Ortho part 1

Question 1

Pathophys of bursitis

Answer 1

Inflammation of the bursa causes synovial cells to multiply and thereby increases collagen formation and fluid production
A more permeable capillary membrane allows entrance of high protein fluid
The bursal lining may be replaced by granulation tissue followed by fibrous tissue

Question 2

Acute phase of bursitis

Answer 2

Local inflammation occurs and the synovial fluid is thickened
Movement becomes painful as a result

Question 3

Chronic phase of bursitis

Answer 3

Leads to continual pain and can cause weakening of overlying ligaments and tendons and, ultimately, rupture of the tendons

Question 4

Etiology of bursitis

Answer 4

Autoimmune disorders
Crystal deposition
Infectious diseases
Traumatic events
Hemorrhagic disorders
Secondary to overuse

Question 5

Hx of bursitis

Answer 5

Localized tenderness
Decreased ROM or pain with movement
Erythema or edema
Hx of repetitive movement
Hx of inflammatory dz
Hx of trauma

Question 6

PE of bursitis

Answer 6

Tenderness at the site of the inflamed bursa
If superficial, localized tenderness, warmth, edema, and erythema of the skin
Reduced active ROM with preserved passive ROM
With chronic bursitis, affected limb may show disuse atrophy and weakness
Tendons may also be weakened and tender

Question 7

What should be part of the differential for bursitis?

Answer 7

Tendinitis 
Muscle injury
Septic arthritis- ROM will not be decreased, and fever will be present
Ligamentous injury
Fracture
OA
Cellulitis
Gout and Pseudogout\
RA

Question 8

Common areas affected by bursitis

Answer 8

Subacromial
Olecrenon
Trochanteric
Prepatellar
Infrapatellar

Question 9

Labs for bursitis

Answer 9

With septic bursitis, leukocyte count and ESR may be mildly to moderately elevated
Draw BCx if concerned about deep infection
Order ESR, ANA, RF, and anti-CCP where autoimmune dz is suspected

Question 10

Procedure workup for bursitis

Answer 10

Joint aspiration and analysis to r/o infection or rheumatic causes
May also be therapeutic
Fluid should be analyzed for monosodium urate crystals, cell count with diff, Gram stain, and culture

Question 11

Cell counts of nonseptic vs septic bursitis

Answer 11

Nonseptic: <2,000, with predominance of mononuclear cells
Septic: >70,000, with a predominance of PMNs

Question 12

What are the most infected bursae?

Answer 12

Olecranon
Prepatellar
Infrapatellar

Question 13

Imaging in bursitis

Answer 13

Plain radiography does not help with dx of bursitis but may be useful for identifying triggering pathology

Question 14

Tx of bursitis

Answer 14

Conservative tx usually:
Rest
Cold and heat txs
Elevation
NSAIDs
Bursal aspiration
Intrabursal steroid injections
When septic suspected, give abx
-Oxacillin or first-gen cephalosporin
-PCN allergy: cipro and rifampin
Surgery for chronic or recurrent

Question 15

When to treat bursitis surgically

Answer 15

Failure of needle aspiration to drain the bursa adequately
Bursa site inaccessible to repeated needle aspirations
Abscess, necrosis, or sinus formation
Need for exploration to assess the extent of infection of adjacent structures
Recurrent or refractory disease after conservative tx

Question 16

What areas does tendinitis most commonly affect?

Answer 16

Rotator cuff
Insertion of the wrist extensors and flexors at the elbow
Patellar and popliteal tendons and iliotibial band at the knee
Insertion of the posterior tibial tendon in the leg
Achilles tendon at the heel

Question 17

Etiology of tendinitis

Answer 17

Usually unknown
RFs:
-Middle aged or older
-Repetitive microtrauma
-Strain
-Excessive or unaccustomed exercise
-FQs

Question 18

Workup for tendinitis

Answer 18

Radiographs if hx of trauma is present, but will be negative with tendinopathy
U/s is good to detect tendinitis
That with u/s is reserved for those whose dx is unclear or who fail conservative management

Question 19

Nonpharmacologic tx of tendinitis

Answer 19

Rest or decrease activity level: restrict activities that cause pain
Ice for first 24-48 hrs
Splint or immobilize; sling for rotator cuff
Strengthening and stretching exercises once pain has subsided

Question 20

Pharmacologic and surgical tx of tendinitis

Answer 20

NSAIDs
Consider corticosteroid injection for conservative tx failure
NEVER use injections for Achilles tendinitis
Avoid repetitive injections
Also consider surgery for conservative tx failure

Question 21

Pathophys of cauda equina syndrome

Answer 21

A LMN lesion

May result from any lesion that compresses cauda equina nerve roots

Question 22

Etiology of cauda equina syndrome

Answer 22

Lumbar stenosis
Spinal trauma
Herniated nucleus pulposus
Neoplasm
Spinal infection/abscess
Idiopathic
Spina bifida and subsequent tethered cord syndrome

Question 23

Presentation of cauda equina syndrome

Answer 23

Gradual and unilateral presentation
Both ankle and knee jerks affect
Severe radicular pain
Numbness localized to saddle area
No sensory dissociation
Asymmetric areflexic paraplegia that is more marked
Atrophy
Urinary retention late in course of disease
Diminished reflexes and muscle strength in lower extremities
Radicular leg pain
Poor anal sphincter tone
Sensation decreased to pinprick and light touch in a dermatomal pattern

Question 24

Workup of cauda equina syndrome: labs

Answer 24

CBC, BG, CMP, BUN and creatinine- to r/o anemia, infection, and renal dysfunction
ESR- may point to inflammatory pathology
Syphilis

Question 25

Workup of cauda equina syndrome: imaging

Answer 25

Plain radiography may be performed in cases of traumatic injury or in search of destructive changes, disk-space narrowing, or spondylolysis CXR to r/o pulmonary source MRI with gadolinium contrast is the diagnostic test of choice

Question 26

Cauda equina syndrome: other tests and procedures

Answer 26

``` Needle EMG Nerve conduction studies SSEPs to r/o MS Duplex u/s LP to r/o inflammatory disease of the meninges or spinal cord ```

Question 27

Tx of cauda equina syndrome

Answer 27

Treat underlying cause | Admit to the appropriate service with frequent neuro checks

Question 28

Etiology of costochondritis

Answer 28

Repetitive minor trauma is most likely cause | Uncommon- bacterial and viral infections

Question 29

Hx of costochondritis

Answer 29

Onset is often insidious Chest wall pain with hx of repeated minor trauma or unaccustomed activity Pain descriptions: -Exacerbated by trunk movement, deep inspiration, and/or exertion -Lessens with decreased movement, quiet breathing, or change of position -Sharp, nagging, aching, or pressurelike -Usually quite localized but may extend or radiate extensively -May be severe -May wax and wane

Question 30

PE of costochondritis

Answer 30

Pain with palpation of affected costochondral joints | PE should include assessment of the lateral ribs and the cervical and thoracic spine

Question 31

Workup for costochondritis

Answer 31

EKG | CXR

Question 32

Tx of costochondritis

Answer 32

Reassure pt that the condition is benign | Use adequate pain control with NSAIDs

Question 33

Etiology of shoulder dislocation

Answer 33

``` 95% from major traumatic event 5% from atraumatic causes Atraumatic causes include: -Ligamentous lax shoulder -Congenital causes -Neuromuscular causes ```

Question 34

Hx of shoulder dislocation

Answer 34

Feeling of shoulder popping out Determine position of shoulder at the time of injury Anterior- arm abducted and externally rotated Ask about previous dislocations Numbness of arm

Question 35

PE of shoulder dislocation

Answer 35

Poor ROM Lot of pain Anterior- abduction and external rotation of arm In thin pts- prominent humeral head can be felt anteriorly, and the void can be seen posteriorly in the shoulder Posterior- arm kept in internal rotation and adduction Thin pts- prominent head can be seen and palpated posteriorly

Question 36

Workup for shoulder dislocation

Answer 36

XR with 2 views- AP and axillary lateral view or scapular Y view If >45 yo, get MRI if rotator cuff testing is positive

Question 37

Tx of shoulder dislocation

Answer 37

Appropriate reduction of shoulder PT Limited course of narcotics (3-4 days) for moderate to severe pain Tramadol or tylenol #3 or #4 for mild to moderate pain

Question 38

PE of humerus fracture

Answer 38

Pain with palpation or movement of shoulder or elbow Ecchymosis and edema Can have radial nerve injury- manifested by wrist drop, fingers are in flexion at MCP joints and thumb is adducted Proximal: -Painful shoulder and very restricted ROM -Obvious deformity with glenohumeral dislocation -Nerve damage is rare Diaphyseal: -Painful deformed arm that may be associated with a radial nerve palsy -Crepitus -Shortening of the arm can be indicative of displacement Complaint of pain while throwing, lifting, or pushing off on affected arm should raise suspicion of stress fracture

Question 39

Workup of humerus fracture

Answer 39

Distal and diaphyseal: AP, lateral of the humerus, transthoracic, and axillary views of the shoulder Proximal: AP of scapula and glenohumeral joint, axillary view, lateral Y view of the scapula

Question 40

Tx of humerus fracture

Answer 40

Proximal: Sling and swathe Refer anatomical neck fractures to ortho Diaphyseal: coaptation splint

Question 41

Pathophys of forearm fracture

Answer 41

Fall onto an outstretched hand or direct blow

Question 42

Etiology of forearm fracture

Answer 42

Sports Trauma, particularly from automobile collisions Blows with blunt object Child abuse

Question 43

PE of forearm fracture

Answer 43

Localized pain, tenderness, and swelling at fracture site Evaluate 2 point discrimination OK sign tests median nerve Extending fingers or wrist against resistance tests radial nerve Separating fingers against resistance tests ulnar nerve

Question 44

Workup of forearm fracture

Answer 44

AP and lateral views of wrist, forearm, and elbow

Question 45

Nightstick fracture

Answer 45

Isolated midshaft ulnar fracture Ortho referral Long-arm splint with 90 degrees of elbow flexion and the hand in a neutral position

Question 46

Monteggia fracutre

Answer 46

Fracture of the ulna with dislocation of the radial head | Long-arm splint

Question 47

Galeazzi fracture

Answer 47

Fracture of the distal one third of the radius with dislocatin of the distal radioulnar joint Long-arm splint Admission for ORIF

Question 48

Concomitant radius and ulna fractures

Answer 48

Potential complication of compartment syndrome | Admission for urgent ORIF

Question 49

Essex-Lopresti fracture

Answer 49

Fracture of radial head and distal radioulnar joint, with partial or complete disruption of the radioulnar interosseous membrane

Question 50

Torus (greenstick fracture)

Answer 50

Long-arm cast for 4-6 week when angulation is <10% | All require ortho referral