Week 4 (Ortho Eval/ Shoulder/Elbow/Wrist)
What does ORIF stand for?
Open Reduction Internal Fixation
○Open reduction and internal fixation (ORIF) - the fracture is reduced in the OR and the fragments are fixed with pins/wires/screws/plates
○External fixation - the fracture fragments are stabilized with external pins/screws
What does Finkelstein's test evaluate for?
DeQuervain's Teonsynovitis
Finkelstein's Test: The patient’s thumb is enclosed in the palm. The wrist is then abruptly deviated ulnarward by the examiner. Positive if first dorsal compartment pain is present.
When diagnosing a patient with Systemic Lupus Erythematosus what process must always be ruled out?
Drug-induced lupus
Shares several clinical and serologic features with SLE but is due to ongoing exposure to a drug
and resolves when the offending drug is discontinued
Nongonococcal Septic Arthritis is most often due to what process that introduces bacteria into a joint?
Hematogenous seeding (bacteremia, nearby osteomyelitis, IVDA, human/animal bite)
Direct inoculation less common (trauma, surgery, arthrocentesis)
A 40 year old mother presents with painful knees, hips, back, shoulders, and spine x 1 week. Her child was recently diagnosed with "slapped cheek syndrome". You confidently tell her that her diagnosis is what disease process?
Viral Arthritis
Parvovirus B19 infection in adult, 50-60% develop polyarthritis, self-limited, resolves in a few weeks, diagnose by IgM serology if desired.
Other etiologies of viral arthritis: Chikungyna fever, acute hep B, chronic hep C
_______epicondylitis is "golfer's elbow" while ______ epicondylitis is "tennis elbow".
Medial epicondylitis is "golfer's elbow" while lateral epicondylitis is "tennis elbow".
If developmental hip dysplasia is not identified appropriately (through testing such as Barlow's and Orolani's tests) what can happen to the hip joint? (brownie points for describing Barlow and Ortolani)
○Permanent dysplastic changes (residual acetabular dysplasia and proximal femoral deformities, both of which increase the risk of early degenerative joint disease)
Barlow Maneuver - flexed calf and knee are gently grasped in the hand, with the thumb at the lesser trochanter and fingers at the greater trochanter. hip is then adducted slightly and gently pushed posteriorly and laterally with the palm – can feel + hear the dislocation of the affected hip
○Ortolani Test - the infant’s hip should first be placed into 90 degrees of flexion. Once in flexion, the thumb is placed on the medial surface of the thigh, and the index and long fingers are placed on the lateral surface of the thigh, with the finger pads over the greater trochanter. The hip is then abducted, using the index and long fingers to place pressure on the greater trochanter, pressing the proximal femur anteriorly – this reduces the displaced hip
Name the 3 types of Rhabdomyosarcomas.
Embryonic, Alveolar, Pleomorphic
20% of all soft-tissue sarcomas - etiology and risk factors remain largely unknown
● Presentation - localized, enlarging mass
● Diagnostics - CT/MRI and biopsy
● Differential diagnosis - osteosarcoma, lipomas, lymphoma, Wilms Tumor
● Three types:
○ Embryonic - presents in children < 15 years old (males more commonly)
■ Most commonly in the head/neck area
■ Treated with local surgical resection plus preoperative and postoperative
chemotherapy
● Prognosis - if localized, 5 year survival is 80%
○ Alveolar - presents in patients 10-25 (males more commonly)
■ Most commonly in the head/neck, but also the thigh/calf
■ Same treatment as embryonic
○ Pleomorphic - presents in adults
■ Most commonly in the lower extremities
■ Surgical resection and radiation therapy
What class of medicine is Allopurinol?
Xanthine Oxidase inhibitor
-○Purine metabolism forms urate - Purine digestion produces xanthine which is converted to uric acid by the action of xanthine oxidase
A 30 year old female presents with a FOOSH injury. Their dorsal wrist is painful, is edematous, has ecchymosis, and has a dinner fork deformity. XR confirms your diagnosis. You appropriately treat with reduction followed by a sugar tong splint after post reduction XR and neurovascular exams are normal. What is the patient's diagnosis?
Colle's Fracture, specific type of distal radius fracture.
-Distal radius fracture with dorsal comminution, dorsal angulation, dorsal displacement, radial shortening, and an associated fracture of the ulnar styloid
What is the difference between a subluxation and a dislocation?
Subluxation: partial disruption of a joint in which some degree of contact between the articular surfaces remain
Dislocation: most extreme form of subluxation where there is a complete disruption of a joint and the articular surfaces of the bones that form the joint are no longer in contact with one another
Name the early and late complications of tibial plateau fractures
●Early: Infection, wound dehiscence, DVT, compartment syndrome
●Later: persistent instability, degenerative joint disease
Late findings of osteoarthritis on Xray can include what findings (3 total)?
X-rays - may reveal (1) narrowing of the joint space early on; (2) later - osteophyte formation and
lipping of marginal bone; and thickened, dense subchondral bone
○ Occasionally bone cysts
What antibiotic regimen is appropriate for the initial treatment of acute osteomyelitis?
Vancomcin or Third Generation cephalosporin (ceftriaxone)
Narrow to best agent once cultures are obtained, then utilize IV antibiotics for 4-6 weeks.
Surgery if: epidural abscess, spinal cord compression, other types of associated abscesses (psoas etc.), extensive disease, recurrent/persistent infection despite treatment
A 22 year old patient presents with knee trauma. They state pain with squatting and a sensation of "catching/locking" in their knee. A special test and a MRI are positive and confirms your diagnosis. What course of action is most appropriate for this patient?
Meniscus repair/replacement for younger patients
Tx: Physical therapy, pain control
○In older patients try conservative management first, if no improvement can consider arthroscopic partial meniscectomy
Dx: Meniscus injury
Special test: McMurray's test (externally rotate the patient’s foot and then extend the knee while palpating the medial knee for “click” in the medial compartment of the knee or pain reproducing pain from a meniscus injury)
Immobilization of a scapula fracture includes what two features?
1. Sling: suspends the arm at 90 degrees
2. Swath: secures the sling to the body at the chest or trunk
What is the most common digit affected in a metacaropphalangeal dislocation?
●Most common location is the 2nd digit
Less common than IP dislocations
●Same presentation and diagnostics as IP dislocations
●Treatment - closed reduction followed by splint with the wrist extended 30 degrees and the MCP joint in 30 to 60 degrees of slight flexion, followed by several more weeks of buddy taping
○If nonreducible, will need open reduction and surgical repair
Define the CREST acronym in presentation of Scleroderma / Systemic Sclerosis
Calcinosis: calcium deposits in skin
Raynaud's phenomenom
Esophageal dysfunction (gerd, decreased motility)
Sclerodactyly
Teleangiectasias
What is the gold standard diagnostic study for Fibromyalgia?
NONE
-Clinical Syndrome: widespread pain, stiffness, tender/trigger points, fatigue, sleep disorders (no REM on sleep study!), numbness, brain fog, >3 months
-Labs: r/o other processes, CBC, ESR, CRP
-Utilize WPI (widespread pain index) and SSS (symptom severity scale) scores to help diagnose.
1a: WPI greater or equal to 7 and SS greater or equal to 5
1b: WPI 3-6 and SS greater or equal to 9
2: >3 months
3: no other disorder that would explain the pain
A 17 year old male presents after a basketball injury. He was trying to catch the ball with his fingers extended and it hit his right 3rd digit. Active ROM of the 3rd DIP joint is absent. Full passive ROM of the 3rd DIP joint is present. An Xray reveals no fracture. You opt for conservative management and recommend to splint his 3rd DIP joint in ______ for ________weeks.
Splint DIP in extension x 6-8 weeks
Dx: extensor tendon injury / Mallet Finger
●Conservative management is preferred
■Allow free movement of PIP joint
●If bone fragment > 50% of surface and volar subluxation hand surgeon referral
○Surgical repair with closed reduction and percutaneous pinning
An adult patient presents with paresthesia and numbness involving the ring and little fingers. A special test that involves the thumb is positive that confirms your diagnosis. What nighttime intervention is needed for this patient?
***Nighttime bracing that limits elbow flexion by holding the elbow at 45 degrees of flexion.
Avoid aggravating activities and use NSAIDs. Conservative management successful in 65% of cases
Dx: Ulnar Nerve Paralysis / Cubital Tunnel Syndrome
Special test: Froment's Sign (hold paper with thumb, thumb innervated from ulnar nerve by adductor pollicis)
An adult patient presents with difficulty lifting her toes, frequent trips, and night cramps. On exam planter flextion and foot inversion are preserved, but you note a high stepping gait with "foot slapping". You arrive at your diagnosis. The patient asks about surgery and you tell them surgy is only indicated in what scenarios?:
●Surgery only if there is a mass compressing the nerve, the nerve is tethered and needs release, or the nerve was severely or completely transected
Dx: Peroneal Nerve Syndrome
Tx:
●Rest and elimination of triggering factors
●Physical therapy and the use of an ankle foot orthosis (AFO) is helpful in recovery of function for foot drop
A 37 year old mother of 2 presents with bilateral joint pain and swelling. On exam she has ulnar deviation of the wrists. You receive lab work which is positive for RF, anti-CCP antibodies, elevated ESR, and elevated CRP. The patient would like to have one more child as she is premenopausal. Which DMARD is appropriate for this patient?
Sulfasalazine
Dx: Rheumatoid Arthritis
MTX: teratogenic
Leflunomide: teratogenic, contraindicated in premenopausal women
A 71 year old Caucasian female presents with 1 week of pain and stiffness in the morning and after sitting for prolonged periods. She has difficulty applying mascara, putting on her favorite cardigan, and standing up from her la-z-boy after watching White Lotus. Her pain is worse at night. On exam she has limited active and passive range of motion of her right shoulder. Muscle strength is preserved. She has a history of GCA. What is the most appropriate treatment option for this patient? Give specific dosing.
●If Giant Cell Arteritis present - treat appropriately (prednisone dose of 1mg/kg/day)
●If no Giant Cell Arteritis - treat with oral prednisone 10-20 mg qday
○May require several months of treatment with prolonged taper
○Can have disease flares with steroid tapering
■Taper based off symptoms, not ESR
○Can add methotrexate to avoid flares during taper
Dx: PMR
A 55 year old female presents with burning/itching eyes, difficulty swallowing dry foods, and vaginal dryness. You suspect a specific disease process and order a workup. Name at least 5 tests that can be part of your workup for your suspected disease process.
CBC: Mild anemia, leukopenia, and eosinophilia
● Polyclonal hypergammaglobulinemia
● Rheumatoid factor positivity (70%)
● Antinuclear antibodies (95%)
● Antibodies against SS-A and SS-B are often present
● Schirmer test which measures the quantity of tears secreted
● Lip biopsy - characteristic lymphoid foci in accessory salivary gland