Musculoskeletal System

Exam tips:

**Swan deformity and boutonnier deformity are signs of late oand or sever RA disease. **Distinguish between RA and OA in terms of classic presentation. With RA joint stiffness last longer. It involves multiple joints and has symmetric distribution. RA is accompanied by systemic symptoms such as fatigue, fever, normocytic anemia. **Bouchards can occur in both RA and OA. Herberdens are only seen with OA or DJD in the PIP joint **Uveitis: Swelling of the uvea, the middle layer of the eye that supplies blood to the retina. (Refer to Opthamologist stat) Patient treated with high dose steroids for several weeks. **Plaquinil is an antimalarial **Methotrexate is a DMARD. It is C/I for use during pregnancy. When prescriing to childbearing women, contraception must be prescribed and adhered to while taking. **Know the presentation of RA and lab findings. Distinguish between presentaion of OA and RA **NSAIDS injure the GI tract by blocking COX1 and cylooxygenase-2 COX 2 resulting in lower levels of systemic prostaglandins. Aspirin: is a type of NSAID. It affects platelets and clotting permanently, but it will rsolve once the affected plateletts resolve life span 10 days if not on chronic NSAIDS.

Ruptured bakers Cyst (Popliteal cyst)

A bakers cyst is a 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. Classic case: Physically active patient jogs or runs or older patient with hx of knee pain from DJD c/o ball-like mass behind one knee that is soft and smooth. The mass will soften when the knee is bend at 45 degrees (Fouchers sign) because there is less tension. Asymptomatic or will have symptoms such as pressure sensation, posterior knee pain, and stiffness. If cyst ruptures, will c/o severe pain, erythema, and tenderness of the calf. It is an inflammatory, reaction resembling cellulitis, dVT, popliteal artery aneurysm, ganglion cyst, tumors. Labs: Dx by clinical presentation and hx. If suspect DVT or uncertain dx initial testing is an US which can show the ruptured cyst or venous compression. MRI if dx is uncertain. Rule out plain bursitis from bursitis with infection (septic joint) If imaging desired or diagnosis in question, intial test is US and plain radiographyof the knee and calf

A patient taking levothyroxine is being over-replaced. What condition is he at risk for? a. Osteoporosis b. Constipation c. Depression d. Exopthalmia

A. Osteoporosis

60 year old female patient complains of sudden onset unilateral, stabbing, surface pain in the lower part of her face lasting a few minutes, subsiding, and then returning. The pain is triggered by touch or temperature extremes. Physical examination is normal. Which of the following is the most likely diagnosis? a. Trigeminal neuralgia b. Temporal arteritis c. Parotiditis d. Bell's palsy

A. Trigeminal neuralgia (TN) is defined clinically by sudden, usually unilateral, severe, brief, stabbing or lancinating, recurrent episodes of pain in the distribution of one or more branches of the fifth cranial (trigeminal) nerve that are triggered by stimulation of the affected trigeminal division.

Successful management of a patient with attention deficit hyperactivity disorder (ADHD) may be achieved with: a. Stimulant medication along with behavioral and family intervention. b. Methylphenidate (Ritalin) in conjunction with diet changes. c. Treatment by a psychiatrist. d. Discipline and removal of offending foods from the diet.

A. stimulant medicatin along with behavioral and family intervention

Orthopedic terminology

Abduction: moving away from the body Adduction: moving towards the body Hands: metacarpals: bones of the hands carpals: bones of the wrist 8 wrist bones phalanges: finger and toes, singular phalanx Metatarsals: bones of the feet Talus ankle bone Calcaneus: the heel bone Proximal: body part located closer to the body Distal: body part farther away from the center of the body

Low back pain from (Disecting Aortic Aneurysm)

Acute and sudden onset of "tearing" severe low back pain/abdominal pain. presence of abdominal bruit with abdominal pulsation. Patient has s/s of shock. More common in elderly males, atherosclerosis, white race and smokers.

Cauda Eequina Syndrome

Acute onset of saddle anesthesia, bladder incontinence ( or retention of urine) and fecal incontinence. Acompanied by bilateral leg numnbess and weakness. Pressure most common cause is a bulging disc on a ssacral nerve root results in inflammatory and ischemic changes to the nerves. A surgical emergency. Needs spinal decompression. Refer to the ED.

Plantar faciitis

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, diabetes, aerobic exercise, flat feet, prolonged standing. Classic case: middle aged adult complains of plantar foot pain (either on one or both feet) that is worsened by walking and weight bearing. Complains that pain is worse with first few steps in the morning and continues to worsen with prolonged walking. TX: NSAIDS aleve twice daily, ibuprofen every 4 to 6 hrs Topical NSAIDS: diclofenac (Voltaren) applied to soles of feet twice a day Use orthoic device at night for a fe 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 sheos with well padded soles and or use a heel cup on affected foot. Consider x ray to rule out fracture, heel spurs, complicated case refer to podiatrist.

Joint injections:

Administering intra-articular/periarticular joint injections with steroid is a controversial tx for inflamed joints. Some expert lpanels suggest about four injections per joint (such as a knee ) in a lifetime. If high resistnce is felt when pushing sytringe, do not force. Withdraw slightly (do not remove from joint) and redirect. Complications: tendon rupture, nerve damage, infection, bleeding, hypothalamic-pituitary-adrenal suppression, others. Joint injections are contraindicated in patients who are on anticoagulation therapy because of the risk of hemarthrosis.

Exam tips

Ankylosing spondylitis: know signs and symptoms, so you are able to dx, bamboo spine is pathognomonic for AS. ** Name of cast for fx of the wrist is "thumb spica cast) ** learn how to treat gout flare up **Learn s/s of cauda equina, If suspected refer to ED

The most effective treatment of non-infectious bursitis includes: a. Systemic antibiotic therapy effective against penicillin resistant Staphylococcus areus. b. Rest, an intra-articular corticosteroid injection, and a concomitant oral NSAID. c. A tapering regimen of oral corticosteroid therapy. d. Frequent active range of joint motion.

B.

A typical description of a tension headache is: a. Periorbital pain, sudden onset, often explosive in quality, and associated with nasal stuffiness, lacrimation, red eye, and nausea. b. Bilateral, occipital, or frontal tightness or fullness, with waves of aching pain. c. Hemicranial pain that is accompanied by vomiting and photophobia. d. Steadily worsening pain that interrupts sleep, is exacerbated by orthostatic changes, and may be preceded by nausea and vomiting.

B. Bilateral occipatal, or frontal tightness or fullness with waves of aching pain

A positive drawer sign supports a diagnosis of: a. Sciatica b. Cruciate ligament injury c. Meniscal injury d. Patellar ligament injury

B. Cruciate Ligament injury

A 72 year old patient exhibits sudden onset of fluctuating restlessness, agitation, confusion, and impaired attention. This is accompanied by visual hallucinations and sleep disturbance. What is the most likely cause of this behavior? a. Dementia b. Delirium c. Medication reaction d. Depression

B.Delerium

Bone metastasis

Bone pain can feel achy, sharp, and well localized or it can feel like neuropathic pain (burning shooting pain) it can be severe with night pain and or pain with weight bearing. It may be accompanied by night sweats, malaise, fever and weight loss. It can be constant or intermittent and can get exacerbated with movement of the joint or bone. Pathologic fx may occur. Bone is one of the most common sites of distant mets. Routine labs may show elevated levels of alpkaline phosphatase and or serum calcium (hypercalcemia) Cancers of the prostate, breast, lung, thyroid, and kidney make up the majority 80% of cases of bone mets. A radiograph has poor sensitiity 44-50%, but it can show bony lesions and may show early lesion. In general, MRI is the most sensitie and specific imaging test.

Which of the following symptoms suggests a more serious cause of back pain? a. Pain associated with coughing or sneezing b. Pain associated with muscle spasm c. Pain associated with lying down at night d. Pain associated with negative straight leg raise

C. Pain associated with lying down

The correct treatment for ankle sprain during the first 48 hours after injury includes: a. Alternating heat and ice, and ankle exercises. b. Resistive ankle exercises, ankle support, and pain relief. c. Rest, elevation, compression, ice and pain relief. d. Referral to an orthopedist after x-rays to rule out fracture.

C. RICE

Diagnostic radiological studies are indicated for low back pain: a. Routinely after 3 weeks of low back pain symptoms. b. To screen for spondylolithiasis in patients less than 20 years of age with 2 weeks of more of low back pain. c. When there is a suspicion of a space-occupying lesion, fracture, cauda equina, or infection. d. As a part of a pre-employment physical when heavy lifting is included in the job description.

C. When there is a suspicion of a space-oc upying lesion, fracture, cauda equina, or infection

Epicondylitis

Common cause of elbow pain. Lateral epicondyle tendon pain (tennis elbow) or medial epicondyle tendon pain (golfers elbow) Usually caused by overuse injury. Most cases not due to sports. Lateral epicondylitis tennis elbow: classic case 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 epicodyle. Medial epicondylitis golfers elbow Classic case: 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 45-64. Occurs in the part of the elbow also call the funny bone (ulnar nerve) Physical exam will show localized tenderness over the meial epicondyle. Complications: 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 scanario is dev. of a permanent deformity called claw hand. Refer to neurologist if suspect ulnar nerve palsy.

Which of the following set of symptoms should raise suspicion of a brain tumor? a. Recurrent, severe headaches that awaken the patient and are accompanied by visual disturbances. b. Vague, dull headaches that are accompanied by a reported sense of impending doom. c. Periorbital headaches occurring primarily in the evening and accompanied by pupillary dilation and photophobia. d. Holocranial headaches present in the morning and accompanied by projective vomiting without nausea.

D. Holoranial headaches present in the mornin gand accompanied by projective vomiting without nausea

A 26 year old female presents with elbow pain that is described as aching and burning. There is point tenderness along the lateral aspect of the elbow and painful passive flexion and extension. She reports she has been playing tennis almost daily for the past month. The most likely diagnosis is: a. Radial tunnel syndrome b. Ulnar collateral ligament sprain c. Olecranon bursitis d. Lateral epicondylitis

D. Lateral epicondylitis Clinical presentation - Patients with elbow tendinopathy typically complain of extra-articular medial or lateral elbow pain associated with specific findings: •Medial elbow tendinopathy (MET; "golf elbow") ‒ Tenderness at origin of wrist flexor tendons at medial epicondyle; pain exacerbated by passive wrist extension; pain exacerbated by resisted wrist flexion •Lateral elbow tendinopathy (LET; "tennis elbow") ‒ Tenderness at origin of wrist extensor tendons at lateral epicondyle; pain exacerbated by passive wrist flexion; pain exacerbated by resisted wrist extension

The most effective intervention(s) to prevent stroke is (are): a. 81 mg of aspirin daily b. Carotid endarterectomy for patients with high-grade carotid lesions c. Routine screening for carotid artery stenosis with auscultation for bruits d. Smoking cessation and treatment of hypertension

D. Smoking cessatin and tx of hypertension The major treatable stroke risk factors are hypertension, dyslipidemia, diabetes, smoking, and physical inactivity. Most patients with an ischemic stroke or transient ischemic attack (TIA) should be treated with all available risk reduction strategies, ideally by a multidisciplinary team, including antithrombotic therapy, blood pressure reduction, low-density lipoprotein (LDL)-lowering therapy, and lifestyle modification. (See 'Major risk factors' above.)

DJD

DJD or OA 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 (Bouchards and Heberdens nodes ) are most commonly affected. If can affect one side or bilaterally. RF include older age, overuse of joints, and postive family history. Goal is to reduce pain Preserve joint mobility and FX Minimize disability and protect joint Classic Case: Gradual onset (over years). Early morning joint stiffness with inactivity. Shorter duration of joint stiffness <15 minutes). compared with RA. Pain aggravated by overuse of joint. During exacerbations, involved joint may be swollen and tender to palpation. May be one-sided (right hip only). Absence of systemic symptoms ( not a systemic inflammatory illness like RA). Herberdens nodes on the DIP joints and on the PIP and or bouchards nodes. HD PB Non pharmacologic Managment: 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 US tx. Use walking aids. Patellar taping by PT will reduce load on knees. Alternative medicine: use glucosameine supplements, SAM-3, tai chi exercises, acupuncture TX plan: 1.) first line medication is acetaminophen 325 mg to 650 mg every 4 to 6 hrs (max of 4g day) prn 2.) Tylenol 325 mg to 1000 mg every 4 to 6 hrs (max of 4g per 24 hrs) prn Dehydration increases risk of hepatic adverse effects; drink a lot of water 3.) If no relief with acetaminophen switch to a short-acting NSAIDS such as ibuprofen, oneto two tablet every 4 to 6 hrs or naproxen (Aleve) BID or Anaprox DS one tablet every 12 hrs. 4.) For added gastrointestinal protection (if long term) add a proton pump inhibitor omeprazole or Cytotec (misoprostol 5.) If pt is at high risk for both GI bleeding and CV side effects avoid NSAIDS. GI bleed risk factors include ulcer, aspirin, warfarin, PUD, platelette disorder 6.) Age older than 75 use topical vs oral NSAIDS for tx 7.) Rule out osteoporosis and order bone mineral density test

GOUT

Deposits of uric acid crystal (monosodium urate) inside joints and tendons due to genetic excess production or low excretion of purine crystals (by products of protein metabolism). High levels of uric acid can crystallize in the peripheral joints such as the first joint of large toe MTP, ankles, hands, and wrists. More common in meddle aged males older than 30 years of age. The gold standard for diagnosing gout is performed by joint aspiration of the synovial fluid of the joint. A microscopy exam using polarized light is used to identify uric acid crystals in the synovial fluid to diagnose gout. Recurrent flares that are accompanied by an elevated serum uric acid level is the most common way to diagnose gout. Classic case: Middle aged man presents with painful, hot, red, and swollen MTP joint of the great toe (podagra). Patient is limping due to severe pain from weight bearing on the affected toe. Hx of previous attacks at the same site. Precipitated by ingestion of alcohol, meats, or seafood. Chronic gout has tophi (small white nodules full of urates on ears and joints) hx of recurrent inflammatory arthritis (gout flare) labs: Uric acid level >6.8mg/dL tx target is<6 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; chemo and radiation CBC: WBC level elevated ESR: elevated CRP: elevated

Pearl

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

Exercise:

Exercise: Adults 150-300 minutes of moderat intensity aerobic activity (or 75-150 minutes of vigorous aerobic activity) and muscle strengthening exercise at least 2 days a week Children and teens: 6 to 17 60 minutes daily of moderate to vigorous physical activity including muscle-strengthening and bone strengthening activity 3 times a week In hypertensive adults, aerobic exercise has been found to lower resting systolic and diastolic **Non weightbearing: Isometric exercises are non-weight bearing exercises that are performed ina fixed state in which the muscle is flexed against a stationary object. Example pushing one fist against the palm of the other hand, which is stationary. **Biking and swimming are aerobic exercises which are non-weight bearing (do not strengthen bones) Weight bearing exercise the bone/muscles are forced against gravity. Weight-bearing exercise is recommended for treating osteopenia and osteoprosis to help strengthen bone durability. Walking, skiing, yoa, taichi, ligting weight and other sports.

Tx: Gout

First goal is to provid pain relief. Tx for gout flar should be started as oon as possible for best results. Medications used are oral steroids, NSAIDS or colchicine **During flares. if patient is taking daily urate lowering therapy allopurinol, probenecid febuxosta, lesinurad, pegloticase, do not discontinue it. Can continue taking these meds with gout flare meds. **Prednisone or prednisolone 30-40 mg given once a day or divided into bid dosing: taper the dose over the next 7 to 10 days. Shorter duration or tapered packs are also effective. Medrol dose pack **NSAIDS if patient refuses steroids and does not have renal or gi disease **Indomethacin BID naproxxen sodium bid, diclofenac bid celecoxib bid or ibuprofen 800mg tid. Do not use narcotics. Can discontinue NSAIDS after 2-3 days of complete resolution **Colchicine Two tablets 1.2 mg at the onset of pain and then one tablet 0.6mg in 1 hr. Do not take more than three tabs per gout flare episode. Advise to avoid eating grapefruit or drinking grapefruit juice with colchicine. **Drug interactions: Macrolides, azole antifungals, some antivirals, calcium channel blockers, cyclospoine, tacrolimus, others **C/I any degree of renal or hepatic impairment **Serious and life threateningeffects: Blood cytopenias, rhabdomyolysis, liver failure, neuropathy Maintenence: Urate lowering agents: Xanthine oxidase inhibitors Allopurinaol (Zyloprim), febuxostat **Black box warning for feuxostat: gout patients with heart disease have higher rate of CV death copared with CV patients with gout treated with alopurinol. **Uricosoric agents: Probenecid, lesinurad (Zurampic) **Uricase: Pegloticase IV can cause anaphylaxis and infusion reactions, premedicate with antihistamine and corticosteroids Urate lowering therapy: Wait several weeks after acute gout flare before starting on urate-lowering therapy. **indications for ULT: tophus or tophi, frequent attacks >2/year **Allopurinol initial dose is 100 mg daily; increase dose until serum uric level is <6. Check CBC affects bone marrow, renal function, liver function at baseline then periodically. Preferred urate lowering agent and generally well tolerated. Allopurinol hypersensitivity: If renal disease at higher risk. Manifests as fever, rash and hepatitis. Stop allopurinol immediately if it occurs and refer. **Consider febuxostst (Uloric) if allergic to allopurinol. Alternative med is probenecid. **Lifestyle changes and dietary education to avoid or minimize alcohol. **if overweight, lose weight. Avoid fructose or corn syrup sweetened beverages (increase uric acid) Remain well hydrated. **Alternative medicine: Cherry or red cherry juice, vitaminC Complications: Joint destruction, joint deformity, tophi

TX for Meniscal tear

Follow RICE Rest the knee and avoid or minimize positions that overstress the knee, such as squatting, kneeling, climbing stairs. Apply ice/cold pack for 15 min every 4 to 6 hrs elevate limb. May need crutches. 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. NSAIDS or acetaminophen for pain as needed. Locking or unstable knees need to be referred to orthopedist; may need arthroscopy to repair menisci. Best test : MRI

TX for Bakers Cyst

Follow RICE, NSAIDS, Large bursa can be drained with syringe using 18 guage needle if causing pain. Synovial fluid is clear, golden color. If cloudy synoial fluid is present nd the joint is red, swollen and hot order a C&S. to rule out septic joint infection. After it is drained an intraarticular injection of a gluccocorticoid can decrease inflammation. Warn the patient that the cyst can recur in the future. Most popliteal cysts are asymptomatic and do not require intervention.

Colles Fracture

Fracture of the distal radius (with or without ulnar fracture) of the forearm along with dorsal displacement of wrist. Hx of falling forward with outstetched hand (as in navicular fracture). This fx also is known as the dinner fork fracture because of the appearnce of arm and wrist after the fracture. It is the most common type of wrist fracture.

Treatment for Ankle Sprain

Grade and determine if ankle x ray series is needed or refer to orthopedics NSAIDS and topical NSAID. Voltaren gel, diclofenec, can be used to treat pain and swelling. Can use combination topical and Po NSAID. **Follow the RICE guide **Grade 1 sprains mild do not require immobilization. Use elastic wrap (ACE bandage) for a few days **Grade 2 sprains moderate may need more support. Use ACE and an aircast or similar splint for a few weeks **Grade III sprains are maged by an orthopedic or sports specialist **Early rehabilitation is important. Refer for PT after initial swelling and pain have decreased so that the patient can tolerate simple exercises.

Pelvic Fracture

H/o significant or high-energy trauma such as a MVC or MCA. S/s delpend on degree of injury to the pelvic bones and other pelvic structures such as nerves, blood vessels, and pelvic organs. Look for ecchymosis and swelling in the lower abdomen, hips, groin, and scrotum. May have bladder and/or fecal incontinence, vaginal or rectal bleeding, hematuria, numbness. May cause internal hemmorhage, which can be life threatening. Check airway, breathing and circulation first (ABC)

Mortons Neuroma

Inflammaation of the digital nerve of the foot between the third an fourth metatarsals. Increased risk with high-heeled shoes, tight shoes, obesity, dancers, runners. Classic case: 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 slpace between the third and fourth toes (metatarsals) on the forefoot. Physical exam of the foot may reveal a small nodule on the space detween the third and fourth toes. Some patients palpate the same nodule and report it as "pebble-like" Mulder test: the test for Mortons neurome is done by grasping the first and first metatarsals and squeezing the forefoot. Positive test is hearing a click along with a patient report of pain during compresison. Pain is relieved when the compression is stopped. TX: Avoid wearing tight narrow shoes and high heels. Use forefoot pad. Wear well-padded shoes. DX: by clinical presentation and hx . Refer to podiatrist

Tx for rotator cuff disease

Initial tx: Rest, and apply cold pack 15 min repeated 2-4 times per day, especially during the acute phase 24-48 hr. NSAIDS PT to rehabilitate shoulder Refer to orthopedic specialist if inadequate or poor response to conservative management.

Exam tips

Ketorolac (Toradol) is limited to 5 days of use. The first dose is given IM or IV **Herberdens and or Bouchards nodes have appeared many times on the exam. Memorize the location. Herberdens: dens=distal Bouchards: Proximal The B comes before the H in the alphabet **Types of tx methods used for DJD Analgesics, NSAIDS by mouth and topical, steroid injection on inflamed joints ( no systemic/oral steroids) surgery (joint replacement) Do not confuse the tx for OA with that for RA Recognize the s/s of a medial tibial stress fx

Disease Review: Medial tibia stress syndrome (shin splints) and medial tibial stress fracture

Lower extremity injury caused by overuse, resulting in microtears and inflammation of the muscles tendons and bone tissue of the tibia. Also known as shin splints. More common in runner (higher incidence in females) and people with flat feet. If severe it can progress into a stress fracture. Females are at higer risk of stress fracture especially those with :female athlete triad" amenorrhea, eating disorder, and osteoporosis) Onset precipitated or worsened with intensification of actiity (increased mileage and or frequency of training. Classic case: female runner reports that she recently increased frequency/distance running and complins of recent onset of pain on the inner edge of the tibia. Pain may be sharp and stabbing or dull and trobbing. Aggravated during and after exercise. C/O 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 fx. of the tibia. TX: follow RICE. Several weeks of rest are recommeded. Apply cold packs during acute exacerbation, for 20 min at a time, several times a day for first 24-48 hrs then as needed. Take NSAIDS as needed Compression bandage or sleeve may help decrease swelling. Using cushioned shoes for ADLs helps decrease tiabial 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, (swimming or stationary bike, elliptical trainer) If stress fx is suspected advise patient to avoid exercising. Stretch before exercise and start at lowe intensity. Wear supportive sneakers. Imaging: if suspect stress fc, bone scan or MRI. A radiograph does not show stress fx. Refer to Orthopedic specialist.

Clinical pearls

MRI best for soft tissue, joints, occult fx and soft tissue. Xray best for bone injuries such as fractures. Some bone fx might not be visible such as stress fx

Tenddinitis

Microtears on a tendon cause inflammation, resultling in pain. Usually due to repetitive microtrauma, overuse, or strain. Gradual onset. Follow RICE mneumonic for acute injuries

Ankylosing spondylitis

More common in males 2-3X. and those who are HLA-B27positive. Average age of onset is 20-40 years. Chronic inflammatory disorder (seronegative arthritis) that affects mainly the spine(axial skeleton) and the sacroiliac joints (axial spondylarthritis). Other joints affected include the shoulders, hips, knees and sternoclavicular joints. A few develop diffuse swelling of the fingers (dactylitis). Pain is diminished with exericse and is not relieved by rest. Classic case: Young adult male c/o chronic case of back pain >3 months that started at the neck and progressed down to the spine.Reports that the pain gradually progressed from the neck to the upper back (thoracic) and then the lower back.Impaired spinal mobility. Joint pain keeps him awake at night. Associated with generalized symptos such as low-grade fever and fatigue. May have chest pain with respiration (costochondritis) and constovertebral tenderness. Long term stiffness improves with activity. Some may have midbuttock pain (sciatica indicates sacroiliac spine is involved) Objective findings: Causes a marked loss of ROM of the spine such as forward bending, rotations and lateral bending. Decreased respiratory excursion down to <2.5 some have lordosis Hyperkyphosis(hunchback)occurs after 10 years or more with the disease **Uveitis up to 40% C/o eye irritation, photosensitiity, and eye pain. Scleral injection and blurred vision occur. Unilateral eye involvement is common. Refer to Opthamologist Labs: ESR elevated CRP elevated RF is negative spinal radiograph bamboo spine

Topical medicine for OA

NSAIDS: Diclofenac gel (Voltaren) apply to painful area and massage well into skin QID\ Capsaicin cream: Apply to painful area QID avoid contact with eyes or mucous membranes Capsaicin comes from chili peppers also used to tx neuropathic pain (shingles) **Do not use on wound/abraided skin. Avoid bathing or showering afterward NSAID drug risk: Highest risk : Ketorolac and piroxican (Feldene) Lowest risk: Ibuprofen and Celecoxib (Celebrex) Highest risk of CV events: Diclofenac and celecoxib at higher doses Lowest risk of CV events: Naproxen

Cllinical pearl

Naproxen is the NSAID with the fewest CV effects, but it has the same GI adverse effacts as other NSAIDS. It can however increase bp so this should be monitored.

Ottawa rules of the Ankle

Ottawa rules are used to determine whether a patient needs a radiograph of the injured ankle in the ED. **In mid to moderate sprains during acute phase, use RICE and elastic bandage wrap. **For pain and swelling, recommend NSAIDS for pain as needed. The Ottawa ankle rules are highly sensitive 96-99.6% for excluding andle fracture Grading of sprains: Grade 1 Mild sprain ( slight stretching some damage to ligament fibers) patient is able to bear weight and ambulate. There is no joint instability during the ankle evaluation. Grade 2: Moderate sprain (partial tearing of ligament) eccymoses, moderate swelling and pain are present. Joint tender to palpation. Ambulation and weight bearing are painful. Mild to moderate joing instability occurs. Consider x ray and referral Grade 3: Complete rupture of Ligaments Severe pain, swelling, tenderness and ecchymosis, significant mechanical ankle instability and sig. loss of function and motion. Unable to bear weight or ambulate. Refer to the ED for ankle fx. Ankle x ray series is required if there is pain in the malleolar zone and: Inability to bear weight immediately after injury Inability to ambulate at least four steps Bone tenderness over the posterior edge or tip of the medial malleous or Bone tenderness over the posterior edge or tip of the lateral malleous Physical examination: First ask about the mechanics of the injury along with symptoms. Look for swelling and ecchymosis. Palpate the entire ankle (lateral and medial side) Achilles tendon and the foot. Check for weight bearing, ROM, ability to ambulate, pedal and posterior pulses. Grade of Sprain

Acute Osteomyelitis

Patient complains of localized bone pain, swelling, redness, and tenderness of affected area and fever. If on leg or hip, may refuse to walk and bear weight. An acute infection of the bone that cuases inflammation and destruction, which can be caused by bacteria, mycobacteria, and fungi. Most cases are due to contiguous spread from a nearby infected wound to the bone. For example, an infected pressure sore on the heel can cause osteomyelitis of the heel bone, or calcaneus (nonhematogenous spread). Hematogenous spread is seeding of the bone from an infection in the bloodstream (bacteremia). For example a patient with bacteremia complains of refractory vertebral pain and tenderness (hematogenous osteomyelitis). Direct trauma to the bone can also result in infection. The most common causes of osteomyelitis is Stphlococcus aueus. An MRI can show changes to the bone and bone marrow before plain x ray or radiograph. WBC count. erythrocye sedimentation (ESR) and C-Reactive are eleated. Blood cultures may be positive. Antibiotic tx is based on cultue and sensitivity C&S resuts. May need surgical debridement, amputation, ad bone grafts.

Hip fracture

Patient with hx of slipping or falling. Sudden onset of one-sided hip pain. Unable to walk and bear weight on affected hip. If mild fracture, may bear weight on affected hip. If displaced fracture, presence of severe hip pain with external rotation of the hip/leg. and leg shortening. More common in elderly Elderly have a 1-year mortality rate from 12% to 37% r/t complications of immobility, such as pneumonia and DVT.

Radiography: CT, MRI,

Plain films: show bone fx, 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. MRI: Gold standard for injuries of the cartilage, meisci, tendons, ligaments, or any joint of the body. MRI uses a magnetic field and radio waves, not radiation (compared to x rays and CT scans) can be done without or with contrast **contraindicated in patients with metal implants, pacemakers, aneurysm clips, insulin pumps, metallic foreign body in the eye, cochlear implant , triggerfish contact lenses, electrodes for deep brain stimulation and metallic joints. CT: CT scanning combines x rays gamma radiation that are rotating in a continuous circle around the patient with computer software to slow slices of three dimensional images. Can be done with or with out contrast. Detects bleeding, aneurysms, masses, pelvic an bone trauma, and fractures

Acute Musculoskeletal injuries TX

RICE **ice is best during first 48 hrs. 15 to 20 min per hour several time/day **rest and elevate affected joint to help decrease swelling **Compress joints as needed. Use eleastic bandage wrap(joints more commonly compressed are knees and ankles) helps with swelling and provides stability **Administer NSAIDS naproxen bid ibuprofen tid

Exam tips

Recognize Bakers cyst presentation Plain radiograph of a joint such as an xray of the knee will show bony changes with OA and narrowing of joint space. The best imaging test for cartilage, meniscus or tendon damage is an MRI. The gold standard for assessing ay joint damage is an MRI.

TX plan for ankylosing spondylitis

Refer to rheumatologist **If smoker advise cessation. Screen for anxiety and depression. Refer to PT for inital evaluation and training, including postural training, rom, and stretching **Exercise therapy combinedd with hydrotherapy s more effective than exercise alone. **Avise pt to buy a mattress with good support **First line initial tx is NSAIDS such as naproxen twie a day, celecoxib twice a day ibuprofen 800 mg tid or other NSAIS. Usually need the max dose to control the pain. ** If high risk of bleeding presciribe a PPI with NSAID or COx 2 inhibitor celecoxib bid **for severe cases tx options are TNF inhibitors, biologics Etanercept, DMARDs methotrexate and spinal fusion

Tx plan for RA

Refer to rheumatologist for early aggressive management to reduce joint damage Surgery: Joint replacement (hip, knees) ameliorate RA Careful assessment is necessary: Never prescribe a biologic or anti-tumor necrosis factor medication if signs and symptoms of infection. TB testing should be ordered before starting anti-TNF therapy Complications: Uveitis (eyes): inflammation of the uvea (middle layer of the eyeball. Sudden onset of eye redness, pain, and blurred vision. It can cause vision loss. Refer to ophthalmologist stat. RA increases risk of anterior uveitis, scleritis, vasculitis, pericarditis RA increases risk of certain malignancies such as lymphoma When prescribing Plaquenil, all patients must have an eye exam before starting medication. Frequent eye exam monitoring should be performed every six months or as recommended y the ophthalmologist to assess and prevent retinal damage, which can lead to blindness.

SLE TX

Refer to rheumatologist, NSAIDs, analgesics, steroids, antimalarial (Plaquenil), immune modulators (methotrexate, biologics) monoclonal antibodies. Patient education: avoid sun between 10 am and 4 pm (causes rashes to break out) Cover skin with high sun protection factor sunblock Wear sun protective clothing Use nonflourescent llight bults ( more sensitive to indoor flourescent lighting)

RICE pneumonic

Rest Ice 20 min on and 10 off for first 24-48 hrs Compression: use an elastic bandage wrap over joints to decrease swelling Elevated prevents or decreases swelling. Avoid weight bearing on affected joint

Normal findings : Joint anatomy

Synovial fluid: thick serous clear fluid (sterile) that provides lubrication for the joint. Cloudy synovial fluid can be indicative of infection : order C&S Synovial space: Space between two bones (the joint) filled with synovial fluid Articular cartilage: the cartiage lining the open surfaces of bones in a joint Meniscus or menisci (pleural) : Cresent-shaped cartilage located in each knee; two menisci in each knee *Damage to menisci may cause locking of the knees and knee instability Tendon: Conects muscle to bone (partial or complete tear of tendon or muscle is a strain) Ligament: Connects bone to bone(partial or complete tear of a ligament is a sprain) Bursae: Saclike structure located on the anterior and posterior areas of ajoint that act as padding; filled with synovial fluid when inflamed (bursitis) Benign Variants: genu recurvatum: Hyperextension or backward curvature of the knees Genu valgum: knock knees Genu varum: bow legged To remember valgum think of gum stuck between the knees : knock knees varum: bow legged

RA

Systemic autoimmune disorder that is more common in women 8:1 Mainfly manifested through systemic inflammation of multiple joints and other parts (skin, blood vessels, kidneys, GI, brai, nerves, eyes). The goal of tx is to prevent joint and organ damage. Patients are at higher risk for other autoimmune disorders including Graves disease and pernicious anemia. Classic Case: Adult commonly middle-aged, woman c/o gradual onset of symptoms over months with daily fatigue, low-grade fever, generalized body aches, and myalgia. C/o genralized join pain, which usually involves multiple joints bilaterally. it usually starts on the finger/hands (PIP and MCP joints and the wrists. Commonly reports early-morning stiffness and pain and warm, tender and swollen fingers in the DIP, PIP (sausage joints) It eventually involves the majority of joints in the body bilaterally. Objective findings: Joint involvement is symmetric, with more joints involved compared with DJD. **Most common joints affected: Hands, wrists, elbows, ankles, feet, and shoulders **sausage joints **Morning stiffness occurs for at least 1 hr and has been present for >6 weeks **RA nodules present (chronic disease) **Swan neck deformity (50%) flexion of the DIP joint with hyperextension of the PIP joint Labs: Sedimentation rate: Elevated CBC: : mild microcytic or nomocyctic anemia common Rheumatoid factor :RF positive in 70-80 of patients Radiographs: Bony erosions, joint space narrowing, subluxations Serology/antibodies: Anti-cyclic citrullinated peptide anti CCP

Orthopedic maneuvers

Test both extremities : use the good limb for baseline Drawer sign: drawer sign is used to test for knee stabiltiy. Excessive laxity of affected knee is suggestive of a torn ligament. Anterior drawer: Patient lies on examination table. The hip is flexed to 45 degrees and the knee is bent to 90 degrees. The examiner sits on the forefoot/toes to sstabilize the knee joint. Then examiner grasps the lower leg by the joint line and pulls the tibia anteriorly (like opening a drawer) a postive test is indicative of a damaged or torn ACL Posterior PCL: The examiner pushes the joint posteriorly like closing a drawer. A positive sign is indicative of a torn PCL Finkelstein test: DeQuevervain's tenosynovitis (or tendonosis is caused by an inflammation of the tendon sheath which is located at the base of the thumb. The screening test is Finkelsteins which is positive if there is pain and tenderness on the wrist on the thumb side (abductor pollicis longus and extensor pollicis brevis tendons) Procedure: 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 test if patient complains that the tendon (on the side of the thumb) hurts with ulnar deviation. McMurrays test: Knee pain and a "click sound upon manipulation of the knee are positive. A positive test suggests injury to the medial mesicus of the knee. Gold standard test for joint damage is the MRI Lachmans sign : positive result is suggestive of ACL damage of the knee Collateral ligaments: Postive finding is an increase in laxatiy of the damaged knee (ligament tear valgus stress test of the knee : test for medial collateral ligament (MCL) Varus stress test of the knee: test for lateral collateral ligament LCL

Hamstring muscle injury

The hamstring is composed of three muscles and is located in the posterior thigh. The hanstring muscles are used for knee flexion and hip extension. Refer patients to orthopedic specialist Classic case: Most hamstsring injuries are acute. The patient with present with 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. Imaging: Musculoskeletal US ad MRI are the best method of assessing hamstring injuries.

Meniscus Tear Knee

The meniscus is the catilaginous lining between certain joints that is shaped like a crescent. Tears in the meniscus result from trauma and or overuse. Sports with higer risk are soccer, basketball, and football. Classic case:: Patient may complain of clicking, locking or buckling of the knee. Some patients are unable to fully extend affected knee. Patient may limp. Complains of knee pain and difficulty walking and bending the knee. Some c/o joing line pain. Decreased ROM. Certain movementns aggravate symptoms. PE: Assess for joint line tenderness and knee ROM. Look for locking or inability to fully extend or straigten the leg. Will be unable to squat or kneel. Knee may be swollen (joint effusion) Observe patients gait. McMurrays test: Pain is upine. The examiner holds the knee and palpated 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 flexiaon then extend the knee with external rotation of the tibia and apply valgus stress. Postive : pain and clicking or if the knee locks Apleys test: Patient is prone with affected knee flexed at 90 degrees. Stabilize patients thigh with examiners knee or hand. Press the patients hell downward push heel toward the floor) while the foot is internally and externally roated. The examiner is compressing the meniscus between the tibia adn femur while twistin the foot. Positive: Pain is elicited with the compression the knee

Sprains

The overstretching or tearing of ligaments at a joint. 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. Ankle sprains are caused by overstretching of the joint, partial rupture, or complete rupture of a ligament. Lateral ankle sprains arae the most common typle. 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 malleous due to pulling by the ruptured deltoid ligament.

Piriformis Syndrome

The piriformis muscle is located in the buttocks and it can compress, irrritate and entrap the sciatic nerve between its muscle layers. It is responsible for 0.3% to 6% ofall cases of low back pain. Classic case: Patient ususally complain s of sciatics 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 heay 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, DTR, and strength testing. Imaging: x ray: consider if limited hip ROM or chronic groin pain. Can help dx osteoarthritis of the hip. US can help dx tendon and soft-tissue injury around the hip and groin. MRI: Can help diagnose sciatic nerve compresison, stress fx of femoral neck, cartiage tears, tendon ruptures TX: Avoid positions that trigger pain. Follow RICE guide, cold packs or heat can be used. Warm up and stretch efore sports or exercises. REst, cold packs and heat may help symtoms Medications; NSAIDS muscle relaxants are the most common method of tx Refer for PT for stretching and exercises Muscle Relaxants: **Centrally active skeletal muscle relaxant **s/e drowsiness, dizziness, nervousness, reddish purple urine, hypotension, do not mix with alcohol or drugs **cyclobenzaprine **Metaxalone (skelaxin) **Tizanadine(Zanaflex) Carisprolol(SOMA) can be addicting it is a schedule IV substance

Tx plan

Tx depends on etiology. For uncomplicated back pain, use NSAIDSS apply warm packs if muscle spasms **muscle relaxants if associated with uscle spasms (causes drosiness, warn patient **abdominal and core-strenghtening 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 docontitioning (loss of muscle tone and endurance) and increase risk of pneumonia Complications: Cauda Equina Syndrome Acute pressure on a sacral nerve root results in infalmmatory and ischemic changes to the nerve. Sacral nerves innervate pelvic structures such as the sphincters (anal and urinalry) Considered a surgical emergency. Needs spinal and or nerve root deompresion. Refer to ED Signs: bladder and bowel incontinence saddle anesthesia bilateral sciatica syumptoms such as paresthesias on midbuttock radiating down back of the leg

Low back pain

Very common disorder with a lifetime incidence of 85%. Usually due to soft-tissue inflammation, sciatica, sprains, mucle spasms, or herniated discs (usually l5-S1) The majority of patiens seen in primary care have nonspecific low-back pain, which is usually self-limited. Rule out fx and other serious etiology **acute back pain: up to 4 weeks **subacute 4-12 weeks **chronic back pain: persists for 12 weeks or longer **RF: obesity, age, female, smoker, anxiety, depression, psychologically strenuous work, physically strenuous or sedentary work, workers commpensation, job dissatisfaction Furthur eval: **hx of sig trauma ** suspect cancer metastases **suspect infection (osteomyelitis) **suspect spinal/vertebral fx elderly with osteopenia/osteoporsis, chronic steroid use **pt age older than 50 with new onset of back pain (rule out cancer) or pain that wakes pt from sleep **suspect spinal stenosis (r/o ankylosing spondylitis) **Fevers, night sweats, weight loss, or signs of systemic illness **symptoms worsening despiteusual tx Herniated disc with symptoms: common site is at L5-S1 Imaging: MRI best method for diagnosing a herniated disc. Bone scan may be helpful in identifying occult lytic lesions. Imaging for low-back pain w/o other symptoms increases risk of additional or invasive procedures

Exercise and injuries:

Within the first 48 hrs, protect joint, and acutely inflamed joints should not: Be exercised in any form (not even isometric) Engage in any active ROM if done too early they will cause more inflammation and damage to the affected joints. Do not undergo exacerbating activities

Navicular Fracture

Wrist pain on palpation of the anatomic snuffbox. Pain on axial loading of the thumb. Hx of falling forward with outstretched hand)hyperextension of the wrist) to break the fall. Initial x-ray of the wrist may be normal, but a repeat x ray in 2 weeks will show the scaphoid fracture (due to callus bone formation). High risk of avascular necrosis and nonunion. Splint wrist (thumb spica plint) and refer to a hand surgeon.

SLE

a multisystem autoimmune disease that is more common in women 9:1. Characterized by remissions and exacerbations. More common in African American and Hispanic women. Organ systems affected are the skin, kidneys, heart, and blood vessels. Milder form of lupus is called cutaneous lupus. Classic Case: 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) UA is positive for proteinuria

The 4 classic features of Parkinson's disease are: a. Mask-like facies, dysarthria, excessive salivation, and dementia. b. Tremor at rest, rigidity, bradykinesia, and postural disturbances. c. Depression, cognitive impairment, constipation and shuffling gait. d. Tremor with movement, cogwheeling, repetitive movement, and multi-system atrophy.

b Tremor at rest , rigidity, bradykinesia, and postural disturbancces

Phalen's test, 90°wrist flexion for 60 seconds, reproduces symptoms of: a. Ulnar tunnel syndrome b. Carpal tunnel syndrome c. Tarsal tunnel syndrome d. Myofascial pain syndrome

b. The principal clinical tests for carpal tunnel syndrome are Phalen's maneuver and Tinel's sign. Phalen's maneuver is positive when flexing the wrist to 90 ...

The most common symptoms of transient ischemic attack (TIA) include: a. Nausea, vomiting, syncope, incontinence, dizziness, and seizure. b. Weakness in an extremity, abruptly slurred speech, or partial loss of vision, and sudden gait changes. c. Headache and visual symptoms such as bright spots or sparkles crossing the visual field. d. Gradual onset of ataxia, vertigo, generalized weakness, or lightheadedness

b. Weakness in an extremity, abruptly slurred speech or partial loss of vision, and sudden gait changes

The most commonly recommended pharmacological treatment regimen for low back pain (LBP) is: a. Acetaminophen or an NSAID b. A muscle relaxant as an adjunct to an NSAID c. An oral corticosteroid and diazepam (Valium) d. Colchicine and an opioid analgesic

b. a muscle relaxant as an adjunct to an NSAID

Which of the following statements about multiple sclerosis (MS) is correct? a. MS is a chronic, untreatable illness that is almost always fatal. b. MS is a disease of steadily progressive and unrelenting neurologic deterioration. c. MS is a chronic, treatable illness with unknown cause and a variable course. d. Patients with MS who take active steps to improve their health have the best cure rate.

c. MS is a chronic treatable illness with unknown cause and a variable course

The diagnosis which must be considered in a patient who presents with a severe headache of sudden onset, with neck stiffness and fever, is: a. Migraine headache b. Subarachnoid hemorrhage c. Glaucoma d. Meningitis

d. Meningitis

The most reliable indicator(s) of neurological deficit when assessing a patient with acute low back pain is(are): a. Patient report of bladder dysfunction, saddle anesthesia, and motor weakness of limbs. b. History of significant trauma relative to the patient's age. c. Decreased reflexes, strength, and sensation in the lower extremities. d. Patient report of pain with the crossed straight leg raise.

decreased reflexes, strength, and sensation in the lower extremities.Explanation Research has shown that report of dysfunction or pain with crossed straight leg raises is a significant indicator of neurological deficit. However, compromised reflexes, sensation, and strength are more reliable. History of significant trauma helps in determining the likelihood of fractu

Rotator cuff disease (supraspinatus tendinitis)

rotator cuff disease usually involves damage to the supraspinatus muscle, which helps move the shoulder durin g 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 weightllifting, gymnastics and volleyball increase the risk for rotator cuff disease. Classic case: Patient with hx of repetive overhead activity sport or job complains of shoulder pain with overhead movements such as brushing hair or putting on a shirt. There is a local point tenderness over the tendon located on the anterior area of the shoulder. May have pain at night while sleeping on the affected side. Maneuvers: Painful arc test: Pain with shoulder ROM>90 degrees of adduction or pain with internal rotation is suggestive of rotator cuff tendinopathy. Postive shoulder pain that occurs between 60 and 120 degrees of active abduction Jobes test (empty can test): This is a test for the strength of the supraspinisus muscle. Instruct pateint to straighten arm at 90 degress of abduction with 30 degress of forward fexion, then internally roate the shoulder. Tell the patient to resist when examiner attempts to adduct the arm. Positive; shoulder pain without weakness (tendinopathy), shoulder pain with weakness (suggests tendon tear) Imaging: Musculoskeletal US is useful for initial evaluation of tendon tears. MRI can identify rotator cuff tears.