Clinical Medicine: Orthopedics 1: Oncology, Spine, Wrist/Hand, Foot/Ankle
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| Where does colon cancer usually metastasize to? | Liver
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| Where does prostate cancer usually metastasize to? | Spine
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| Where does breast cancer usually metastasize to? | Bone
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| Malignant tumors of mesenchymal origin: | Sarcomas
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| Describe soft tissue | non-epithelial extraskeletal tissues of the body that support, connect, and surround other discrete anatomic structures
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| One of the most common soft tissue tumors: | benign lipoma
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| Preferred imaging of soft tissue tumors of the extremities, head, neck | MRI
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| Preferred imaging of soft tissue tumors found in retroperitoneum and abdomen | CT
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| Definitive Dx for a soft tissue tumor; difference w/ retroperitoneal? | core-needle Bx; CT guided Bx w/ retroperitoneal
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| 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
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| Where do chondrosarcomas usually occur? | Pelvis and other flat bones
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| Where do Ewing sarcoma tumors usually occur? | Diaphyseal (shaft) portion of the long bones
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| Most common presentation of bone sarcomas | bone pain and presence of a mass
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| Parosteal | outer layer of periosteam
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| Periosteal | inner layer of periosteam
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| _______________ are altered in a variety of sequences and combinations with the common result of cellular proliferation that is tumorigenesis. | Multiple genetic targets
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| 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)
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| 5 biggest cancers at risk for developing metastatic bone cancer | 1) Prostate 2) Renal 3) Lung 4) Breast 5) Thyroid
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| T/F: initial evaluation of bone or sarcoma should be XRAY | True
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| Geographic or well-circumscribed implies; exception? | benignity; multiple myeloma
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| When should you get a bone scan? | if multiple bony lesions (metastatic carcinomas/lymphomas of bone) suspected
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| Preferable screening for multiple myeloma and metastatic carcinomas? Why? | skeletal surveys (bone scan can give a FALSE NEGATIVE)
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| Imaging for smaller lesions involving cortical structures of bone or spine? | CT; can be >MRI as MRI has inferior resolution of cortical bone
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| T/F: Osteocarcinomas in Males>Females | True 2x
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| 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
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| Tumor of adulthood/old age, presents w/ pain and swelling. Lobular appearance with mottled or punctate or annular calcification of the cartilaginous matrix | Chondrosarcoma
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| Onion peel periosteal reaction w/ generous soft tissue mass. Dx? | Ewing's Sarcoma; Dx on Bx; #2 primary bone malignancy in kids, especially males
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| Monoclonal gammopathy of undetermined clinical significance causing bone lysis and infiltration | Multiple Myeloma
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| Normocytic normochromic pancytopenia, elevated sed rate (over 100), renal failure with HYPERcalcemia, osteopenia | Complications of Multiple Myeloma
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| What is kind of ironic about the immunoglobulin spike in Multiple Myeloma? | MONOclonal immunoglobulin spike
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| 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
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| T/F: Primary bone tumors > metastatic tumors of bone | FALSE, mets are MORE common
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| Main pseudotumor condition? | Osteomyelitis
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| 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)
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| 3 stages of Paget's Disease of Bone | 1) Resorption 2) Disordered bone formation 3) Osteosclerosis
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| 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
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| What causes osteomyelitis in pediatrics? | Can be spontaneous
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| 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)
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| Most common primary hand tumor | Enchondromas
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| 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
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| 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
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| 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.
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| 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
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| degenerative osteoarthritis of the joints in between each vertebra (arthritis) | Spondylosis
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| the forward translation (slippage) of one vertebra above the vertebra below | Spondylolisthesis
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| a defect or fracture in the pars interarticularis of the vertebral arch | Spondylolysis
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| a lateral curve or rotational deformity of the spine | Scoliosis
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| a forward curve in the sagittal plane (hunchback) | Kyphosis
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| T/F: Large majority of back and neck pain resolves on its own. | True, w/in 2 weeks often. REASSURANCE is very important
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| Neck pain greatest in: | White females
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| Lower back pain greatest in | White males
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| True hip pathology radiates: | to the groin
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| Root compression: DTR decreased knee reflex: | L3 or L4
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| Root compression: Dorsiflexion strength testing: weakness in resistance or dorsiflexion of ankle | L4
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| Root compression: Extensor hallucis longus: great toe extension against resistance | L5
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| Root compression: Quadriceps testing: weakness of knee extension | L3 or L4
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| Radiographs that are must haves for spinal imaging: (2) | AP and Lateral
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| Scotty dog with a collar on oblique XRAY view? | Pars defect
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| 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
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| 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
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| Cause of cervical spondylosis | ingrowth of osteophytes and a couple of other things which narrow the neural foramen
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| Spurling's sign; what conditions does it associate with? | Move head back, rotate, extend -> pain in arm; Cervical Radiculopathy, cervical spondylosis
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| Tx of Cervical spondylosis | NSAIDs, relaxers, prednisone, narcs for radicular Sx; PT
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| Nerve root compression in the cervical spine causing neurologic symptoms in the distribution of the affected nerve root | Cervical radiculopathy
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| What motion can relieve Sx of cervical radiculopathy? | abducting arm over head
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| Only difference in Tx between cervical spondylosis and cervical radiculopathy | Rest resolves most in radiculopathy, otherwise, all Tx are the same
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| when the spinal cord experiences pathophysiologic changes secondary to neural compressive lesions. Common causes? | Cervical Myelopathy; chronic disc herniations, osteophytes, instability
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| problems w/ fine motor movements, positive upper motor neuron signs (Babinski, clonus etc.), muscle atrophy | Cervical Myelopathy
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| 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
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| T/F: Lumbar pain will radiate down the legs | FALSE, may radiate to buttocks but not legs
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| Difference in Tx between Cervical spondylosis and lumbar sprain? | Nada, bro!
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| 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
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| Displacement of nucleus pulposus through anulus fibrosis posterolateral most common in 4th and 5th decades | Herniated Lumbar Disc
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| 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)
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| 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
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| 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
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| Shopping cart sign | Spinal stenosis
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| Which imaging would you use for a herniation/Stenosis? Vascular claudication? | H and S: MRI, VC: arterial doppler
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| T/F: Stenosis coming from back of the spine, herniation is coming from the front of the spine | True!
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| Treatment for spinal stenosis other than conservative therapy? | surgical decompression
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| Which condition is isthmic? Spondylolysis or Spondylolithesis? | They can be both; more associated w/ spondylolysis
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| Which condition is degenerative? Spondylolysis or Spondylolithesis? | They can be both; more associated w/ spondylithesis
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| 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
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| Older population, overweight, may be comorbid w /stenosis, step off on palpation | Degenerative
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| Main Tx for Isthmic? Degenerative? | Isthmic: REST; Degenerative: Nerve root block
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| 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!!!
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| Severe neck pain, paraspinous muscle spasms/point tenderness (though lack of these Sx don't exclude injury) | Fracture of Cervical Spine
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| Burst fracture of ring of C1. Cause? | Jefferson Fracture; C: usually axial-loading force on head
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| Fracture of pars interarticularis of C2 & disruption of C2-C3 junction . What type of injury is this? | Hangman's Fracture; Traumatic spondylolisthesis
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| 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
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| Standard imaging for fracture of cervical spine (3) | 1) AP 2) Lateral 3) Odontoid
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| 3 Tx for fracture of cervical spine | 1) Immobilization for 7-10 days 2) IV steroids for cord injury 3) PT for scapular stabilization
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| 2 main causes of thoracic and lumbar spine fracture? | 1) MVC 2) fall from heights
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| T/F: Single compression Fracture involves 1 entire vertebral body | False, ONLY anterior half of vertebral body
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| 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
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| 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
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| Step off or gap between spinous processes w/ swelling/hematoma formation is the hallmark sign of: | unstable flexion-distraction injury
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| Tx for thoracic and lumbar spine (5) | hyperextension brace, spine board and log rolling, pain meds, kyphoplasty, vertebroplasty
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| Winking owl sign | loss of a pedicle (obliterated pedicle wall) indicating metastatic disease of the spine
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| Best screening study for metastatic disease? | Technetium bone scan
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| When should you refer for metastatic disease of the spine? | Most of the time
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| What kind of imaging is important for scoliosis? | STANDING XRay
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| "New mother's thumb" | DeQuervain's Tenosynovitis
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| 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)
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| Most common Pediatric Salter-Harris fracture? | Type 2: breaks bone but doesn't go through growth plate
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| "Kids' buckle". Tx? | Torus fracture, heals well with cast
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| Tx for breaking both bones in forearm in kids? | Surgery
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| Mid shaft radius Fx + DRUJ (distal radial ulnar joint) dislocation | Galeazzi fracture/dislocation
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| Management for distal radius and galeazzi fractures | Immobilize past elbow
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| Thing to remember about splinting/casting... | Always in flexion!
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| 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.
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| 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
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| TTP over thumb after wrist has been hyperextended/hyperflexed. Tx? | Thumb sprain; RICE (rest, ice, compression, elevation), splint/cast, NSAIDs
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| 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
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| 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.
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| 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
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| 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)
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| Common flexor tendon attachment: medial epicondyle | Golfer's elbow
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| Common extensor tendon attachment: lateral epicondyle | Tennis elbow
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| 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
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| 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
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| Common hand fracture, "the object always wins". Management | Boxer's Fracture, break of 5th phalange. Splint at 45 degrees, refer to ortho
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| Make sure to check nail bed for open fracture of distal phalanx in kids | Seymour fracture
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| Management for phalange fractures? | Splint in a bent fashion
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| "Jersey Finger", ruptures from forced extension while grabbing something. 4th finger FDP most common. Loss of PIP and MP flexion | Flexor tendon rupture
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| Hyperextension of PIP joint + flexion of DIP. Tx? | Swan Neck Deformity; OT/PT for splinting and/or surgery
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| 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"
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| 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.
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| 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.
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| 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
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| 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
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| 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
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| Management for Septic Tenosynovitis? | ER admit, IV ABX (clinda or azithro), refer to hand (may do an I&D)
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| What differentiates cellulitis from septic tenosynovitis on PE? | Cellulitis will be red and warm but no pain with finger motion
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| 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
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| 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
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| 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
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| T/F: Don't I&D herpetic witlow | True, can spread virus
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| Necessary step with nail injuries? | Get a XRAY, ~50% have fractures associated fix
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| Crush injury to finger Swollen, pain and hematoma. Tx? | Subungual hematoma. Tx: Evacuate blood w/ sterile needle, soak, ABX
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| 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
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| Imaging and Tx of Trigger finger? | Imaging: NONE; Tx: Injection (70% success), possible surgical release
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| 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
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| Pes planus? What sign occurs with this? | flat foot; "too many toes sign"
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| Pes cavus? What sign occurs with this? | high arch; "Peek a boo" heels sign
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| 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
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| Dysfunction of what tendon when patient can't evert foot | Peroneal tendon
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| Dysfunction of what tendon with trouble flexing/extending great toe | Extensor hallucis longus & flexor hallucis longus
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| What does the Thompson test look for? | Plantarflexion of foot. Assesses integrity of Achilles tendon
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| Typical 3 XRAY views for the ankle: | 1) AP 2) Lateral 3) Mortise
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| Typical 3 XRAY views for the foot: | 1) AP 2) Lateral 3) Oblique
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| Pain and swelling along Achilles especially w/ runners. Feel mass in tendon. Often 40 yo male weekend warrior. | Achilles tendinosis
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| 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
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| 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
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| Tx for Posterior Heel Pain. What should you not do? | Rest, ice, stretching, night splint, NSAIDs. DON'T INJECT (70% will rupture Achilles)
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| 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
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| What is Tennis leg? Negative Thompson's sign. | Gastocnemius tear.
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| T/F: 50% of Achilles Tendon Ruptures that are surgically repaired will have repeat injuries. | FALSE, 5%
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| Syndesmotic ligament sprain between tibia and fibula | High ankle sprain
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| 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
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| Tx for ankle sprains | RICE, boot 2-4 weeks, wt bear as tolerated, early mobilization, NSAIDs/steroids
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| Chronic degenerative changes and micro tears of ________ at it's origin on the medial calcaneus | plantar fascia; Plantar Fasciitis
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| 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
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| 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.
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| 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)
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| 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.
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| 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.
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| 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
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Review the information in the table. When you are ready to quiz yourself you can hide individual columns or the entire table. Then you can click on the empty cells to reveal the answer. Try to recall what will be displayed before clicking the empty cell.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
To hide a column, click on the column name.
To hide the entire table, click on the "Hide All" button.
You may also shuffle the rows of the table by clicking on the "Shuffle" button.
Or sort by any of the columns using the down arrow next to any column heading.
If you know all the data on any row, you can temporarily remove it by tapping the trash can to the right of the row.
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Created by:
crward88
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