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528 Cards in this Set

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Define ligament.
fibrous connective tissue connecting bone to bone
Define tendon.
fibrous connective tissue connnecting muscle to bone
Define fascia.
fibrous connective tissue connecting muscle to muscle (and other structures)
What are the four muscles that make up the rotator cuff?
SITS = supraspinatus, infraspinatus, teres minor, subscapularis
Define thenar eminence.
muscles found on palmar surface at base of thumb
Define hypothenar eminence.
muscles found on palmar surface at base of little finger
What equipment is needed for the musculoskeletal exam?
skin-marking pencil
tape measure
reflex hammer
optional: goniometer
What causes muscle wasting?
trauma resulting in limited use of arm due to pain
muscle problem
nerve problem
Define spasticity.
increase in muscle tone
List the grading scale for muscle strength.
5 = full ROM against gravity, full resistance
4 = full ROM against gravity, some resistance
3 = full ROM against gravity, no resistance
2 = passive ROM
1 = trace movement
0 = no movement
Mosbys p707
Describe the steps of the musculoskeletal exam.
1. inspection → gait and posture
2. inspection → symmetry, contour, discoloration, swelling, masses
3. palpation
-all muscles, bones, joints
-warmth, swelling, crepitus, fluctuation of a joint (associated with effusion), resistance to pressure, tenderness
3. ROM
What is the ddx for crepitus?
rubbing of bones (moving joint, broken bone)
tenosynovitis
Mosbys p707
When should you use a goniometer?
when increase or limitation in ROM; begin with joint fully extended and then flex it; meausure angles of greatest extension and flexion and compare with expected values
Mosbys p707
What are you evaluating when you ask patient to clench teeth?
temporalis and masseter muscles → motor function of trigeminal nerve
Mosbys p707
Define cubitus valgus.
lateral carrying angle >15 degrees
What is a normal carrying angle?
5-15 degrees
Define cubitus varus.
medial carrying angle
Define fracture.
broken bone
Define myopathy.
disorder of muscle
Define neuropathy.
disorder affecting single peripheral nerve
Define polyneuropathy.
disorder affecting multiple peripheral nerves
What is another name for cubitus varus?
gunstock deformity
cubitus varus
cubitus valgus
What is a swan neck deformity?
hand deformity characterized by hyperextension of PIP joint and hyperflexion of DIP joint
What is the ddx for swan neck deformity?
congenital
trauma
RA
What are possible problems of the elbow joint?
dislocation
fracture
tendonitis
arthritis
infection
What is the purpose of Adson's Test?
suspected thoracic outlet syndrome
How do you perform Adson's test?
1. ask patient to stand
2. palpate radial pulse while pulling arm backward (abduction, external rotation, hyperextension)
3. ask patient to rotate head to involved side, take deep breath and hold it
4. positive for thoracic outlet syndrome if diminished or absent radial pulse
What is thoracic outlet syndrome?
disorder involving compression of the neurovascular bundle passing between the anterior and middle scalene muscles at the superior thoracic outlet
What are the types of thoracic outlet syndrome?
1. neurogenic TOS → compression of brachial plexus
2. arterial TOS → compression of subclavian artery
3. venous TOS → compression of subclavian vein
What does TOS stand for?
thoracic outlet syndrome
What is the purpose of Yergason's test?
suspected
1. bicipital tendonitis
2. laxity or tear of transverse humeral ligament → instability of long head of the biceps brachii tendon in bicipital groove
How do you perform Yergason's test?
1. ask patient to sit or stand
2. adduct arm, flex arm to 90°, and place forearm in neutral position (thumb facing upward)
3. stabilize elbow inferiorly and grasp forearm with other hand
4. move glenohumeral joint into external rotation and proximal radioulnar joint into supination
5. positive if pain or snapping in bicipital groove

OR

1. ask patient to sit or stand
2. adduct arm, flex elbow to 90°, and pronate forearm
3. place thumb in bicipital groove while grasping forearm with other hand
4. ask patient to move glenohumeral joint into external rotation and proximal radioulnar joint into supination while you provide resistance
5. positive if bicipital tendonitis or laxity/tear of pain or snapping in bicipital groove
What is the function of the tranverse humeral ligament?
secures long head of the bicep tendon in bicipital groove
What is the purpose of the apprehension test?
suspected dislocation or dislocatability of shoulder
How do you perform the apprehension test?
1. patient may be standing, sitting, or supine
2. flex elbow 90° and abduct arm 90°
3. externally rotate arm
4. positive for dislocation or dislocatability if look of apprehension on patient's face
What is the purpose of the drop arm test?
suspected rotator cuff tear
How do you perform the drop arm test?
1. passively abduct arm 90°
2. ask patient to slowly lower arm
3. positive for rotator cuff tear if pain + difficulty in lowering arm smoothly
What is the most common type of rotator cuff tear?
supraspinatus tear
How do you test for medial epicondylitis (golfer's elbow)?
1. flex wrist
2. palpate medial epicondyle → origin of common flexor tendon
3. positive if pain
How do you test for lateral epicondylitis (tennis elbow)?
1. extend wrist
2. palpate lateral epicondyle → origin of common extensor tendon
3. positive if pain
olecranon bursitis
Which is more common, anterior or posterior shoulder dislocation?
anterior (98%)
How do you perform the valgus stress test for the knee?
1. flex knee 15°
2. place one hand on lateral knee so thenar eminence is against fibular head
3. place other hand on medial ankle
4. push medially against knee and laterally against ankle
5. palpate medial joint line for gapping indicative of MCL joint instability
Hoppenfeld p185
What is the purpose of the valgus stress test of the knee?
suspected MCL joint instability
Hoppenfeld p185
How do you perform the varus stress test for the knee?
1. flex knee to 15°
2. place one hand on medial knee so thenar eminence is against tibia
3. place other hand on lateral ankle
4. push laterally against knee and medially against ankle
5. palpate lateral joint line for gapping indicative of LCL joint instability
Hoppenfeld p185
What is the purpose of the varus stress test of the knee?
suspected LCL joint instability
Hoppenfeld p185
Which is more common, MCL injury or LCL injury?
MCL injury
Hoppenfeld p185
Which is worse, an MCL or LCL tear?
MCL tear → MCL is crucial to joint stability whereas an LCL tear may have little to no effect on stability
Hoppenfeld p185
What is the function of the ACL and PCL?
prevention of anterior and posterior dislocation of the tibia
Hoppenfeld p185
How do you perform the anterior/posterior drawer sign?
1. have patient lie supine
2. flex knees 90°
3. stabilized patient's foot by sitting on it
4. place fingers on insertion of medial and lateral hamstrings
5. place thumbs on medial and lateral joint lines
6. pull tibia anteriorly to perform anterior drawer sign
7. positive if tibia slides anteriorly
8. indicative of possible ACL tear
9. push tibia posteriorly to perform posterior drawer sign
10. positive if tibia slides posteriorly
11. indicative of possible PCL tear
Hoppenfeld p186
What is the purpose of the anterior/posterior drawer sign?
anterior drawer sign → suspected ACL instability/injury
posterior drawer sign → suspected PCL instability/injury
Hoppenfeld p186
Which is more common, ACL or PCL tear?
ACL tear
*PCL is rare
Hoppenfeld p186
Which is more accurate, anterior drawer test or Lachman's test?
Lachman's test
How do you perform Lachman's test?
1. have patient supine
2. flex knee 20°
2. place one hand behind femur
3. place other hand behind tibia
4. pull tibia anteriorly
5. positive if anterior displacement of tibia or soft endpoint
6. indicative of ACL injury
What is the purpose of Lachman's test?
suspected ACL instability/injury
What is the purpose of McMurray's test?
suspected medial meniscus tear
How do you perform McMurray's test?
1. have patient supine
2. place one hand on heel and flex leg fully
3. place other hand with thumb on lateral joint line of knee and fingers on medial joint line
4. push on lateral knee, externally rotate leg, and flex/extend leg
5. positive if palpable or audible "click" within joint
7. indicative of probable medial meniscus tear
Hoppenfeld p191
What is the purpose of Aply's grinding test?
suspected meniscus tear
How do you perform Aply's grinding test?
1. have patient lie prone
2. flex knee 90°
3. place your knee on patient's thigh to stabilize it
4. push down on heel and rotate tibia internally and externally
5. positive if pain
6. if pain on medial side → indicative of medial meniscal tear
6. if pain on lateral side → indicative of lateral meniscal tear
Hoppenfeld p191
What is the purpose of Allen test?
suspected arterial insufficiency or prior to performing ABG
What is the purpose of Apley's distraction test?
to distinguish between meniscal injury and ligament injury of knee
How do you perform Apley's distraction test?
1. have patient lie prone
2. flex knee 90°
3. place your knee on patients femur to stabilize it
4. pull up on ankle
5. internally and externally rotate tibia
6. pain indicative of ligament injury
7. pain should not occur if meniscal injury
Hoppenfeld p193
How do you perform the Allen test?
1. compress radial and ulnar arteries
2. ask patient to clench and unclench fist several times
3. patient's hand should appear blanched
4. release compression of ulnar artery
5. patient's hand should "blush" within 5-10 sec
6. positive if blushing does not occur within 5-10 sec
7. if positive, do not perform ABG or cannulation since ulnar arterial supply to hand is not sufficient
What is scoliosis?
lateral curvature of the spine associated with rotation of involved vertebrae (usually thoracic or lumbar, rarely cervical)
Orthopedics p158
Current Pediatrics
What is the etiology of scoliosis?
if structural (i.e.fixed, fail to correct with lateral flexion) → usually idiopathic, but also congenital abnormalities, neurofibromatosis, neurologic or myopathic conditions

if non-structural (i.e. flexible, correct with lateral flexion) → compensatory mechanism secondary to leg length discrepancy, acute lumbar disc disease, or local inflammation

6x more common in females than males
usually occurs between 8-13y/o
infantile scoliosis may occur between 2-4y/o
Orthopedics p158
Current Pediatrics
What is the clinical presentation of scoliosis?
asymptomatic
lateral curvature of the spine
assymmetry of the heights of the ribs or paravertebral muscles
right thoracic curves most common
Orthopedics p158
What is the diagnostic workup of scoliosis?
standing radiograph of the spine
Orthopedics p158
What is the management of scoliosis?
if nonstructural:
1. treat primary cause

if structural:
1. refer to specialist
2. if <20 degrees → frequent observation
3. if >20 degrees → spinal bracing via Miwaukee brace or thoracolumbosacral orthotic
4. brace worn 23 hours per day
5. exercises performed in brace
6. if >45 degrees → surgery
Orthopedics p158
What are the complications of scoliosis?
pain, deformity, disability, cardiopulmonary compromise
Orthopedics p160
What is the patient education for scoliosis?
1. spinal brace may have to be worn for >2 years
2. bracing does not eliminate curve but prevents progression
3. surgery may cause loss of spine motion
4. if >25 degree curve + pregnant → curve may increase
Orthopedics p161
What is the etiology of genu varum and genu valgum in children?
normal variant
genu varum → normal from infancy to 2 years
genu valgum → normal from 2-8 years
When are genu varum and genu valgum normal?
genu varum → normal from infancy to 2 years
genu valgum → normal from 2-8 years
Peds Current
What is the clinical presentation of genu varum and genu valgum?
genu varum → bow-legged
genu valgum → knock-kneed
Peds Current
When is the management for genu varum and genu valgum?
refer to orthopedist if:
bowing persists beyond 2/yo
bowing increases rather than decreases
bowing is unilateral
knock-knees associated with short stature
Peds Current
What are the complications of genu varum and genu valgum?
failure to straighten in appropriate time frame
genu varum → normal from infancy to 2 years
genu valgum → normal from 2-8 years
genu varum
genu valgum
What is the common name for talipes equinovarus?
clubfoot
What is the etiology of talipes equinovarus?
1. idiopathic (hereditary)
2. neurogenic
3. associated with a disorder (arthrogryposis, Larsen syndrome)

occurs in 1:1000 live births
Peds Current
What is the clinical presentation of talipes equinovarus?
1. plantar flexion of foot at ankle joint (equinus)
2. inversion of heel (varus)
3. medial deviation of forefoot (varus)
Peds Current
talipes equinovarus
What is the management of talipes equinovarus?
1. immediate manipulation of foot following birth
2. splint to hold foot in correct position
3. once full correction obtained, long-term night brace
4. if resistant to manipulation and casting → surgery
Peds Current
What is the etiology of metatarsus varus?
congenital
usually 2° to positioning in uterus
Peds Current
What is the clinical presentation of metatarsus varus?
medial deviation of the forefoot
angulation at base of 5th metatarsal
vertical crease in arch if rigid form
Peds Current
What is the management of metatarsus varus?
if flexible → resolve spontaneously
if rigid → cast changed at intervals of 2 weeks
Peds Current
What conditions are commonly associated with congenital hip dysplasia?
torticollis
metatarsus varus
Peds Current
Define dysplasia.
abnormal growth or development
How do you perform the Ortolani and Barlow maneuvers?
place infant on back
obtain complete relaxation of infant

ORTOLANI:
place long finger over greater trochanter and thumb over inner side of thigh
flex hips to 90°
slowly abduct from midline one hip at a time
attempt to lift greater trochanter forward
feeling of slipping as head relocates is sign of instability

BARLOW:
apply pressure with thumb over inner side of thigh
adduct thigh
attempt to slip hip posteriorly
eliciting a jerk as hip dislocates is sign of instability
CONGENITAL DYSPLASIA OF THE HIP:
ETIOLOGY:
congenital → both acetabulum and femur underdeveloped
occurs in 1:1000 live births

CLINICAL PRESENTATION:
abnormal relationship between proximal femur and acetabulum (dysplasia, subluxable hip, dislocatable hip, dislocated hip)
Ortolani and Barlow reveal instability (signs of instability less evident after 1 m/o)
if abduction limited to <90° → contracture around hip joint
if knees unequal heights when hips and knees flexed → dislocated hip on side of lower knee
if walking → painless limp, lurch to affected side, standing on affected leg results in dip in pelvis of opposite side d/t weakness of gluteus medius muscle (Trendelenburg sign)
if bilateral dysplasia → waddling gait, widened perineum, lumbar lordosis

MANAGEMENT:
1. completely reversible if corrected within first few weeks of life
2. if <4 m/o → manual reduction by flexion and abduction of hip, then pavlik harness to maintain reduction
3. if > 4m/o → traction x 2-3 weeks, then reduction under general anesthesia, then hip spica x 6 months
4. if unstable after closed reduction → open reduction
5. if older age → open reduction + correction of deformity

COMPLICATIONS:
if not corrected → dysplasia will be become progressive and irreversible and deformity will worsen, especially after walking age
What is the etiology of tibial torsion?
if <16-18 months → normal variant
if persists beyond 16-18 months → sleeping with feet turned in
Peds Current
What is the management of tibial torsion?
self-limiting → resolves by 16-18 months
if persists beyond 16-18 months → external rotation splint worn nightly
Peds Current
What is the clinical presentation of tibial torsion?
internally rotated tibia
usually 20°
sometimes accentuated by laxity of knee ligaments
Peds Current
What is the clinical presentation of femoral anteversion?
internally rotated femur
Peds Current
What is the management of femoral anteversion?
returns to neutral by 6-8y/o
encourage external rotation exercises → bike riding, skating
refer to orthopedist if no external rotation of hip in extension
Peds Current
What are the disorders associated with "in-toeing"?
metatarus varus
tibial torsion
femoral anteversion
What does SCFE stand for?
slipped capital femoral epiphysis
Where does SCFE often refer?
knee
What is a SCFE?
displacement of proximal femoral epiphysis
usually displaced medially and posteriorly relative to femoral neck
PEDs Current
What is the etiology of a SCFE?
displacement of proximal femoral epiphysis d/t disruption of growth plate

cause unknown
may be d/t weakness associated with hormonal changes

associated with:
obesity
trauma
hypothyroidism

most common in obese adolescent males
PEDs Current
What is the clinical presentation of a SCFE?
pain and limp
referred pain to thigh and medial knee (knee pain may be only complaint)
limited internal rotation of hip

stable if able to bear weight
unstable if unable to bear weight
PEDs Current
What is the diagnostic workup of a SCFE?
AP and lateral radiographs of the hip
PEDs Current
What is the management of a SCFE?
crutches for non-weight bearing
immediate referral to orthopedics for surgical fixation
PEDs Current
What are the complications of a SCFE?
AVN
premature degenerative arthritis
What is another name for Legg-Calves-Perthes disease?
avascular necrosis of proximal femur
LEGG-CALVES-PERTHES DISEASE:
ETIOLOGY:
idiopathic osteonecrosis of capital femoral epiphysis
usually occurs between 4-8 y/o

CLINICAL PRESENTATION:
persistent pain in hip or groin
referred mild or intermittent pain in thigh or knee
atrophy of thigh 2° to disuse
↓ internal rotation and abduction
limping gait

MANAGEMENT:
1. radiograph of hip
2. protect hip joint and maintain normal joint motion to prevent degenerative arthritis
3. little benefit from bracing and surgery controversial

COMPLICATIONS:
poorer prognosis if metaphysical defects, complete involvement of femoral head, or late childhood onset
What is nursemaid's elbow?
subluxation of radial head from annular ligament
PEDS Current
What is the etiology of nursemaid's elbow?
being lifted or pulled by the hand

consider abuse!
PEDs Current
What is the clinical presentation of nursemaid's elbow?
painful fully pronated elbow
complaint that elbow will not bend
radial head tenderness
PEDs Current
What is the diagnostic workup of nursemaid's elbow?
radiographs normal
PEDs Current
What is the management of nursemaid's elbow?
1. reduction → fully supinate arm and move from full extension to full flexion, will often hear click, and child will immediately feel better
2. sling x few days
PEDs Current
What is the most common cause of septic arthritis?
staph aureus
Current p777
What is the diagnostic workup of septic arthritis?
synovial fluid:
cell count >50,000 cells/mcL
differentail >90% PMNs
gram stain
culture

BC positive in 50% of cases
Current p777
SEPTIC ARTHRITIS:
ETIOLOGY:
source varies according to age:
infant → usually d/t adjacent osteomylelitis
child → usually isolated infection without bone involvement
teenager → usually organism with affinity for joints (gonococcus) or underlying systemic infection
organism varies with age:
<4 m/o → group B strep, staph aureus
4 m/o to 4 y/o → staph aureus, h. flu (less common d/t immunizations)
>4 y/o → staph aureus, staph pyogenes

CLINICAL PRESENTATION:
inflammatory monoarticular arthritis
commonly affects knee, hip, wrist, shoulder, or ankle
acute pain, swelling, warmth
worsens over hours
joint effusion
infant → suspect if irritable, poor feeding, decreased abduction; paralysis of limb d/t inflammatory neuritis
child → fever, malaise, vomiting, restriction of motion

MANAGEMENT:
1. joint aspiration → WBC count >50,000
2. hospitalization and surgical drainage
3. empiric antibiotic therapy → nafcillin or oxacillin + 3rd generation cephalosporin
4. narrow-spectrum antibiotic therapy → selected based on age, gram stain, culture; 3 weeks for staph infection, 2 weeks for other infections

COMPLICATIONS:
if not detected before 24 hours, destruction of joint cartilage occurs, followed by arthrosis and fibrosis
damage to growth plate may also occur
Define torticollis.
stiff neck
What is a ganglion cyst?
soft tissue lesion found adjacent to a joint or tendon sheath
Orthopedics p111
What does the term "Bible bump" refer to and why?
refers to a ganglion cyst because common treatment in the past consisted of hitting the cyst with a bible (a book that most people possessed), causing it to rupture and drain
What is a Colles fracture?
fracture of the distal radius with fragment displaced dorsally
Orthopedics p125
What is the etiology of a Colles fracture?
fall onto extended wrist (i.e. outstretched hand)
Orthopedics p125
What is the clinical presentation of a Colles fracture?
history of fall on outstretched hand
acute pain, swelling, and tenderness of wrist
dinner-fork (or silver-fork) deformity
EOMC p350
dinner fork deformity → colles fracture
What is the diagnostic workup of a Colles fracture?
AP and lateral radiographs of forearm and wrist → dorsal angulation, radial deviation, and shortening of distal radial fragment
possible associated injury to ulnar styloid or ulnar collateral ligament
Orthopedics p124
EOMC p350
What is the management of a Colles fracture?
1. reduction
2. short arm cast x 6 weeks
3. repeat radiographs immediately following reduction
4. repeat radiographs in 7-10 days
5. once cast removed, splint x 3 weeks
6. gentle exercises → shoulder, elbow, fingers
Orthopedics p124
EOMC p350
What are the complications of a Colles fracture?
deformity, malunion, loss of wrist or finger motion, wrist arthritis, carpal tunnel syndrome, compartent syndrome, parasthesias
EOMC p350
What is a Smith's fracture?
fracture of distal radius with fragment displaced ventrally (i.e. reverse Colles fracture)
What is the etiology of a Smith's fracture?
fall onto flexed wrist
What is the difference between a Colles fracture and a Smith's fracture?
both are fractures of the distal radius
Colles → radial fragment displaced dorsally
Smith's → radial fragment displaced ventrally (volarly)
What is a boxer's fracture?
fracture of the distal metaphysis of the 5th metacarpal
Orthopedics p132
What is the etiology of a boxer's fracture?
usually fist fight
Orthopedics p132
What is the clinical presentation of a boxer's fracture?
history of fist fight
acute pain, swelling, and tenderness
depression of knuckle of affected finger
decreased ROM
EOMC p355
depression of 5th "knuckle" → boxer's fracture
What is the diagnostic workup of a boxer's fracture?
AP, lateral and oblique radiographs of the hand
EOMC p355
boxer's fracture → fracture of distal metaphysis of 5th metacarpal
What is the management of a boxer's fracture?
1. if stable + minimal angulation → compression dressing x 1 week, gradual exercise, repeat radiographs after 1 week
2. if unstable + minimally angulated → ulnar gutter splint x 2-3 weeks
3. if >25 degrees angulation → reduction + plaster or fiberglass splint x 4 weeks
Orthopedics p132
EOMC p355
What is the patient education for a boxer's fracture?
if adult, knuckle will always be less prominent when fist made
Orthopedics p132
What is a Bennett's fracture?
oblique fracture of the base of the 1st metacarpal that enters the carpometacarpal (CMC) joint
Orthopedics p132
What is the etiology of a Bennett's fracture?
abductor pollicis longus tendon pulled proximally → causing 1st metacarpal to be displaced proximally while small medial fragment of 1st metacarpal remains attached to volar oblique ligament
EOMC p348
What is the clinical presentation of a Bennett's fracture?
pain, swelling, and ecchymosis at base of thumb
limited ROM
EOMC p348
What is the diagnostic workup of a Bennett's fracture?
AP and lateral radiographs of thumb
EOMC p348
What is the management of a Bennett's fracture?
1. if non-displaced → thumb spica cast x 4 weeks
2. if displaced → reduction + surgical fixation
*most Bennett's fractures usually requires surgery
Orthopedics p132
EOMC p348
What is paronychia?
infection of the distal phalanx that occurs along the edge of the nail
Current p141
Orthopedics p122
What is the etiology of paronychia?
local trauma resulting in infection (bacterial or fungal)
if acute → think staph
if chronic → think candida

associated with:
biting nail
picking hangnail
trimming cuticle
onychomycosis
diabetes
people who have hands in water for long periods of time
Orthopedics p122
What is the diagnostic workup of paronychia?
bacterial or fungal culture
What is a felon?
infection of the closed space of the pad of the distal phalanx
Orthopedics p122
What is the etiology of a felon?
infection of the fingertip pulp → usually staph aureus

associated with:
wooden splinters
minor cuts
complication of paronychia
Orthopedics p122
What is the clinical presentation of a felon?
rapidly increasing pressure and pain
erythema, swelling, and tenseness of fingertip

cellulitis → tight prickling pain → abscess formation → throbbing pain, edema, increased pressure → compromised blood flow → possible necrosis
Orthopedics p122
What is the clinical presentation of paronychia?
erythema, swelling, and tenderness of finger
Orthopedics p123
What is the management of paronychia?
If acute:
1. oral antibiotics
2. if abscess → I&D

If chronic:
1. oral antifungals
Orthopedics p123
What is the management of a felon?
1. early I&D
2. antibiotics for S. aureus
Orthopedics p122
What are the complications of humeral shaft fracture?
-radial nerve injury
-brachial plexus injury
-vascular injury
-persistent stiffness of shoulder/elbow
What is the etiology of humeral shaft fracture?
-acute trauma (MVA, fall on outstretched hand)
What are the symptoms/signs of humeral shaft fracture?
-severe pain, swelling
-deformity if displaced
What diagnostics should be ordered if suspected humeral fracture?
-AP and lateral radiographs
-include shoulder and elbow joints
What are the symptoms/signs of radial nerve injury?
-weakness in wrist and finger extension
-numbness in first dorsal webspace
Proximal humeral fractures are most commonly seen in what patient population?
elderly w/ osteoporosis (especially women)
What is the etiology of radial head fracture?
fall on outstretched hand while elbow extended
What are the symptoms/signs of radial head fracture?
-pain, swelling, tenderness over radial head
What are the physical exam findings in radial head fracture?
-pain elicited on flexion/extension
-limited passive forearm rotation
What diagnostics should be ordered for suspected radial head fracture?
-AP and lateral radiographs
-nondisplaced/minimally displaced fractures difficult to see on radiographs, but treat empirically if high index of suspicion
What are the complications of radial head fracture?
-loss of extention (especially last 10-15°)
-traumatic arthritis
What is the differential diagnosis of radial head fracture?
-elbow dislocation - diffuse pain, deformity
-olecranon process fracture of ulna
-supracondyle ridge fracture of humerus
What are the types of radial head fracture?
type I - nondisplaced/minimally displaced
-type 2 - displaced > 2mm
-type 3 - comminuted
What is the treatment for radial head fracture?
-type 1 - sling or splint for 7-10 days, early active motion
-type 2 - aspiration -> if no mechanical block to forearm rotation, treat like type I; if block, open reduction
-type 3 - early excision of radial head fragments
What are the associated injuries of radial head fracture?
-hemarthrosis
-dislocation
-associated forearm/wrist injury
What muscle is most commonly torn in rotator cuff tear?
supraspinatus
What is fat pad sign?
sign seen on lateral elbow radiograph
indicative of intra-articular hemorrhage which is often associated with radial head fracture
fat pad sign → intra-articular hemorrhage → possible occult radial head fracture
What is the mechanism of injury for anterior/posterior shoulder dislocation?
anterior → fall on externally rotated, abducted arm

posterior → force directed against internally rotated arm; seizure
Orthopedics p70
What is the clinical presentation of anterior/posterior shoulder dislocation?
prominent acromion
absence of normal fullness of humeral head
severe pain upon movement

anterior → anterior shoulder full, arm externally rotated, internal rotation painful

posterior → anterior shoulder flat, arm internally rotated, external rotation painful
Orthopedics p70
What is more common, anterior or posterior shoulder dislocation?
anterior (95%)
Orthopedics p70
What is a bankart lesion?
tear in labrum due to anterior shoulder dislocation
Orthopedics p72
What is the diagnostic workup of anterior/posterior shoulder dislocation?
AP and lateral radiographs
anterior shoulder dislocation
What is the management of anterior/posterior shoulder dislocation?
1. reduction
2. sling x few days
3. gradual active motion
4. rehabilitation exercises
5. avoid positions of known instability
Orthopedics p74
After initial shoulder dislocation, in what percent of young males does redislocation occur?
60-80%
What is the mechanism of injury for AC joint separation?
fall on shoulder or direct blow to top of shoulder → driving acromion away from clavicle
Orthopedics p75
What is the clinical presentation of AC joint separation?
lateral clavicle elevated
swelling and tenderness over AC joint
Orthopedics p75
What is the diagnostic workup of AC joint separation?
AP radiograph
Orthopedics p75
AC joint separation
What is the management of AC joint separation?
1. graded I-V where:
I = AC contusion or strain
II = rupture of AC ligaments
III = rupture of coracoclavicular ligaments
IV and V = significant displacement
2. if incomplete separation → sling x few days + active shoulder motion as soon as tolerated
3. if grade IV or V → surgery
Orthopedics p75
What is the etiology of clavicular fracture?
trauma
What is the clinical presentation of clavicular fracture?
clavicular deformity, skin tenting, tenderness
Orthopedics p79
clavicle fracture
skin tenting → fracture of LT clavicle
What is the diagnostic workup of clavicular fracture?
AP and lateral radiograph
clavicle fracture
What is the management of clavicular fracture?
1. immobilization via figure-8 splint or simple sling x 4-5 weeks for child and 8 weeks for adult
2. splint must be periodically retightened
3. splint discomfort can be relieved by lying down and abducting arms
4. if fracture lateral to coracoclavicular ligament + minimal displacement → only use sling
5. if fracture lateral to coracoclavicular ligament + displacement → refer to orthopedic specialist due to high rate of nonunion
6. prominence at fracture site often persists in adult but nonunion rare
Orthopedics p79
What is the common name for medial epicondylitis?
golfer's elbow
What is the common name for lateral epicondylitis?
tennis elbow
What is the etiology of medial/lateral epicondylitis?
unknown
direct blow
overuse → repetitive use of flexors or extensors of forearm

leads to degeneration (tendinosis)
Orthopedics p92
What is the clinical presentation of medial/lateral epicondylitis?
gradual onset, dull ache, pain with rotation

medial epicondyltis → pain at common flexor tendon, increases with flexion of hand against resistance

lateral epicondylitis → pain at common extensor tendon, increases with extension of hand against resistance
Orthopedics p92
What is the diagnostic workup of medial/lateral epicondylitis?
none
What is the management of medial/lateral epicondylitis?
1. usually self-limited
2. NSAIDs
3. rest
4. ice after activity
5. avoid offending activity
6. exercise program of gentle stretching and strengthening as pain subsides
7. steroid/lidocaine injection usually provides permanent or long-lasting relief
8. surgery if refractory to treatment
Orthopedics p92
What test would you perform for suspected anterior/posterior shoulder dislocation?
apprehension sign → positive if look of apprehension
What is gamekeeper's thumb?
chronic injury to ulnar collateral ligament (UCL) connecting 1st metacarpal to proximal phalanx
Orthopedics p331
What is the mechanism of injury for gamekeeper's thumb?
acute → fall on hand → forced abduction or hyperextension of proximal phalanx; skiers
chronic → repeated hyperabduction; gamekeepers

may cause torn UCL or avulsion fracture
Orthopedics p331
What is the clinical presentation of gamekeeper's thumb?
chronic:
history of instability
MCP joint effusion, tenderness
weakness with pinch
Orthopedics p331
What is the diagnostic workup of gamekeeper's thumb?
thumb radiograph to R/O avulsion fracture
Orthopedics p331
What is the management of gamekeeper's thumb?
Acute:
1. if partial tear or non-displaced avulsion fracture → cast x 5 weeks
2. if complete tear → surgery

Chronic:
1. if associated with traumatic arthritis → ligament reconstruction
2. if associated with degenerative arthritis → arthrodesis
Orthopedics p331
What is the name for acute gamekeeper's thumb?
skier's thumb
Orthopedics p331
What is another name for mallet finger?
baseball finger
Orthopedics p327
What is mallet finger?
avulsion of the extensor tendon where it inserts at the base of distal phalanx (or possibly associated avulsion fracture)
Orthopedics p327
What is the mechanism of injury for mallet finger?
blow to tip of extended finger → forced flexion of DIP joint
Orthopedics p327
What is the clinical presentation of mallet finger?
flexed distal phalanx
swelling and tenderness of dorsal DIP joint
lost of active extension of distal phalanx

if long-standing injury, hyperextension of PIP joint may occur → swan neck deformity
Orthopedics p327
What is the diagnostic workup of mallet finger?
finger radiograph to R/O avulsion fracture
Orthopedics p327
What is the management of mallet finger?
1. if no avulsion fracture or small avulsion fracture → splint x 5 weeks with slight hyperextension of DIP
2. if large displaced fracture + joint stability → same treatment as above
3. if large displaced fracture + instability → surgery
4. redness, swelling, and tenderness may last 2-3 months
Orthopedics p327
mallet finger
What is trigger finger?
catching, locking or snapping of involved finger flexor tendon
What is the mechanism of injury for trigger finger?
swelling of flexor tendon and sheath

if child + thumb → think congenital
if multiple fingers → think rheumatoid disease
Orthopedics p114
What is the clinical presentation of trigger finger?
nodular thickening, swelling and tenderness near MCP joint
finger may lock in flexion or extension
if locked in flexion, manipulation to unlock it may produce palpable snap
worse with rest, better with activity
Orthopedics p114
What is the diagnostic workup of trigger finger?
none
What is the management for trigger finger?
1. often self-limiting
2. splinting of DIP
3. surgical release
Orthopedics p115
trigger finger
What is the etiology of frozen shoulder?
cause unknown
may be associated with rotator cuff tendinitis, bicipital tendonitis, reflex symphathetic dystrophy
associated with ischemic heart disease, lung disease, and thyroid disease

more common in women and diabetics
What is the clinical presentation of frozen shoulder?
insidious onset of pain in 5th decade
restriction ROM
3 stages:
1. freezing
2. frozen
3. thawing
tenderness around rotator cuff
LOSS OF INTERNAL ROTATION (active and passive)
What is the diagnostic workup of frozen shoulder?
radiograph to R/O posterior shoulder dislocation
What is the management of frozen shoulder?
1. pain relief
2. restoration of motion
3. moist heat
4. analgesics
5. sedation
4. injection of steroid
5. exercises on hourly basis
6. recovery usually takes >6 months
What is another name for frozen shoulder?
adhesive capitulitis
What is frozen shoulder?
shoulder disorder characterized by insidious onset of pain and restriction of motion
What is the etiology of navicular fracture?
fall on outstretched hand → hyperextension of wrist
What are the complications of navicular fracture?
AVN → arthritis
What is the clinical presentation of navicular fracture?
pain in anatomical snuffbox
What is a tuft fracture?
fracture of distal phalanx
usually caused by crush injury
What is the most common complication of a humeral fracture?
radial nerve injury
What is hallux valgus?
lateral deviation of great toe at MTP joint
Orthopedics p260
What is a bunion?
bony and soft tissue enlargement over medial aspect of head of 1st MTP associated with hallux valgus
Orthopedics p260
What is the etiology of hallux valgus?
cause unknown

associated with:
hereditary factors
tight-fitting shoes
high heels
Orthopedics p260
What is the clinical presentation of hallux valgus?
affects women 10x more than men

1st MTP joint:
pain and tenderness when wearing tight-fitting shoes or high-heels
erythema
bunion → bony and soft tissue enlargement over medial aspect of head of 1st MTP
lateral deviation of great toe at MTP joint
possible hyperextension and callus formation on 2nd toe
Orthopedics p260
hallux valgus
hallux valgus → with hyperextension of 2nd toe
What is the diagnostic workup of hallux valgus?
AP radiograph →
lateral displacement of proximal phalanx of great toe
medial exostosis of head of 1st metatarsal
possible degeneration of MTP joint
Orthopedics p260
hallux valgus
What is the management of hallux valgus?
1. goal → relieve pressure over bunion
2. do not wear tight-fitting shoes, high-heels, or tight-fitting stockings
3. if hyperextended 2nd toe → wear "extra-depth" shoe or use splint to separate 1st and 2nd toes
4. if acute pain → rest and moist heat
5. if disabling pain with deformity → surgery with realignment of great toe and excision of exostosis
Orthopedics p260-261
What is the patient education for hallux valgus?
1. >50% of cases respond by changing shoes
2. requires permanent lifestyle change if not surgical treated
3. do not wear tight-fitting shoes, high-heels, or tight pantyhoes
Orthopedics p261
What is morton's neuroma?
perineural fibrosis of the plantar nerve where the medial and lateral plantar branches communicate between 3rd and 4th metatarsals → painful fusiform (spindle-like) swelling of plantar nerve
Orthopedics p258
What is the etiology of morton's neuroma?
cause unknown

associated with:
repetitive trauma
wearing tight shoes
Orthopedics p258
What is the clinical presentation of morton's neuroma?
burning pain between 3rd and 4th metatarsals (sometimes 2nd and 3rd)
possible numbness
aggravated by tight shoe
alleviated by removing shoe and massaging foot
tenderness on pressure between 3rd and 4th metatarsals or transvere compression of forefoot
possible decreased sensation
Orthopedics p258
Where is morton's neuroma most commonly found?
between 3rd and 4th metatarsals
What is the diagnostic workup of morton's neuroma?
none → diagnosis made clinically
Orthopedics p258
What is the management of morton's neuroma?
1. for symptomatic relief → NSAIDs or local injection of lidocaine/steroid into web area from dorsal approach
2. pad separating 3rd and 4th metatarsals
3. do not wear tight-fitting shoes
4. surgical removal often necessary
Orthopedics p258
What is the patient education for morton's neuroma?
do not wear tight-fitting shoes
Orthopedics p258
What is the plantar fascia?
thick band of connective tissue extending from calcaneus to proximal phalanges; involved in gait
Orthopedics p253
What is the plantar fasciitis?
inflammation of plantar fascia
What is the etiology of plantar fasciitis?
probable overuse with development of degeneration and microtears

associated with:
tight heel cords (i.e. reduced dorsiflexion)
obesity
running
Orthopedics p253
What is the clinical presentation of plantar fasciitis?
affects men and women equally
pain → usually at medial tubercle of calcaneous where plantar fascia originates but sometimes along medial longitudinal arch
aggravated with first steps of morning or after prolonged sitting or after weight-bearing activities
tenderness with direct pressure or sometimes dorsiflexion
if bilateral → may be associated with RA, gout, AS
Orthopedics p253
List disorders associated with bilateral plantar fasciitis.
RA
gout
ankylosing spondylitis
Orthopedics p253
What is the diagnostic workup of plantar fasciitis?
radiographs →
often normal
possible osteophyte on calcaneous (but not cause of pain)
Orthopedics p254
What is the management of plantar fasciitis?
1. for symptomatic relief → ice, NSAIDs, lidocaine/steroid injection
2. taping and pads slightly beneficial
3. cast x 6 weeks very beneficial
4. night splint holding foot in dorsiflexion if refractory
5. exercises to stretch heel cord and plantar fascia
6. if refractory after 6-12 months → surgery with detachment of plantar fascia at calcaneous
Orthopedics p254
What is the patient education of plantar fasciitis?
1. medical treatment effective in 95% of cases
2. improvement may take up to 1-2 years
3. OTC orthoses are as effective as more expensive ones
4. do not perform exercises if in acute pain
Orthopedics p255
Name the bones of the foot.
calcaneous
talus
navicular
cuboid
medial cuneiform
intermediate cuneiform
lateral cuneiform
metatarsals
phalanges
What is another name for onychocryptosis?
ingrown toenail
What is the etiology of calcaneous fracture?
usually fall on heel
Orthopedics p268
What is the clinical presentation of calcaneous fracture?
severe pain and swelling of heel
swelling may lead to blistering and skin necrosis
Orthopedics p269
What is the diagnostic workup of calcaneous fracture?
radiograph → AP and lateral of hindfoot; AP and mortise of ankle
usually crushed
displacement of fragments varies
Orthopedics p269
EOMC p633
What is the management of calcaneous fracture?
Initial management to control swelling and hemorrhage:
1. compression dressing, ice, elevation
2. do not apply cast immediately after injury → only intensifies pain and swelling

Later management:
1. if minimally displaced → cast x 2-3 weeks + immobilization or crutches
2. remove cast ASAP but do not allow weight bearing for 6-8 weeks
3. eversion and inversion exercises
4. prolonged immobility is not advised
5. if displaced → same treatment as above or open/closed reduction
6. if symptoms persist → surgery
Orthopedics p269
What is the patient education for calcaneous fracture?
1. temporary disability may persist 1-2 years
2. some permanent impairment common → often widening of heel; some restriction of eversion and inversion
Orthopedics p269
What disorder occurs in 10% of calcaneous fractures?
compression fracture of lumbar spine

palpate spine for tenderness
if tenderness → order AP and lateral spinal radiographs
EOMC p633
What is the etiology of phalangeal fractures?
direct trauma to phalange
EOMC p639
What is the clinical presentation of phalangeal fracture?
pain, swelling, ecchymosis
EOMC p639
What is the diagnostic workup of phalangeal fracture?
AP radiograph
EOMC p639
fracture of 5th proximal phalanx
What is the management of phalangeal fractures?
1. if undisplaced → place gauze pad between injured toe and medially adjacent toe and buddy tape them together x 3-4 weeks (change as often as needed)
3. closed or open reduction rarely necessary → but consider for markedly angulated fractures, fractures involving MTP joints, fractures involving interphalangeal joints of great toe
Orthopedics p271
EOMC p639
What is the etiology of onychocryptosis?
soft tissue overgrows and obliterates nail sulcus

associated with:
improper nail trimming → small nail spike irritates soft tissue → infection
cleaning nail with tools that penetrate skin
tight-fitting shoes and stockings
bony deformities
Orthopedics p263
What is the clinical presentation of onychocryptosis?
usually affects great toe
soft tissue overgrowth + normal nail
pain, inflammation, pus
Orthopedics p263
What is the diagnostic workup for onychocryptosis?
none
Orthopedics p263
What is the management of onychocryptosis?
1. antibiotics
2. soak nail
3. elevate nail edge with cotton wad until grows beyond soft tissue reaction → must be patient since takes 3 months for nail to grow 1 cm
4. if refractory → surgery usually by removing one or both nail margins
Orthopedics p263
What is the patient education for onychocryptosis?
for prevention:
1. use proper nail-trimming technique → always trim nail straight across, do not round or cut too short
2. wear properly fitted shoes and stockings
Orthopedics p263
onychocryptosis
What are the Ottowa rules for ordering ankle radiographs?
Unable to bear weight for 4 steps + one of the following:
1. bony tenderness at posterior edge of medial malleolus
2. bony tenderness at posterior edge of lateral malleolus
What are the Ottowa rules for ordering foot radiographs?
Unable to bear weight for 4 steps + one of the following:
1. bony tenderness over the navicular
2. bony tenderness over the base of the 5th metatarsal
What are the Ottowa rules for ordering knee radiographs?
Any of the following:
1. >55y/o
2. inability to bear weight for 4 steps following injury and in ER
3. patellar tenderness
4. fibular head tenderness
5. inability to flex knee to 90 degrees
What is another name for chondromalacia patella?
patellofemoral pain syndrome
Orthopedics p227
Waht is chondromalacia patella?
pain over anterior aspect of knee in absence of other identifiable pathology (i.e. diagnosis of exclusion)
Orthopedics p227
What is the clinical presentation of chondromalacia patella?
usually affects teenagers and young adults
pain near or beneath patella
worse when walking stairs, prolonged sitting with knee flexed
often bilateral
crepitus
Orthopedics p227
What is the etiology of chondromalacia patella?
unknown cause

associated with:
any anatomic abnormality or injury causing irregular movement of patella
quadriceps imbalance
high-riding patella
genu valgum
direct trauma
vigorous squatting
overuse
Orthopedics p226
What is the management of chondromalacia patella?
1. reassure patient that problem is benign
2. treat underlying cause if present
3. avoid flexion load
4. NSAIDs
5. ice after activity
6. moist heat
7. exercise program
8. often resolves spontaneously
Orthopedics p226
What is a Baker's cyst?
enlargement of semimebranous bursa normally present in medial aspect of popliteal fossa
Orthopedics p220
What is the etiology of a Baker's cyst?
if child → primary
if adult → secondary to intra-articular knee disorder (posterior tear of medial meniscus, OA, or RA) which causes increase in joint fluid → fluid fills bursa
Orthopedics p220
What is the clinical presentation of Baker's cyst?
cyst in medial aspect of popliteal fossa
associated knee effusion
if ruptures, may resemble thrombophlebitis or venous thrombosis!
Orthopedics p220
What is the diagnostic workup of a Baker's cyst?
radiographs normal
ultrasound studies confirm benign cyst
Orthopedics p221
What is the management of a Baker's cyst?
1. if child → self-limited in 1-2 years
2. if adult + asymptomatic → observation
3. if adult + symptomatic/burst → aspiration +/- injection of triamcinolone 20-40mg anteriorly, rest, elevation
Orthopedics p221
What is Osgood-Schlatter's syndrome?
disorder involving growing tibial tuberosity
Orthopedics p231
What is the etiology of Osgood-Schlatter's syndrome?
cause unknown

traumatically produced lesion that occurs at attachment of patellar tendon to tibial tuberosity

affects adolescents, 3x more males than females, usually evident between 8-15y/o
Orthopedics p231
What is the clinical presentation of Osgood-Schlatter's syndrome?
local pain, swelling and tenderness over tibial tubercle
pain worsened by activity, walking stairs, squatting, knee extension against resistance
Orthopedics p231
What is the diagnostic workup of Osgood-Schlatter's syndrome?
knee radiograph usually normal
possible separation and fragmentation of proximal tibial epiphysis
Orthopedics p231
What is the management of Osgood-Schlatter's syndrome?
1. self limited → resolving with closure of proximal tibial growth plate
2. remove stress on tendon
3. stretching, ice, and NSAIDs after activity
4. if refractory → knee splint and temporary immobilization
Orthopedics p231
What is the etiology of pre-patellar bursitis?
direct trauma
recurrent trauma → kneeling (housemaid's knee)
Orthopedics p234
What is the clinical presentation of pre-patellar bursitis?
swelling around patella
What is the diagnostic workup of pre-patellar bursitis?
none
What is the management of pre-patellar bursitis?
If acute:
1. rest
2. aspiration for pain relief or suspected infection
3. repeated aspirations since fluid often returns

Chronic:
1. possible excision
Orthopedics p234
What is a Jones fracture?
fracture in proximal 1/3 of 5th metatarsal
Approach To The Orthopedic Patient handout
What is a Dancer's fracture?
avulsion fracture of the 5th metatarsal
What are the complications of a Jones fracture?
high rate of non-union due to lower vascularity → treat aggressively!
Approach To The Orthopedic Patient handout
What is a boxer's fracture?
fracture of proximal metacarpal → usually 5th metacarpal
What are the medial and lateral meniscus of the knee made of?
fibrocartilage
What are 4 important ligaments of the knee?
medial collateral ligament (MCL)
lateral collateral ligament (LCL)
anterior cruciate ligament (ACL)
posterior cruciate ligament (PCL)
What test is performed for suspected achilles tendon rupture?
Thompson's test → positive if squeezing calf does not produce plantar flexion of foot
What is the mechanism of injury for achilles tendon rupture?
spontaneous rupture due to gradual degeneration of achilles tendon → often caused by jumping, pushing off forefoot

high incidence if taking quinolones
Orthopedics p257
What is the clinical presentaiton of achilles tendon rupture?
hear "pop"
walk flat footed; unable to stand on ball of foot
hemorrhage
palpable sulcus at rupture site
tenderness
excessive passive dorsiflexion
positive Thompson's test
Orthopedics p257
What is the diagnostic workup of achilles tendon rupture?
none
What is the management of achilles tendon rupture?
1. refer to orthopedist immediately for surgery
2. refrain from excessive activity for 1 year
3. recurrence common
Orthopedics p257
What is the mechanism of medial/lateral meniscus tear?
flexion with external rotation or extension with internal rotation
Orthopedics p217
What is the clinical presentation of medial/lateral meniscus tear?
history of twisting injury to knee with foot in weight-bearing position
popping or tearing sensation
severe pain
localized medially or laterally depending on meniscus injured
joint effusion occurs gradually over several hours
acute symptoms replaced by intermittent locking, buckling, giving out, swelling, and mild pain
difficulty walking stairs or squatting
pain at joint line
limited ROM
positive McMurray test
Orthopedics p217
What is the diagnostic workup of medial/lateral meniscus tear?
radiograph to R/O fracture
Orthopedics p218
What is the management of medial/lateral meniscus tear?
1. conservative treatment initially
2. RICE
-Robert Jones compression dressing
3. crutches
4. quadricep-strengthening exercises x 2-4 weeks
5. gentle ROM exercises after 2-3 days (swimming is excellent)
6. resume weight-bearing as pain subsides
7. MRI is continued pain
8. surgery is continued pain or irreducible locking
Orthopedics p218
Which is more common, medial or lateral meniscus tear?
medial meniscus

10x more common because its more firmly attached
Orthopedics p217
What is the most common knee injury?
meniscus tear
What is the mechanism of injury for ACL/PCL sprain?
twisting injuries
Orthopedics p222
What is the mechanism of injury for MCL/LCL sprain?
MCL → valgus stress against the knee
LCL → varus stress against the knee
Orthopedics p222
What is the clinical presentation of ACL/PCL sprains?
popping or tearing sensation
inability to bear weight
immediate swelling due to hemorrhage
positive anterior drawer sign or lachman test if ACL tear
positive posterior drawer sign if PCL tear
What is the clinical presentation of MCL/LCL sprains?
inability to bear weight
ecchymosis within few days
positive valgus stress test if MCL tear
positive varus stress test if LCL tear
Orthopedics p223
Which is more painful, incomplete or complete knee ligament tears?
incomplete
Orthopedics p223
What is the diagnostic workup of ACL/PCL and MCL/LCL sprains?
radiograph of knee to R/O fracture/avulsion fracture
Orthopedics p223
What is the management for ACL/PCL sprains?
1. dependent on age and lifestyle of patient
2. if minor sprain → ice, compression dressing, elevation x 2-3 days, then exercises
3. if highly active → surgery
Orthopedics p223
What is the management for MCL/LCL sprains?
1. rest, ice, compression dressing
2. hinge brace
3. early rehabilitaiton
4. if complete LCL tear → surgery
Orthopedics p223
What is the mechanism of injury for patellar dislocation?
lateral dislocation can occur if sudden valgus stress to knee or direct blow to medial aspect of patella
Orthopedics p229
What is the clinical presentation of patellar dislocation?
laterally displaced patella
Orthopedics p229
What is the diagnostic workup of patellar dislocation?
knee radiograph to R/O fracture
Orthopedics p229
What is the management of patellar dislocation?
1. reduction → lift heel of leg off examining table + gentle pressure against patella
2. knee immobilizer x 2-3 weeks
3. quadriceps exercises ASAP
Orthopedics p229
Twisting knee injury + acute hemarthrosis usually indicates?
ACL tear
Orthopedics p229
What is the mechanism of injury for a patella fracture?
fall onto knee or direct blow
Orthopedics p236
What is the management of a patella fracture?
Undisplaced:
1. compression dressing
2. splint or cast x 5-6 weeks
3. exercise program

Displaced → surgery
Orthopedics p236
What is the diagnostic workup of patellar fracture?
AP and lateral radiographs of knee
What is the most common cause of kyphosis/gibbus?
compression fractures from osteoporosis
Mosbys p708
Orthopedics p161
Where do 95% of lumbar disc lesions occur?
L4 and L5 disc spaces
Orthopedics p145
List the parts of an intervertebral disc.
outer portion → annulus fibrosus
inner portion → nucleus pulposus
Does a lumbar disc herniation affect the spinal root above or below it?
below
Orthopedics p146
Which part of the annulus fibrosus is most susceptible to nucleus propulsus herniation?
posterolateral
Orthopedics p145
What is the clinical presentation of lumbar disc herniation?
lower back pain → localized near disc, one-sided, deep, aching, may refer to iliac crest or buttock, exacerbated with lateral flexion toward affected side
if nerve root compression, radicular pain → radiates over buttock, down posterior or posterolateral leg
Orthopedics p147
List 5 types of lumbar disc disease.
1. herniation without compression of nerve root
2. herniation with compression of nerve root
3. cauda equina syndrome
4. chronic degenerative disease with or without leg symptoms
5. spinal stenosis
Orthopedics p147
How can you differentiate back pain due to muscle strain and back pain due to intervertebral disc disease?
during lateral flexion:
if muscle strain → pain increases with flexion away from affected side
if intervertebral disc disease → pain increases with flexion toward affected side
Orthopedics p144
If back pain or radicular pain does not improve with bed rest, what should be considered?
spinal cord tumor
Orthopedics p147
What is the treatment for lumbar disc disease?
1. NSAIDs, analgesics, and moist heat as needed
2. if radicular pain → best rest x 5-10 days
3. careful exercise program
4. physical therapy
5. if severe or progressive neurological deficits or refractory to treatment after 6 weeks → surgery
Orthopedics p149
What is the treatment for chronic degeneration of lumbar disc?
1. NSAIDs, analgesics, moist heat, rest
2. lumbrosacral corset
3. postural training
4. exercise program or physical therapy
Orthopedics p151
What is the etiology of acute lumbosacral strain?
trauma
if chronic back pain, consider risk factors
What is the clinical presentation of acute lumbosacral strain?
pain and tenderness over affected area
Orthopedics p153
What are the risk factors for chronic lumbar back pain?
poor muscular tone
obesity
smoking
lack of daily exercise
incorrect postural and lifting habits
high-heels
Orthopedics p153
What is the treatment for acute lumbosacral strain?
If simple:
1. rest x 1-2 days followed by physical activity
2. mild analgesics
3. proper lifting and bending habits

If complicated:
1. encourage weight loss, smoking cessation
2. daily postural exercises
3. exercise program

*treatment based on symptoms not radiographs
Orthopedics p153
What is "bamboo spine"?
complication of ankylosing spondylitis characterized by fusion of vertebrae
List the number of each type of vertebra.
cerivcal → C1-C7 (C1 atlas, C2 axis, C7 vertebra prominens)
thoracic → T1-T12
lumbar → L1-L5
sacral → S1-S5 (fused)
coccyx
spondylolisthesis (at L4-L5)
What is spondylitis?
inflammation of the vertebrae
What is spondylolysis?
stress fracture of pars interarticularis
What is spondylolisthesis?
anterior displacement of a vertebra in relation to the one below
What is the etiology of spondylolysis?
hereditary predisposition → thin vertebral bone

sports (especially gymnastics and football) → impact loading and hyperextension of lumbar spine → stress fracture of pars interarticularis
Orthopedics p154
What is the etiology of spondylolisthesis?
spondylolysis
congenital
traumatic
degenerative
pathologic → metabolic bone disease, tumor
Orthopedics p154
What is the most common cause of spondylolisthesis?
bilateral stress fracture of pars interarticularis → spondylolysis → spondylolisthesis
Orthopedics p155
What is the clinical presentation of spondylolysis and spondylolisthesis?
often asymptomatic

pediatric:
often no pain
paraspinal muscle spasm → hamstring tightness → postural deformity and gait abnormality

adult:
low back pain

increased lordosis
palpable step-off
tenderness in affected area
neurologic deficits rare
Orthopedics p155
Where does spondylolisthesis most commonly occur?
L5-S1
Orthopedics p154
What is the diagnostic work-up of spondylolisthesis?
lateral radiograph of lumbosacral spine
What is the grading scale for spondylolisthesis?
Grade 1 → <25% anterior displacement
Grade 2 → 25-50% anterior displacement
Grade 3 → 50-75% anterior displacement
Grade 4 → >75% anterior displacement
Orthopedics p154
What are the complications of spondylolysis?
spondylolisthesis
Orthopedics p154
What are the complications of spondylolisthesis?
nerve compression
spinal stenosis
What is the treatment for spondylolysis and spondylolisthesis?
pediatric:
1. goal → heal stress fracture
2. restrict activity for several months
3. back brace

adult or nonunion:
1. NSAIDs
2. rest
3. weight loss
4. exercise program → hamstring exercises
5. intermittent use of back brace
6. if refractory or progressive → surgery
Orthopedics p154
What is the patient education for work-related low back pain?
1. few days rest
2. mild analgesics
3. educate about proper posture, bending, and lifting
4. use chair with good lumbar support and armrests; temporarily avoid bending and lifting
5. encourage early exercise → walking, biking, swimming followed by exercise program
7. avoid passive treatment → heat, massage
8. encourage return to work
9. if refractory to treatment after 6-8 weeks → refer to specialist
Orthopedics
What is diagnostic workup of Reiter's syndrome?
HLA-B27 antigen → positive 85%
ESR → elevated
Orthopedics p167
What is ankylosing spondylitis?
type of seronegative spondyloarthopathy
chronic arthritis of axial skeleton
What is costochondritis?
inflammation of the junctions where cartilage connects ribs to sternum
What is the clinical presentation of costochondritis?
chest pain → musculoskeletal chest pain localized near sternum → pain on palpation of chest wall that increases with breathing/movement
What is the management of costochondritis?
self-limited
NSAIDs
ice/heat
avoid exacerbating activities
What is the etiology of costochondritis?
usually idiopathic
chest wall trauma
viral infection
arthritis → ankylosing spondylitis, psoriatic arthritis
fibromyalgia

common cause of chest pain in adolescents
What is the diagnostic workup of costochondritis?
R/O other causes of chest pain
What is the difference between costochondritis and Tietze's syndrome?
Tietze's syndrome is a more severe form of costochondritis that is characterized by SWELLING of the costal cartilages
What is the etiology of rib fracture?
usually MVA causing blunt thoracic trauma
EMED Current
What is the clinical presentation of rib fracture?
localized pain
pain with inspiration
crepitus
EMED Current
What is the diagnostic workup of rib fracture?
PA and lateral CXR
*though 50% aren't detected on CXR
EMED Current
What are the complications of rib fracture?
pneumothorax
hemothorax
hypoventilation
atelectasis
pneumonia
EMED Current
What is the management for rib fracture?
1. rapid mobilization
2. respiratory support
3. pain management
EMED Current
What is scoliosis?
lateral curvature of the spine
Orthopedics p158
What is the etiology of scoliosis?
if structural (i.e.fixed, fail to correct with lateral flexion) → usually idiopathic, but also congenital abnormalities, neurofibromatosis, neurologic or myopathic conditions

if non-structural (i.e. flexible, correct with lateral flexion) → compensatory mechanism secondary to leg length discrepancy, acute lumbar disc disease, or local inflammation

6x more common in females than males
usually occurs between 10-13y/o
Orthopedics p158
What is the management of scoliosis?
if nonstructural:
1. treat primary cause

if structural:
1. refer to specialist
2. if <20 degrees → frequent observation
3. if >20 degrees → spinal bracing via Miwaukee brace or thoracolumbosacral orthotic
4. brace worn 23 hours per day
5. exercises performed in brace
6. if >45 degrees → surgery
Orthopedics p158
What is the clinical presentation of scoliosis?
asymptomatic
lateral curvature of the spine
right thoracic curves most common
Orthopedics p158
What is the diagnostic workup of scoliosis?
standing radiograph of the spine
Orthopedics p158
What are the complications of scoliosis?
pain, deformity, disability, cardiopulmonary compromise
Orthopedics p160
What is the patient education for scoliosis?
1. spinal brace may have to be worn for >2 years
2. bracing does not eliminate curve but prevents progression
3. surgery may cause loss of spine motion
4. if >25 degree curve + pregnant → curve may increase
Orthopedics p161
What is kyphosis?
posterior curvature of the spine
Orthopedics p161
What is the etiology of kyphosis?
diseases of disc and vertebral bodies
compression fractures from osteoporosis
congenital (rare)
trauma
radiation
surgery
if senile kyphosis → thoracic disc degeneration → wedging
if adolescent → often minor muscle imbalance and weakness
Orthopedics p161
What is the clinical presentation of kyphosis?
poor posture
fatigue
pain
posterior curvature of spine
local tenderness
Orthopedics p161
What is the diagnostic workup of kyphosis?
lateral radiograph of spine
Orthopedics p161
What is the management of kyphosis?
if adolescent:
1. full time brace x 1 year then night brace x 1 year
2. postural exercises → hamstrings, pelvic tilt

if any age:
1. if severe deformity with pain or neurological symptoms → surgery
Orthopedics p161
What is the common name for hyperextension/hyperflexion of the cervical spine?
whiplash
What is the etiology of whiplash?
usually MVA causing sudden hyperextension of neck
EMED Current
What is the clinical presentation of whiplash?
neck pain, muscle spasm, HA, hoarseness, dysphagia 12-24 hours following trauma
neck tenderness and limited ROM
EMED Current
What is the diagnostic workup of whiplash?
AP and lateral radiographs of cervical spine
EMED Current
What is the management of whiplash?
1. if persistent cervical spine tenderness along midline (i.e. possible ligament instability) → rigid cervical collar 24 hours/day x 7-10 days
2. analgesics
3. muscle relaxants
4. heat
5. re-examination in 7-10 days
EMED Current
What is the clinical presentation of spinal fracture?
if no spinal cord injury:
focal pain and tenderness over vertebral column
no neurological deficits

If spinal cord injury:
neurological deficits
EMED Current
What is the diagnostic workup of spinal fracture?
AP and lateral radiographs of spine
EMED Current
What is the management of spinal fracture?
1. immobilization on spinal board with cervical collar if being transported
2. analgesics
3. hospitalization
EMED Current
How is most commonly affected by ankylosing spondylitis?
males between 20-40y/o
What drug is most commonly used to treat ankylosing spondylitis?
indomethacin
What is the clinical presentation of trochanteric bursitis?
pain over trochanter that radiates down iliotibial tract to lateral aspect of thigh and knee
local point tenderness
pain with hip motion, especially internal rotation and abduction
What is the diagnostic workup of trochanteric bursitis?
radiographs normal
Orthopedics p205
What is the management of trochanteric bursitis?
1. NSAIDs or steroid/lidocaine injection
2. moist heat
3. rest
Orthopedics p205
What is the etiology of aseptic necrosis (AVN) of the hip?
idopathic in most cases

associated with:
hip dislocation
gout
alcoholism
chronic renal disease
divers and workers who use compressed air
long-term steroid therapy

more common in men
Orthopedics p204
What is the clinical presentation of aseptic necrosis of the hip?
gradual
pain
slight limp
progressively restricted ROM
Orthopedics p204
What is the diagnostic workup of aseptic necrosis of the hip?
hip radiograph → increase in density in superior portion of femur
Orthopedics p204
What is the managment of aseptic necrosis of the hip?
1. goal → prevent collapse of femoral head and encourage repair of necrotic area
2. prolonged use of crutches
3. if collapsed → prosthetic replacement
Orthopedics p204
What is aseptic necrosis of the hip?
infarction in the anteriosuperior weight-bearing portion of the femoral head →
bone necrosis → collapse → secondary degenerative arthritis
Orthopedics p204
What is the etiology of hip dislocation?
posterior dislocation → blow to knee while hip and knee flexed
anterior dislocation → blow to knee while hip abducted
Orthopedics p206
What is the clinical presentation of hip dislocation?
posterior dislocation → hip flexed and internally rotated

anterior dislocation → hip in external rotation
Orthopedics p207
What are the complications of hip dislocation?
associated knee or acetabular fracture
AVN
Orthopedics p206
Which is more common, anterior or posterior hip dislocation?
posterior
Orthopedics p206
What is the management of hip dislocation?
EMERGENCY!!!
1. reduce immediately to prevent AVN
2. prohibit weight-bearing
Orthopedics p207
What is the diagnostic workup of hip dislocation?
AP and lateral hip radiograph

*posterior hip dislocation pictured above
What is a giant cell tumor?
benign vascular lesion in bone but may transform into malignancy
Orthopedics p386
What is the etiology of giant cell tumor?
spontaneous
associated with hyperparathyroidism
rare
usually occurs between 20-40y/o
rare in children and elderly
What is the clinical presentation of a giant cell tumor?
bone pain usually affecting distal metaphysis and epiphysis of femur
possible pathologic fracture
What is the diagnostic workup of a giant cell tumor?
AP and lateral radiographs of femur → "soap bubble" appearance
Orthopedics p386
What is the management of a giant cell tumor?
surgical removal
List types of bone tumors and their characteristic radiographic appearance.
osteosarcoma → sunburst appearance
ewing's sarcoma → onion skin appearance
giant cell tumor → soap bubble appearance
Benign and malignant lesions typically develop in which part of a long bone?
metaphysis
What percent of 2° bone tumors affect the spine?
40%

*spine = most common site for bone metastasis
Orthopedics p356
What is an enchondroma?
benign bone tumor originating from cartilage (i.e. cartilage cyst)
Orthopedics p446
What is the clinical presentation of enchondroma?
usually occurs between 10-50 y/o
nonspecific symptoms
no pain
usually in small bones of hands and feet
discovered incidentally or following pathologic fracture
enlarged fingers
deformities
Orthopedics p446
Where do enchondromas most commonly occur?
small bones of hands and feet
Orthopedics p446
What is the diagnostic workup of enchondroma?
radiograph
usually located centrally in bone
What is the management of enchondroma?
1. observation → periodic radiographs
2. if diagnosis uncertain → surgery to R/O chondrosarcoma
3. if recurrent fracture → surgery
Orthopedics p446
How do you distinguish between enchondroma and chondrosarcoma?
enchondroma → painless
chondrosarcoma → painful, bone erosion
enchondroma (of 5th metacarpal)

L: radiograph
R: MRI
What is an osteochondroma?
classified as benign bone tumor but thought to be a developmental abnormility where part of physis forms outgrowth on bone surface
Orthopedics p446
What is the clinical presentation of osteochondroma?
painless mass
usually occurs at distal metaphysis of femur or proximal metaphysis of tibia
growth ceases with skeletal maturity
Orthopedics p446
What is the management of osteochondroma?
1. observation → periodic radiographs → often regresses once reach skeletal maturity
2. if symptoms (pain, blood vessel or nerve compromise, large cartilage cap) → surgical removal once reach skeletal maturity
Orthopedics p446
What is the diagnostic workup of osteochondroma?
radiograph →
sessile or pedunculated lesion
continuous with cortex and marrow cavity
small cartilage cap
pedunculated osteochondroma of distal femur + associated fracture
What is chondrosarcoma?
malignant cartilage tumor
primary or secondary from enchondroma
Orthopedics p448
What is the clinical presentation of chondrosarcoma?
occurs >40 y/o
shoulder girdle, pelvis, proximal femur
painful swelling
Orthopedics p448
What bone tumor presents at the diaphysis?
Ewing's sarcoma
Orthopedics p448
What is the diagnostic workup of chondrosarcoma?
radiograph → speckled calcifications in destructive radiolucent lesion
Orthopedics p449
bone destruction + sunburst pattern → osteosarcoma (of proximal fibula)
chondrosarcoma of inferior ramus of pubis
Ewing's sarcoma (of femur)
What is the management for chondrosarcoma?
1. refer to orthopedic specialist
2. surgical resection
3. NOT sensitive to chemotherapy or radiation
Orthopedics p449
What is the most common tumor of the hand?
enchondroma
What is multiple myeloma?
neoplastic proliferation of plasma cells of bone marrow
Orthopedics p168
What is the difference between raynaud's disease and raynaud's phenomenon?
raynaud's disease = primary
raynaud's phenomenon = secondary
Current p756
What is the etiology of raynaud's disease/phenomenon?
paroxysmal digital ischemia caused by exaggerated response to cold or emotional stress

may be primary or secondary
primary usually affects young women 15-30y/o
Current p756
What is the clinical presentation of raynaud's disease/phenomeon?
paroxysmal well-demarcated digital pallor or cyanosis followed by rubor
precipiated by cold or emotional stress
relieved spontaneously or by warm room or warm water
Current p756
What is the ddx for raynaud's?
primary
secondary:
scleroderma
SLE
mixed connective tissue disease
Current p757
What is the diagnostic workup?
if primary → none
if secondary → dependent on suspected cause
What is the management of raynaud's?
keep body warm
protect hands from injury → since wound heal slowly and are difficult to control
apply lotion to hands frequently
stop smoking
if severe symptoms or tissue injury → calcium channel blockers, sympathectomy
Current p757
What are the differences between primary and secondary raynaud's?
primary → symmetric, benign
secondary → may lead to digital pitting, ulceration, and gangrene
Current p756
raynaud's disease/phenomenon
What is polyarteritis nodosa?
necrotizing arteritis of medium-sized arteries
Current p765
What is the etiology of polyarteritis nodosa?
unknown
10% associated with hepB where presentation occurs within 6 months of hepB infection
Current p765
What is commonly associated with polyarteritis nodosa?
hepB
Current p765
What is the clinical presentation of polyarteritis nodosa?
dependent on vessels affected
insidious onset
fatigue, fever, weight loss
livedo reticularis
abdominal pain
arthralgia, myalgia, neuropathy
mononeuritis multiplex → manifests as foot drop
Current p765
What is the diagnostic workup of polyarteritis nodosa?
anemia
leukocytosis
elevated ESR and CRP
negative ANCA
hepB
angiogram or tissue biopsy
Current p765
What is the management of polyarteritis nodosa?
high dose corticosteroids
if severe → immunosuppressants
if hepB → corticosteroids + antiviral therapy + plasmapheresis
Current p765
What is giant cell arteritis?
systemic arteritis affecting medium and large-sized vessels
What is the clinical presentation of giant cell arteritis?
HA, visual changes, jaw claudication, throat pain polymyalgia rheumatica (50%)
Current p767
What is the clinical presentation of polymyalgia rheumatica?
pain and stiffness of shoulders and hips without other explanation
Current p767
What are the major differences between polymyalgia rheumatica and giant cell arteritis?
polymyalgia rheumatica:
does not cause blindness
responds to low dose corticosteroids

giant cell arteritis:
can cause blindness
requires high dose corticosteroids
Current p767
What is the diagnostic workup of giant cell arteritis?
elevated ESR and CRP
Current p767
What is the management of giant cell arteritis?
1. immediate high-dose prednisone
2. temporal artery biopsy
Current p767
What is the management of polymyalgia rheumatica?
low-dose prednisone
Current p767
What is Behcet's syndrome?
vasculitis involving small, medium, and larger arteries and veins
Current p772
What is the etiology of Behcet's syndrome?
unknown

tends to effect people with Asian, Turkish, Middle Eastern descent
Current p772
What is the clinical presentation of Behcet's syndrome?
recurrent aphthous ulcers of mouth (>3/year)
aphtous ulcers of genitals
erythema nodosum-like rash
folliculitis
uveitis
-if anterior → photophobia, red eye, hypopyon
-if posterior → symptoms manifest late
nonerosive arthritis of knees and ankles
neurologic lesions that mimic MS
Current p772
What is the diagnostic workup of Behcet's syndrome?
elevated ESR and CRP
pathery test → prick skin; positive if sterile pustule formation within 24-48 hours
Current p772
What is the management of Behcet's syndrome?
corticosteroids → prednisone
Current p772
What is pathery and what disease is it associated with?
formation of sterile pustule at site of needle stick associated with Behcet's syndrome
Current p773
What is the workup of fibromyalgia?
9x more common in women than men
between 3-50y/o
multiple trigger points
chronic (>3 months) diffuse pain
vague aching joints, especially spine, shoulder, hips
vague symptoms → fatigue, HA, stiffness, abdominal symptoms, sleep disorders
depression
radiographs normal
R/O other more likely causes of pain
Orthopedics p301
What is the diagnostic criteria for fibromyalgia?
1. history of chronic widespread pain
2. >3 months in duration
3. pain in 11 of 18 characteristic trigger points
4. all 4 body quadrants affected
Orthopedics p302
What is the management of fibromyalgia?
1. treat empirically and symptomatically
2. all treatments have uncertain success rates
3. NSAIDs, muscle relaxants, trigger point injections, antidepressants, aerobic fitness programs, physical therapy, acupuncture, transcutaneous nerve stimulation
4. address social and environmental factors
5. recommend self-education and management, support groups
7. prognosis uncertain → symptoms may come and go for years despite tx approach
Orthopedics p302
What percent of the general population is affected by fibromylagia?
2-3%
Orthopedics p301
What is another name for reflex sympathetic dystrophy (RSD)?
complex regional pain syndrome
Orthopedics p441
What is the workup of reflex sympathetic dystrophy?
unknown cause
relatively minor injury → sympathetic nervous sytem disturbance → symptoms
pain → burning, throbbing, shooting
hyperalgesia, allodynia, hyperpathia
stiffness, edema
atrophy of skin, hair, and nails
autonomic dysfunction → anhidrosis or hyperhydrosis, heat and cold insensitivity
affects extremities
Orthopedics p441
RSD lecture
Define hyperalgesia.
increased sensitivity to pain
Define allodynia.
pain from a stimulus that normally does not cause pain
Define hyperpathia.
abnormally painful reaction to a stimulus
What is the management of regional sympathetic dystrophy?
1. prevention → immediate attention to injury, control of pain and swelling (elevation of extremity), active use of extremity despite pain, no smoking
2. early → corticosteroids, pain meds, mobilization
3. intermediate → sympathetic block, calcitonin, pain meds, mobilization
4. late → pain meds, physical therapy
Orthopedics p441
RSD lecture
What is osteomyelitis?
infection of the bone
What is the etiology of osteomyelitis?
bone infection caused by either:
1. adjacent infection
2. dissemination in blood → elderly, sickle cell, IV drug abuse
3. skin breakdown due to vascular insufficiency

if sickle cell → think salmonella
if IV drug abuse → think s. aureus
if adjacent joint → think s. aureus or staph epidermidis
Current p780
What is the diagnostic workup of osteomyelitis?
ESR → extremely high (>100mm/h)
bone biopsy
culture from bone biopsy

radiographs:
if early → soft tissue swelling, periarticular demineralization
if >2 weeks → bone erosion
Current p780
What is the clinical presentation of osteomyelitis?
fever, chills, bone pain and tenderness
if adjacent infection → inflammation, lower fever
if skin breakdown → ulcer, absent fever
Current p780
What is the management of osteomyelitis?
1. debridement of necrotic bone
2. prolonged antibiotics x 6-8 weeks
Current p780
What are the indications for aspirin?
analgesic
antipyretic
anti-inflammatory
anti-platelet → prevention of MI, TIA, CVA; current MI; post-MI; revascularization procedures
Pharmacology p504
What is the mechanism of action of aspirin?
IRREVERSIBLY inhibits COX-1 → preventing thromboxane A2 production

COX-1 normally converts arachidonic acid to prostaglandin H2 → prostaglandin is converted to thromboxane A2
Pharmacology p233, 502
What are the adverse effects of aspirin?
prolonged bleeding time
GI problems → distress, ulcer, hemorrhage, iron-deficiency anemia
sodium and water retention → edema, hyperkalemia
hemorrhagic stroke
Pharmacology p233, 502
Why may aspirin cause GI bleeding?
↑ gastric acid secretion
↓ mucus production
Pharmacology p502
If an NSAID causes GI bleeding, and continued NSAID treatment is necessary, what should you prescribe?
proton pump inhibitor (PPI) or misoprostol
Pharmacology p502
Toxic doses of aspirin cause?
respiratory depression
What are the symptoms of aspirin toxicity?
HA, dizziness, nausea, vomiting, mental confusion, tinnitus, hyperventilation → restlessness, delirium, hallucinations, convulsions, coma, respiratory and metabolic acidosis, death from respiratory failure
Pharmacology p505
What are the contraindications for aspirin?
<15y/o
pregnancy and breast-feeding
surgery within 1 week
probenecid, sulfinpyrazone increase uric acid secretion (whereas aspirin decreases uric acid secretion)
Pharmacology p505, 506
Why must aspirin be avoided in adolescents <15y/o?
aspirin + viral infection = potential Reye's syndrome
Pharmacology p504
What is the patient education for aspirin?
1. take with fluids and food to decrease dyspepsia
2. do not take concurrently with other salicylates
3. do not take 1 week prior to surgery
4. do not take with probenecid or sulfinpyrazone
5. may need to lower warfarin, phenytoin, or valproic acid etc. since aspirin causes higher plasma concentrations of those drugs
Pharmacology p233, 506
What is the dosing for aspirin?
prevention of MI → 81-162 mg/d
prevention of stroke → 50-325 mg/d
acute MI → 162-325mg
OA or RA → 3g/d
Pharmacology p505
What type and dose of aspirin should be given for acute MI?
162-325mg of nonenteric coated aspirin chewed and swallowed immediately
Pharmacology p505
What are the indications for ibuprofen?
analgesic
antipyretic
anti-inflammatory
anti-platelet
Pharmacology p507
What is the mechanism of action for ibuprofen?
REVERSIBLY inhibits COX-1 → preventing synthesis of prostaglandins (but not leukotrienes)
Pharmacology p507
What are the adverse effects of ibuprofen?
GI → dyspepsia, bleeding
CNS → HA, dizziness, tinnitus
Pharmacology p507
What is the mechanism of action for indomethacin?
REVERSIBLY inhibits COX-1
Pharmacology p507
What are the indications for indomethacin?
OA of hip
ankylosing spondylitis
acute gout

*analgesic, antipyretic, and anti-inflammatory effects but use limited to above conditions due to toxicity
Pharmacology p507
What are the indications for meloxicam?
OA
RA
ankylosing spondylitis
Pharmacology p507
What are the indications for ketorolac?
potent analgesic → short-term relief of moderate to severe pain up to 5 days after first dose administered via IV or IM

*only moderate anti-inflammatory
Pharmacology p508
What are the contraindications for ketorolac?
pediatrics
Pharmacology p508
What are the adverse effects of ketorolac?
GI bleeding
stomach or intestinal perforation
fatal peptic ulcer
Pharmacology p508
What is the patient education for ketorolac?
if mild or chronic pain → do not exceed 40mg/d
Pharmacology p508
What is the mechanism of action for celecoxib?
reversible inhibition of COX-1 but mostly COX-2
Pharmacology p508
What are the indications for celecoxib?
pain
OA
RA

*no anti-platelet function
Pharmacology p508
What are the adverse effects of celecoxib?
HA, dyspepsia, abdominal pain, diarrhea

*less GI bleeding than aspirin
Pharmacology p508
What are the contraindications for celecoxib?
sulfonamide allergy
severe heart disease
severe hepatic disease
severe renal disease
may increase levels of some B-blockers, antidepressants, antipsychotics
Pharmacology p509
What is the generic name for Motrin?
ibuprofen
What is the generic name for Vicodin?
hydrocodone
What is the generic name for Valium?
diazepam
What is the generic name for Percocet?
oxycodone
What is the generic name for Demerol?
meperidine
What are the indications for acetominophen?
analgesic → pain, OA
antipyretic
*no anti-inflammatory effects
What are the adverse effects of opioids?
sedation
respiratory depression
constipation
tolerance
withdrawal
addiction
What are the contraindications for morphine?
respiratory depression
renal failure
What is the MOA of colchicine?
1. bind and depolymerizes tubulin, a protein involved in mobilization of neutrophils → decreasing their accumulation in gout affected sites
2. blocks cell division by binding to myotic spindles
3. inhibits leukotriene synthesis
What are the indications for colchichine?
pain relief in acute gout
prevention of acute gout attacks
Pharmacology p516
What are the contraindications for colchicine?
pregnancy
What are the adverse effects of colchicine?
nausea, vomiting, diarrhea, abdominal pain
List ucosuric medications.
probenecid
sulfapyrazone
What is the MOA of ucosurics (probenecid and sulfapyrazone)?
inhibits urate-anion exchanger in proximal tubule → inhibiting resorption → increasing renal clearance of uric acid
What are the indications for probenecid or sulfapyrazone?
prevention of gout where uric acid is undersecreted
What are the contraindications for probenecid or sulfapyrazone?
renal insufficiency
kidney stones
high dose aspirin therapy
List xanthine oxidase inhibitors.
allopurinol
What is the MOA of allopurinol?
inhibits xanthine oxidase which normally catalyzes uric acid synthesis
What are the indications for allopurinol?
prevention of chronic gout if:
1. overproducer of uric acid
2. undersecreter of uric acid + renal insufficiency
List natural, semi-synthetic, and synthetic opiods.
natural → morphine, codeine
semi-synthetic → hydromorphone, hydrocodone, oxycodone
synthetic → tramadol, methadone, meperidine
List the indications for opioid analgesics.
mild to moderate pain → tylenol with codeine,
moderate to severe pain → morphine, hydromorphone, hydrocodone, oxycodone, meperidine, tramadol
opioid detox → methadone
What are the most common adverse effects of opioids?
constipation, sedation, respiratory depression
Urinary retention is a common side effect of meperidine (demerol), true or false?
true