MRI is most sensitive imaging for tear

Question 29

Morton's neuroma

Answer 29

Inflammation of the digital nerve of the foot between the third and fourth metatarsals. Increased risk with high-heeled shoes, tight shoes, obesity, dancers, runners.

Question 30

Morton's neuroma s/s

Answer 30

Pain, burning or numbness with walking especially in heels or tight shoes. May have small nodule between 3rd and 4th toes

Question 31

Mulder Test

Answer 31

This test for Morton’s neuroma is done by grasping the first and fifth metatarsals and squeezing the forefoot (Figure 14.6). Positive test is hearing a click along with a patient report of pain during compression. Pain is relieved when the compression is stopped.

Question 32

Treatment for morton's neuroma

Answer 32

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

Question 33

Osteoarthritis

Answer 33

Inflammatory process with altered joint function that is associated with characteristic pathologic changes in the joint tissue and destruction of the articular cartilage. 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.

Question 34

S/s of OA

Answer 34

- insidious onset over years - early morning joint pain stiffness or pain and stiffness with inactivity. usually lasts les than 30 minutes - pain worse with joint overuse - usually asymmetrical - Deformities such as Heberden’s and/or Bouchard’s - crepitus - decreased ROM

Question 35

Heberden’s nodes

Answer 35

Found in OA. Bony nodules on the distal interphalangeal (DIP) joints

Question 36

Bouchard’s nodes

Answer 36

Found in OA Bony nodules on the proximal interphalangeal (PIP) joints

Question 37

OA managment

Answer 37

- exercise with weight bearing - warm or cold packs - thai chi, acupuncture, - NSAIDs (start with topical) - duloxetine for patients where NSAIDS are contraindicated - r/o osteoporosis

Question 38

Piriformis syndrome

Answer 38

Piriformis muscle, located in the buttocks, can compress, irritate, and entrap the sciatic nerve between its muscle layers

Question 39

Piriformis syndrome s/s

Answer 39

- pain and numbness of the buttocks- may radiate down the leg. - - pain is worse with prolonged sitting/driving - Pain may 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.

Question 40

Freiburg test

Answer 40

Evaluates for piriformis syndrome positive when pain or sciatic symptoms are caused by placing the hip in extension and internal rotation, and then resisting external rotation.

Question 41

Pace sign

Answer 41

Evaluates for piriformis syndrome Pain elicited when the seated patient resists abduction and external rotation.

Question 42

Imaging for piriformis syndrome

Answer 42

Radiograph (x-ray): Consider if limited hip ROM or chronic groin pain. Can help diagnose OA 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.

Question 43

Treatment for piriformis syndrome

Answer 43

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

Question 44

Plantar Fasciitis

Answer 44

cAute or recurrent pain in the plantar region of the foot that is aggravated by walking. Caused by microtears in the plantar fascia due to tightness of the Achilles tendon.

Question 45

Treatment for plantar fascitis

Answer 45

- NSAIDS - PO or topical - Orthotic foot appliance: Used 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. Shoes: Well-padded soles and/or a heel cup on affected foot.

Question 46

Popliteal (Baker’s) Cyst

Answer 46

Type of bursitis that is located behind the knee (popliteal fossa). The bursae are protective, fluid-filled synovial sacs located on the joints that act as a cushion and protect the bones, tendons, joints, and muscles. Sometimes when a joint is damaged and/or inflamed, synovial fluid production increases, causing the bursa to enlarge.

Question 47

Treatment for baker's cyst

Answer 47

- RICE - NSAIDS Large bursa can be drained with syringe using 18-gauge needle if causing pain. 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. Warn patient that the cyst can recur in the future. Most popliteal cysts are asymptomatic and do not require intervention.

Question 48

The best imaging test for suspected stress fractures is ...

Answer 48

MRI. Plain radiographs do not show stress fractures initially after injury.

Question 49

Rheumatoid arthritis

Answer 49

Chronic, systemic autoimmune and inflammatory disorder. Mainly manifested through systemic inflammation of multiple joints and other parts (skin, heart, blood vessels, kidneys, GI, brain/nerves, eyes

Question 50

RA s/s

Answer 50

- fatigue - low-grade fever - generalized body aches - myalgia - joint pain, stiffness, and swelling -early-morning stiffness/pain and warm, tender, and swollen fingers in the DIP/PIP joints Swan neck deformity and boutonniere deformity are signs of late and/or severe RA disease.

Question 51

RA treatment

Answer 51

- refer to rheumatology - PT/OT - DMARDS

Question 52

Ottawa Rules (of the Ankle)

Answer 52

Plain radiographs of the ankle are only indicated if there is pain in the malleolar zone and - Bone tenderness over the posterior edge or tip of the medial or lateral malleolus or - Inability to bear weight both immediately after the injury and for four steps into the ED or provider’s office. Plain radiographs of the foot are only indicated if there is pain in the midfoot zone and - Bone tenderness at the base of the fifth metatarsal or at the navicular or - Inability to bear weight both immediately after the injury and for four steps into the ED or doctor’s office. In regard to the Ottawa ankle rules: Bearing weight includes the ability to transfer weight twice to each foot (even if limping). Assess for bone tenderness by palpating the distal 6 cm of the posterior edge of the fibula.

Question 53

Grade I Sprain

Answer 53

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.

Question 54

Grade II Sprain

Answer 54

Moderate sprain (partial tearing of ligament); 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.

Question 55

Grade III Sprain

Answer 55

Complete Rupture of Ligaments 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.

Question 56

Treatment for sprains

Answer 56

Grade I sprains (mild sprains) do not require immobilization. Use elastic wrap (ACE bandage) for a few days. Grade II sprains (moderate sprain) may need more support. Use ACE and an Aircast or similar splint for a few weeks. May require brief period of immobilization and non-weight bearing. Grade III sprains are often managed by an orthopedic or sports specialist. Non-weight bearing and immobilization for brief period (about 10 days). May require surgery and functional rehabilitation.

Question 57

Systemic Lupus Erythematosus

Answer 57

Multisystem autoimmune disease characterized by remissions and exacerbations affecting the skin, kidneys, heart, and blood vessels.

Question 58

S/S SLE

Answer 58

- fever - fatigue - weight loss - arthralgias - maculopapular butterfly-shaped - - rash on the middle of the face - - - nonpruritic thick scaly red rashes on sun-exposed areas - Photosensitivity, - ocular manifestations, - abdominal pains - joint symptoms. May have cardiac symptoms, vascular abnormalities (e.g., Raynaud’s phenomenon), pleuritis, pulmonary hypertension, cognitive dysfunction, anemia, and leukopenia. Urinalysis (UA) may be positive for proteinuria with kidney involvement. Antinuclear antibodies (ANA) are positive in virtually all patients

Question 59

Treatment for SLE

Answer 59

NSAIDs, analgesics, steroids, antimalarial [Plaquenil], immune modulators [methotrexate, biologics], monoclonal antibodies). For mild symptoms: Bedrest, naps, avoidance of fatigue