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80 Cards in this Set
- Front
- Back
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How do you differentiate articular vs. nonarticular pain?
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Articular: deep or diffuse pain, limited ROM on active and passive movement, swelling, crepitation, instability, "locking," and deformity.
Nonarticular: painful on active ROM, focal tenderness away from articular structures, physical findings away from joint capsule, and seldon with crepitus, instability, or deformity. |
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What are the four cardinal signs of inflammation?
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erythema, warmth, pain, swelling
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What are systemic symptoms of pain?
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prolonged morning stiffness, fatigue, fever, weight loss, rash, and neuropathy
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What is laboratory evidence of inflammation?
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elevated ESR or CRP, thrombocytosis, anemia of chronic disease, or hypoalbuminemia
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What are characteristic of noninflammatory disorders?
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pain without swelling or warmth
absence of inflammatory or systemic features minimal or absent morning stiffness normal labs |
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What can cause inflammatory disorders?
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infectious
crystal-induced - gout, pseudogout immune-related - RA, SLE, RA, Reiter's syndrome idiopathic |
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What are the causes of noninflammatory disorders?
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Trauma
- rotator cuff tear Ineffective Repair - osteoarthritis Neoplasm Pain amplification - fibromyalgia |
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Do you do an arthrocentesis on a patient on anticoagulation therapy?
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Yes, use a small-gauge needle if INR is <3.0
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You do a paracentesis on a patient. Examination of the joint fluid shows a WBC count of 120,000/mcL. Is this considered noninflammatory, inflammatory, or purulent?
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Purulent
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You do a paracentesis on a patient. Examination of the joint fluid shows a WBC count of 1,000/mcL. Is this considered noninflammatory, inflammatory, or purulent?
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noninflammatory
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You do a paracentesis on a patient. Examination of the joint fluid shows a WBC count of 5,000/mcL. Is this considered noninflammatory, inflammatory, or purulent?
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inflammatory
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You do a paracentesis on a patient. Examination of the joint fluid shows calcium pyrophosphate. What is this considered? What might it indicate?
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positive birefringent
pseudogout |
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You do a paracentesis on a patient. Examination of the joint fluid shows monosodium urate. What is this considered? What might it indicate?
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negatively birefringent
gout |
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What medication causes gout?
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Thiazides
Niacin ACEI Aspirin Cyclosporin |
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How do you treat acute gout?
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colchicine
NSAIDs corticosteroids |
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How do you treat chronic gout?
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allopurinol
probenacid |
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Allopurinol interacts with what drugs?
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ACEI
anacids anticoagulants cyclophosphamide |
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Colchicine has what side effects?
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GI distress
aplastic anemia |
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If a patient has the symptoms of gout, decrease phosphorus and increased calcium, what might be the problem?
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pseudogout/hypoparathyroidism
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What causes of low back pain require further evaluation?
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1. Infection
2. Cancer 3. Inflammatory back disease 4. AAA 5. Significant or progressive neurological deficits |
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What is sprain? What is strain?
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sprain: acute ligamentous
strain: acute muscular |
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What are the key questions to ask everyone with back pain?
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1. radiation
2. increased pain with coughing, sneezing, or straining 3. increased pain with recumbency 4. nocturnal pain 5. bowel or bladder dysfunction 6. sexual dysfunction 7. saddle anesthesia |
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98% of back pain is caused by what?
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mechanical causes
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Is disk herniation most commonly anterior or posterior?
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posterior
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What is the most common site for disk injury?
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L4-L5
L5-S1 |
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Back pain associated with urinary retention, incontinence, or saddle anesthesia could be what? What do you do about it?
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cauda equina
emergent neurosurgeon consult |
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What labs do you get to rule out multiple myeloma?
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total protein and calcium
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What two tests can be used to test for disk injury?
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straight leg raise
crossed straight leg raise |
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What are the mechanical causes of back pain?
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Disk injury
Degenerative Spinal stenosis Vertebral body fracture Soft tissue injury or disorder Sacrolitis |
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What is degenerative mechanical back pain? When is this type of pain at its worst?
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changes in facet joints
worse with trunk extension |
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What is spinal stenosis?
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narrowing of the lumbar spinal canal which may cause pressure on sciatic nerve roots
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What are the symptoms of spinal stenosis?
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irritation during activity - pain in one or both extremities while walking
relieved with rest, flexion, exacerbated with extension |
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What conditions may cause spinal stenosis?
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osteoarthritis
Paget's disease spondylolithesis |
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What condition mimicks spinal stenosis? How do you differentiate?
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lower extremity claudication
differentiate by examining lower extremities for skin changes, pulses, and possible ultrasound |
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Who gets vertebral body fractures? How do you treat it?
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people with osteoporosis or those on steroids
treat with pain medications |
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True or False: Soft tissue injuries are usually self-limiting.
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True
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What are the systemic causes of back pain?
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Ankylosing spondylitis
Primary tumor Metastatic disease |
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What is ankylosing spondylitis?
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systemic rheumatic disease characerized by inflammation of the axial skeleton and large peripheral joints.
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What are the characteristics of ankylosing spondylitis?
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pain that worsens with rest and improves with activity
pain is worse with hyperextension |
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Who usually gets ankylosing spondylitis?
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men younger than 40
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What systemic symptoms are associated with ankylosing spondylitis?
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acute irisitis
low grade fever, fatigue, anorexia can present with sciatica, cauda equina, aortic insufficiency, angina, pericarditis |
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What is the prognosis of ankylosing spondylitis?
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good prognosis with early treatment
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How do you diagnose ankylosing spondylitis?
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x-ray (first seen in the SI joint)
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What is a late sign of ankylosing spondylitis?
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"bamboo spine"
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What is the most common cause of primary tumor associated back pain?
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multiple myeloma
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Back pain caused by metastatic disease usually comes from what primaries?
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breast, prostate, lung, kidney, and thyroid
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True or False: Most metastatic disease are sclerotic.
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False: Most are lytic except for prostate and thyroid, which are sclerotic.
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What disorders can be referred to back pain?
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1. GI disorders - pancreatitis, perforated ulcer, cholecystitis
2. GU disorders - nephrolithiasis, prostatitis, pyelonephritis 3. GYN disorders - ectopic pregnancy, pelvic tumors 4. AAA 5. Hip disorders |
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Hyperreflexia with clonus suggests what?
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upper motor neuron disease
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Look at the nerve roots associated with movement and sensation.
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Patellar reflex - L4
Achilles reflex - S1 Hip abduction, extentsion - L5 Quadriceps extension - L3 Sensory: Medial calf - L4 Medial forefoot - L5 Lateral foot - S1 |
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What are the Waddell signs?
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Superficial touch causes pain
Wide area of pain Axial loading Distraction SLR Sensory loss not in dermatome Overreaction Watch patient get dressed, walk in and out of exam room |
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What are the indications of L-S films in patients with low back pain?
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1. symptoms last >6 weeks
2. suspicion or history of malignancy 3. Patient taking steroids 4. Age >50 5. Age <20 6. History of trauma or neurological defects |
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True or False: If patient history is consistent with muscle strain, it's important to get an x-ray.
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False: No need.
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What do you do if you suspect infectious or neoplastic causes of lower back pain?
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MRI
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If severe symptoms of lower back pain persist for several weeks desprite conservative treatment or have progressive or severe neurologic signs and symptoms, what do you do?
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MRI
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True or False: Almost all back pain will be better in one week.
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False: 40% better in 1 week; 60-85% better in 3 weeks; 90% better in 2 months
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What are the negative prognostic factors of acute back pain?
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>3 episodes, gradual onset, prolonged absence from work
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What is a poor prognosis for chronic back pain?
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>1 year
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With back pain, what are the indications for admission and referral?
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1. Cauda equina syndrome
2. Severe neurologic deficits 3. Progressive neurologic deficit 4. Multiple nerve root involvement |
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What is torticollis?
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focal dystonia with involuntary tonic contractions or intermittent spasm of neck muscles causing tilting of the head
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How do you treat torticollis?
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intestive physical therapy with daily passive stretching of involved muscle
if not treated early, operative anticholinergics and benzodiazepines |
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What are the most commonly affected nerve roots in neck pain?
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C5-C6
followed by C6-C7 |
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What is cervical radiculopathy?
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pain in distribution of cervical nerve and is the result of anything that compresses or irritates the nerve
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What ar ethe signs/symptoms of cervical radiculopathy?
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painful neck extension
absent or decrease DTRs |
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If a patient has cervical radiculopathy and has increased DTR's, where is the lesion located?
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lesion centrally located in spinal cord or brain involving the pyramidal system.
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What are the characteristics of neoplastic neck pain?
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pain gradual, but progressive onset, constant, not relieved by rest
especially worse at night |
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A patient has unrelenting, constant, intolerable pain in the neck. What would you suspect would you the cause?
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Infectious
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What is scoliosis?
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a spinal deformity with a lateral curvature >10 degrees
- lateral flexion plus rotation of involved vertebrae around vertical axis |
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What can cause scoliosis?
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cerebral palsy, poliomyelitis, muscular dystrophy
most are idiopathic |
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In scoliosis, what is the most common presentation?
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most curves are convex to the right in the thoracic area and to the left in the lumbar area
the right shoulder higher than the left |
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How do you diagnose scoliosis?
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AP and lateral views on x-ray
screen early |
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At what point do you brace for curvature in scoliosis? When do you do surgery?
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brace at 20-50 degrees
surgery at >45 degrees or worsening |
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Who does slipped capital femoral epiphysis happen to?
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overweight adolescent boys
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What are the signs and symptoms of slipped capital femoral epiphysis?
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initially - hip stiffness that improves with rest leading to a limp and hip pain radiating to the anteromedial thigh to knee OR knee pain solely
advanced - pain on ROM of hip with limited flexion, abduction, and medial rotation, knee pain, limp affected leg externally rotated |
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With a slipped capital femoral epiphysis, what would you see on x-ray?
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AP and "frog-leg" lateral x-rays
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What is the most common area of avascular necrosis of the hip?
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femoral head
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What is an intracapsular hip fracture?
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femoral head and neck
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What is an extracapsular hip fracture?
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intertrochanteric and subtrochanteric
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With a hip fracture, what do you see on exam?
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affected leg foreshortned and externally rotated
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How do most hips dislocate?
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90% posterior
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