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Musculoskeletal Problems Flashcards

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0
Q

Factors that exacerbate pain in disc herniation

A
  • maneuvers that increase intraspinal pressure (coughing, sneezing)
  • forward flexion: sitting, driving, lifting; worsens leg pain
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1
Q

Most common causes low back pain

A
  • musculoligamentous strain
  • degenerative disc disease
  • facet arthritis
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2
Q

Low back pain

A

2nd most common reason for med office visits in US

acute: sx 12wks

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3
Q

Radicular leg pain…

A

nerve compression likely;

lumbar spine MRI if: leg symptoms severe, objective weakness present (but unnecessary in most patients who present with acute episode of pain)

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4
Q

Patients with spinal stenosis…

A

have leg pain on back extension; pain worsens with standing or walking ; relief when bending or sitting

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5
Q

Cauda equina syndrome

A
  • caused by severe stenosis in lumbar spine, most commonly due to acute disc herniation
  • patients present with severe back pain or leg pain (uni or bilateral) with or without weakness in legs.
    key findings: bladder dysfunction (retention incontinence) and saddle anesthesia (numbness in perineal or buttock region)
  • symptoms can have acute onset, or start with leg pain initially and over ensuing days progress to weakness and bladder dysfunction
  • surgical emergency! obtain MRI immediately
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6
Q

Lumbar disc herniation

A

majority of patients with lumbar disc herniation and sciatica improve with conservative care.
only about 10% will require surgical intervention

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7
Q

Imaging findings and back pain

A

imaging findings do not necessarily correlate with symptoms!

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8
Q

sciatica is aka

A

radicular leg pain

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9
Q

Pathology in other organ systems cause back pain and should be ruled out…

A
  1. vascular disease: aortic aneurysm, aortic dissection
  2. pancreatic disease
  3. urologic disease: prostate infection, renal calculi (“kidney stones”)
  4. gynecologic/obstetric disease: endometriosis, ectopic pregnancy, pelvic inflammatory disease)
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10
Q

Chronic lower back pain

A

imaging findings on MRI dont nec correlate w presence or severity of pain; psychosocial variables much stronger predictors of pain + disability

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11
Q

Neoplasms in spine

A

most common spinal tumor is metastasis: breast, lung, prostate, kidney, thyroid

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12
Q

vertebral compression fracture

A
  1. minor stress in elderly pts
  2. long term steroid treatment
    pain at level of fracture w local radiation across back and around trunk
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13
Q

INfection: discitis or osteomyelitis

A

suspect in pts with hx IV drug use, dialysis, indwelling catheter

labs to order: CBC w differential, ESR, CRP
MRI if suspicion high

epidural abscess in cervical and thoracic spine can –> rapid neuro deterioration and in most cases need sx decompression

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14
Q

Major segmental innervation of lower limb

A 
hip flexion: L2
knee extension: L3
ankle dorsiflexion: L4, L5
great toe dorsiflexion: L5
ankle plantar flexion: S1
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15
Q

RAdiologic imaging and lower back pain

A

generally unnecessary in evaluation of low back pain

image appropriate if: sx dont resolve within 1 month or if there are neuro signs and symptoms

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16
Q

Differentiate patients w predominantly low back pain from those with predominantly leg pain

A

when conservative treatment fails sx often effective for leg pain but results for low back pain less predictable

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17
Q

Management lower back pain

A

avoid pronged inactivity (leads to deconditioning)

in 1st wk: attempt walking routine (20 mins, 3x/day, interspersed with bed rest)

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18
Q

chronic axial neck pain

A

without radiating arm pain: common, hard to treat

with radiculopathy: arm pain, numbness, tingling, weakness; unilateral neck pain radiating to arm in dermatomal pattern most common

most common cause = cervical spondylosis (osteoarthritis) and disc herniation

ddx: shoulder pathology (impingement syndrome, rotator cuff dz), peripheral nerve entrapment (carpal tunnel or cubital tunnel syndrome), thoracic outlet syndrome, zoster, Pancoast tumor (can present with brachial plexus symptoms)
best test to dx nerve root compression: MRI cervical spine

rare for pt w cervical radiculopathy to progress to myelopathy; appears these are 2 distinct entities

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19
Q

shoulder impingement syndrome

A
  • often confused w cervical radiculopathy involving C5 nerve root
  • in in doubt: inject shoulder (subacromial space) w cortisone to see if sx resolve
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20
Q

Gait unsteadiness in elderly pts

A

often not investigated and attributed to “Old age”; whenever elderly pt begins to rely more on assistive devices for walking, consider cervical stenosis and order MRI

refer for surgical consult if stenosis present

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21
Q

cervical myelopathy

A

neurologic dysfunction 2/2 spinal cord compression (cervical stenosis) in cervical spine
dx: MRI of cervical spine

earliest symtpom: gait disturbance! (unsteady while ambulating)
other: loss of hand dexterity (clumsiness, difficult buttoning shirts, change in handwriting), bowel and bladder dysfunction* are late findings

pain not common finding so pts may go undiagnosed until myelopathy severe

conservative measures dont help with cervical stenosis w myelopathy need surgery to prevent further neuro worsening

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22
Q

Clinical pearl: causes of arthritis

A

-osteoarthritis (most common cause)
- systemic immune dz: rheumatoid arthritis, SLE, IBD, seronegative spondyloarthropathies
- crystal disease: gout, pseudogout (cppd)
- infectious: septic arthritis, Lyme disease
- trauma
- charcot joint (diabetes)
- pediatric orthopedic conditions: congenital hip dysplasia, legg-calve-perthes disease, slipped capital femoral epiphysis
- hematologic: sickle cell disease (avascular necrosis of femoral head), hemophilia (recurrent hemarthrosis)
- deposition diseases: Wilson’s disease, hemochromatosis
s

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23
Q

Patellofemoral pain

A

common cause of anterior knee pain

send these pts to physical therapy to strengthen/stretch quadriceps and hamstrings

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24
Degeneration or tear of meniscus
- may be due to specific injury or degenerative process (old ppl) - key features: recurrent knee effusions, tenderness along medial or lateral joint lines, positive mcmurray test
25
Recurrent knee effusion
sign of intra-articular pathology and further investigation warranted
26
Baker's cyst
intra articular pathology (eg meniscus tear) rupture can --> pain,swelling if extends to calf may mimic thrombophelbitis or acute dvt majority resolve spontaneously
27
Clinical pearl: physical exam for knee pain
- assess distortion of normal knee contours, irregular bony prominences at joint margin - determine presence of effusion - check for muscle atrophy - assess meniscal injury by mcmurray (supine) and apley (prone) tests - determine range of motion - test stability of collateral ligaments - assess anterior cruciate ligament stability via lachman test or anterior drawer test - assess joint tenderness (medial or lateral)-meniscus tear or osteoarthritis - patellar grind test-Push down on patella and ask patient to raise leg
28
Ottawa ankle rules
1. patient able to walk four steps at time of injury and at time of evaluation 2. there is no bony tenderness over distal 6 cm of either malleolus avoid unnecessary radiographs of ankle clinically significant fractures not missed
29
most commonly injured lateral ligament of ankle
anterior talofibular ligament (ATFL)
30
pain due to ankle sprain
usually tender directly over injured ligament
31
Treatment of all acute ankle sprains
--> even severe sprains RICE: rest, ice, compression, elevation + physical therapy sx rarely if ever needed acutely recurrent ankle sprains require evaluations for possible surgery
32
Impingement syndrome
1. common cause of shoulder pain 2. due to impingement of greater tuberosity on acromion 3. pain with overhead activity 4. may lead to rotator cuff pathology over time 5. steroid injections give temporary relief 6. surgery (acromioplasty) v effective
33
Most common cause of shoulder pain
tendinitis (esp supraspinatus (rotator cuff) tendinitis-impingement syndrome) pain poorly localized, difficult for pt to pinpoint, insidious onset, generally over lat delt, pain w arm abduction
34
Best test for diagnosing rotator cuff tear
MRI
35
Tennis elbow
lateral epicondylitis at elbow inflammation/degeneration of extensor tendons of forearm (originate from lat epicondyle) excessive/repetitive supination/pronation splint forearm, not elbow itself
36
Golfer's elbow
medial epicondylitis pain distal to medial epicondyle exacerbated by wrist flexion; caused by overuse of flexor pronator muscle group;
37
De Quervain's disease
pain at radial aspect of wrist (esp w pinch gripping) common for pain to radiate to elbow or thumb inflammation abductor pollicus longus and extensor pollicis brevis positive finkelsteins test: pt clench thumb under other fingers when make fist, ulnar deviate wrist --> pain reproduced if +
38
Osteoarthritis dx quick hit
hip osteoarthritis: presents with groin pain lateral hip pain (over greater trochanter) or in buttock not due to osteoarthritis before dx osteoarthritis of hip as source of pain: make certain patient's symtpoms are primarily in groin
39
Ddx hand numbness (as seen in carpal tunnel syndrome)
- cervical radiculopathy (nerve root compression in cervical spine) - peripheral neuropathy (diabetes) - median nerve compression in forearm
40
Phalen's sign and Tinel test
do not exclude carpal tunnel syndrome if negative
41
carpal tunnel syndrome
median nerve compression in carpal tunnel --> numbness and pain in median nerve distribution ; if long standing and severe --> atrophy of thenar muscles sx usually worse at night; sometimes pain or nubmness along entire arm
42
conditions assoc w carpal tunnel
hyperthyroidism, diabetes, repetiive use of hands in both activities, pregnancy, recent trauma or fracture of wrist
43
TEsts for carpal tunnel
tinel's sign: tap over median n at wriste crease --> paresthesias in median nerve dist phalen's test: palmar flexion of wrist for 1 min --> paresthesias in median n dist EMG and nerve conduction velocity studies definitive dx
44
The following can contribute to or exacerbate forces to cartilage
- compromised pain sensation or proprioception - ligamental laxity - falls of very short distance (not enough time for compesatory mvmts to decrease impact load)
45
If spine involved in osteoarthritis...
nerve roots may become compressed and --> radicular pain
46
Hip osteoarthritis
causes pain in groin (not lateral hip or buttock); | if pt is tender over lateral aspect of hip, suspect greater trochanteric bursitis
47
Osteoarthritis clinical features
often monoarticular; insidious destruction of cartilage over time; deep dull ache relieved with rest, worsened with activity; stiffness in morning or after period of inactivity; limited range of motion late stages; no systemic sx (erythema, warmth); swelling may be present (inflammation)
48
Radiographic findings in osteoarthritis
initial tests; ideally obtained in standing position for lower extremities - joint space narrowing - osteophytes - subchondral sclerosis - subchondral cysts
49
Common "pimp" info
Bouchard's nodes: bony overgrowth and significant osteoarthritis changes (ie, osteophytes) at PIP joints Heberden's nodes: bony overgrowth and significant osteoarthritis changes (ie, osteophytes) at DIP joints
50
PHarmacologic treatment osteoarthritis
1st line: acetaminophen NSAIDs just as effective but concern w GI bleeding long-term
51
Osteoarthritis of hips
pain is in *groin region* and sometimes radiates to anterior thigh
52
quick hit: for left knee or hip pain...
...can should be held in right hand!
53
Xray findings and OA
although xrays not diagnostic of OA, not all patients with xray findings of OA have symptoms; there is no consistent correlation bw sx and severity of xray findings
54
Osteoporosis: primary vs secondary
OFten difficult to distinguish primary vs secondary osteoporosis and the 2 may coexist. best: attempt to Id any predisposing conditions and eliminate them if possible
55
Primary osteoporosis 2 types that are impractical clinically...?
type I: postmenopausal women 51-75 years; excess loss of trabecular bone; vertebral compression fractures and Colles fractures common type II: men and women 70+; equal loss of both cortical and trabecular bone; fractures of femoral neck, proximal humerus, and pelvis = most common
56
Secondary osteoporosis
obvious cause is present, such as excess steroid therapy/Cushing's syndrome, immobilization, hyperthyroidism, long-term heparin, hypogonadism in men, vitamin D deficiency
57
elderly patients and kyphosis
some elderly patients have progressive kyphosis (hunch-back deformity) bc they have multiple vertebral compression fractures
58
osteoporosis is a silent dz
asymptomatic until a fracture occurs
59
risk factors for osteoporosis
1. estrogen depletion (postmenopausal : estrogen deficient state but not all postmenopausal women get osteoporosis; hx of athletic amenorrhea, eating disorders, oligomenorrhea; early menopause) 2. female gender: women have lower peak bone mass and smaller vertebral end plates 3. calcium deficiency/vit d deficiency 4. decreased peak bone mass 5. heritable risk factors: fam hx, european or asian ancestry, thinness/slight build 6. decreased physical activity (prolonged immobility) 7. endocrine: hypogonadism in men (with low testosterone), hyperthyroidism, vit d deficiency 8. smoking and alcohol abuse 9. medications: corticosteroids, prolonged heparin use
60
mainstay of therapy for prevention and treatment of osteoprosis
exercise program w calcium and vit d supplements
61
PROOF trial and calcitonin
- no effect at hip - shown to decrease risk of vertebral fractures by as much as 40% - slight increase in bone density at lumbar vertebrae
62
Clinical pearl: osteoporotic fracture risk assessment
validated risk factors for osteoporotic fracture risk that are independent of bone mineral density: - advanced age - previous osteoporotic fracture - long term steroid therapy - cigarette smoking - low body weight (< 58 kg) - fam hx hip fracture - excess alcohol intake - rheumatoid arthritis - secondary osteoporosis
63
Highest morbidity and mortality among fragility fractures
hip fractures
64
colles fracture
distal radius fracture usually due to fall on outstretched hand
65
REcommend the following to all patients with osteoporosis
daily calcium daily vitamin d weight bearing exercise smoking cessation
66
Bone mineral density T-score criteria for osteopenia and osteoporosis
normal: >=1.0 osteopenia: bw -1 and -2.5 osteoporosis: <= -2.5 and fragility fracture
67
DEXA (dual-energy x-ray absorptiometry)
if DEXA scan normal and no risk factors, repeat DEXA in 3-5 years gold standard for precise measurements of bone density
68
Indications for bone mineral density measurement
all woman >=65 postmenopausal women < 65 w 1 or more risk factors for fracture men w risk factors for fracture
69
Rule out secondary causes of osteoporosis before making dx
check calcium, phosphorous, alkaline phosphatase, TSH, vitamin D, free PTH, creatinine, CBC
70
pts with fragility fractures receiving osteoporosis therapy?
most pts w fragility fractures dont subsequently receive osteoporosis therapy, despite data showing benefit in reducing risk of 2nd fracture
71
smoking role in osteoporisis
accelerates bone loss
72
1st line treatment osteoporosis
bisphosphonates inhibit bone resorption decrease osteoclastic activity (bind to hydroxyapatite) and decrease risk of fractures oral bisphosphonates: alendronate, risedronate preferred side efx: reflux, esophageal irritation, IV bisphosphonates
73
PTH therapy (or human recombinant pth therapy)
pth is an effective drug that increases bone mineral density and reduces fracture risk but not 1st line (cost, subcutaneous admin, long term safety concerns) max duration of treatment: 24 months (concern for osteosarcomas)
74
Estrogen-progestin therapy to treat osteoporosis in postmenopausal women
no longer 1st line bc of increased risk of breast cancer, stroke, venous thromboembolism, and perhaps coronary artery disease

Ambulatory Medicine (19 decks)

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