Exam 8: Ortho and Rheum
what is the suffix for local anesthetics? how do we tell the difference b/w ester local anesthetics and amide local anesthetics?
"-caine" ester = 1 "i" amide = 2 "i's"
Suffix for Glucocorticoids
"-sone"
what type of joint is the main ankle joint? what motions are allowed? what bones are involved? what other motions are allowed by other joints in that region?
-hinge -ankle flexion and extension -tibia/fibula and talus the subtalar joint allows ankle inversion and eversion
tx for femoral neck fracture
-if blood supply of femoral head intact (ex: nondisplaced fractures): internal fixation and reduction (ORIF) -if blood supply compromised (ex: displaced fractures): decompression OR hemiarthroplasty OR total hip replacement
What postural changes typically occur in ankylosing spondylitis?
-loss of lumbar lordosis -exaggerated thoracic kyphosis -cervical hyperextension *these together create the characteristic "question mark posture"
Skin manifestations of SLE
-malar (butterfly) rash -discoid rash (scars) -alopecia
Criteria for a Level 1 Trauma (as given by lecturer)
-motorcycle v car -pedestrian struck -intrusion into car > 12in -death in the same passenger compartment -fall > 10ft
most common types of primary benign spinal tumors
-osteoid osteoma -osteoblastoma
Wong-Baker Faces
-pain rating scale asks patients to compare their pain to a series of faces ranging from a broad smile to a tearful grimace -used for adults and children 3+y/o in all patient care settings
where are primary benign spinal tumors typically located? where are primary malignant and metastatic tumors typically located?
-posteriorly in the spinal cord/column -in the vertebral body (anteriorly)
what organism is likely to cause osteomyelitis in a: -sickle cell pt? -IV drug user? -HIV/AIDS pt w/ a cat scratch or bite? -immunosuppressed pt? -Potts disease pt? -neonates?
-salmonella -pseudomonas -bartonella -fungi -TB (Potts is TB in the spine) -grp B strep
what motion aggravates the back pain and paresthesias in spinal stenosis? what motion relieves it?
-spinal extension aggravates (further narrows the canal) -spinal flexion relieves (opens up the canal)
action of rotator cuff muscles
-supraspinatus: elevates the shoulder, initiates abduction -infraspinatus and teres minor: external/lateral rotation -subscapularis: internal/medial rotation
hypothalamic-pituitary-adrenal (HPA) axis: hypothalamus releases _____ --> ______ releases ACTH --> adrenal cortex releases _____ --> ______
-the biological system responsible for the stress response CRH anterior pituitary cortisol immune system suppressed
Mason Classification of Radial Head Fractures
1. Non-displaced or minimally displaced 2. Displaced more than 2 mm 3. Comminuted and displaced 4. fracture w/ elbow dislocation
What are the three main sx of osteoarthritis?
1. Pain 2. Joint stiffness 3. Restricted range of motion
Valgus Stress Test
MCL injury -Knee opens up on medial side when valgus force applied at 30° flexion
The most common genetic predisposition for SLE is found w/ changes in the ____ locus, w/ HLA-____ and HLA-____ as predisposing genetic factors.
MHC DR2, DR3
Seronegative spondyloarthropathies are associated w/ [morning, evening] stiffness/joint pain
Morning -pain is worse in the morning (or w/ rest) and gets better throughout the day w/ use
Inflammatory back pain is usually worst at what time of day? Mechanical back pain?
Morning (> 30min) - worse w/ rest, better w/ use Night - worse w/ use, better w/ rest
Tx of Bennett's Fracture
ORIF - it's unstable and needs surgery -stabilization w/ a thumb spica splint temporarily
standard of care/main test for scoliosis
PA x-ray -use Cobb's angle to measure the curve of the spine
name the 4 subtypes of seronegative spondyloarthropathies
PAIR 1.psoriatic arthritis 2.ankylosing spondylitis 3.IBD 4.Reactive arthritis (Reiter's syndrome) P&R = asymmetric A&I = symmetric
the _____ is the primary restraint of knee motion during deep flexion
PCL
what other injury may be mistaken for an ACL injury? -what test can you do to determine to dx?
PCL -test w/ a posterior drawer test
a direct blow to the anterior tibia of a flexed knee (ex: dashboard injury) is likely to cause what injury?
PCL injury
Posterior Sag Sign
PCL injury -Posterior sag of tibia w/ pt supine & knee flexed 90°
Posterior Drawer Test
PCL tear -abn posterior mobility -similar to the anterior drawer test: flex the pt's knee to 90° and sit on the pt's foot to restrain it. Wrap both hands around the proximal tibia and push it backward
what type of imaging is used if you suspect metastases w/ spinal tumors?
PET scan
most common joints involved in early RA
PIP, MCP (similar to SLE)
Tx w/ the best long-term efficacy for OA
PT
treatment of glenohumeral instability
PT for 3-6 mon (ex: closed kinetic chain exercises = pushups) -if fail: surgery (capsular reconstruction)
Which muscles are injured in a lumbosacral strain/sprain? What sort of motion can cause these injures?
Paraspinal muscles -twisting/lifting
Which neurologic level is responsible for foot eversion (contraction of the peroneus longus and brevis) and plantar flexion, Achilles reflex, and sensation to the lateral foot and posterior thigh?
S1
Injury to a tendon is called a ____, while injury to a ligament is called a _____
Strain (Tendon = sTrain) Sprain
Stages of a herniated disk
1. Protrusion = bulge is entirely contained w/in the annulus (nucleus pulposus doesn't break thru the annulus fibrosis) 2. Prolapse = malt ruptures thru to the outer layers of the annulus 3. Extrusion = tissue migrates thru a defect in the annulus 4. Sequestration = free fragment of the nucleus breaks off
What are the two types of nociceptive pain? What is the main difference b/w the two?
1. Somatic = localized 2. Visceral = NOT localized
Adult Nonverbal Pain Scale
Assessment to determine pain levels in nonverbal adults (ex: pts on a ventilator) -Categories: face, activity (mvmt), guarding, physiology (vital signs), respiratory -higher score = higher pain level
why is acetaminophen preferred in OA while NSAIDs are preferred in RA for pain?
RA is an inflammatory arthritis, so it requires an anti-inflammatory medication (NSAIDs) -OA is not inflammatory, so you can use a medication w/o anti-inflamm properties (acetaminophen)
how do we convert dosages from one opioid to another?
1. calculate total daily dose of drug 1 2. convert dose of drug 1 to morphine dose 3. convert morphine dose to drug 2 dose 4. account for cross-tolerance by calculating 50-75% of the dose in step 3 5. divide the total daily dose of drug 2 by the number of doses per day
Kosher Criteria for Septic Arthritis Diagnosis
1. non-weight-bearing on affected side 2. ESR > 40mm/hr 3. fever 4. WBC count > 12,000 *if meet all 4 criteria, there is a 99% chance of septic arthritis -if meet 3: 93% -if meet 2: 40%
Quadriceps muscles
1. rectus femoris ("rectus" means straight) 2. vastus lateralis 3. vastus medialis 4. vastus intermedius
which 3 nerves innervate the hip?
1. sciatic (L4-S4) - posterior 2. femoral (L2-L4) - anterior 3. obturator (L2-L4) - medial
Rotator cuff tears present w/ AROM [<, >, =] PROM
< -there is a greater loss of AROM than PROM (you injured muscles, so you can't actively move them well...but the other stuff is okay, so it can be moved)
Internal rotation weakness OR excessive passive external rotation of the shoulder
Subscapularis injury
Ottawa Appropriateness Criteria
Subset of the ACR Appropriateness Criteria, which indicates when it is most appropriate to obtain an x-ray
Amitriptyline/nortriptyline and imipramine/desipramine are examples of what type of medication?
TCAs
Dupuytren's contracture
Thickening and shrinking of the fascia of the palm with fingers being drawn into a flexed position -physical exam shows contraction of the finger flexors (esp in the ring and pinky fingers) w/ a palpable cord within the palmar fascia
Gel phenomenon
Thickening of the synovial fluid after long period of rest - occurs in osteoarthritis and rheumatoid arthritis -feels like you're moving your joint thru jello
Compartment syndrome occurs most commonly after what type of injury?
Type III open tibia fractures -watch out for tibia and forearm fractures generally
first choice imaging for Achilles tendon rupture? gold standard imaging? first line tx?
U/S MRI surgery to repair the tendon
best imaging for lateral or medial epicondylitis
U/S (will see a thickened and hypoechoic extensor carpi radialis brevis muscle in lateral OR common flexor tendon in medial)
tx for acute osteomyelitis? chronic?
acute: IV abx; non-operative choronic: surgical debridement + abx
the pectineus and gracilis muscles perform what motion at the hip?
adduction
what is the difference between an anesthetic and an analgesic?
anesthetic = loss of sensation (including pain); may lose consciousness analgesic = lack of pain (w/o loss of consciousness)
what motion typically causes ankle sprains? what ligament is most commonly injured in ankle sprains?
ankle inversion OR twisting anterior talofibular ligament (ATF)
Occiput-to-wall test aka wall-occiput test
ankylosing spondylitis
Question mark posture
ankylosing spondylitis
Schober test
ankylosing spondylitis
Bamboo spine
ankylosing spondylitis -vertebral fusion and ossification of the annulus fibrosus of the disks
Relocation Test and Release test
anterior glenohumeral instability or dislocation -relocation: pt relief upon provider pressing joint posteriorly (w/ arm in same position as for apprehension test) -release: pt apprehension/pain when examiner releases pressure after the relocation test
Most commonly injured ligament in the ankle
anterior talofibular ligament (ATFL)
Anterior Drawer Test (ankle)
anterior talofibular ligament (ankle) sprain -Absence of firm end point with asymmetric or excessive motion when translating the foot slightly forward on the ankle with the patient seated and the knee flexed approximately 90° & ankle in approximately 20° of plantar flexion
most common etiology of knee pain in the older population
arthritis
"hair on end" or "sun ray/burst" appearance on x-ray
osteosarcoma -may also have Codman's triangle periosteal rxn
most common bone malignancy
osteosarcoma, (most common <20y)
osteotomy vs arthroplasty in arthritis tx
osteotomy = cut the bone and insert plates/screws to restore joint alignment arthroplasty = replace the arthritic joint (or the fractured or AVN joint)
shopping cart sign
spinal stenosis -relief of spinal stenosis symptoms (neurogenic claudication) if the pt bends over when pushing their shopping cart
most common form of back pain in children and adolescents
spondylolysis
which structures typically form static restraints of the joints? dynamic restraints?
static (while joint is still) = tendons and ligaments, labrums dynamic (while joint is in motion) = muscles
static restraints of the glenohumeral joint? dynamic restraints?
static = GH ligaments, glenoid labrum dynamic = rotator cuff (RTC), biceps brachii, periscapular muscles
Trigger Finger - what is it and how does it present?
stenosis of the flexor tunnel - specifically the A1 pulley in the hand tenderness over the A1 pulley (worse in morning d/t inaction) + clicking or locking/catching upon finger flexion
tx for trigger finger
steroid injection into the pulley -last resort: surgical release of the pulley (cut it open so the finger can move again)
why are steroid injections NOT recommended in the case of cubital tunnel syndrome?
the nerve is very superficial and the injection could result in further damage to the area
Tx for radial head fracture
type 1: immobilization w/ a sling (NOT splint) type 2: either immobilization OR surgery type 3/4: surgery ORIF
what type of bone healing is used for intra articular fractures and diaphyseal forearm fractures?
type I -use this type anytime the bone will need perfect alignment and fn soon after the procedure
what type of bone healing is used for diaphyseal and comminuted fractures?
type II -esp in kids...just get the bone ends close enough and they will heal on their own
tx for osteosarcoma
surgical resection OR amputation -w/ chemotherapy
Sx of Osgood-schlatter disease
tenderness at/near the tibial tuberosity -may also have an enlarged bony prominence in this area from new bone proliferation
what is another name for lateral epicondylitis? medial epicondylitis?
tennis elbow golfer's elbow
most common cause of elbow pain
tennis elbow/lateral epicondylitis
most common elbow overuse syndrome
tennis elbow/lateral epicondylitis
which 3 muscles flex the elbow?
the 3 Bs 1. biceps 2. brachialis 3. brachioradialis
general anesthesia
the blockage of all body sensations, causing un-consciousness and loss of reflexes -pt is unarousable, even to painful stimuli
Jeanne's sign
cubital tunnel syndrome -pt pinches paper with key pinch + = extreme hyperextension of MPJ + = weakness of adductor pollicis (AP) (ULNAR NERVE)
most common type of "bump" in the hand
cysts
muscle most commonly injured in lateral epicondylitis
extensor carpi radialis brevis (ECRB) -this muscle extends the wrist and attaches on the lateral epicondyle of the humerus
most common wrist-specific tendinopathy d/t overuse
extensor carpi ulnaris tendinitis
Unhappy (O'donoghue's) triad
injury to ACL + MCL + medial meniscus
the piriformis, quadratus femoris, superior and inferior gemellus, and obturator internus and externus perform what motion at the hip?
external rotation
in what direction does the leg most commonly turn during a hip fracture? a hip dislocation?
external rotation and abduction internal rotation and adduction (posterior hip dislocations are most common)
[T/F] Pts w/ achondroplasia have a decr lifespan
false
[T/F] OA and RA are similar because they are both autoimmune diseases that destroy the joints
false -OA is NOT autoimmune
[T/F] for acute pain in pts taking opioid maintenance therapy (methadone or buprenorphine), it is safe to add other opioids to the pt's regimen
false -it is safe for pts taking methadone, but it is not safe in pts taking buprenorphine
[T/F] most disk herniations present w/ back pain
false -most are asx
[T/F] most bone tumors originate from mutations in osteocytes (primary bone tumors)
false -most bone tumors are mets from other cancer site (ex: lung, breast, kidney, prostate, thyroid)
[T/F] septic arthritis can spread to the bone and become osteomyelitis, and vice versa
false -the bone and the joint space have different blood supplies, so there is usually not direct spread between the two tissues
[T/F] compression fractures typically present w/ neuro sx in addition to back pain
false -the compression is in the anterior vertebra, away from the nerve root (which is posterior)
[T/F] avascular necrosis can spread into the joint space
false -the joint space is typically spared (unlike in OA or septic arthritis)
[T/F] we mainly use opioids for their anesthetic and anti-inflammatory fx
false -these are analgesics, not anesthetics nor anti-inflammatories
[T/F] we treat asx elevations of uric acid
false -treat after 1st acute attack is over
[T/F] we can use primary or secondary bone healing on every bone in the body
false -we cannot use secondary healing for the hip b/c it lacks a cambium layer in the periosteum
[T/F] psoriatic arthritis usually occurs simultaneously with psoriatic skin disease
false joint disease usually occurs 7-8yrs after the skin disease (tho it can occur simultaneously)
[T/F] treat mucous cysts in the DIP w/ aspiration of the cysts followed by splinting
false - do NOT aspirate these
[T/F] synovial joints are vascular but not innervated
false. they are both innervated and vascular -think: the synovial fluid is filtered from the blood, so it must at least have vascularity
Tx for compartment syndrome
fasciotomy
most common location of osteosarcoma
femur
Bones involved in the knee joint? what mvmts do they allow?
femur, tibia, patella -the main joint is between the medial and lateral condyles of the femur and the tibial plateau (medial and lateral condyles) flexion and extension; some medial and lateral rotation
opioid of choice for epidural administration
fentanyl (rapid onset and no systemic fx at low doses)
only available transdermal opioid
fentanyl patches
the ilipsoas, rectus femoris, tensor fascia lata, and sartorius muscles perform what motion at the hip?
flexion
Baker's cyst
fluid-filled sac behind the knee (in the popliteal region) -causes pain in the posterior knee
two patterns of tinea pedis
interdigital mocassin
prednisone, prednisolone, methylprednisolone, and triamcinolone are the [short, intermediate, long] acting synthetic glucocorticoids
intermediate
most common type of hip fracture
intertrochanteric femur fracture
what is the difference between an intra articular fracture and an extra articular fracture?
intra articular involves the joint space
Bennett's fracture
intraarticular fracture thru the base of the first metacarpal bone -may have a large distal fragment dislocated radially and dorsally by the abductor pollicis longus muscle
what side effect should you suspect if the pt's disease has not progressed but their pain is no longer relieved by their opioids?
hyperalgesia (paradoxical rxn: incr pain of lack of pain relief from meds) would tolerance also apply?
"mouse/rat bite" "punched out erosions"
gout x-ray
Tx for open fracture
surgical intervention
Leading cause of disability in pts <50y/o ??
Low back pain (LBP)
The shoulder is innervated by which plexus?
brachial plexus (C5-T1)
bones involved in the shoulder joint
humerus (head) and scapula (glenoid cavity)
most accurate test for PCL injuries
posterior drawer test (@ 90degrees flexion)
most common pathogen responsible for osteomyelitis
S. aureus (for both children and adults)
Most common etiology of osteomyelitis
S. aureus infection
spondylolisthesis is most common in what age group? what is the most common presentation in this age group?
10-15y/o asx (tho may have low back pain)
MOA of hydroxychloroquine concerning side fx?
#2 synthetic DMARD inhibits locomotion of neutrophils and chemotaxis of eosinophils retinopathy
2 anatomical parts of the lumbar disk
(1) Nucleus pulposus (central core of proteoglycans and water) surrounded by the (2) annulus fibrosis (circumferential rim of collagen)
prime mover of knee extension
(Quadriceps) Rectus femoris, Vastus lateralis, Vastus medialis, Vastus intermedius
name at least 3 non-adrenal disorders for which we could rx corticosteroids (glucocorticoids specifically)
*inflammatory or autoimmune conditions (since glucocorticoids are anti-inflammatories and immunosuppressants) -RA -SLE -IBD -gout -asthma/COPD -bursitis -dermatologic conditions (ex: eczema, dermatitis, psoriasis, acne, vitiligo, etc) -neoplasms (ex: ALL, lymphomas)
Tx of spinal stenosis
*Lumbar epidural corticosteroid injection* or decompression laminectomy
Classes of shoulder separation (I-V)
*note: class I-III MC I = normal CXR (AC ligament sprain) II = slight widening (AC rupture, CC ligament sprain) III = significant widening (AC and CC rupture) IV = class III + displacement of clavicle into/thru trapezius V = class IV + disruption of clavicular attachments
Prostaglandin E2 (PGE2)
*produced by COX1 acts on distal tubule and collecting duct to increase sodium and water excretion -also responsible for gastric protection
What are some non-pharmacologic measures we can use in the tx of SLE?
-*sun protection (and supplement Vitamin D to compensate) -exercise (to rebuild muscle, and good for joints) -smoking cessation (cuts down inflammation)
WHO 3 step analgesic ladder - what is it and what are the 3 steps?
-3 step progression for pharmacologic Pain treatment Step 1 (mild pain 1-3): nonopioids +/- adjuvants Step 2 (moderate 4-7): weak opioids +/- nonopioids +/- adjuvants Step 3 (severe 8-10): strong opioids +/- nonopioids +/- adjuvants
Acromioclavicular crossover test aka scarf test
-AC joint separation Pain when pt (w/ arm at shoulder level) crosses arms over chest - stretches the injured ligament
type I/primary bone healing (aka ______) is performed using _____, and there [is, is NOT] additional bone/callus formation type II/secondary healing is performed using _____, and there _____ additional bone/callus formation which is more invasive?
-Haversian canal remodeling -compression plating/techniques -is NOT -casts, external fixation, intramedullary nails, plate fixation -is (follows the typical bone healing process) type I is more invasive
which labs will be positive in RA?
-RF (rheumatoid factor) - nonspecific for RA -anti-CCP - specific ESR, CRP, and WBCs will also be elevated d/t inflammation
Acute pain vs chronic noncancer pain: -duration? -pathology present? -predictable prognosis? -psychosocial component present?
-acute: hrs to wks; chronic: mon to yr -acute: yes; chronic: no -acute: predictable; chronic: unpredictable -acute: no; chronic: yes
Bankart lesion
-associated w/ anterior glenohumeral dislocation a fracture of the anteroinferior portion of the rim of the glenoid fossa anterior pointing motion you may make when you say "and you can take THAT to the bank!"
Hill-Sachs lesion
-associated w/ anterior glenohumeral dislocation indentation of the posterior humeral head resulting from the humerus hitting the glenoid during dislocation *makes a little hill on the place you hold your Sachs purse
Subacromial impingement syndrome is usually associated w/ injury to what structures?
-compression of RTC (esp supraspinatus) -inflammation of subacromial bursa
Immunology tests (other than ANA) we can use to test for SLE (tests that are SLE-specific)
-dsDNA antibody test -Anti-Smith antibody test *both of these are 100% specific for SLE
How is the inflammatory arthritis in SLE similar to that of RA?
-fx joints -more common in women than men -autoimmune diseases -correspond w/ fatigue/weakness -both have a genetic component
Normal ROM for hip flexion
0-120
normal ROM for knee
0-135 degrees
Normal ROM for shoulder flexion
0-180
allopurinol dose should be titrated to get uric acid levels < ___
6
7 Ps of compartment syndrome
1. *Pain out of proportion w/ injury* 2. pulselessness 3. paresthesias (numbness and tingling) 4. paralysis 5. pallor 6. poikilothermia 7. pressure
[T/F] we do not treat asx disk herniation pts
true -it's so common that we only treat pts w/ sx
Main patterns of psoriatic arthritis (5)
1. Asymmetric oligoarticular arthritis 2. Symmetric polyarticular arthritis (MC) 3. Spondylitis 4. Distal interphalangeal predominant (DIP fx DIP joints hehe) 5. Arthritis mutilans
3 key components of SLE pathophysiology
1. Autoantibody production 2. Immunocomplex deposition 3. Systemic inflammation
SLE most commonly manifests in which two areas of the body?
1. Joints 2. Skin (Tho we also discuss deep organ manifestations generally)
what are the two types of osteoporosis?
1. Primary - postmenopausal/senile (MC in women) 2. Secondary - d/t chronic disease or meds (MC in men)
3 main ligaments of the elbow
1. Radial collateral ligament - b/w humerus and radius 2. Ulnar collateral ligament - b/w humerus and ulna 3. Annular ligament - b/w radius and ulna
Ankylosing spondylitis diagnosis - either: 1. _____ w/ at least one of the features below OR 2 _____ w/ at least two of the features below Features: -inflammatory back pain, enthesitis, arthritis, uveitis, dactylitis, psoriasis, IBD, fam hx of AS, elevated CRP, aortic regurg or aortitis, absence of subcutaneous nodules and serum factors (ex: RF)
1. Sacroiliitis on imaging 2. HLA-B27 positive
main physiologic fx of glucocorticosteroids (2)
1. anti-inflammatory 2. immunosuppressive
hamstring muscles (3)
1. biceps femoris 2. semitendinosus 3. semimembranosus
Types of pain scale (6)
1. Wong-Baker Faces - pictures 2. Visual Analog Scale (VAS) - numbers 3. Pain Assessment in Advanced Dementia (PAINAD) - FCN BB 4. Adult Nonverbal Pain Scale - for pts in the ICU 5. Pain Quality Assessment Scale (PQAS) - quality of the pain 1-10 6. Brief Pain Inventory (BPI) - for chronic pain
Which imaging studies will you order for osteoporosis?
1. X-ray first 2. DEXA (dual-energy x-ray absorptiometry) scan of the lumbar spine and head of femur - measures bone density
Which imaging studies will you order for a suspected sprain/strain?
1. X-ray first line to check for bone damage and other musculoskeletal concerns 2. MRI after x-ray to check for soft tissue injuries
2 main methods of pathogen entry in osteomyelitis and septic arthritis
1. direct inoculation 2. hematogenous spread (MC in kids)
3 Phases of Trauma Mortality
1. early phase - immediate death (within golden hour) 2. second phase - death within min to hrs after event 3. third phase - delayed death (days after event)
types of distal humerus fractures (3)
1. extra-articular 2. intra-articular 3. intra-articular with comminution
osteonecrosis/AVN most commonly affects what 3 bones? why?
1. femoral head 2. scaphoid 3. navicular The blood supply of these bones runs retrograde, so blood flow is more easily disrupted
4 stages of bone fracture healing
1. hematoma formation 2. fibrocartilaginous callus formation 3. bony callus formation 4. bone remodeling
2 etiologies of olecranon bursitis
1. inflammatory 2. infectious
two types of Achilles tendonitis
1. insertional = pain/inflammation where the tendon inserts on the calcaneus 2. noninsertional = pain/inflamm ~4-6cm above the insertion of the tendon *this one has more inflammation and edema, and is more palpable
3 main nerves of the elbow and their contributing nerve roots
1. median C5-T1 2. radial C5-T1 3. ulnar C8-T1 *alphabetical order
most common etiologies of glenohumeral instability (2)
1. microtrauma fr overuse (sports injury) 2. general ligamentous laxity (from connective tissue disorder)
Stages of acetaminophen poisoning
1. n/v, abd pain, sweating, LFTs normal 2. liver injury and URQ pain; rise in LFTs 3. peak hepatotoxicity; rapid and severe hepatic failure, encephalopathy, hypoglycemia, coma and death 4. recovery stage for those who survive stage 3
what are the major differences b/w synthetic glucocorticoids and endogenous cortisol? (2)
1. synthetics are usu stronger 2. synthetics usu have longer half-lives
3 types of olecranon fracture
1. undisplaced (comminuted or noncomminuted) 2. displaced - stable (comminuted or noncomminuted) 3. unstable (comminuted or noncomminuted) - joint has been dislocated
The use of skeletal muscle relaxant neuropathic pain adjuvants is limited to ____ days to avoid side fx
14-21 Ex: carisoprodol, baclofen
___% of pts w/ psoriasis develop psoriatic arthritis
15
degrees of sprains/strains and their treatment
1st degree = sprain/strain -conservative tx 2nd = incomplete tear -conservative tx 3rd = complete tear -possible surgical repair
a scoliosis curve of > ____ in an adolescent warrants a brace, while a curve >____ (skeletally immature) or >____ (skeletally mature) warrants surgical correction/fusion
25 40 50
how many bones are in the adult human body?
206 bones
March fracture most commonly occurs in which bone?
3rd metatarsal -distal metatarsal fracture
minimum duration of abx for spinal infections
6 wks (or 3-6 mon if hardware is involved)
Gabapentin, pregabalin, topiramate, carbamazepine, and lamotrigine are examples of what type of medication?
Anticonvulsants
Pinprick sensation over the deltoid indicates _____
Axillary nerve injury (watch for this when reducing a shoulder dislocation)
What position typically alleviates pain in pts w/ spinal stenosis? A. Lumbar extension B. Lumbar flexion C. Lumbar side-bending D. Lumbar rotation
B
what is unique about March fractures on x-ray?
50% will not initially appear on imaging
in chronic opioid therapy, ____% of their total daily dose will be used as the long-acting dose, and the rest will be used as their ____ dose
50-75% prn/breakthrough
Max daily dose of acetaminophen
4000 mg (4g) -OR 2000mg (2g) w/ alcohol or warfarin *can cause acute liver failure
Intracompartmental pressure > ___ OR within ____ of the diastolic bp = compartment syndrome
40mmHg 30mmHg *note, though, that compartment syndrome is usually a clinical dx
Your body completely replaces its skeleton every __ years
5
Pain Assessment in Advanced Dementia (PAINAD)
5 item assessment to determine pain levels in nonverbal adults OR adults w/ dementia (clinician-driven pain scale) 1. Facial expression 2. Consolability 3. Negative vocalization (screaming, moaning, etc) 4. Breathing (NOT vocalization) 5. Body language
a force of up to _____x times body weight can be exerted on the human foot while running. Most force is exerted on the _____ regions of the foot
5-7 heel, ball, and pad of the big toe
Cubital tunnel syndrome will show nerve conduction < ___ m/sec with a flexed elbow on EMG
50
The cortex of the finger bones should make up ___% of the fingers' width on x-rays
50%
it is recommended that all women over the age of ___ be screened for osteoporosis. What screening test is used?
65 DEXA scan
when do we start screening for osteoporosis? What test do we use in screening?
65 y/o for women 70 y/o for men Use a DEXA bone density scan
in CT, what is the maximum opioid supply you can rx for first time outpt use? for minors? what are the CE requirements for prescribing opioids?
7 days 5 days 1 contact hr every 2 yrs, and register for/review the database every 90 days
Compartment syndrome: Without surgery, irreversible muscle damage occurs within ___ hrs and irreversible nerve damage occurs within __ hrs
8 (though you have possible irreversible damage as early as 4 hrs) 8 (though nerve conduction deficiencies start at 2 hrs and neuropraxia occurs at 4 hrs)
first line drug for RA second line?
Methotrexate hydroxychloroquine (anti-malarial)
Which neurologic level is responsible for extensor hallucis longus contraction (big toe extension) and sensation to the dorsal foot and lateral thigh?
L5
in the hand, retinacular cysts arise from the _____ while mucous cysts arise from the _____
A1 pulley DIP
you are more likely to hear a "pop" with a(n) [ACL, PCL] injury
ACL
Lachman's Test
ACL Injury -abn anterior mobility at 30degrees knee flexion -One hand stabilizes the distal femur while the other firmly grasps the proximal tibia, a gentle anterior translation is applied to the proximal tibia
Pivot Shift Test reverse pivot shift test
ACL injury PCL injury
most common knee ligament injury
ACL tear
Anterior Drawer Test (knee)
ACL tear -Abnormal anterior mobility of the tibia at 90° knee flexion -Flex the knee to 90° and sit on the pt's foot to restrain it. Wrap both hands around the proximal tibia, and pull it forward w/ both hands
pain at the ___ nerve root could be from an L4-L5 disk space herniation OR an L5-S1 far lateral herniation
L5
Most common initial test for SLE
ANA (antinuclear antibody) test -very sensitive but nonspecific (many false positives)
Which view is preferred for spinal x-rays?
AP (placing the spine further from the x-ray source minimizes the distortion of the spine) *this is only my educated guess*
What type/view of x-ray do we typically get for orthopedic/rheumatologic complaints?
AP and lateral (at least)
enthysopathy most commonly fx the ______
Achilles tendon *enthysopathy = disease of the entheses, where ligaments and tendons attach to bone
Thompson Test
Achilles tendon rupture -lack of plantar flexion of foot when squeeze calf
most common form of dwarfism
Achondroplasia
Topical pain relief is used mainly for [acute, chronic] pain
Acute
Which types of cells malfunction in SLE?
Adaptive immunity = B-cells and T-cells
The recurrence rate for shoulder dislocations corresponds w/ what pt factor?
Age at dislocation - 90% recurrence rate if 1st dislocation at <20y/o
Ill-defined borders, "spiculated" or "Codman's triangle" periosteal rxn, and soft tissue involvement/cortical destruction = [aggressive, non-aggressive]
Aggressive
MOA of aldosterone
Aldosterone is a steroid hormone (mineralocorticoid family) produced by the outer section (zona glomerulosa) of the adrenal cortex in the adrenal gland. It plays a central role in the regulation of blood pressure mainly by acting on the distal tubules and collecting ducts of the nephron, increasing reabsorption of Na+ and water in the kidney, to cause the conservation of sodium, excretion of potassium, increased water retention, and increased blood pressure.
Most common vertebral level of spondylolysis and spondylolisthesis
L5-S1
Most effective tricyclic antidepressant adjuvant for neuropathic pain
Amitriptyline
Maisonneuve fracture
An external rotation injury of the ankle with an associated spiral fracture of the proximal third of the fibula -also assoc w/ ruptured interosseus and syndesmosis mem, deltoid ligament tear
Medical terminology breakdown: ankylosing spondylitis
Ankylosing = stiffening Spondylitis = inflammation of the vertebrae
Most common seronegative spondyloarthropathy
Ankylosing spondylitis
Most common type of shoulder dislocation
Anterior
You fall on your outstretched arm: What shoulder position will result in an anterior glenohumeral dislocation? A posterior dislocation?
Anterior: abduction and external rotation Posterior: adduction and internal rotation
Which occurs first in IBD enteropathic arthritis: GI sx OR arthritis?
Arthritis
Most severe pattern of psoriatic arthritis
Arthritis mutilans - severe joint damage
Covers and protects bone ends; allows bones to move w/ little friction and absorbs some of the compressive forces on the joint
Articular cartilage
Pain quality assessment scale (PQAS)
Ask the pt specific questions related to the quality of their pain (ex: how hot is your pain? How much of a shooting quality does it have?) -ask the pt to rate their pain on a scale of 1-10 for each question
most common location of a herniated disk
L5-S1 (b/c it's the jn b/w the mobile and non-mobile spine)
pts with HLA-____ are more genetically susceptible to developing seronegative spondyloarthropathies
B27
most common tumors to mets to the spine
BLT-KP breast lung thyroid kidney prostate
mechanism of action of local anesthetics
Block voltage-gated sodium channels - Na+ can't flow in and K+ cannot flow out of the neuron, stopping signal conduction
Gout pathophysiology
Body can't metabolize uric acid so it accumulates in the blood and tissues. Urate salts form needlelike crystals that form deposits especially in the smaller bones of the feet. Extremely painful.
Why do osteophytes form in osteoarthritis?
Body's attempt to spread out the pressure on the joint by increasing the joint surface area
Wolffe's Law
Bone responds w/ stronger bone in the presence of physical stress -basically, bone heals better when you stress it a little (ex: weight-bearing exercise)
What pain scale can we use for chronic pain?
Brief pain inventory (BPI) -tracks/detects improvements in pain over time -focused on functionality (ex: how much does your pain affect your sleep, relationships, etc.?)
Patient is a 45y/o healthy male admitted to hospital d/t worsening bilateral leg pain L>R lateral leg pain into dorsal foot. Exam: +SLR (straight leg raising) on left, 4/5 weakness in left EHL (extensor hallucis longus). What is the pt's dx? A. L3-4 disk herniation B. L4-5 spinal stenosis C. L4-5 disk herniation D. L5-S1 epidural abscess
C
Varus Stress Test
LCL injury -Knee opens up on lateral side when varus force (force to the medial knee) applied at 30° knee flexion
spinal nerve root most commonly impinged in cervical radiculopathy -what are the motor, sensory, and reflexes affected?
C5 -d/t a C4-C5 herniated disk -motor: deltoid, biceps -sensory: lateral arm -reflex: biceps
which nerve is in charge of the biceps reflex?
C5 (injured by a C4-5 herniation)
which nerve is responsible for the brachioradialis reflex?
C6 (injured by a C5-6 herniation)
which nerve is responsible for the triceps reflex?
C7 (injured by a C6-7 herniation)
Which type of imaging is typically used for pre-op planning in ortho and rheum complaints?
CT
celecoxib has a black box warning for ______
CV risk (but does NOT inhibit platelet fn...therefore, best in pts w/ a low CV risk but a high risk of bleeds)
On x-ray: incr density of the calcaneus + rough bone edges + soft tissue swelling (hazy) + decr Bohler's angle (<20-40degrees) should cause suspicion of a _____
Calcaneal fracture - typically from a jump
Name the tarsal bones mnemonic?
Calcaneus, talus, navicular, medial/intermediate/lateral cuneiforms, cuboid mnemonic: The Circus Needs More Interesting Little Crazy Clowns
Key mineral for the creation and repair of bones
Calcium
Mnemonic for classic triad of reactive arthritis
Can't see, can't pee, can't climb a tree (Conjunctivitis, urethritis, arthritis)
Spongy bone is also called ____ bone Compact bone is also called ____ bone
Cancellous Cortical
Drug of choice for trigeminal neuralgia
Carbamazepine (tho lamotrigine may also be used) - anticonvulsants
Describe the joint distribution of IBD enteropathic arthritis
Pauciarticular, possibly asymmetric, may be migratory
New onset loss of bowel or bladder function, perineal or saddle paresthesia, radiating leg pain/numbness, severe lower back pain, and decr anal spincter tone (no "anal wink")
Cauda equina syndrome - neurosurgical emergency!
Most common selective COX-2 inhibitor
Celecoxib
Central neuropathic pain originates from injury or impairment of the _______ Peripheral neuropathic pain?
Central NS: brain or spinal cord Peripheral NS: nerve roots, plexus, DRG, or peripheral nerves
Most common pathogen trigger of reactive arthritis
Chlamydia trachomatis
myasthenia gravis pathophysiology
Chronic autoimmune disease of neuromuscular (NM) junction w/ fluctuating weakness of certain skeletal muscle groups (ex: diplopia, ptosis) -Triggered by autoantibodies that attack acetylcholine (ACh) receptor sites at NM junction, interfering with impulse transmission in the muscles
Dinner fork deformity
Colles fracture
Rolando's fracture
Comminuted Bennett's fracture of the 1st metacarpal bone
Condition in which increased pressure within a limited space compromises the circulation and fn of tissues w/in that space
Compartment syndrome
The highest hazard ratios for SLE occur w/ deficiencies of _____
Complement components (C1q, C4A/B, C2)
Cauda equina syndrome pathophysiology and common etiology
Compression of the cauda equina of the spinal cord (nerve roots)- neurosurgical emergency!!! -d/t herniated lumbar disk (or anything that can compress that area of the lumbar spine)
First line tx for subacromial impingement syndrome
Conservative: PT, oral NSAIDs, steroid injections (assuming there is no rotator cuff tear)
Most common finding on a CBC for a pt w/ SLE
Cytopenias (anemia, leukopenia, lymphopenia, thrombocytopenia)
What is a typical presentation of cauda equina syndrome? A. Low back pain B. Lower extremity paresthesias alone C. Abdominal paresthesias D. Lower extremity paresthesias/weakness, bowel/bladder incontinence E. None of the above
D
The end of a long bone is called the _____ The middle of a long bone is called the ______ The _____ separates these two parts in adult bones
Epiphysis Diaphysis Epiphyseal line
Which type of bone heals better, cancellous or cortical? Why?
Cortical = more vascular
IBD enteropathic arthritis is more common in [Crohn's, UC]
Crohn's
Name the muscle connective tissue sheaths fr internal —> external
Endomysium (surrounds muscle fibers) —> perimysium (surrounds fascicles) —> epimysium (surrounds muscles) *the convergence of these 3 layers creates the tendon
Which finger joints are most commonly affected in OA?
DIP and base of thumb (1st CMC)
which joints are commonly spared in RA?
DIPs, spine (except C1 and C2) -unlike OA
main treatment for RA -drug of choice?
DMARDs (disease-modifying anti-rheumatic drugs) -methotrexate = drug of choice
Osteoporosis presents with [lighter, darker] than normal bone on x-ray
Darker (lost bone density)
Finkelstein's test
DeQuervain's Tenosynovitis -Pain along distal radius w/ ulnar deviation or thumb extension/abduction
Ankylosing spondylitis pts will have [incr, decr] chest expansion at the xiphoid. Why?
Decr (<2.5cm) -decr range of motion of the costovertebral joints
Lytic lesions = bone [degeneration, proliferation] Blastic lesions = bone _____
Degeneration (darker bone on imaging) Proliferation (whiter on imaging)
antidiarrheal opioids
Diphenoxylate, Loperamide
AC joint separation results from what mechanism of injury? (W/ injury to which ligaments)
Direct blow to an adducted shoulder, causing injury to the AC and/or coracoclavicular ligaments
Exercise [does, does NOT] improve sx of inflammatory back pain. Exercise ____ improve sx of mechanical back pain.
Does Does NOT (use makes sx worse)
most common and most severe muscular dystrophy
Duchenne's muscular dystrophy
ECU synergy test
ECU tendinitis -Pain at the ECU tendon when pt abducts thumb against resistance
which tendon is most commonly injured in a Colles fracture?
EPL (extensor pollicis longus) tendon - rupture most common
Early vs late x-ray findings of ankylosing spondylitis
Early: square-shaped vertebrae (fr syndesmophyte formation) Late: bamboo spine
Bone that is too opaque on x-ray signifies ____ Bone that is too dark signifies ______
Extensive mineralization Bone degeneration
Most common cause of rotator cuff repair failure
Failure of the cuff tissue to heal
Most common etiology of Colles fracture
Fall on a outstretched arm
[T/F] cartilage generally heals easily
False -cartilage has no blood supply, so it takes a long time and is very difficult for it to heal
[T/F] acetaminophen (Tylenol) is an analgesic, antipyretic, and anti-inflammatory medication
False -it is NOT an anti-inflammatory (only an analgesic and anti-pyretic
[T/F] in osteoarthritis, there is a good correlation b/w the pt's sx and the severity of the joint degradation on imaging
False "can't read pain from an x-ray"
The ANA test is mainly used for dx confirmation (NOT dx) b/c it gives a lot of ____ results
False positive (it's sensitive but not specific)
[T/F] lumbosacral strains/sprains can result in neurologic changes
False. -isolated muscle injury...should not affect the nerves
[T/F] incr doses of NSAIDs increases both analgesia intensity and duration
False. Duration only
[T/F] you can use a hand x-ray for dx of wrist pathology
False. Get a wrist view x-ray
[T/F] cartilage contains nerves but no blood vessels
False. It contains neither blood vessels nor nerves
[T/F] inflammatory back pain can be an acute OR chronic condition
False. It is a chronic condition w/ insidious onset. -this is in contrast to mechanical back pain, which can be acute OR chronic w/ a variable onset
[T/F] Humerus x-rays and radius/ulnar are good if you want to look at two joints simultaneously
False. You cannot see into the joint space, so these scans are NOT used for the dx of joint pathologies -these scans are best for dx of pathologies in the diaphysis of these bones
[T/F] surgery is an acceptable course of action in severe isolated low back pain (LBP)
False...we want to avoid surgery in these cases
A family history of early (<40y/o) and multiple joint replacements suggests what etiology of OA?
Familial primary OA (d/t rare genetic syndromes)
What is the difference between a fatigue fracture and an insufficiency fracture?
Fatigue = repetitive stress on a normal bone Insufficiency = normal stress on an abn bone
Tx for AC joint separation
For types I-III (MC): sling immobilization For types IV-V: ORIF
What types of infections can trigger reactive arthritis?
GI or GU
Garden grades of femoral neck fractures
Garden I = valgus impacted or incomplete II = complete, non-displaced III = complete, partial displacement IV = complete, full displacement
"Popped out" sensation in the shoulder
Glenohumeral dislocation
Squared-off shoulder held in abduction
Glenohumeral dislocation (anterior)
podagra
Gout (in the 1st MTP joint of hallux)
Arthroscopic grading system for OA
Grade 0 = normal cartilage I = softening and swelling II = superficial fissures III = deep fissures w/o exposed bone IV = exposed subchondral bone
Myerding Grading System for spondylolisthesis
Grade 1: <25% of vertebral diameter 2: 25-50% 3: 50-75% 4: 75-100% spondyloptosis: 100%
Seronegative spondyloarthropathies are associated with what genetic antigen?
HLA-B27 (human leukocyte antigen B27)
genes associated with RA
HLA-DR1, HLA-DR4 (HLA-DRB10) (w/ SLE it's DR2 and DR3)
plantar verruca is associated with what microorganism?
HPV
Compartment syndrome corresponds w/ [hypotension, hypertension] and [hypokalemia, hyperkalemia]
Hypotension (renal failure) Hyperkalemia (cardiac arrest)
Osteophytes are abnormal bone proliferation in what direction? Syndesmophytes?
Horizontal (ex: osteoarthritis) Vertical (ex: ankylosing spondylitis)
Explain the location of the humeral head on a normal Y view x-ray
Humeral head should rest in the middle of the "Y" which is formed by the scapula -humerus outside the "Y" indicates a dislocation
What anti-malarial drug is recommended for most pts w/ SLE (even those pregnant or breastfeeding)?
Hydroxychloroquine
Stages of Knee Osteoarthritis
I = doubtful; minimum disruption II = mild; joint space narrowing and cartilage begins to break down III = moderate; moderate joint space reduction, gaps in the cartilage can expand until they reach the bone IV = severe; joint space greatly reduced, loss of cartilage reaches 60%, and large osteophytes are noted
5 types of Salter-Harris fracture
I = thru physis II = thru metaphysis and physis III = thru epiphysis and physis IV = thru metaphysis, epiphysis, and physis V = destruction of the growth plate
Gustilo and Anderson Classification of Open Fractures and the tx for each type
I: <1cm soft laceration -tx: 1st gen cephs II: 1-10cm laceration -tx: 1st gen cephs + aminoglycosides IIIA: >10cm, no coverage needed B: coverage needed C: vascular repair needec -tx: 1st gen cephs + amino + pcn
most opioids are category ___ drugs, except for which two drugs mentioned in lecture?
II codeine (category varies by formulation) tramadol C-IV
How can you distinguish a pediatric (immature) skeleton from an adult (mature) skeleton on x-ray?
Immature long bones have open physes/growth plates where cartilage proliferates to grow/extend the bone -this epiphyseal plate will calcify into an epiphyseal line as the patient ages
Vertebroplasty vs Kyphoplasty
In both procedures, bone cement is injected into a fractured vertebra with the goal of relieving back pain caused by vertebral compression fractures. -vertebroplasty: done in the OR -kyphoplasty: done by radiology
Which neurologic level is responsible for hip flexion and knee extension, patellar reflex, and distal anterior thigh sensation?
L3
Indications for a total joint replacement for OA -contraindications?
Indications = refractory pain despite conservative tx, significant functional limitations Contraindications = severe obesity, uncontrolled DM, other medical contraindications (it's an elective procedure)
DeQuervain's Tenosynovitis
Inflammation/stenosis of the sheath over the abductor pollicis longus (APL) and extensor pollicis brevis (EPB), resulting in pain in the radial wrist
External rotation lag sign
Infraspinatus injury -inability to maintain external rotation of the shoulder; weakness at 0° abduction
What type of rash is the classic lupus rash (as seen on histology)?
Interface dermatitis (inflammation occurs at the dermal-epidermal jn)
On x-ray, the glenohumeral joint space is better visualized w/ [internal, external] rotation
Internal
"Light bulb" appearance of humerus on x-ray
Internal rotation of the humerus at the shoulder makes the humeral head look like a light bulb -this appearance may be seen on the x-ray of a posterior shoulder dislocation (b/c in this injury, the shoulder is internally rotated)
an L4 nerve root injury occurs w/ a lumbar disk herniation at what level?
L3/L4
Which neurologic level is responsible for foot inversion (tibialis anterior contraction) and dorsiflexion, patellar reflex, and sensation of the medial foot and anterior thigh?
L4
Most common joint manifestation of SLE
Joint pain
Classic Triad of SLE
Joint pain + malar rash + fever
Most common location of osteoarthritis
Knee
Common locations of OA
Knee Cervical and lumbar spines Hand and foot Hip *MC in weight-bearing joints
Which neurologic level is responsible for hip flexion and inguinal region sensation?
L1
the spinal cord end at what spinal level? what structure extends inferiorly?
L1 cauda eqina (nerve roots)
Which neurologic level is responsible for hip flexion and anterior mid-thigh sensation?
L2
most sensitive test for ACL tears/instability
Lachman test (@ 30degrees flexion)
Fleck's sign
Lisfranc fracture -fracture at the base of the 2nd metatarsal and subsequent widening b/w the 1st and 2nd tarsometatarsal joints
achondroplastic dwarfism
Long bones stop growing in childhood (inhibition of normal cartilage formation at growth plate chondrocytes) Normal torso, short limbs -enlarged head, bulging forehead, conspicuous depression of the root of the nose
Best imaging for soft tissue visualization in orthopedics/rheumatology
MRI
Gold standard imaging for evaluating nerve compressions
MRI
Gold standard imaging for evaluating rotator cuff pathologies
MRI
Gold standard imaging for subacromial impingement syndrome
MRI
In cases of infection and myositis (muscle inflammation), what type of imaging do we want to get?
MRI
Which diagnostic imaging do we use to evaluate soft tissue injury in ortho complaints?
MRI
gold standard imaging to assess ligamentous or meniscus injuries
MRI
gold standard imaging to evaluate nerve compression
MRI
imaging test of choice for lumbar disk herniation
MRI
imaging test of choice to evaluate spinal stenosis
MRI
gold standard imaging for septic arthritis what diagnostic test will give us a definitive dx?
MRI positive blood culture
gold standard imaging for spinal disorders
MRI (allows us to visualize the spinal cord)
Gold standard imaging for RTC tears
MRI (look at soft tissue structures)
What type of scan do we use for early detection of osteomyelitis?
MRI OR bone scan (x-ray is insensitive early on)
How is a Schober's test performed, and what does a positive test indicate?
Mark L5 (superior iliac spine) and mark 10cm superior to L5. Measure the distance b/w the marks when the pt bends over -distance < 15cm = positive test (indicates lumbar flexion restriction)
joint line tenderness to palpation (TTP) test
Meniscus injury Pain upon palpation of the medial or lateral knee when the knee is flexed at 90° -medial pain = medial meniscus injury -lateral pain = lateral injury
Most common source of bone tumor
Metastases from other cancers
Ankylosing spondylitis is more common in [men, women, both equally]
Men (think of all the example pictures you see...they're all of men!)
McMurray Test
Meniscal tear -Click sound + pain while tibia is rotated For medial: external rotation + 90° flexion For lateral: internal rotation + 90° flexion
OA: [inflammatory, non-inflammatory] [involves, does not involve] infection in the joint [symmetric, asymmetric] joint space narrowing Feels better [in the morning, at night]
Non-inflammatory Does NOT involve joint infection Asymmetric In the morning (after rest)
What test can we use to visualize the spinal cord if MRI is contraindicated?
Myelogram - inject contrast into the spinal canal for visualization (fluoroscopy) -you will see a "pinch" in the dye at the location of cord impingement
Most common primary cancer of bone
Myeloma
Structural hierarchy of muscle fr smallest —> largest unit
Myofilament —> sarcomere —> myofibril —> muscle fiber (muscle cell) —> fascicle —> muscle (organ)
Antidote for acetaminophen toxicity
N-acetylcysteine
Toxic metabolite of acetaminophen
NAPQI
toxic metabolite of acetaminophen - what is and what is its major effect?
NAPQI -hepatotoxicity and acute liver failure
Main/first line treatment for seronegative spondyloarthropathies
NSAIDs [then methotrexate for P or R] then TNF inhibitors
drug of choice for acute gout attack
NSAIDs (ex: indomethicin)
Tx for acute gout attack
NSAIDs (indomethicin), colchicine, glucocorticoids (ex: prednisone)
Tx for reactive arthritis
NSAIDs for acute, methotrexate for chronic -TNF inhibitors if fail
Tx for psoriatic arthritis
NSAIDs initially, methotrexate if severe (Anti-TNF last ditch, steroids always wrong)
Best initial tx for osteoarthritis
NSAIDs or acetaminophen (w/ other forms of conservative mgmt)
Neuropathic pain originates from injury to the _____ Nociceptive pain?
Nervous system Tissues
What does neuropathic pain feel like? Nociceptive?
Neuro = numbness, tingling, burning, shooting, electric shock, hot/cold Noci = mechanical, thermal, mixed
Adjuvants work well for _____ pain -what are some classes of adjuvants? (4)
Neuropathic 1. Serotonin-norepinephrine reuptake inhibitors (SNRI) 2. Tricyclic Antidepressants (TCA) 3. Anticonvulsants 4. Skeletal Muscle Relaxants
_____ pain is harmful, while _____ pain is protective
Neuropathic Nociceptive
Circumscribed borders, no periosteal rxn, and no soft tissue involvement/cortical destruction = [aggressive, non-aggressive]
Non-aggressive
Opioids will work for _____ pain but not ____ pain
Nociceptive (tissue origin) Neuropathic (neuro origin)
Visual Analog Scale (VAS)
Numeric only (no pictures) pain scale -ask the pt to rank their pain on a scale of 0-10
if the 1st CMC is arthritic, it's probably _____ if the MCP joints are affected, it's probably _____
OA RA
how does RA differ from OA in the hand joints it affects?
OA = DIP, CMC of the thumb RA = PIP, MCP *alphabetical...R comes after A, and P/M come after D/C
How is OA different from RA in the portion of the joint they affect?
OA = degradation of articular cartilage RA = proliferation of synovial membrane (and bone erosion)
what type of surgery is preferred for subtrochanteric femur fractures? femoral neck and intertrochanteric fractures?
ORIF ORIF OR THA
Hand phenotype of arthritis mutilans
Opera glass hand (aka telescoping fingers) -this phenotype is also common in rheumatoid arthritis
most common cause of chronic knee pain in active adolescents
Osgood-Schlatter disease
Most common type of arthritis in the US
Osteoarthritis
Progressive degradation of articular cartilage
Osteoarthritis
Heberden's nodes
Osteoarthritis - DIP osteophytes
Bouchard's nodes
Osteoarthritis - PIP osteophytes
_____ are the cells that actively produce and secrete new bone _____ are the cells that break down bone and resorb the matrix
Osteoblasts Osteoclasts
Looser's zones
Osteomalacia (pseudofractures/insufficiency fractures) -appear as symmetrical radiolucent lines in the bone cortex perpendicular to the long axis
What DEXA score indicates osteopenia? Osteoporosis? Severe osteoporosis?
Osteopenia = 1-2.5 standard deviations below the mean Osteoporosis = 2.5+ SD below the mean Severe = 2.5+ SD below the mean + fragility fractures
Most common primary sarcoma of bone
Osteosarcoma
Picture frame vertebrae + very dense bone in pelvis, skull, or hands
Paget's disease (chronic disease of the osteoblasts and osteoclasts)
Brief pain inventory (BPI)
Pain scale used for chronic pain...detects improvements over time
Layers of bone in the diaphysis of a long bone, from outside —> in
Periosteum Compact/cortical bone Endosteum (lines the medullary cavity)
First structure irritated or inflamed in a skeletal disease process
Periosteum (outer layer of bone)
Psoriatic arthritis is primarily a(n) [axial, peripheral, both] disease Ankylosing spondylitis is primarily _____ Reactive arthritis is primarily ____ IBD arthritis is primarily ____
Peripheral Axial (it's also called axial spondyloarthritis) Peripheral Both
Most common approach to arthrodesis
Posterior (want to avoid the internal organs as much as possible)
Lightbulb sign
Posterior glenohumeral dislocation -humeral head looks like a lightbulb on AP x-ray
Most common type of osteoarthritis, and what is the etiology of this type
Primary OA, idiopathic/aging (decr ability of the cartilage to repair normal wear and tear)
Which medications are risk factors for drug-induced SLE?
Procainamide (antiarrhythmic) Hydralazine (vasodilator) INH (isoniazid; anti-TB) Quinidine (antiarrhythmic, anti-malarial)
Boutonniere deformity, Swan neck deformity, cock-up toes, and ulnar deviation of fingers
RA
Erythematous rash w/ thick, silvery-white scales Aka, for us who speak regular, white scales on a red base
Psoriasis
Psoriasis is associated with what rheumatologic diagnosis?
Psoriatic arthritis
Onycholysis is associated with which rheumatologic diagnosis?
Psoriatic arthritis (b/c it's associated w/ psoriasis)
disease w/ extraarticular manifestations including infections, pericarditis/endocarditis/myocarditis, depression, subcutaneous nodules, pulmonary nodules and ILD, vasculitis, scleritis
RA
most common elbow fracture in adults
Radial head fracture
Terrible triad of elbow
Radial head fracture + Coronoid fracture + Lateral Collateral Ligament tear
Dx criteria for ____ 1. Asymmetric oligoarthritis, predominantly lower limbs w/ enthesitis AND proven infection w/ a pathogen associated w/ this disease OR diarrhea or urethritis/cervicitis within the past 6 wks OR 2. Acute inflammatory arthritis including mono arthritis and/or axial inflammation AND proven infection w/ a pathogen associated w/ this disease
Reactive arthritis
In pts w/ recent GI or GU infections, be on the lookout for which type of arthritis?
Reactive arthritis (overzealous immune response to certain GI or GU pathogens)
Keratoderma blenorrhagicum
Reactive arthritis (scaly lesions on the palms and soles)
What is the difference b/w red bone marrow and yellow bone marrow?
Red = site of blood cell production (located in the trabeculae) Yellow = site of fat storage (located in the medullary cavity)
Reactive arthritis may also be called ____
Reiter's Syndrome
What is the developmental significance of the epiphyseal line?
Remnant of the epiphyseal plate (growth plate) in kids...location of bone growth
Ankylosing spondylitis may progress to what lung pathology?
Restrictive lung disease (d/t Ltd chest wall expansion) - it can also lead to pulmonary fibrosis
Osteomalacia in adults is the equivalent of _____ in children. Both are the result of ____
Rickets Vitamin D deficiency or abn Vit D metabolism -leads to defective bone deposition or calcification
Most common cause of shoulder pain in pts >40y/o
Rotator cuff tears
Overhead motions w/ quick decelerations (ex: pitching a baseball) can cause what type of injury?
Rotator cuff tears
most common guilty organism in septic arthritis?
S. aureus
most common organism causing infectious olecranon bursitis
S. aureus
Muscles of the rotator cuff
SITS down: supraspinatus, infraspinatus, teres minor, subscapularis (Down = minor)
Serositis, fever, oral/nasal ulcers, glomerulonephritis, retinitis, cytopenias, and CNS sx are potential systemic fx associated with what rheumatologic disease?
SLE
UV light, certain drugs, viruses/infections, and estrogen are risk factors for what rheumatologic disease?
SLE
Butterfly (malar) rash
SLE *note: it's a photosensitivity rash across the nose and cheeks
Discoid (annular) rash
SLE *note: it's a photosensitivity rash that is deep and leaves a scar
How is the inflammatory arthritis in SLE different from that of RA?
SLE inflammatory arthritis is less destructive and deforming (no erosive changes or cartilage destruction), the joint space is usually preserved, and it is reducible. -pts w/ SLE usually also have sx in other organ systems (ex: skin) and have constant joint pain, while RA pt sx are mainly in the joints, and their pain improves throughout the day w/ use
Duloxetine, venlafaxine, and minalcipran are examples of what type of medication?
SNRIs
In ankylosing spondylitis, autoimmune attack on the entheses causes inflammation, which can eventually lead to new bone formation in what locations?
Sacroiliac joint and vertebral joints (eventually causes vertebral fusion)
Most frequently fractured carpal bone
Scaphoid
Which NSAIDs are best for short-term use in pts w/ a high risk for GI bleeds and a low CV risk?
Selective COX-2 inhibitors
Sensitivity and specificity of DEXA (bone density) scans in osteoporosis
Sensitivity = 88.2% Specificity = 62.5% *sensitive but less specific (therefore potential for false positives)
Which generally occurs first in compartment syndrome: sensory deficits OR motor deficits?
Sensory (remember your pt who couldn't feel her leg but could still move it?)
Mnemonic for common pathogen triggers of reactive arthritis
ShY ChiCS Shigella Yersinia Chlamydia trachomatis (MC) Campylobacter Salmonella *all are GI or GU pathogens*
Shoulder separation presents as pain during what motion?
Shoulder adduction (pt crossing arms over chest - stretches the injured ligament) OR when lifting the arm at the shoulder
What motion (general) causes pain in subacromial impingement syndrome?
Shoulder elevation (overhead mvmts like reaching up to reach taller shelves)
What is the difference b/w a simple fracture and a compound fracture?
Simple = bone breaks but does not break through the skin Compound = bone ends break thru the skin
Baclofen and carisoprodol are examples of what type of medication?
Skeletal muscle relaxants
SMART goals for pain mgmt
Specific Measurable Attainable Relevant Timely
Progression of periosteal rxn (benign —> very aggressive): solid —> lamellated (onion) —> ____ —> _____
Spiculated (sunburst pattern) Codman's triangle (periosteum gone b/c can't keep up repair)
Which is lighter on CT: spinal cord OR CSF?
Spinal cord (more dense than the surrounding CSF)
If a pt comes in with a calcaneal fracture, what other injury do you need to check for?
Spinal fracture (T12-L2)
Spondylolysis vs spondylolisthesis
Spondylolysis = defect/fracture of the pars interarticularis joint Spondylolisthesis = fracture + anterior slippage of one vertebra over another
Stages of General Anesthesia
Stage 1: Analgesia; pt's eyes roving Stage 2: Excitement or delirium; pupils fixed and laryngeal reflexes compromised Stage 3: Surgical Stage 4: Medullary paralysis; respiratory and cardiac collapse
Neer's Test
Subacromial impingement syndrome -Pain during passive forward arm flexion >90° w/ arm fully pronated (thumb down) while shoulder is held down to prevent shrugging
Hawkins-Kennedy Test
Subacromial impingement syndrome -elbow and shoulder flexed to 90degrees: sharp pain w/ internal rotation
Which rotator cuff muscle is most commonly injured? Which is least commonly injured?
Supraspinatus Subscapularis
Jobe Test (Empty Can Test)
Supraspinatus injury -inability to resist downward force while "emptying a can" OR pain w/ abduction against resistance
Drop arm test
Supraspinatus injury -pain w/ the inability to lift or hold arm above shoulder level OR severe pain when slowly lowering the arm after the shoulder is abducted to 90degrees
Tx for RTC pts w/ night pain
Surgery = subacromial decrompression and RTC debridement OR RTC repair OR tendon transfer OR reverse total shoulder arthroplasty
Multimodal pain mgmt
System for pain mgmt developed in response to the opioid crisis -emphasizes non-opioids, adjuvants, and mobility to pain mgmt -encourages pain prevention (ex: NSAIDs)
In DEXA scans, we use a ___ score for postmenopausal women and men > 50y/o (older populations generally), while we use a ___ score for premenopausal women, men < 50y/o, and children (populations in which osteoporosis is uncommon).
T Z *think: Z comes after T in the alphabet = it's "younger" than T...Z score used for younger pts
[T1, T2]-weighted MRI is best for the evaluation of nerve compression
T2 (fluid bright)
What is the difference b/w a tendon and a ligament?
Tendon = connects bone to muscle (think of the Achilles' tendon) Ligament = connects bone to bone (think of the ACL)
Hornblowers test
Teres minor injury -external rotation weakness at 90/90° (shoulder/elbow) abduction and external rotation
What anticonvulsant adjuvant used for neuropathic pain and migraine prophylaxis is also often used as a weight-loss drug?
Topiramate
Most common method for shoulder reduction after dislocation
Traction-countertraction -you can also use the Stimson maneuver or scapular manipulation
[T/F] bones contain both blood vessels and nerves
True
[T/F] drug-induced lupus is NOT associated with kidney damage, CNS damage, or alopecia
True
[T/F] lupus is an autoimmune disease
True
[T/F] typically, the x-ray of a major long bone will include the joint above and below the bone
True
[T/F] the joint in question is typically held at an angle in joint x-rays
True -allows for better articulation of the articulations and joint space
[T/F] for chronic back pain, the efficacy of CAM (complementary and alternative medicine) is superior to that of opioids
True (ex: chiropractic care, acupuncture)
[T/F] inflammatory back pain responds well to NSAIDs
True! NSAIDs are anti-inflammatory meds...so duh -this is in contrast to mechanical back pain, for which NSAIDs may or may not be effective
[T/F] we generally do not surgically repair meniscus tears
True. -there is insufficient blood supply to heal the area, so we generally do NOT surgically operate
3 clinical courses of RA -which is the most common type?
Type 1 = self-limiting and doesn't need tx Type 2 = mild progression but responds well to tx and typically doesn't cause deformities Type 3 (MC) = debilitating progression over time
Ortho physical exam guidelines: 1. always compare bilaterally: eval the [injured, uninjured] side first 2. Always check ____ in addition to the injured joint 3. Check ____, motor, and sensory fn in addition to _____
Uninjured (gives you their baseline) The joints above and below the injured joints Pulse; ROM (AROM and PROM) -pulse, motor, sensory = PMS
Vargus corresponds w/ [medial, lateral] OA and [knock-kneed, bowlegged] stance Valgus corresponds w/ _____ OA and ______ stance
Vargus, medial, bowlegged -Aaaargh, Matey, go to the BOW and walk the plank! Valgus, lateral, knock-kneed
For ortho and rheumatology complaints, CT is usually performed just w/ IV contrast, except for _____ issues, which are performed w/ and w/o contrast. If using contrast during an MRI scan, order the scan ______ contrast
Vascular W/ and w/o
what role does Vitamin D play in Ca2+ regulation in the body?
Vitamin D helps your body absorb calcium from the GI tract
What is the main difference b/w the progression of ankylosing spondylitis and rheumatoid arthritis?
While both have erosive bone destruction (catabolic process), AS also has inflammation and osteoproliferation (syndesmophytes; anabolic process) after the destruction, while RA doesn't.
Less aggressive bone lesions appear [whiter, darker] on x-ray
Whiter (body is better able to heal itself)
Chronic pain is more common in [men, women]
Women
Osteoarthritis is more common in [men, women] and [younger, older] populations
Women Older (incidence increases w/ age - highest b/w 50-70 y/o)
SLE is more common in [men, women], [younger, older] populations, and _____ ethnicities
Women Younger (15-45 y/o) Asians, African Americans, Hispanic Americans (compared to Caucasians)
SLE is most common in what population?
Women of reproductive age
The pain of osteoarthritis is worst at what time of day?
Worst at night (worst w/ use, improves w/ rest) *opposite of inflammatory arthritis
Duchenne muscular dystrophy
X-linked recessive disorder causing defects in dystrophin in the muscle, leading to progressive muscle weakness and degeneration -eventually, the respiratory muscles are affected, and the pt dies
1st line diagnostic imaging for any ortho complaint
X-ray
Of x-ray, MRI, and CT, which provides the highest resolution image?
X-ray
First line imaging for skeletal/orthopedic/rheumatology complaints
X-ray/plain film
Tx of Dupuytren's contracture
Xiaflex (collagenase) injection, steroid injection, surgery -no role for PT or stretching
Name the biologic DMARDs
abatacept - inhibits T-cells rituximab - B-cell cytotoxic (rash) tocilizumab - anti-IL6 receptor antibody adalimumab - TNF-alpha blockade etanercept infliximab
the gluteus medius and minimus, and the tensor fascia lata muscles perform what motion at the hip?
abduction
Scoliosis
abnormal lateral curvature of the spine
cervical strain typically results from what motion?
accel/decel of the cervical spine, causing hyperextension and flexion of the neck -usu seen in MVAs (whiplash)
leading cause of death in young adults
accidents -trauma
leading cause of calls to poison control centers
acetaminophen OD
chondrosarcomas are most common in what population?
adults (40-75y/o)
bone tumors w/ ill-defined borders, a moth-eaten/patchy appearance, a destroyed cortex, and soft tissue masses are more likely [benign, aggressive]
aggressive
Wrist Ganglion
aka "Bible cyst" -benign soft tissue tumor (usually along tendons or joints and their sheaths) in the wrist -most commonly located on the dorsal wrist
Hallux Abducto Valgus - what is it and what is another name for it?
aka bunion -medial deviation and subluxation of the 1st metatarsal at the 1st MTPJ, and lateral deviation of the hallux -usu d/t abn foot mechanics
Jumper's Knee - what is it and what is another name for it?
aka patellar tendonitis -microtears of the patellar tendon d/t overuse
Haglund's deformity
aka pump bump -prominent bony enlargement on the posterior calcaneus (present at birth)
regions of the adrenal cortex: -the zona glomerulosa releases _____ -zona fasciculata releases ______ -zona reticularis releases ____
aldosterone cortisol DHEA *the endogenous corticosteroids
avascular necrosis (AVN) - what is it and what is another name for it?
an area of bone tissue death caused by insufficient blood flow *hannah, it's literally in the name aka osteonecrosis
plantar fasciitis
an inflammation of the plantar fascia on the sole of the foot (esp near its medial calcaneal attachment)
how can we test the median, ulnar, and radial nerves simultaneously?
ask your pt to make the "ok" sign - if they can do this, there are no deficits in any of the 3 nerves
main dose-dependent side effect of nitrous oxide
asphyxiation
we avoid giving what medication to children (d/t the risk of Reye's syndrome)?
aspirin
carpal boss
asx natural anatomic variant -bony prominence on the dorsal wrist where the second/third metacarpals meet the carpals
which are the asymmetric seronegative spondyloarthropathies? the symmetric?
asymmetric = psoriatic arthritis + reactive arthritis (P and R of the PAIR mnemonic) symmetric. = ankylosing spondylitis + IBD (A and I of the PAIR mnemonic)
most patients with RA die from _____
atherosclerotic diseases (b/c atherosclerosis is another inflammatory process and is sped up by the RA inflammation)
Guillain-Barre syndrome
autoimmune condition that causes nerve demyelination, resulting in symmetric ascending paralysis -major concern: failure of respiratory muscles OR autonomic fn
what type of genetic disorder is Achondroplasia? it typically involves mutations in what gene?
autosomal dominant FGFR3 (fibroblast growth factor receptor 3)
sickle cell anemia, hypercoagulable states, steroid use, pregnancy, trauma, alcohol/smoking, and viral infections are all risk factors for what bone disorder?
avascular necrosis
what complication do we really need to watch for with hip fractures?
avascular necrosis -the medial circumflex artery supplying the femoral head has a retrograde blood flow
in what position is it easiest to dislocate the elbow?
axial loading + supination + valgus force
which nerves innervate the rotator cuff?
axillary (teres minor) and suprascapular (other 3 muscles)
a higher minimum alveolar concentration (MAC) = [less, more] potent drug = [lower, higher] dose required for the same fx
less higher
definitive diagnostic test for bone malignancies
biopsy (same as for any cancer)
where is the epidural space located?
b/w the vertebrae and the dura mater (contains fat)
what type of joint is the hip? what bones are involved? what motions does it allow?
ball-and-socket femur (head) and pelvic (acetabulum) motion in all axes
Greenstick fracture
bending and incomplete break of a bone - a portion of the cortex remains intact -most often seen in children (b/c their bones are softer and more pliable)
bone tumors that are well-circumscribed, w/ the cortex intact and reactive margins, and w/o soft tissue masses are more likely [benign, aggressive]
benign
enchondroma - what is it? where does it commonly occur? in what population?
benign cartilage tumor -MC in the hand -younger population
Prime movers of knee flexion
biceps femoris, semitendinosus, semimembranosus (hamstrings)
prime movers of hip extension and knee flexion
biceps femoris, semitendinosus, semimembranosus (hamstrings)
Prime movers of hip extension
biceps femoris, semitendinosus, semimembranosus (hamstrings) gluteus maximus also assists
1st line pharm tx for osteoporosis
bisphosphonates - slow down bone loss, but do NOT reverse it
mechanism of action of inhaled anesthetics
blocks signal transmission at the synapse -inhibits presynaptic ntm release -decreases postsynaptic response
Charcot joint
bone and joint destruction secondary to a neuropathy in DM pts -causes the foot arch to collapse (rockerbottom foot)
in mild DM ulcers, we want to give abx against which organisms specifically? in severe infections?
broad spectrum oral abx gram- and anaerobes
which local anesthetic is preferred for epidurals (w/ fentanyl)? for peripheral nerve blocks?
bupivacaine ropivacaine
what two opioids are used in the tx of opioid dependence?
buprenorphine (partial agonist/antagonist) methadone (strong agonist)
how can we distinguish olecranon bursitis from septic arthritis?
bursitis pts will have a greater ROM than septic arthritis pts (septic pts experience severe pain w/ even a little motion)
what opioid can we use during L&D for women who do not want an epidural?
butorphanol (mixed agonist/antagonist
Mondor's sign
calcaneal fracture -Plantar ecchymosis/hematoma that extends distally along the plantar foot
Talar Tilt Test
calcaneoficular ligament (ankle) sprain -Increased inversion of ankle w/ pt seated
Most frequently fractured tarsal bone
calcaneus
most commonly fractured tarsal bone
calcaneus
"my wrist hurts and my hand goes numb. I wake up from sleep with pain and numbness in my hand/arm" suggests what ddx?
carpal tunnel syndrome
most common upper extremity (compression) neuropathy
carpal tunnel syndrome
Durkan's test
carpal tunnel syndrome -Numbness in thumb, index, middle & radial ring finger w/ pressure over carpal tunnel for 30 secs
Phalen's test
carpal tunnel syndrome -Pain or paresthesias over median nerve distribution w/ wrist volar flexion for 60 sec (compresses the medial nerve)
Tinel's sign (wrist)
carpal tunnel syndrome -Tingling or pain in median nerve distribution (thumb, 2nd & 3rd digits) w/ percussion over median nerve at volar carpal tunnel
which medication is the selective COX-2 inhibitor?
celecoxib
Lhermitte's sign
cervical myelopathy -"Electric shock" in extremities w/ cervical flexion or extension (looking down)
Hoffman's sign
cervical myelopathy -Flexion of thumb & index finger when hyperextending distal middle finger -d/t hyperreflexia
Arm Abduction Test
cervical radiculopathy -Pain/numbness relieved w/ abduction of upper extremity
Spurling's Sign
cervical radiculopathy -Upper extremity pain/numbness w/ extension, rotation, & lateral bending of the neck
what is the medical name for "whiplash"?
cervical strain
Name the vertebrae of the spine and give the number in each section
cervical: C1-C7 thoracic: T1-T12 lumbar: L1-L5 *breakfast at 7, lunch at 12, dinner at 5 sacral: 5 coccygeal: 4-5
Rings and arcs calcification on x-ray
characteristic of chondroid lesions (enchondromas and chondrosarcomas)
_____ is the precursor molecule for all corticosteroids (DHEA, aldosterone, and cortisol)
cholesterol
Your patient presents w/ clawing of the ring and pinky finger, and positive Wartenberg sign, Jeanne sign, Tinel sign, and elbow flexion test. What is your dx?
cubital tunnel syndrome
Elbow Flexion Test
cubital tunnel syndrome -Pt experiences sx (ex: pain, numbness/tingling) in the path of the ulnar nerve within 60sec of elbow flexion -this motion compresses the ulnar nerve
what is the ACR/EULAR criteria used for in rheumatoid arthritis?
classification system used for early ID of pts at risk for RA -based on joint involvement, serology, acute phase reactants (ESR, CRP), duration of sx
injuries [closer to, further from] the center of the menisci are less likely to heal
closer to -closer to the center of the meniscus = further from the blood supply
which opioid is a prodrug of morphine?
codeine (requires metabolic activation - careful in ultra-rapid metabolizers)
antitussive opioids
codeine and hydrocodone, and dextromethorphan
which tendon is most commonly injured in medial epicondylitis?
common flexor tendon (tendon for the pronator teres, flexor carpi radialis, etc)
Wartenberg's sign
cubital tunnel syndrome -pinky finger abduction
Anterior wedging and loss of vertebral body height are characteristic of ____
compression fractures -associated with osteoporosis
carpal tunnel syndrome
compression of the median nerve as it passes between the transverse carpal ligament and the carpal bones -presents w/ pain and numbness/tingling in the portions of the hand innervated by the median nerve (ex: 1-3 digit, 1/2 of 4th digit, thenar muscles, NOT the pad of the thumb) -pain worse at night (b/c sleep w/ wrist flexed)
Cervical Myelopathy
compression of the spinal cord in the neck
Classic Triad of Reactive Arthritis
conjunctivitis + urethritis + arthritis Mnemonic: can't see, can't pee, can't climb a tree
tx for March fractures
conservative care -except in 5th metatarsal
naturally occurring glucocorticoid naturally occurring mineralocorticoid
cortisol aldosterone
tx for septic arthritis
surgical mgmt w/ irrigation and debridement (get that infection out of there!) followed by 2-4wks of abx
definitive tx for olecranon bursitis
drain the bursa -if infectious, cephalexis abx 1st line
"my wrist hurts when I lift or hold my new baby" suggests what ddx?
deQuervain's tenosynovitis
"new mom's tendinitis" is another name for ______
deQuervain's tenosynovitis
most common stenosing tenosynovitis at the wrist
deQuervain's tenosynovitis
basal joint arthritis
degradation of articular cartilage in the 1st CMC joint (base of the thumb)
prime mover of arm abduction
deltoid
which NSAID is available topically?
diclofenac
what is the difference b/w osteoporosis and osteomalacia?
osteomalacia is an issue in building bone, while osteoporosis is the problem of breaking down already formed bone
which inhaled anesthetic is associated with marked respiratory depression and airway irritation?
desflurane
monofilament test
diabetic peripheral neuropathy -Lack of sensation when a monofilament pokes various locations on the plantar foot
what mechanism of injury causes olecranon fractures? radial head fractures?
direct fall on the olecranon fall on an outstretched arm (extended, pronated elbow drives the radial head into the capitulum)
Radiculopathy
disease of the spinal nerve roots aka pinched nerve
Lisfranc injury
disruption between the articulation of the intermediate (2nd) cuneiform and base of 2nd metatarsal
describe type III bone healing
distraction osteogenesis/ilizarov -the bone is cut and pins and rods are inserted to slowly pull on the bone so it lengthens
main side effect to watch for with hydroxychloroquine
effects on the eye/vision -retinopathy, retinal pigment changes, visual field changes, photophobia
what etiologic organism do we worry about in a pt w/ septic arthritis and a human bite?
eikenella -common in cases of "fight bite" on the 4-5th metacarpal bone
hip fractures are most common in what population?
elderly, osteoporotic women (though they can occur after high-energy activities in younger populations)
are allergic rxns more common w/ ester or amide local anesthetics? is there cross-reactivity b/w esters? b/w amides?
esters yes b/w esters no b/w amides
which IV anesthetic inhibits cortisol production?
etomidate
the gluteus maximus and hamstrings muscles perform what motion at the hip?
extension
kyphosis - what is it and are neuro changes involved?
excessive outward curvature of the upper spine, causing hunching of the back -no neuro changes
Tx for ankylosing spondylitis
exercise + NSAID —> anti-TNF
Comminuted fracture
fracture in which the bone is shattered, splintered, or crushed into many small pieces or fragments
snowboarders fracture
fracture of lateral talus bone due to eversion and axial loading
Boxer's fracture
fracture of the 5th metacarpal -may lose the knuckle on exam OR have rotational deformity
Colles fracture
fracture of the distal radius at the wrist -results in an upward (dorsal) displacement of the wrist and obvious deformity (dinner fork aka bayonet deformity)
Jones Fracture - what is it and what is the preferred tx?
fracture of the proximal 5th metatarsal tx: surgery (ORIF) b/c the 5th metatarsal bears a lot of weight and is less supported by other bones of the foot)
Salter-Harris fracture
fractures that involve the growth plate (physis)
Rickets Clinical Manifestations
genu varum (bow-legged), muscle weakness, fractures, dentition issues -basically, problems anywhere that Ca2+ is necessary (b/c Vit D plays an important role in Ca2+ regulation in the body
most common type of soft tissue mass in the hand
giant cell tumor of the tendon sheath (GCTTS) -tx w/ surgical excision
Sulcus Sign
glenohumeral instability -indentation in infra-acromial area d/t partial separation of humerus and glenoid during gentle downward traction (arm hanging down neutral)
Apprehension Test of shoulder
glenohumeral instability OR dislocation -arm abducted to 90 and externally rotated; put other hand on back of shoulder, push gently forward while gently extending arm pos = any look of alarm/pain on patient's face
diuretics (thiazides, loop), ACEi, pyrazinamide, ethambutol, asa, and ARBs are all medications that can cause _____
gout
tophi
gout -collection fo solid uric acid in soft tissues
which types of hip fractures are non-operative?
greater and lesser trochanter fractures (tho most minor trochanter fractures will heal on their own too)
which nerve supplies the hamstrings? the quadriceps?
hamstrings = sciatic quadriceps = femoral
"my wrist hurts from too much typing" ddx
hand and wrist fatigue (NOT carpal tunnel)
ropivacaine, bupivacaine, and tetracaine are [low, moderate, high] potency local anesthetics
high
transverse fractures of the femur are usu d/t _____ and are usu assoc w/ ______ injury
high-energy impact vascular
what type of joint is the ulnohumeral joint? what motions does it allow?
hinge; flexion and extension
discuss the main rehab principles of hip fractures, diaphyseal fractures, and sports-related knee injuries
hip fractures and diaphyseal fractures: day-of mobilization, early PT w/ weight-bearing exercises to regain strength sports-related knee: time, initially non-weight-bearing (b/c usu a ligament or tendon injury)...set progressive goals to regain full fn
[Hyperparathyroidism, hypoparathyroidism] causes weakened bone b/c _____
hyperparathyroidism -parathyroid hormone (PTH) induces osteoclast activity -incr PTH = incr bone breakdown = weakened bone
cervical myelopathy presents w/ [hyperreflexia, hyporeflexia]
hyperreflexia -and clonus -(surprisingly)
disk herniation will present w/ [hyporeflexia, hyperreflexia]
hyporeflexia
Name the NSAIDs
ibuprofen nabumetone naproxen ketorolac celecoxib (selective COX-2) diclofenac etodolac (partially selective) meloxicam (partially selective) indomethacin
which ligament offers the greatest support for the hip joint?
iliofemoral ligament (aka Y ligament of Bigelow) -it's the strongest there is also the ischiofemoral ligament and the pubofemoral ligament supporting the hip
prime mover of thigh/hip flexion
iliopsoas (iliacus + psoas)
generally, we treat nondisplaced fractures (w/ no ligament ruptures) with _____ and displaced or comminuted fractures with ____
immobilization ORIF surgery
Glenohumeral Instability
inability to keep the humeral head centered in the glenoid fossa
incr concentration of inhaled anesthetic in the brain = [incr, decr] anesthesia depth
incr
incr lipid solubility in opioids means: [incr, decr] CNS fx [incr, decr] "rush" sensation [requires, does NOT require] a loading dose [lower, higher] maintenance dosing required [shorter, longer] duration of action
incr incr requires lower longer
use-dependent blockade
incr nerve stimulation during administration of a local anesthetic = incr nerve blockade (b/c more drug is able to enter the neurons)
which NSAID has the greatest toxicity?
indomethicin (also used to tx gout)
what is the difference in location of a spinal tumor vs a spinal infection?
infections usually involve the disk space, while tumors usually spare the disk space
main indications for glucocorticoids
inflammation (glucocorticoids are anti-inflammatories)
septic arthritis
inflammation of the joint caused by infection (usu S. aureus)
Osgood-Schlatter disease
inflammation or irritation of the tibia at its point of attachment with the patellar tendon d/t overuse (tendon microtears from the tendon pulling away from its attachment on the tibial tuberosity d/t overuse)
Osteomyelitis
inflammation/infection of bone and bone marrow
what sx are common to all seronegative spondyloarthropathies (to varying degrees)? (6)
inflammatory back pain (w/ morning stiffness), enthesitis, sacroiliitis, uveitis, dactylitis (sausage fingers), peripheral arthritis
avoid ____ in pts w/ malignant hyperthermia what is the tx for malignant hyperthermia?
inhaled anesthetics (except NO) -will cause a hypermetabolic crisis dantrolene sodium
Methotrexate MOA for RA
inhibits intracellular AMP deaminase --> incr AMP levels --> incr adenosine (anti-inflammatory -immunosuppressive, anti-inflammatory (therefore good for autoimmune diseases w/ inflammation)
MOA of azathioprine
inhibits purine synthesis, disrupting cell fn and leading to apoptosis
initial imaging for glenohumeral instability -gold standard?
initial: x-ray (anterior and Y view) gold standard: MRI
Sequestrum & Involucrum
osteomyelitis -areas of dead bone (sequestrum) surrounded/sequestered by new bone (involucrum)
What are some sx of opioid withdrawal?
irritability, hyperventilation, diarrhea, runny nose/eyes, chills/peripheral vasoconstriction
cubital tunnel syndrome
irritation, compression, and entrapment of the ulnar nerve within the medial epicondyle
which inhaled anesthetic has the slowest onset? fastest? fastest recovery? best analgesic properties?
isoflurane desflurane and NO NO nitrous oxide (the only one w/ analgesic properties)
acute osteomyelitis is more common in [kids, adults], while chronic osteomyelitis is more common in _____
kids adults *S. aureus = most common organism in both populations
[small, large] disk herniations are more likely to resorb on their own
large (more water content)
biceps femoris tendonitis and popliteus tendonitis will present with pain to what portion of the knee?
lateral
scoliosis
lateral curvature of the spine > 10degrees
Distal ITB syndrome will present with pain to what portion of the knee?
lateral knee
prime mover of arm extension
latissimus dorsi
herniated disk
leaking of the nucleus pulposus out of the annulus fibrosis -aka herniation of the nucleus pulposus (HNP)
betamethasone and dexamethasone are the [short, intermediate, long] acting synthetic glucocorticoids
long
an injury to which nerve results in scapular winging? a. subcutaneous nerve b. long thoracic nerve c. axillary nerve d. radial nerve
long thoracic nerve
Osteoporosis
loss of bone density -body's bones become weak and break easily
seronegative spondyloarthropathies are most common in what population?
males <40 y/o -inflammatory back pain usu occurs before age 45, as opposed to mechanical back pain, which can occur at any age (Hannah, remember when you had acute bad back pain?)
Chondrosarcoma
malignant cartilage tumor
which plexus innervates the knee?
lumbar and sacral
Femoral Nerve Stretch Test
lumbar disk herniation affecting L2-L4 nerve roots -Anterior thigh pain with hip extension & knee flexion
Lasegue's test (aka straight leg raise)
lumbar disk herniation at L5-S1 -Leg pain & paresthesias at 30-70° hip flexion
what type of surgery would address a lumbar disk herniation?
lumbar diskectomy (make a hole over the nerve root to relieve pressure)
most common location of spinal infection
lumbar spine (thoracic next most common, then cervical) *think of it as being near the grossest parts of the body
most common tumor to metastasize to the hand
lung
most common location of osteosarcoma metastases
lungs
Compression fractures of the spine are most commonly associated with what orthopedic disease?
osteoporosis
which foot fracture is commonly seen in soldiers and military recruits?
march fracture -fracture of the distal metatarsal (3rd metatarsal MC)
which meniscus tear is more common: lateral or medial?
medial -more bony attachments on this side
the femoral head and neck receive blood from which artery?
medial circumflex (a branch of the femoral)
on what portion of the knee will pain present w/ saphenous neuritis?
medial knee
3 main nerves that innervate the hand
median ulnar radial
which NSAID has once daily dosing?
meloxicam
Gout is more common in men or women?
men
Achilles tendonitis is more common in [men, women] and is typically d/t _____
men overuse/repetitive stress
most common form of metabolic bone disease
osteoporosis
most common type of spinal tumor
metastatic tumor (from cancer at another site)
name the synthetic DMARDs
methotrexate azathioprine cyclosporine leflunomide sulfasalazine hydroxychloroquine tofacitinib
arthritis, degenerative meniscus tears, spontaneous AVN, and overuse syndromes are more common etiologies of knee pain in the [young adult-middle age, middle age-elderly] population
middle age-elderly
which joint is most commonly affected in charcot joint?
midtarsal joint (b/w tarsal and navicular)
a CDAI of >10 indicates [mild, moderate, severe] RA
moderate -severe > 22
fentanyl and heroin are [less, more] fat soluble than morphine
more -therefore they have greater CNS fx (greater "rush" sensation)
cortisol levels are highest at what time of day?
morning
at what time of day is RA joint pain worst?
morning -worse after rest, better w/ use -opposite of OA
Heroin is derived from ____
morphine
drug of choice for acute severe pain
morphine
list the following in order of potency from least to most potent: oxymorphone morphine fentanyl hydromorphone sufentanil
morphine hydromorphone (6-10x morphine) oxymorphone (10x) fentanyl (100x) sufentanil (1000x)
which opioids from lecture have active metabolites? (2)
morphine (morphine-6-glucuronide - twice as potent mu receptor agonist) meperidine (normeperidine - may accumulate in pts w/ renal or kidney disease)
which opioids from lecture agonize all 3 opioid receptors? (2) which drug antagonizes all 3 receptors?
morphine and fentanyl naloxone
radiculopathy of the C6 nerve root corresponds w/ what motor, sensory, and reflex effects?
motor: biceps, wrist extensors sensory: thumb, index finger reflex: brachioradialis
radiculopathy of the C7 nerve root corresponds w/ what motor, sensory, and reflex effects?
motor: triceps sensory: middle finger reflex: triceps
what is the main receptor agonized by clinical opioids? what opioid receptor would be targeted with an "ideal opioid"?
mu delta (b/c it would have analgesic fx without respiratory depression or physical dependence)
match the endogenous opioids w/ their opioid receptor (mu, kappa, or delta) -endorphins = ____ -enkephalins = ____ -dynorphins = ___
mu delta kappa
External tibial rotation and asymmetric hyperextension of the knee are typically d/t issues in [one, multiple] structure(s) that typically retrain(s) the joint
multiple
Pain during AROM suggests injury to the _____ pain during PROM suggests injury to the ______
muscles bone, ligament, tendon
contrast cervical myelopathy and cervical radiculopathy
myelopathy = compression of the spinal cord (more widespread pathology) radiculopathy = compression of specific nerve roots (more localized pathology)
which three opioids mentioned during lecture would be difficult to reverse with naloxone?
nalbuphine (mixed agonist/antag...higher affinity for receptors than nalox) buprenorphine tramadol (b/c analgesia d/t a different mechanism - blocked serotonin/norepi reuptake)
spinal stenosis
narrowing of the spinal canal with compression of nerve roots (results in back pain and paresthesias)
most common direction of hip dislocation? what motion of the thigh would cause this?
posterior -adduction and internal rotation (same as for posterior shoulder dislocations)
what type of crystals are found in the synovium of a pt with gouty arthritis?
negatively birefringent, needle-shaped monosodium urate crystals
"foot drop" indicates injury to what nerve OR to what muscle?
nerve = common fibular/peroneal *can be injured in an LCL injury muscle = tibialis anterior
drug of choice for dental procedure conscious sedation
nitrous oxide
inhaled anesthetic w/ the least fx on the cardio and resp systems
nitrous oxide
ACL injury is more likely to occur during [contact, non-contact] events
non-contact -sudden twisting (esp internal rotation), hyperextension of knee, and/or valgus force
paresthesia
numbness and tingling, pins and needles sensation
a DVT will cause pain in which portion of the knee?
posterior (where the popliteal vein - a deep vein - is located)
spinal stenosis is more common in [younger, older] populations
older -assoc w/ degenerative changes in the spine
cortisone is only available in what formulation? prednisone? triamcinolone?
oral oral topical
describe the composition of bone
organic matls (35%) inorganic matls (65%): calcium hydroxyapatite
which opioids mentioned in lecture are only available PO?
oxycodone and hydrocodone
what are the characteristics of the ideal opioid?
pain control + minimal risk of abuse/dependence + few/mild adverse fx + alleviate psychologic fx of pain *note: delta receptor agonists would meet most of these criteria
Pes Anserine Bursitis - what is it and where will the pain present?
pain in the medial knee -inflammation of the bursa located between the shinbone (tibia) and three tendons of the hamstring muscle at the MEDIAL knee. It occurs when the bursa becomes irritated and produces too much fluid, which causes it to swell and put pressure on the adjacent parts of the knee.
opioids work by upregulating _____ and downregulating ____
pain inhibitory pathways neurotransmitter release and pain transmission
Sciatica
pain that follows the pathway of the sciatic nerve, caused by compression or trauma of the nerve or its resistance
chondrosarcomas are typically [painless, painful]
painful
osteosarcoma is typically [painless, painful]
painful
spondylosis
painful condition of the spine resulting from the degeneration of the intervertebral disk -term used to describe OA degeneration of the spine
Paronychia vs Felon
paron: acute or chronic soft tissue infection around the nail body felon: infection of the distal pulp space of the fingertip
Subluxation
partial dislocation of a joint
driving force for equilibrium w/ inhaled anesthetics
partial pressure gradient
patellofemoral tracking abnormalities
patella shifts out of place during flexion/extension
Segond fracture
pathognomonic for ACL tear -Avulsion fracture of the lateral tibial condyle
what is the typical first sign of osteoporosis?
pathologic fracture -for postmenopausal: usu in wrist or vertebrae -for senile: usu in pelvis or femur
prime mover of arm flexion
pectoralis major
most common cause of heel pain
plantar fasciitis
post static dyskinesia in the foot
plantar fasciitis -pain after long-term rest
most common direction of elbow dislocation
posterolateral
which opioid receptors are located on the presynaptic neuron for spinal pain transmission? the postsynaptic?
pre: mu, kappa, and delta post: mu only
type of spinal tumor most common in young adults
primary benign spinal tumor
which IV anesthetic requires the highest dose? which has the longest onset and duration?
propofol ketamine
which IV anesthetic must be discarded 12 hrs after opening?
propofol - dissolved in a fat emulsion
what joint allows for supination or pronation of the hands?
proximal radioulnar joint
Pencil-in-cup deformity
psoriatic arthritis (deformity associated w/ the DIP arthritis common in PsA)
gout is related to ____ foods
purine-rich (ex: meat, seafood, alcohol, yeasts)
which arteries form the blood supply of the hand?
radial and ulnar
What bones make up the wrist joint? what type of joint is this? what motions does it allow?
radius + scaphoid and lunate (carpal bones) condylar flexion, extension, abduction, adduction, circumduction
Circinate balanitis
reactive arthritis (dermatitis of the glans penis)
What is the difference b/w an open reduction and a closed reduction?
reduction: realignment of bone ends Open = bones are realigned and joined surgically w/ pins or wires Closed = bones are realigned w/o surgery
Shoulder separation
separation of the acromioclavicular (AC) joint. (do NOT confuse this with shoulder dislocation...it's an injury to a different joint)
MOA of glucocorticoids
regulate gene expression (specifically by regulating transcription) -can take a few hrs to kick in since we have to wait for new proteins to be formed to see fx
most common type of elbow dislocation
simple (no associated fractures)
RICE acronym in orthopedics
rest, ice, compression, elevation
Chronic, systemic autoimmune disease characterized by bone erosion, thinning of articular cartilage, and pannus formation
rheumatoid arthritis
Swan neck deformity
rheumatoid arthritis -PIP hyperextension and DIP flexion
Boutonnniere deformity
rheumatoid arthritis -flexion of the PIP and extension of the DIP
most common inflammatory arthritis
rheumatoid arthritis (RA) -note, however, that the most common arthritis overall is OA
Seronegative spondyloarthropathies are defined as testing negative for which lab tests?
rheumatoid factor (RF) and antinuclear antibody (ANA)
Hammer toes - what are they and which joint do they most commonly affect?
rigid contracture of the toes at the PIP, DIP, or MCP joints d/t contraction of the toe extensors PIP joint of the toes
lateral malleolus fracture is typically d/t a ____ injury
rotational (ex: rolling the ankle)
bone injuries usually occur on the [same, opposite] side as the injurious contact, while ligament injuries occur on the ____ side
same opposite
anatomical snuffbox pain suggests what injury?
scaphoid fracture
most common carpal bone fracture
scaphoid fracture
which type of hand or wrist fracture may not initially appear on imaging?
scaphoid fracture
Name the carpal bones mnemonic?
scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate mnemonic: Sally Left The Party To Take Carmen Home
Adams forward bend test
scoliosis -Pt bends forward at the waist w/ feet together, arms hanging, knees extended, and palms together -lateral curvature: scoliosis
inflammatory back pain (w/ morning stiffness) + sacroiliitis + peripheral arthritis + ethesitis + dactylitis (sausage fingers) + uveitis
seronegative spondyloarthropathies
category of chronic inflammatory diseases which involve both the joints and entheses, have shared genetic susceptibility, and are negative for rheumatoid factor (RF) and antinuclear antibody (ANA)
seronegative spondyloarthropathies (SpA)
scapular winging is caused by injury to the _____ muscle or its innervation, the _____ nerve
serratus anterior, long thoracic
first and most common symptom of basal joint arthritis
severe pain at the base of the thumb, esp when gripping or pinching objects
which inhaled anesthetics can be used for induction?
sevoflurane and nitrous oxide
cortisol/hydrocortisone and cortisone are the [short, intermediate, long] acting synthetic glucocorticoids
short
Tx for whiplash
short-term immobilization
factors affecting the action of local anesthetic action: incr pH = [shorter, longer] onset simultaneous admin of epinephrine = ____ efficacy decr nerve diameter = _____ efficacy
shorter (d/t incr tissue penetration) incr incr (more sensitive)
most common joint dislocation
shoulder dislocation -2nd most common = elbow
incr blood-gas partition coefficient = [faster, slower] onset of action incr fat-blood partition coefficient = _____ recovery
slower slower *think of the coefficients as "solubility"
Most common cause of shoulder pain overall
subacromial impingement syndrome
Insertions of rotator cuff muscles
subscapularis = lesser tubercle of the humerus other 3 = greater tubercle
Belly Press test
subscapularis injury -pt unable to press on belly (internal rotation of shoulder w/ shoulder at 45degrees and elbow at 90degrees) without bending their wrist
what type of splint do we use for Colles fractures?
sugar tong splint/cast
contraindication to local anesthetics
sulfite allergy
most common elbow fracture in children
supracondylar fracture -the humerus is probably too strong to break in normal adults, but in kids it's still flexible
which muscle runs b/w the acromion and humerus?
supraspinatus
Abduction of the shoulder vs resistance helps localize pain in which of the following: a. supraspinatus b. infraspinatus c. teres minor d. subscapularis
supraspinatus (empty can test)
which of the following rotator cuff tendons is most likely to sustain injury d/t repeated impingement b/w the humeral head and the undersurface of the anterior third of the acromion and coracoacromial ligament? a. supraspinatus b. infraspinatus c. teres minor d. subscapularis
supraspinatus (think pitching...quick elongation of the muscle)
tx for cervical myelopathy
surgery! -decompression and stabilization *NO conservative tx...the pt needs surgical intervention
Arthrodesis
surgical fusion of a joint
RA is a [symmetric, asymmetric] disease
symmetric (like SLE, unlike OA)
most common pattern of psoriatic arthritis
symmetric polyarticular arthritis -5+ joints on both sides of the body, usu hands and feet
what part of the joint produces synovial fluid?
synovial membrane of the articular capsule
MOA of leflunomide concerning side fx?
synthetic DMARD -Inhibit dihydroorotate dehydrogenase (pyrimidines) --> decr nucleuotide synthesis --> decr cell growth contraindicated in pregnancy; diarrhea
MOA of tofacitinib
synthetic DMARD -inhibits JAK enzyme
MOA of cyclosporine concerning side fx?
synthetic DMARD inhibits production of IL-1 and IL-2 receptors -Inhibits IL-2 leading to no activation of cytotoxic T cells or activation of B cells cardiotoxic
splint used for most complaints involving the thumb
thumb spica splint
what type of splint do we use for a scaphoid fracture? what complication should we watch for?
thumb spica splint avascular necrosis
the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) are named for their attachments on the ______
tibia
the sciatic nerve branches into the _____ and _____ nerves [superior, inferior] to the knee the femoral artery becomes the _____ artery, which branches into the ____ and _____ arteries [superior, inferior] to the knee
tibial and common peroneal (fibular) -superior popliteal, anterior tibial and posterior tibial -inferior
scaling on an erythematous base on the foot
tinea pedis (athletes foot)
the dorsal muscle group of the foot is responsible for what actions? the plantar group?
toe extension toe flexion, abduction, and adduction
what is the difference b/w a total hip arthroplasty and a hemiarthroplasty?
total = cup (on the acetabulum) + ball + stem hemi = ball + stem only
[T/F] drinking alcohol while taking acetaminophen is very bad for your liver
true - increases the amt of NAPQI (hepatotoxic metabolite of acetaminophen)
[T/F] if a pt can bear weight on the joint, they likely did not fracture (or otherwise injure) any of the bones
true
[T/F] if pt complains of numbness in the pad of their thumb only, it is NOT carpal tunnel syndrome
true
[T/F] in cases of acute knee effusion, we get an MRI early on for young pts but delay the MRI for older or arthritic pts
true
[T/F] in monitored anesthesia care (MAC), the pt is generally awake and can maintain their own airway
true
[T/F] adolescent scoliosis usually does NOT have neuro sx, while adult scoliosis DOES
true -adolescent is idiopathic -adult is from asymmetric degeneration of the intervertebral disks (as the disks collapse, the vertebrae compress the nerve roots)
[T/F] anything that increases pressure on the spine increases the pt's risk of a disk herniation
true -ex: chronic cough or constipation, obesity, heavy lifting
[T/F] there is no cure for a local anesthetic OD causing cardiac fx
true -however, we can give a fat emulsion to act as a lipid sink to draw the drug away from cardiac tissue
[T/F] cervical strain usually does NOT involve the extremities
true -it's a tendon issue, NOT a spinal column issue
Tx for Boxer's Fx
ulnar gutter splint w/ joints in at least 60 degrees flexion
bones involved in the main elbow joint
ulnohumeral joint: humerus (trochlea) + ulna (trochlear notch)
tx for olecranon fractures
undisplaced = immobilize elbow at 45degrees all other types = sugery (ORIF)
guiding principle for steroid dosing
use as small of a dose as possible for as little time as possible -you don't want to suppress the pt's ability to produce endogenous cortisol
what can we do to prevent pain w/ injection for local anesthetics? what is the tx for methemoglobinemia side fx of local anesthetic?
use buffered lidocaine OR warm the injection to body temp methylene blue
how does vascular claudication differ from neurogenic claudication?
vascular = d/t muscle hypoxia -more comfy when sitting down (less metabolic demand); easier walking downhill (less met demand); distal pain worse than proximal; walking endurance lasts over a defined distance neurogenic = d/t nerve compression -more comfy when spine flexed (opens up canal); easier walking uphill (more flexion); proximal pain worse than distal; walking endurance varies
COX 1/2 vascular and platelet fx gastric fx? kidney fx?
vasodilation (2), vasoconstriction (1) platelet aggregation gastric protection (1) incr Na+ and H2O excretion
most common type of spinal infection
vertebral osteomyelitis
tx for chondrosarcoma
wide surgical resection (b/c most are resistant to chemio/radiation)
RA is more common in [men, women]
women
carpal tunnel syndrome is more common in [men, women], [children, adults], and pts with what comorbidity?
women adults diabetes mellitus
Scoliosis is most common in [men, women] and [younger, older] populations
women younger (8-10y/o)
what type of splint do we use for carpal tunnel syndrome?
wrist (volar) splint
lateral epicondylitis is caused by the repetition of what motion?
wrist extension and pronation against resistance (ex: tennis backhand) -try it...extend your wrist...the muscles by your lateral epicondyle will contract
medial epicondylitis is caused by the repetition of what motion?
wrist flexion and pronation against resistance -try it...flex your wrist...the muscles by your medial epicondyle will contract
first line imaging for bone tumors
x-ray
first line imaging for hip AVN? most common tx?
x-ray hip arthroplasty
best screening test for wrist and hand pathology
x-ray -3 views: AP, lateral, oblique/scaphoid
1st line imaging for osteomyelitis? gold standard?
x-ray MRI
first line imaging for hip fracture? most sensitive imaging?
x-ray MRI
tx for chronic gout
xanthine oxidase inhibitors (allopurinol, febuxostat) -inhibits urate production -febuxostat has a black box warning for CV risk
overuse syndromes, meniscus tears, tendon ruptures, exacerbation of underlying early OA, and ligament tears are more common etiologies of knee pain in the [young adult-middle age, middle age-elderly] population
young adult-middle age
