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Ortho 1

Clinical Medicine: Orthopedics 1: Oncology, Spine, Wrist/Hand, Foot/Ankle

Where does colon cancer usually metastasize to? Liver
Where does prostate cancer usually metastasize to? Spine
Where does breast cancer usually metastasize to? Bone
Malignant tumors of mesenchymal origin: Sarcomas
Describe soft tissue non-epithelial extraskeletal tissues of the body that support, connect, and surround other discrete anatomic structures
One of the most common soft tissue tumors: benign lipoma
Preferred imaging of soft tissue tumors of the extremities, head, neck MRI
Preferred imaging of soft tissue tumors found in retroperitoneum and abdomen CT
Definitive Dx for a soft tissue tumor; difference w/ retroperitoneal? core-needle Bx; CT guided Bx w/ retroperitoneal
4 indications for a Bx of a soft tissue mass (these definitive rule out a lipoma) 1) symptomatic 2) enlarging 3) >5cm 4) persisted 4-6+ weeks
Where do chondrosarcomas usually occur? Pelvis and other flat bones
Where do Ewing sarcoma tumors usually occur? Diaphyseal (shaft) portion of the long bones
Most common presentation of bone sarcomas bone pain and presence of a mass
Parosteal outer layer of periosteam
Periosteal inner layer of periosteam
_______________ are altered in a variety of sequences and combinations with the common result of cellular proliferation that is tumorigenesis. Multiple genetic targets
General age of patient when they get a 1) Ewing sarcoma 2) Multiple myeloma 3) Classic osteosarcoma 1) childhood/adolescence (Ewing) 2) >40 (MM) 3) 10-30 (classic osteosarcoma)
5 biggest cancers at risk for developing metastatic bone cancer 1) Prostate 2) Renal 3) Lung 4) Breast 5) Thyroid
T/F: initial evaluation of bone or sarcoma should be XRAY True
Geographic or well-circumscribed implies; exception? benignity; multiple myeloma
When should you get a bone scan? if multiple bony lesions (metastatic carcinomas/lymphomas of bone) suspected
Preferable screening for multiple myeloma and metastatic carcinomas? Why? skeletal surveys (bone scan can give a FALSE NEGATIVE)
Imaging for smaller lesions involving cortical structures of bone or spine? CT; can be >MRI as MRI has inferior resolution of cortical bone
T/F: Osteocarcinomas in Males>Females True 2x
Lifting of periosteum characteristic ("hair on end" or "sun ray spicules"). What is the sign called and what is the disease it is associated with? Codman's Triangle; Osteosarcoma
Tumor of adulthood/old age, presents w/ pain and swelling. Lobular appearance with mottled or punctate or annular calcification of the cartilaginous matrix Chondrosarcoma
Onion peel periosteal reaction w/ generous soft tissue mass. Dx? Ewing's Sarcoma; Dx on Bx; #2 primary bone malignancy in kids, especially males
Monoclonal gammopathy of undetermined clinical significance causing bone lysis and infiltration Multiple Myeloma
Normocytic normochromic pancytopenia, elevated sed rate (over 100), renal failure with HYPERcalcemia, osteopenia Complications of Multiple Myeloma
What is kind of ironic about the immunoglobulin spike in Multiple Myeloma? MONOclonal immunoglobulin spike
What is another lab finding that is indicative (but not definitive about Multiple Myeloma? What about on imaging? Bence Jones proteins; multiple mini-lytic-lesions that create pathological fractures
T/F: Primary bone tumors > metastatic tumors of bone FALSE, mets are MORE common
Main pseudotumor condition? Osteomyelitis
A condition usually ASx, elevated bone alkaline phosphatase, elevated calcium and immobility, kyphosis, bone pain, and deformity Paget's Disease of Bone (bone lesions of increased turnover w/ disorganized osteoid formation)
3 stages of Paget's Disease of Bone 1) Resorption 2) Disordered bone formation 3) Osteosclerosis
1) calor (warmth), 2) dolor (pain), 3) rubor (redness), and 4) tumor (swelling) Essential Quartet of Infection as described in the first century, still considered vital signs of infection
What causes osteomyelitis in pediatrics? Can be spontaneous
Extremely painful night pain, 75% <25 yo, 50% in cortex of femur or tibia, considered benign. Hyperdense on XRay, active on bone scan. Tx for pain and problem? Osteoid Osteoma; Tx: Pain dramatically relieved by aspirin, normally treated by conservative surgery or ablation (NO RADIATION, can become malignant)
Most common primary hand tumor Enchondromas
Exostosis, relatively benign lesion as a cartilage-capped outgrowth that is attached to the skeleton by a bony stalk. Always occur near a joint (growth plate usually) but point away from the joint Osteochondromas
ASx usually detected on XRAY incidentally and spontaneously resolve w/in years, 30-50% of all children have them and they are considered developmental defects. Few enlarge to nonossifying fibromas. Fibrous cortical defects
Occurs in those unable to maintain a normal soft-tissue envelop over subjacent bone (paraplegics/diabetics). Also elevated risk w/ immunodeficiency and IV drug use Adult osteomyelitis.
Benign vs Malignant bone tumors B: present for extended period, ASx, incidental findings, softer, mobile, distinct edges M: noticed and grow faster, Fevers, chills, night sweats, malaise, change in appetite, weight loss (DD: infx), firmer
degenerative osteoarthritis of the joints in between each vertebra (arthritis) Spondylosis
the forward translation (slippage) of one vertebra above the vertebra below Spondylolisthesis
a defect or fracture in the pars interarticularis of the vertebral arch Spondylolysis
a lateral curve or rotational deformity of the spine Scoliosis
a forward curve in the sagittal plane (hunchback) Kyphosis
T/F: Large majority of back and neck pain resolves on its own. True, w/in 2 weeks often. REASSURANCE is very important
Neck pain greatest in: White females
Lower back pain greatest in White males
True hip pathology radiates: to the groin
Root compression: DTR decreased knee reflex: L3 or L4
Root compression: Dorsiflexion strength testing: weakness in resistance or dorsiflexion of ankle L4
Root compression: Extensor hallucis longus: great toe extension against resistance L5
Root compression: Quadriceps testing: weakness of knee extension L3 or L4
Radiographs that are must haves for spinal imaging: (2) AP and Lateral
Scotty dog with a collar on oblique XRAY view? Pars defect
Difference between a sprain and a strain? What can often cause cervical strain and/or sprain? Sprain: Injury to spinal ligaments Strain: Irritation and spasm of the neck muscles; Whiplash
Imaging (3) and Tx (5) for cervical strains and sprains? Dx: AP, Flexion lateral, extension lateral (XRAY usually normal though). Tx: Relieve stress, NSAIDs, benzos, Ice then heat, reassurance
Cause of cervical spondylosis ingrowth of osteophytes and a couple of other things which narrow the neural foramen
Spurling's sign; what conditions does it associate with? Move head back, rotate, extend -> pain in arm; Cervical Radiculopathy, cervical spondylosis
Tx of Cervical spondylosis NSAIDs, relaxers, prednisone, narcs for radicular Sx; PT
Nerve root compression in the cervical spine causing neurologic symptoms in the distribution of the affected nerve root Cervical radiculopathy
What motion can relieve Sx of cervical radiculopathy? abducting arm over head
Only difference in Tx between cervical spondylosis and cervical radiculopathy Rest resolves most in radiculopathy, otherwise, all Tx are the same
when the spinal cord experiences pathophysiologic changes secondary to neural compressive lesions. Common causes? Cervical Myelopathy; chronic disc herniations, osteophytes, instability
problems w/ fine motor movements, positive upper motor neuron signs (Babinski, clonus etc.), muscle atrophy Cervical Myelopathy
Most common back complaint? Usually from lifting. 90% of adults suffer w/in life. 80% of pts better w/in 1 months; an injury to the paravertebral spinal muscles, as well as injury to the deep ligamentous structures surrounding the facet joints. Lumbar sprain
T/F: Lumbar pain will radiate down the legs FALSE, may radiate to buttocks but not legs
Difference in Tx between Cervical spondylosis and lumbar sprain? Nada, bro!
due to dehydration of the disc the nucleus pulposis degrades, thus losing disc height, and causing ligaments to become redundant. Disc loses its biomechanical properties causing tears in the disc, thus causing osteoarthritis and pain Lumbar Degenerative Disc
Displacement of nucleus pulposus through anulus fibrosis posterolateral most common in 4th and 5th decades Herniated Lumbar Disc
Back pain worse w/ sitting, numbness, weakness and tingling in lower extremity, ABRUPT onset. PE: listing to one side, drop foot. Occurs in younger people. Lumbar Herniated Nucleus Pulposus (HNP)
Back pain worse w/ standing (relieved with rest). Occurs in older people. Vascular compromise; Narrowing of the spinal canal and/or neural foramina Spinal Stenosis
Tx of Lumbar HNP 80% resolve w/o surgery 1) limited rest 2) typical spine pain meds 3) stretching/PT/Exercise 4) Nerve block 5) alternative medicine
Shopping cart sign Spinal stenosis
Which imaging would you use for a herniation/Stenosis? Vascular claudication? H and S: MRI, VC: arterial doppler
T/F: Stenosis coming from back of the spine, herniation is coming from the front of the spine True!
Treatment for spinal stenosis other than conservative therapy? surgical decompression
Which condition is isthmic? Spondylolysis or Spondylolithesis? They can be both; more associated w/ spondylolysis
Which condition is degenerative? Spondylolysis or Spondylolithesis? They can be both; more associated w/ spondylithesis
Usually adolescents w/ high incidence in athletes that stress the area w/hyperextension), radiates to legs, stork sign (loss of lumbar lordosis/extension [stand on 1 leg and bend back]) Isthmic
Older population, overweight, may be comorbid w /stenosis, step off on palpation Degenerative
Main Tx for Isthmic? Degenerative? Isthmic: REST; Degenerative: Nerve root block
Lower extremity sensory and MOTOR function, saddle anesthesia, retention -> incontinence. Most common cause? Tx? Cauda Equina Syndrome (CES); herniated lumbar disc; surgical decompression preferably w/in 24 hours!!!
Severe neck pain, paraspinous muscle spasms/point tenderness (though lack of these Sx don't exclude injury) Fracture of Cervical Spine
Burst fracture of ring of C1. Cause? Jefferson Fracture; C: usually axial-loading force on head
Fracture of pars interarticularis of C2 & disruption of C2-C3 junction . What type of injury is this? Hangman's Fracture; Traumatic spondylolisthesis
a flexion compression injury often associated with diving accidents. It is characterized by an anteroinferior bone fragment that rotates anteriorly because of pull from the intact anterior longitudinal ligament. Catastrophic injury Teardrop Fracture
Standard imaging for fracture of cervical spine (3) 1) AP 2) Lateral 3) Odontoid
3 Tx for fracture of cervical spine 1) Immobilization for 7-10 days 2) IV steroids for cord injury 3) PT for scapular stabilization
2 main causes of thoracic and lumbar spine fracture? 1) MVC 2) fall from heights
T/F: Single compression Fracture involves 1 entire vertebral body False, ONLY anterior half of vertebral body
fall from a height, landing on feet, typical; involve only compressive failure of vertebral body both anteriorly & posteriorly, w/ failure of both anterior & middle columns;            - -> high shear stress on the vertebral end plate. What occurs? Burst fracture; Large central posterior-superior fragment is left
flexion-distraction injury (seatbelt injury (when they only had lap belts)); middle and posterior columns fail under tension; anterior column fails under compression Chance fracture
Step off or gap between spinous processes w/ swelling/hematoma formation is the hallmark sign of: unstable flexion-distraction injury
Tx for thoracic and lumbar spine (5) hyperextension brace, spine board and log rolling, pain meds, kyphoplasty, vertebroplasty
Winking owl sign loss of a pedicle (obliterated pedicle wall) indicating metastatic disease of the spine
Best screening study for metastatic disease? Technetium bone scan
When should you refer for metastatic disease of the spine? Most of the time
What kind of imaging is important for scoliosis? STANDING XRay
"New mother's thumb" DeQuervain's Tenosynovitis
Fall w/ wrist flexed or extended. What should you be concerned with? Where is the pain? What should you check for on XRAY? Distal radius fracture, should be concerned with neurovascular status, Pain at distal 1/3 radius, Check for volar tilt (2-25 degrees)
Most common Pediatric Salter-Harris fracture? Type 2: breaks bone but doesn't go through growth plate
"Kids' buckle". Tx? Torus fracture, heals well with cast
Tx for breaking both bones in forearm in kids? Surgery
Mid shaft radius Fx + DRUJ (distal radial ulnar joint) dislocation Galeazzi fracture/dislocation
Management for distal radius and galeazzi fractures Immobilize past elbow
Thing to remember about splinting/casting... Always in flexion!
Snuff box tenderness w/ history of a lot of weight through thumb side. Tx? Schaphoid fracture, 3-5 month recovery in splint (surgery reduces that by a month), refer.
If you're going to have scaphoid fracture, best place for it? Distal. Proximal near the wrist is worse may have avascular necrosis) and may need surgery
TTP over thumb after wrist has been hyperextended/hyperflexed. Tx? Thumb sprain; RICE (rest, ice, compression, elevation), splint/cast, NSAIDs
Often postpartum woman where a repetitive action causes painful inflammation of the thumb area, especially w/ thumb abduction. Tx? DeQuervain's Tenosynovitis; Tx: Splint, ice, NSAIDs, specialist
Most common wrist injury? What nerve? (what does it innervate) Carpal Tunnel of the median nerve; innervates thumb through 3rd digit and half of the 4th.
PE for Carpal Tunnel; Tx? Tinel's (tap on wrist), Phalen's (backs of hands together); Tx: remove inciting element! Brace, change ergonomics, gloves for night time! Refer to ortho for surgery or injections if indicated
Compression of ulnar nerve? Where can this occur (2)? Tx? Cubital tunnel syndrome! 1) medial elbow 2) Hamate bone of wrist; Tx: remove compression (NO INJECTIONS)
Common flexor tendon attachment: medial epicondyle Golfer's elbow
Common extensor tendon attachment: lateral epicondyle Tennis elbow
Gradual onset w/ intermittent increases in pain often secondary to trauma in the distal radioulnar joint (DRUJ). Better w/NSAIDs and rest. How will it look on XRAY? Wrist osteoarthritis; XRAY: looks like the wrist is blurred together
Bump on dorsal or volar wrist fluctuating in size and pain w/ push ups/axially loading wrist. Tx (3)? How is reoccurrence? Ganglion cysts; Tx: 1) Brace 2) Aspirate 3) Surgery. Reoccurence occurs 90% in aspiration and 15% after surgery
Common hand fracture, "the object always wins". Management Boxer's Fracture, break of 5th phalange. Splint at 45 degrees, refer to ortho
Make sure to check nail bed for open fracture of distal phalanx in kids Seymour fracture
Management for phalange fractures? Splint in a bent fashion
"Jersey Finger", ruptures from forced extension while grabbing something. 4th finger FDP most common. Loss of PIP and MP flexion Flexor tendon rupture
Hyperextension of PIP joint + flexion of DIP. Tx? Swan Neck Deformity; OT/PT for splinting and/or surgery
Usually traumatic avulsion of extensor tendon (common slip) off base of distal phalanx resulting in dip flexion. Swelling and reduced ROM w/ 00/5 strength at DIP extension Mallet finger or "droopy finger"
Management for mallet finger? Splint in slight hypertension and send. Splint PIP free but NO MOTION for 6-10 weeks. Even one bend and you need to restart the time.
Usually an acute rupture of the common extensor tendon (common slip) at the PIP joint resulting in PIP joint flexion and DIP extension. Management? Boutonniere Deformity; Splint, NSAIDs, Ice.
Forced extension/abduction of CMC joint; Hx: fall onto hand w/ thumb bent backwards. Swelling and TTP over ulnar side of thumb. Imaging and Tx? Gamekeeper/Skier's Thumb; Imaging: MCP joint, fracture usually avulsion of UCL (NO MRI). Tx: Immobilize thumb w/ splint/cast and refer
Decreased ROM but can move in all directions, TTP, no tendon disruption, XRAY negative, hurts, stiff, swollen. Tx? Jammed finger, Tx: Splint for less than 2 weeks, work on motion after that
Puncture wound on volar side of finger (staph/strep) that travels w/in tendon sheath progressively. Sausage digit and EXTREME pain w/ passive extension. Can progress into bone Septic flexor tenosynovitis
Management for Septic Tenosynovitis? ER admit, IV ABX (clinda or azithro), refer to hand (may do an I&D)
What differentiates cellulitis from septic tenosynovitis on PE? Cellulitis will be red and warm but no pain with finger motion
Cutaneous infection of fingertip. Most common infx. Nail biting, hang nail causing a disruption in nail fold/plate. Tx? Paronychia. Tx: Soaks, occasional I&D, PO ABX, nail hygiene
Pulp infection in periosteum of fingertip. Staph aureus secondary to puncture wound often or diabetic finger sticks. Tender, red, swollen for a short period of time. Management: Felon; Excisino and drainage, packing, ABX, soaks
Swollen, not super tender with red blisters or vesicles. Associated w/ regular contact w/ saliva. Who gets these? Dx? Tx? Herpetic witlow; Children sucking their thumbs, speech therapists, dental workers get these. Dx: Tzanck smear
T/F: Don't I&D herpetic witlow True, can spread virus
Necessary step with nail injuries? Get a XRAY, ~50% have fractures associated fix
Crush injury to finger Swollen, pain and hematoma. Tx? Subungual hematoma. Tx: Evacuate blood w/ sterile needle, soak, ABX
Tendon thickening gets trapped under annular rings/pulleys. Causes pain +/- snapping or catching, locking. “My finger keeps jumping out of socket”. Worse in AM and w/ tight gripping. More prominent in diabetics as glucose makes joint "sticky" Flexor tendon stenosing tenosynovitis or Trigger Finger
Imaging and Tx of Trigger finger? Imaging: NONE; Tx: Injection (70% success), possible surgical release
thickening +/-nodular formation of the palmar fascia. The pain, stiffness and nodules are felt more in the PALM; in the area of the distal palmar crease. Northern European descent and minimal Sx. Managment? Dupuytren's (palmar fibromatosis); 1) nothing 2) refer for collagenase injection ($2,000) 3) surgical excision/release
Pes planus? What sign occurs with this? flat foot; "too many toes sign"
Pes cavus? What sign occurs with this? high arch; "Peek a boo" heels sign
Dysfunction of what tendon causes foot drop on heel raise attempt? Older women (>55) that are overwt), gradual onset, activity related pain. Tx? Posterior tibialis tendon; Tx: Short leg cast or boot walker for 4 weeks. Molded ankle foot orthosis following cast removal. NO INJECTIONS
Dysfunction of what tendon when patient can't evert foot Peroneal tendon
Dysfunction of what tendon with trouble flexing/extending great toe Extensor hallucis longus & flexor hallucis longus
What does the Thompson test look for? Plantarflexion of foot. Assesses integrity of Achilles tendon
Typical 3 XRAY views for the ankle: 1) AP 2) Lateral 3) Mortise
Typical 3 XRAY views for the foot: 1) AP 2) Lateral 3) Oblique
Pain and swelling along Achilles especially w/ runners. Feel mass in tendon. Often 40 yo male weekend warrior. Achilles tendinosis
Most commonly affects older or larger-BMI patients where pain directly over the posterior heel at the insertion of the Achilles tendon due to an abnormal prominence or spurring. Haglund deformity or Insertional achilles tendonitis
Pinch directly over the anterior border of the tendon both medially and lateral just proximal to the insertion over the posterior heel...pain Retrocalcaneal bursitis
Tx for Posterior Heel Pain. What should you not do? Rest, ice, stretching, night splint, NSAIDs. DON'T INJECT (70% will rupture Achilles)
Most common in 40-60 yo usually playing stop/go sport by sudden, forceful eccentric load. Usually 5-7 cm proximal to insertion. Positive Thompson sign. Achilles Tendon Rupture
What is Tennis leg? Negative Thompson's sign. Gastocnemius tear.
T/F: 50% of Achilles Tendon Ruptures that are surgically repaired will have repeat injuries. FALSE, 5%
Syndesmotic ligament sprain between tibia and fibula High ankle sprain
Proximal fibula fracture w/ ankle syndemosis sprain. Tx? Maisonneuve fracture. Tx: 4 weeks in boot for syndesmotic injuries after surgery (for sprain of syndesmosis, not fibula); REFER
Tx for ankle sprains RICE, boot 2-4 weeks, wt bear as tolerated, early mobilization, NSAIDs/steroids
Chronic degenerative changes and micro tears of ________ at it's origin on the medial calcaneus plantar fascia; Plantar Fasciitis
How long do you Tx plantar fasciitis? What are the best things for it? UNTIL PAIN GOES AWAY; Tx: NSAIDs, plantar fascia stretches, night splints
What is hallux rigidus? Dx? Arthritis of the Hallux MTP joint (big toe joint) (can be due to a bone spur and/or decreased joint space). XRAY DX.
What is the layman name for Hallux valgus? What is it? Cause and Tx BUNIONS. Lateral deviation of hallux at the MTP joint. Due to INAPPROPRIATE SHOES. Tx is wearing good shoes or surgery (completely avoidable)
Feels like walking on a marble. Patients complain of activity related pain over plantar surface of 2/3rd, 3/4th toes. 90% have reproducable pain over 2/3rd websapce (that is the 3rd and 4th toes). Tx? Modifying shoewear or just take it out.
Pain is activity related, directly over plantar metatarsal heads due to abnormal metatarsal (2nd usually) length. Tx? Metatarsalgia. Tx: Achilles stretching exercises, occasionally injection placed into MTP joint and surgery last resort.
Sprain of Hallux MTP joint common in athletes resulting from a fall. FORCED HYPEREXTENSION injury, pain worse w/ dorsiflexion. Tx? Turf toe. Nasty injury taking months to improve. Tx: immobilization, ice, rest, NSAIDs, orthotic
Created by: crward88