ORTHO BLOCK1 Flashcards
1
Q
Define Clinical Symptoms and adverse outcomes of Osteoarthritis
A
Clinical:
Stiffness, joint pain, deformity Common locations: fingers, knees, hips, and spine Mechanical symptoms Secondary- history of trauma *Fracture *Osteonecrosis *Developmental hip dysplasia
Adverse:
Progressive degeneration Chronic pain Decreased ROM Decreased strength Instability Lower extremity contracture
2
Q
Pt on Physical exam:
presents with decreased ROM, Crepitus, Muscle atrophy, and joint line tenderness
What is Most likely Dx?
A
OA
3
Q
Shoulder arthritis presents as
A
Posterior shoulder pain
4
Q
OA in the hands presents as
A
DIP (herberden) and
PIP (Bouchard)
5
Q
OA in the thumb presents as
A
CMC ( Carpal/ Metacarpal) OA,
W/ grip and pinch activity pain
6
Q
What is a CMC grind test
A
Pushing in the thumb and grinding it, pain is a positive finding of OA
7
Q
OA in the Hip present with…
A
Anterior pain; Walk in external rotation with limited internal rotation
8
Q
OA in the Knee presents with
A
Most commonly genu varum due to medial compartment wear
9
Q
OA in the foot presents with..
A
1st MTP= hallux rigidus, subtalar joints
10
Q
Hallmark imaging findings of OA
A
joint space narrowing Sclerosis -(whiting of bone sub joint space) subchondral cysts Osteophytes (bone spurs)
11
Q
Referral and Red Flag points for OA
A
Non-operative failure
Limited functional ROM
Young with severe disease
12
Q
What is the best imaging study for finding fragments in a joint
A
CT
13
Q
How does RA vs OA progress over the day
A
OA is better after rest ( mornings) and gets worse throughout the day
RA is worse in the morning and improves throughout the day
14
Q
RA most commonly infects which joints
A
Small joints, wrist, MCP, PIP, MTP
15
Q
What are the adverse outcomes associated with RA
A
C1- C2 instability due to erosion of odontoid ligaments
Tendon Ruptures
Deformity of the hands fingers and toes
16
Q
What are the wrist and finger deviations in RA
A
Wrist will radially deviate
Fingers will ulnarlly deviate
17
Q
Osteopenia and bony erosions, w/ symmetric joint space narrowing/ involvement
Malalignment of joints
Indicates…
A
RA
18
Q
What is the best lab test for specificity of RA
A
Anti CCP
Anti Cyclic citrullinated peptide bodies
19
Q
What is the DOC for RA
A
DMARDS
- TNF alpha
- ANAKINRA
- RITUXIMAB
- ABATACEPT
2* Injections
20
Q
Seronegative spondyloarthropathies most often affect what joints
A
The sacral joints, S1 (BACK PAIN)
21
Q
What is the cant see, cant pee, cant bend the knee
A
Conjunctivitis + enthesitis + urethritis
Reuters syndrome
MOC: Chlamydia
22
Q
Limited ROM, male 15-30, back pain, hand swelling, and nail abnormalities, enthesitis
Indicates
A
Ankylosis spondylitis
23
Q
What is the #1 S/s of compartment syndrome
A
PAIN OOPT
24
Q
What is the most sensitive earliest exam finding in compartment syndrome
A
Passive stretch of the muscles in the compartment
25
Parenthesis in the 1st web space ( dorsal) with weak Dorsi flexion with pain on passive great toe flex is compartment syndrome where
Anterior leg
26
Pain with passive ankle inversion is compartment syndrome where
Lateral leg
27
Pain with passive extentsion of the great toe is compartment syndrome where
Deep posterior leg
28
Pain with passive Dorsi flexion of the ankle is compartment syndrome where
Superficial posterior leg
29
What is a NML resting compartment pressure
Less than 15 mmHg
30
What are the pressure readings for acute compartment syndrome
Absolute pressure greater than 30 mmHg or w/in 30 mmHg oh the DBP
31
What are the pressure readings for chronic compartment syndrome
Resting pressure greater than 15mmHg
Greater than 30 mmHg post exercise
or
Greater than 20 mmHg 5 minutes post exercise
32
What are type I and II Complex regional pain syndrome
Type 1- No identifiable nerve injury
| Type 2- Nerve lesion exists
33
What does algodystrophy mean
Burning pain ( associated with Complex regional pain syndrome)
34
What are the clinical findings in Complex regional pain syndrome
START NOW
```
Swelling
Temperature
Agony/ Pain
Redness
Tremors
```
Nerve medication (DOC) (Gabapentin)
Opiods (Helpful)
Workouts (key to Tx)
35
What does Homans test detect
DVT
36
What disorder is marked by osteophyte formation spanning three or more intervertebral disks involving the anterior longitudinal ligament
DISH
| Diffuse idiopathic skeletal hyperostosis
37
True or False:
| DISH effects men more than women?
True
Men ( 2:1) and older than 60
38
What is the Tx approach to DISH
Non operative, Walking, NSAIDS
39
What is the most common soft tissue tumors of the hand and wrists oh pts between 15-40 years old
Ganglia
40
Where is a bakers cyst located
Popliteal cyst
41
Mucoid cysts are located where
In the fingers
| ( typically in arthritic pts)
42
What imaging study is best to look at ganglia
US ( popliteal cysts)
43
What imaging study can find occult volar wrist cysts
MRI
44
Should you aspirate cysts located on fingers
No!
45
What is the referral criteria for a ganglia
Atypical location
Aspiration failure
Septic joints
46
What is the most common spread of osteomyelitis in peds
Hematogenous spread
47
All open fx patients get referred to ortho to prevent
Osteomyelitis
48
Most common organisms that cause osteomyelitis
S. Aureus ( most common overall)
S. Epidermis ( prosthetic joints)
Salmonella ( common in sickle cell)
Group B Strep ( neonates)
Group A beta hemolytic (Skin or peds)
Pseudomonas ( Puncture wounds in tennis shoes)
49
Knee Inflamation is…
| Bone infection/ inflamation
Knee: septic joint
Bone: osteomyelitis
50
Osteopenia with soft tissue swelling and periostea reaction/ elevation is an early indication of ..
Osteomyelitis
51
What is the gold standard/ definitive Dx for osteomyelitis
Biopsy/ bone aspiration
52
What 4 labs should be ordered for osteomyelitis
ECP( more useful)
ESR
WBC
Blood culture
53
Are oral ABX effective against osteomyelitis
NO!, use IV and debridement
54
What joints are most likely to be infected in young children vs adults with septic arthritis
Hip in young children
Knee most common in older children and adults
55
What are the organisms that cause septic arthritis
S. Aureus ( most common in all age groups )
Strep Group A and B ( Neonates and infants)
N. Gonorrhea ( sexually active young adults)
Pseudomonas ( Immunocomp pts)
56
What are the ADE of septic arthritis
Joint destruction and OA
57
What is the best initial and most accurate test for septic arthritis
```
Joint aspiration
( WBC > 50, 000- primarily neutrophils)
( WBC> 1,100 In prosthethic joints)
```
58
What is the difference between type I and type II primary osteoporosis
Both types most common in women
Type I: hormonal changes that lead to bone loss
Type II: metabolic changes that leads to bone not forming
59
What DEXA scan numbers relate to osteoporosis
O to -1 is normal
- 1 to -2.5 is osteopenia
- 2.5 or below is osteoporosis
60
What is a strain
| What is a sprain
Strain Involves muscles or ligaments
Graded 1-4
Sprain involves ligaments
Graded 1-3
61
Grade 1 strain
Less than 10 percent muscle involved
62
Grade 2 strain
10-50 percent muscle involvement
63
Grade 3 strain
50-100 percent muscle involved
64
Grade 4 strain
100 percent of the muscle and fascia is disrupted
65
Grade1 sprain
Partial tear without instability
66
Grade2 sprain
Partial tear with laxity
67
Grade 3 sprain
Complete tear of the ligament
68
Is it more likely for a child with an open growth plate to sprain a joint or fracture a bone
No, salter Harris 1 are more common as the growth plates are weaker than the ligaments
(Opposite in adults)
69
Referral criteria for a Sprain/ strain
Chronic laxity
| Severe Grade 2 and above
70
What is the difference between radiculopathy and myelopathy
Radiculopathy:
Disease of the spinal nerve roots and spinal nerves
Myelopathy:
Disease of the spinal cord
71
Where does the cauda equina start
After the conus medularis at L1-L2
72
Cauda equina causes what kind of paralysis ?
Paralysis without spasticity
73
Bilateral radicular saddle distribution S/s w/ loss of bowel and bladder control (s2-4) think what pathology
Cauda equina
74
What are the common causes of cervical radiculopathy in young vs old pts
Young: disk herniation
Old: osteophytes at the foramen
75
What is the Tx approach for cervical radiculopathy
Non-operative-
Anti-inflammatory and traction
Physical therapy
NO NARCOTICS, no manipulation
Operative-
Decompression +/- fusion
76
What is the AKA for Degenerative Disk Dz
Cervical spondylosis
| Bone spurs w. Narrowing of disks
77
Pts with palmar paresthesias, decreased dexterity, and gait disturbances ( Tandem Walk)
Cervical spondylosis
78
What is Hoffmanns sign
Flicking the Middle DIP causes the thumb or first finger to flex involuntarily
79
What are the most common changes in the spine with cervical spondylosis
Osteophytes at C5-6 and C6-7
BIG BONE SPURS
With joint space narrowing
80
Tx approach to Cervical Spondylosis
NSAIDS
Doxepin or Amitriptyline (sleep)
PT
NOT NARCS
Operative- Decompress
81
What is the most common pathogen for discitus
Staph Aurus
82
When giving Cortisosteroid injections it is important to avoid what anatomical structures
TENDONS!
83
What are the ADE of Steroid injections
Depressions in the skin, degeneration of bone/ joint and tendon degen
84
What imaging modality is;
| Confirmatory, used for surgical planning, assentuates soft tissues, spine and required pediatric sedation
MRI
85
What imagine modality is used for surgical planning, is good for fracutures at joints, used in stable trauma pts and required s pediatric sedation
CT
86
Is OA reversible
NO
87
Lower extremity contracture is an ADE outcome of what arthritis DZ
OA
88
On physical exam you find decreased ROM, Joint line tenderness, crepitus without obvious inflammation.. .suspect?
OA
89
What are the non operative Tx options for OA?
What are the operative?
Non op: NSAID, rest, Wt loss, low impact activities
Injections
Op;
Arthorplasty
Or arthodesis
90
ADE outcomes of steroid injections
Infection RSK
Transient synovitis
Cartilage destruction
91
A pt with Morning joint stiffness greater than 1 hr for 6 weeks.. suspect/.?
RA
92
OA is associated with what joints
RA is assoc with what joints
OA: weight bearing ( KNEE, HIP, SPINE)
RA ( small joints, wrist, fingers, FOOT ANKLE)
93
Synovial Hypertophy is know as.? And is associated with?
“Boggy joint”
RA
94
What are the op Tx for RA
tenosynovectomy ( tendon and protective sheath)
If severe: Arthroplasty/ Arthodesis
95
Sacroiliac back pain that is “ascending” in nature is a clinical S/s of what spinal D/o
Seronegative spondyloarthopathies
96
A pt with a negative RF and ANA, positive HLA-B27, on X-ray there is resorption of phalanges, and bone reactions in the DIPs
Suspect
Psoriatic Spondylosis
97
What is the Tx approach to Arthritis w/ IBS?
Tx the IBS
98
Tx approach for psoriatic arthritis
DMARDs
99
Tx approach to reactive arthritis/ rieters syndrome
Tx the active infection (Chlamydia)
100
HLA B27 positivity indicates
Seroneg Spondylosis
- ankylosing
- psoriatic
- reactive/ Rieters
101
What are the 6 Ps of compartment syndrome
```
Pain
Pallor
Parenthesias
Pulslessness
Paresis
Poikilothremia (cool to touch)
```
102
Chronic compartment syndrome is defined as
Compartment syndrome S/s on activity w/o S/s 30 min post activity
103
What are the ADE outcomes of compartment syndrome
Necrosis
Nerve damage
Kidney failure
Limb loss
104
Back pain, stiffness, decreased ROM, worse in the morning and at rest, decreases with activity and exercise/ activity, +sacroiliitis, and is Seronegative
+HLA B27
May have: uveitis
Pulm fibrosis
AV blocks, AR
Ankylosing Spondy
105
What is an early finding of Ankylosising Spondylosis
Narrowing of the SI joint
Bamboo spine is later found
106
Keratoderma Blennorrhagicum is what? And is a sign of what
| D/o?
Hyper-keratotic lesions on the palms and soles
Is a sign of reactive arthritis aka Rieters syndrome
107
Septic arthritis presents with WBC of what in athrocentsis
Greater than 50, 000
108
Alpha fetoprotein is a tumor marker for what
Hepatocelllualr CA
| Nonseminomatous germ cell testicular CA
109
What is the most common cause of Compartment syndrome from trauma
Fx of a Long bone (75%)
| And Crush injuries
110
What is the definition of Complex regional pain syndrome
Cyclic inflammatory response
Reflex sympathetic dystrophy
111
What is podagra
Swelling of the big toe (1st MTP joint) associated with GOUT
112
Triangular Fibrtocartillage Complex calcifications on X-ray is a sign of
Psuedo gout
113
Subchonrdal erosions, with periarticualr spurs, and a negative bifringment crystals are a sign of
Gout
114
What is the Tx approach for crystalline deposition Dz like gout and psuedo gout
Indomethacin/ NSAIDs
COLCHICINE!
Underexcresion: probenecid
Overproduces: Allopurinol
115
How does Allopurinol work
Decreases uric acid production
Used as a 1st line agent for over production GOUT
116
What is the DOC that can be used in both GOUT and psuedo GOT
Colchicine
| Anti-inflammatory medication
117
What is Virchows triad
Venous stasis
Injury
Hyper-coag
118
What are the imaging modalities used to observe a DVT
```
Venous US ( 1st line)
Contract venography ( CT)
EKG- PE?
CXR-PE?
VQ scan- PE?
```
119
What are the non op and preventative Tx for DVT
Non op: mechanical prophylaxis ( stocking, compression)
Prevention
1: Hepari/ enoxaparin
2: warfarin
3: aspirin
120
When should a DVT be referred to Vascular
Proximal DVT in the popliteal area or higher
121
Osteophyte formation spanning 3 or more intervertebral disks, involving the thoracic or thoracolumbular spine (specifically the Anterior longitudinal ligament)
DISH
122
DISH is worse in what joints
Excessive bone formation worst around the spine and hips
| Leading to Hip and knee replacements
123
A pt with Decreaed spine ROM in both forward flexion and extension, reduced hip motion, +/- knee OA, spinal stiffness in both the morning and evening, with excessive bone formation worse around the spine and hips is what condition
DISH
124
Ganglia are filled with..
Joint fluid
125
A ganglion cyst located in the wrist should raise worry of what vascular issue
Mass effect of the radial artery
126
What is the Tx approach for Cysts
Treat the underlying Cause
In the wrist: immobilize, aspirate, and possible surgery
Hand: aspirate, possible surgery
Finger: DO NOT ASPIRATE
Knee: US guided aspiration
127
Why do all open fractures get referred to ortho
Prevent osteo myelitis
128
What are the S/s of osteomyelitis in Adults and Kids
Adults : fever (100.4) , deep pain (not a joint), with Hx of injury/ puncture, possible gait changes and Decreased ROM
Peds: malaise, crying (signs of pain or discomfort), fever greater than 100.4, Hx of illness (hematogenous)
129
What is the definitive D/o for osteomyelitis
Biopsy
130
Tx approach for Osteomyelitis
Surgical debridement
| IV ABX
131
What is the most common cause of hemoatogeouns spread of Osteomyelitis in adults
Vertebral Osteo
132
What is the WBC # in septic arthritis of a prosthetic joint
Greater than 1,100
133
WBC # greater than 50,000 in a knee is indiacation of
Septic Arthritis/ joint
134
What is the Tx approach to septic joint
1: aspirate and culture
2: empiric ABX tx
3: Surgical washout
135
What is the referral criteria for septic joint
ALL PTs
136
Secondary Osteoporosis (from drugs, diet, or Endo D/op) is most common in men or women ?
Men
137
What is the precursor to osteoporosis
Osteopenia
138
Post menopausal women/ old
| Are at increased risk of what bone D/o
Osteoporosis
139
What is the best diagnositic scan for osteoporosis
DEXA scan
| osteoporosis hides,and so did dexter
140
What is the Tx approach to osteoporosis
```
Calcium and Vit D
Walking for Wt loss
Avoid Alcohol and smoking
Decrease fall risk
Overall prevention
```
141
When evaluating a sprain or strain what is the Physical exam approach
Locate point of maximal tenderness
```
Palpate for a defect ( strain)
Evaluate strength (5/5?)
Test stability (Special tests)
```
142
Define Ottowa Ankle rules
There is any pain in the malleolar zone; and,
Any one of the following:
-Bone tenderness along the distal posterior edge of the tibia or tip of the medial malleolus
Or
Bone tenderness along the distal posterior edge of the fibula or tip of the lateral malleolus
- An inability to bear weight both immediately and in the emergency department for four steps.
- Pain over the navicular
- pain at the base of the 5th metatarsal
143
When should you MRI a sprain or strain
When the D/o is unclear or there is excessive laxity of the joint
144
TX approach to strains and sprains
PRICE, NSAIDs, Rehab
Severe: Reconstruction or repair
145
What is the difffernce between dermatomes and myotome
Dermatomes are associated spine and skin innervation
Myotome is associated spine and muscles inneravtion
146
What is the SOC from Cauda equina
MRI is best…
US can asses post void residual (Overflow inconstinence)
147
A pt presents with unilateral parasethsias in a dermatomal/myotomal pattern in the neck/ shoulder… suspect?
Cervical radiculopathy
148
Radiculopathy progresses to..
Myelopathy
149
A pt with cervical radiculopathy needs what images ordered
X-ray to r/o spondylosis
MRI to ID nerve/ root compression
CT w/ myelogram
EMG to locate area of neuro dysfunction
150
A pt with decreased ROM in the neck and Pain with up right activity.. suspect
Cervical spondylosis
151
Referral criteria for Cervical Spondylosis
Intractable neck pain or major neuro changes
152
What is the most common mechanism of cervical strain
Whiplash
153
S/s of cervical strain
Whiplash Hx
No radical non focal neck pain
Mechanical pain ( pain on movement)
Headache
Back Spasms
154
A pt with non radicular non focal pain in the neck with a head ache and back spasm.. suspect what ?
Whiplash Hx
Cervical strain
155
Is there nerve involvemt in cervical strain
NO !
156
Tx approach to cervical strain
Non op
Reassurance (self limiting)
Soft collar ( placebo)
NSAID, muscle relaxers
Doxepin/ Amytryptline ( SLEEP)
157
Most common area for cervical spondylosis
C5-6 C6-7
158
Discitis in a pt older than 5 is typically caused by
Osteomyelitis
159
A pt with fever malaise and BACK PAIN, suspect
Discitis (inflammation/ infection of the spinal disc)
160
ADE outcomes of Discitis
Disc space narrowing or vertebral fusion
161
TTP over a specific vertebrae indicates
Possible Discitis
162
What is the imaging modality for Discitis
MRI!
163
Tx approach to Discitis
Non op:
Bed rest, brace, ABX 6wks (2 wks inpatient)
Operative (RARE)
Biopsy, debridement, decompression of any absecess
164
Referral criteria for Discitis
ALL PTS! ADMIT!
165
What is the normal “kyphosis” (curvature) of the spine
20-50 degrees (on lateral view)
166
What are the two causes of hyperkyphosis
Postural ( correctable)
- women
- slouching
Scheurmanns Dz ( uncorrectable)
- men
- wedge shapes discs
167
Tx approach to postural vs scheurmanns kyphosis
Postural: exercise
Scheurmanns: brace
168
Acute LBP presents where
Pain over buttocks and posterior thighs
169
What are phase I and phase II of acute LBP Tx
Phase I: S/s Tx
| Phased II: return to duty
170
Where is the most common area for lumbar herniated disc
L4-LF (L5 root)
Or
L5- S1 (S1 root)
171
L1 radicular pain is pain where?
Over the buttocks at the L1 area
172
L2 Radicualr pain is where
From the Buttocks at L2 down to the superior Lateral thigh
173
L3 radicualr pain is where
Medial thighs
174
L4 radicualr pain is where
medical calf’s
175
L5 radicular pain is where
Lateral calf
176
A pt with severer unilateral radicular pain in the lower extremity/ lower back with pain even on minor activities.. suspect
Lumbar herniated disc
177
For lumbar herniated disc, what is a postive finding on seated leg raise
The pt will lean back to lift the leg
178
For lumbar herniated disc, what is a postive finding when doing a contra lateral straight leg raise
The with have pain on the symptomatic side
179
When do you order an MRI for Lumbar herniated Disc
When S/s are longer than 4 weeks, or have a neuro deficit
180
A pt with a PMHx of spinal surgery presenting with LBP/ Lmbar disc herniation gets what imaging modality
Contrast MRI
181
Tx approach to herniated disc ((lumbar)
NSAIDs,
Profile ( limited standing, walking, running)
PT
Epidural steroids injections
Operative: discetomy +/- fusion
182
What is the definition of lumbar spinal stenosis
```
Narrowing of the spinal canal,
Arthritic changes (bone spurs) narrow or compress the canal.
```
183
What are the common sites for lumbar spinal stenosis
L3-l4, L4-L5, then L2-l3
184
A pt presents with neurogenic Claudication that improves when leaning forward.. suspect
Lumbar spinal stenosis
185
Claudication that does not resolve immediately, improves on stationary bike, moves proximally to distally, and is worse when walking down hill
Neurogenic Claudication
| spinal stenosis
186
What is a positive Romberg test
Standing and placing arms at the side, and the patient falls over or sways side to side
187
A pt with lumbar spinal stenosis will have what findings on X-ray
DDD or spondylothesis
188
Tx approach to Lumbar spinal stenosis
NSAIDSs,
PT
Epidural steroids
Operative:
Surgical decompression or fusion
189
Dz of the spine is most often from..
Metastatic Dz from other CA
190
A pt that present with back pain that prevents them from sleeping.. think
Metastatic Spinal CA
191
“ Winking owl” pattern on the spine is a sign of
Pedical degeneration
| Metastatic cancer of the spine
192
Imaging that can find metastatic Dz
Tc99m bone scan
193
Tx approach to metatatic dz of the spine
Non op: treat the tumor
Operative: stabalize the spine
194
What is the Cobb angle in scoliosis
Greater than 10 degrees
| Girls greater than 30 degrees
195
When should you order an MRI for scoliosis
```
Young pt, abNML Phys exam
AbNML X-rays
+kyphosis
Wide canal on X-ray
Erosions on X-ray
Rib changes
```
196
Tx approach to Scoliosis
NSAIDs + exercise
(Swimming)
operative:
Surgical correction
197
What is spondylolisthesis; degenerative
Disk+facet joint changes = Slipage of disk
Lamina remains intact
Non Inter articular (pedical) defects
Commonly at L4-L5
Commonly anterior
Commonly Women
Can be radicular or myelopathy
198
What is the Tx approach to Degenerative spondylothisis
NSAIDs
exercise
Wt loss
Brace
operative: fusion
199
What is spondylolisthesis : isthmic
Slipage of the spine form the Inter articular defect
Most common at the L5
Common in young pts with repetitive axial loading
200
Back pain that radiates beyond the knees, with hamstring spasms.. suspect
Spondy slippage from Isthmic cause
201
What does the Scotty dog collar defect indicate
Spondy spillage from isthmic
202
Immature (young) pts with Spondy slippage get what imaging
SPECT scan
203
What view is important in Spondy slippage
Oblique view
