PANCE Blueprint Musculoskeletal (8%)

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PANCE Blueprint Musculoskeletal (8%)

PANCE Blueprint Musculoskeletal (8%)

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58 Lessons

1 hour 25 mins

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Follow along with the NCCPA™ PANCE and PANRE Musculoskeletal Content Blueprint

Lessons

  4. Musculoskeletal 126 Question Comprehensive Exam

    Comprehensive PANCE/PANRE MSS Blueprint Exam

  5. Musculoskeletal System Flashcards and Cheat Sheet

    Flashcards covering all MSS PANCE/PANRE NCCPA Content Blueprint topics. Download and print the flashcard cheat sheet and access our premium Quizlet flashcard sets

    1. Additional Musculoskeletal Flashcards

  7. MRI Imaging of the Spine (Lecture)

    1. Chest/rib Deformities

      The most common are pectus excavatum (sunken chest or funnel chest) or pectus carinatum (pigeon chest)
      • Less common types of chest wall abnormalities include Poland's syndrome, Jeune's syndrome, and defects of the ribs and sternum
      • Suspected from visual examination of the anterior chest and chest x-rays are useful in the diagnosis
      • Treatment includes orthotic bracing, physical exercise, and surgery

    2. Chest/Rib Fractures and Trauma (ReelDx)

      Blunt trauma refers to mechanisms causing increased intrathoracic pressure such as car collisions (the most common cause of thoracic trauma) and falls
      • Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are most frequently involved. Patients usually report inspiratory chest pain and discomfort over the fractured rib or ribs. Physical findings include local tenderness and crepitus over the site of the fracture.
      • Flail chest involves three or more consecutive rib fractures in two or more places, which produce a free-floating, unstable segment of chest wall
      • Sternal fractures cause pain, tenderness, bruising, and swelling over the fracture site. CPR has also been known to cause thoracic injury
      • Pulmonary contusion resulting from blunt trauma to the chest causing interstitial edema that impairs compliance and gas exchange
      • Ruptured diaphragm - should be considered in patients who sustain a blow to the abdomen and present with dyspnea or respiratory distress
      • Blunt myocardial injury - dysrhythmias, ST changes
      • Pneumothoraces in blunt thoracic trauma are most frequently caused when a fractured rib penetrates the lung parenchyma
      Penetrating trauma largely refers to gunshot and stab wounds, occasionally impalement

  9. Compartment Syndrome (Lecture)

    11 mins

    Presents with 6 P’s: pain out of proportion, paresthesias, pallor, paralysis, pulselessness, and poikilothermia (limb unable to regulate temp).
    • Acute muscle pain with a background of fracture, trauma, burns, and tight casts or pressure dressings.
    • Diagnosis is made by measurement of compartment pressure > 30-45 mmHg; Increased CK and myoglobin.
    • Treat with fasciotomy and decompression of pressure.

  10. Degenerative diseases (PEARLS)

    1. Osteoarthritis (Lecture)

      Osteoarthritis is a chronic degenerative joint disease characterized by the breakdown of cartilage, bone remodeling, and inflammation, leading to pain, stiffness, and loss of function
      • Defined by morning stiffness lasting < 30 minutes, evening joint stiffness, worsens with use and improves with rest.
      • Worsened by use and relieved by rest. Crepitus or grating sensations may develop.
      • Commonly involves the hands, hips, and knees.
      • Heberden nodes: swelling of the distal interphalangeal joints.
      • Bouchard nodes: Swelling of the proximal interphalangeal joints.
      • Treat with stretching, acetaminophen, NSAIDs (oral and topical), and joint replacement surgery.

    1. Osteomyelitis (ReelDx)

      Staphylococcus aureus - most common cause overall. Pasteurella multocida - seen in cases caused by cat and dog bites.  Salmonella spp. in patients with sickle cell.
      • Classic X-ray triad of demineralization, periosteal reaction, and bone destruction.
      • Treat with surgical debridement.
      • IV antibiotics - Empiric therapy (vancomycin + ciprofloxacin or ceftazidime or cefepime) pending cultures and sensitivities.

    2. Septic arthritis (ReelDx + Lecture)

      4 mins

      Single, swollen, warm, painful joint that is tender to palpation along with constitutional symptoms: fever, sweats, myalgia, malaise, and pain.
      • Most common in the knee (50%).
      • Staphylococcus aureus is responsible for 40-50% of cases; Neisseria gonorrhea in sexually active young adults.
      • Joint fluid analysis: Purulent fluid, >50,000 leukocytes, >75% neutrophils, organism present.
      • Healthy patients: Vancomycin. IV drug users and sick patients: Vancomycin + ciprofloxacin or an antipseudomonal beta-lactam (ie. Ceftriaxone).

  12. Lower extremity disorders (PEARLS)

    1. Avascular necrosis/Osteonecrosis (Lecture)

      Insidious onset of a dull ache or throbbing localized to the groin, lateral hip, or buttocks - think trauma, steroid use, or sickle cell.
      • In children AVN is known as Legg-Calve' Perthes disease - will present with persistent pain and a limp.
      • MRI is the study of choice for early detection.
      • Treatment may be conservative or may eventually need a joint replacement.

    2. Developmental Dysplasia of the Hip (ReelDx)

      Will present with asymmetric skin folds and limited hip abduction on the affected side. Hip exam at every well-child visit until 2 years old
      • Barlow test: hip adduction causes dislocation
      • Ortolani test: hip flexion and abduction with anterior pressure causes reduction of hip dislocation (CLICK auscultated)
      • Ultrasound is used to assess. Radiographs are unreliable until the patient is at least four months old because of the radiolucency of the femoral head
      • < 6 months old: Pavlik harness (abduction bracing)
      • 6-15 months old: hip spica cast
      • 15-24 months old: open reduction followed by hip spica cast.

    3. Fractures and dislocations of the hip (ReelDx)

      Hip Fractures → Femoral head and neck fractures will present with severe hip, groin, or thigh pain, often with a history of recent trauma or fall.
      • The involved leg is abducted and externally rotated and may appear shortened.
      • Occurs after a fall in elderly patients with osteoporosis.
      • Management: Open reduction and internal fixation (ORIF) - 48 hours for best results.
      • High incidence of avascular necrosis with femoral neck fractures.
      • DVT prophylaxis until ambulatory.
      Hip dislocation → Hip pain with leg shortened and internally rotated and adducted after a trauma is the most common cause (fall from a height, motor vehicle accident).
      • Posterior dislocation - in 90% of cases, the hip will be adducted, flexed, and internally rotated.
      • Anterior dislocation - hip will be abducted, flexed, and externally rotated.
      • Radiographs: anteroposterior (AP) pelvis.
      • Closed reduction under conscious sedation. Open reduction if failure of closed reduction or radiographic evidence of incarcerated intra-articular fragments.
      • Repeat X-ray and neurovascular exam after reduction.

    4. Slipped capital femoral epiphysis (Lecture)

      Hip disorder common in adolescents in which the head of the femur slips off the neck of the femur inferiorly and posteriorly, often due to mechanical overload.
      • Patient will present as  → a 7-16 y/o obese male during a growth spurt with a limp and knee pain with external rotation of affected the leg.
      • Radiography - AP and frog-leg lateral of both hips.
      • Treat with surgical fixation with screw for all patients.

    5. Fractures and dislocations of the knee (ReelDx)

      • Knee Dislocation
        • Often after a high impact trauma and patient cannot extend knee.
        • Worry about popliteal artery injury diagnosed with arteriogram.
        • Pre-and post reduction x-rays.
        • MRI required to evaluate soft tissue injury (ligaments, meniscus) and for surgical planning.
        • Orthopedic emergency: early reduction is essential. Check distal pulses and peroneal nerve function.
      • Tibial Plateau Fractures
        • Commonly in children in MVA.
        • AP, lateral and oblique radiographs are performed.
        • If displaced check peroneal nerve (foot drop) hard to see on X-ray; may need to confirm with CT/MRI.
        • TX: nondisplaced cast 6-8 weeks; displaced ORIF.
      • Patella Fracture
        • High impact trauma to a flexed knee. Hemarthrosis and inability to extend the knee. 
        • Radiographs: patella alta - the pull of quad muscles cause fracture displacement. Best evaluated on lateral x-ray. The degree of fracture displacement correlates with degree of retinacular disruption.
        • Treat with 6-8 weeks or immobilization-  partial weight bearing.
        • Displaced fractures will need open reduction and internal fixation (ORIF).
      • Patellar dislocation is distinct from patellar subluxation or knee dislocation as follows:
        • Patellar dislocation – Patellar dislocations most commonly are lateral, although medial or superior dislocations are described. The patella is displaced from the trochlear groove. Intra-articular dislocations with lodging of the patella within the joint space may be superior, inferior, or vertical
        • Patellar subluxation – Patellar subluxation describes excessive lateral movement of the patella and may occur as a result of trauma or in patients with laxity. The patella still tracks within the trochlear groove but may cause discomfort and a feeling of instability

    6. Osgood-Schlatter disease (ReelDx + Lecture)

      Tenderness over the tibial tubercle in a 9-14-year-old male who has undergone a rapid growth spurt and is doing sports that involve running.
      • Repetitive traction of the apophysis of the tibial tuberosity results in microtrauma and micro-avulsion - the proximal patellar tendon insertion separates from the tibial tubercle.
      • Pain and swelling over the tibial tubercle at the point of insertion of the patellar tendon.
      • Pain on resisted knee extension with a lump below the knee and prominent tibial tuberosity.
      • Lateral radiograph of the knee demonstrates irregularity and fragmentation of the tibial tubercle.
      • Benignand self-limiting - conservative analgesics, ice, and physical therapy - first-line treatment for Osgood-Schlatter disease.

    7. Soft tissue injuries of the knee (ReelDx)

      • Prepatellar Bursitis (Housemaid's Knee)
        • Pain with direct pressure on the knee (kneeling).
        • Swelling over the patella.
        • Common in wrestlers: concern for septic bursitis in wrestlers - aspiration with gram stain and culture.
        • Treatment: compressive wrap, NSAIDs, +/- aspiration, and immobilization for 1 week. Corticosteroid use is controversial.
      • Patellar Tendinitis
        • Activity-related anterior knee pain associated with focal patellar tendon tenderness. Also known as "jumper's knee" (up to 20% of jumping athletes).
        • Swelling over tendon and tenderness at the inferior border of the patella.
        • Basset's sign: tenderness to palpation at the distal pole of the patella in full extension and no tenderness to palpation at distal pole of the patella in full flexion.
        • Radiographs - AP, lateral, skyline views of the knee - usually normal -may show inferior traction spur (enthesophyte) in chronic cases.
        • Ultrasound - thickening of tendon and hypoechoic areas.
        • MRI in chronic cases - demonstrates tendon thickening.
        • Ice, rest, activity modification, followed by physical therapy. Surgical excision and suture repair as needed.
        • Cortisone injections are contraindicated due to the risk of patellar tendon rupture.
      • Anterior Cruciate Ligament (ACL) Tear
        • Pop and swelling along with instability or "giving out" the knee after a quick plant and twist injury.
        • Quickly stopping movement and changing direction while running, landing from a jump, or turning leads to rotation or valgus stress of the knee and can result in injury to the ACL. Common in skiers, football, and basketball players.
        • Contact injury that causes hyperextension or valgus deformation of the knee.
        • Anterior Drawer Test: the proximal tibia is anteriorly pulled while the patient is supine, and the knee is flexed at 90 degrees - if there is anterior translation, then the test is positive.
        • Lachman's Test (most sensitive): the proximal tibia is anteriorly pulled with one hand, while the other hand stabilizes the distal femur while the knee is flexed at 30 degrees.
        • Magnetic resonance imaging (MRI) can confirm the diagnosis.
        • Physical therapy and lifestyle modifications for low-demand patients with decreased laxity.
        • Surgical reconstruction is performed in young and active patients with high-demand sports or jobs and/or significant knee instability.
      • Medial Collateral Ligament (MCL) Tear
        • Results when the knee is forced into valgus and external rotation force to the lateral knee.
        • A "pop" reported at the time of injury, along with medial joint line pain and difficulty ambulating due to pain or instability.
        • MRI definitive study
        • Conservative treatment with bracing and therapy is typically effective
        • Surgery for chronic instability
        • Testing: Valgus stress test - Patient will have pain with valgus stress applied to the knee.
      • Lateral Collateral Ligament (LCL) Tear
        • The main cause of LCL injuries is direct-force trauma to the inside of the knee, causing excessive varus stress, external tibial rotation, and/or hyperextension.
        • Isolated injury is extremely rare - 7-16% of all knee ligament injuries when combined with lateral ligamentous complex injuries, particularly posterolateral corner (PLC) injury.
        • Radiographs - AP, lateral, and varus stress radiographs
        • MRI definitive study - provides information about severity (complete vs. partial rupture) and location (avulsion vs. midsubstance tear).
        • Conservative treatment with bracing and therapy typically effective.
        • Surgery for grade III LCL injury.
        • Testing: Varus stress test
      • Posterior Cruciate Ligament (PCL) Tear
        • Blow to the knee while it is flexed, or bent, such as landing hard during sports or a fall, or from a car accident (also known as dashboard knee). May result from non contact hyperflexion with a plantar-flexed foot or a hyperextension injury.
        • Testing: posterior drawer sign, sag sign (tibia sagging posteriorly), active quad test
        • MRI is the confirmatory study for the diagnosis of PCL injury
        • Protected weight bearing and rehab indicated for isolated Grade I (partial) and II (complete isolated) injuries.
        • Surgical repair for PCL + ACL or PLC injuries and PCL + Grade III MCL or LCL injuries.
      • Meniscal Tear
        • After a "twist" injury with locking, a feeling of the knee giving away, walking up and down stairs or squatting is difficult and painful.
        • Triad of joint line pain, effusion, locking
        • Effusion typically 6-24 hours after injury
        • Roughly 1/3 experience locking
        • McMurray test: the patient is supine, knee flexed, and externally (medial meniscus) or internally (lateral meniscus) then extended - pain indicates a tear.
        • Apley test: Pt prone, knee to 90 degrees, axial load with rotation causes pain with meniscal pathology.

    8. Fractures and dislocations of the ankle and foot (ReelDx)

      • Ottawa ankle rules - order an X-ray if any of the following apply:
        • Pain along lateral malleolus, medial malleolus.
        • Midfoot pain, 5th metatarsal or navicular pain.
        • Unable to walk more than four steps in the ER or exam room.
      • Jones fracture
        • Proximal 5'th metatarsal diaphysis fracture,
        • Pain over the lateral border of the forefoot, especially with weight bearing.
        • The area has a poor blood supply.
        • Treatment: Walking boot/cast, RICE, surgery for displaced fractures. Requires 6 weeks of non-weight bearing. 
      • Stress Fracture
        • Common in athletes and in the military - due to overuse.
        • Most common in the 3rd metatarsal, calcaneus, talus, midshaft of tibia, femur, and humerus.
        • Bone scan/MRI.
        • Treatment: rest (avoid high-impact activities), splint, or post-op shoe.
      • Talus Fracture
        • High force impact -falling from a significant height, high energy trauma - incidence common in snowboarders.
        • X-ray demonstrates talus fracture.
        • Non-weight bearing cast is typically used in non-displaced fractures. Surgery typically in displaced fractures.
      • Tibial Plafond Fractures
        • Forceful axial load, high-impact trauma (motor vehicle accidents, falls from height).
        • X-ray demonstrates fracture.
        • ORIF definitive fixation for the majority of pilon fractures.
      • Ankle Dislocation
        • Usually, it is a result of a fall, motor vehicle crash, or sporting injury.
        • In addition to the bony injury, there can be damage to blood vessels, nerves, and skin.
        • X-ray reveals dislocation
        • Treat with reduction +/- ORIF.
      • Weber Ankle Fracture Classification: level of fibular fracture relative to the syndesmosis.
        • A: below syndesmosis.
        • B: level of syndesmosis.
        • C: above level of syndesmosis.

    9. Soft tissue injuries of the ankle and foot (ReelDx)

      • Ankle Sprains
        • Anterior talofibular ligament (ATFL) with inversion 85%. The deltoid ligament is affected by eversion injuries.
        • Range from stretching with microscopic damage (grade I) to partial disruption (grade II) to complete disruption (grade III).
        • Anterior drawer test: assesses for anterior displacement of the talus on the tibia - suggests injury to the anterior talofibular lateral ligament.
        • Talar tilt test: assesses the integrity of the calcaneofibular ligament.
      • Achilles Tendon Rupture
        • Pop with weakness and difficulty walking along with pain in the heel.
        • (+) Thompson test  - weak/absent plantar flexion (when gastrocnemius is squeezed).
        • MRI will show acute rupture with retracted tendon edges.
        • Management: Surgical repair allows for early ROM. Splint with the ankle in some plantar flexion..
      • Plantar Fasciitis
        • Pain on plantar surface, usually at the calcaneal insertion of plantar fascia upon weight bearing, especially in morning or on initiation of walking after prolonged rest.
        • Dancers, runners, court sport athletes.
        • Calcification may lead to the development of heel spur.
        • Treat with stretching, ice, calf strengthening and NSAIDS.
      • Tarsal Tunnel Syndrome
        • Posterior tibial nerve compression from overuse, restrictive footwear, edematous states.
        • Pain and numbness at the medial malleolus, heel, and sole. Pain worsens at night with activity. Pain with prolonged standing or walking, often vague and misleading medial foot pain, sharp, burning pains in the foot.
        • Diagnosis (+) Tinel's sign - symptoms exacerbated with dorsiflexion. Nerve conduction tests, electromyography.
        • Treatment involves avoiding exacerbating activities. NSAIDs, corticosteroids injection if no improvement, surgery.
      • Bunion (Hallux Valgus)
        • Hallux valgus is a deformity of the first metatarsophalangeal joint causing lateral deviation of the great toe, often leading to overlapping of the second toe and formation of a bony prominence (bunion) on the medial aspect of the foot
        • History of poorly-fitted shoes, pes planus (flat feet), or rheumatoid arthritis. Presents with difficulty with shoe wear due to medial eminence.
        • Pain over prominence at the MTP joint and compression of the digital nerve may cause symptoms.
        • Radiographs - lateral displacement of sesamoids.
        • Treatment: comfortable, wide-toed shoes; surgical - when symptoms present despite shoe modification.
      • Morton's Neuroma
        • Degeneration/proliferation of plantar digital nerve producing painful mass near tarsal heads. Most common in women 25-50 y/o especially with tight-fitting shoes, high heels, and flat feet.
        • Sharp pain with ambulation at the 3'rd metatarsal head. May be associated with numbness/paresthesias. Reproducible pain on palpation.
        • MRI may be needed for diagnosis.
        • Treatment: Wide shoes, glucocorticoid injections, surgical resection if conservative management fails.

  13. Musculoskeletal Neoplastic Disease (Benign and Malignant)

    • Osteosarcoma (kids 10-14 years)
      • Progressively worsening night pain, bone pain/joint swelling – may look similar to growing pains and can be easily missed.
      • X-ray: sun ray/burst or hair on end appearance followed by bone scan look for metastasis.
      • Lung is the most common site of metastasis, followed by bone.
      • Treat with limb-sparing resection or radical amputation - 76% long-term survival with modern treatment.
    • Ewing's Sarcoma (kids 5-25 years)
      • Pain often accompanied by fever, often mimics an infection. May have palpable mass, swelling, and local tenderness.
      • X-ray: appears as a lytic lesion with an onion-skin appearance of the periosteum.
      • Treat with chemotherapy, surgery and radiation therapy.
    • Chondrosarcoma (adults 50 + years)
      • Cancer of cartilage seen commonly in adults ages 50+ years.
      • X-ray: intra-lesional popcorn mineralization may be seen described rings, arcs, and stipples of mineralization.
      • Treat with complete surgical ablation is the most effective treatment, but sometimes this is difficult leading to amputation.
    • Osteochondroma (10-20 years)
      • Benign chondrogenic lesion derived from aberrant cartilage - the most common benign bone tumor mostly in males ages 10-20 years old.
      • X-ray: sessile (broad base) or pedunculated (narrow stalk) lesions found on the surface of bones.
      • Treat with observation, resection if it becomes painful
    • Ganglion
      • A ganglion is a noncancerous mucin-filled synovial cyst caused by either trauma, mucoid degeneration, or synovial herniation
      • Occurring usually on the hands, especially on the dorsal aspect of the wrists
      • Diagnosis is usually clinical - Firm and well-circumscribed, often fixed to deep tissue but not to the overlying skin, transilluminates
      • Most ganglia do not require treatment. However, if the patient is disturbed by its appearance or if the ganglion is painful or tender, a single aspiration with a large-bore needle is effective in about 50% of patients.

  14. Rheumatologic Disorders (PEARLS)

    1. Fibromyalgia (Lecture)

      Fibromyalgia is a long-lasting condition that causes widespread muscle pain, excessive tenderness in many areas of the body, and sleep disturbances.
      • People with fibromyalgia have a lower threshold to pain.
      • The diagnosis is often made with a clinical history that shows over three months of widespread pain that cannot be due to another disorder.
      • The treatment for fibromyalgia includes stress reduction, sleep/exercise, antidepressants (amitriptyline, SSRIs, and SNRIs), and anticonvulsants (pregabalin/gabapentin).
      • The FDA has approved three drugs to treat fibromyalgia: the antidepressants duloxetine (Cymbalta) and milnacipran (Savella), plus the anti-seizure medicine pregabalin (Lyrica).
      • Exercises to gently stretch the affected muscles should be done daily.

    2. Gout and pseudogout (Lecture + ReelDx)

      Gout: accumulation of uric acid in the soft tissue of joints and bone.
      • Inflammatory joint pain. The great toe is often first affected (podagra).
      • Associated with purine-rich foods (alcohol, liver, oily fish, yeasts) and diuretic use.
      • Joint fluid analysis: rod-shaped, negatively birefringent urate crystals.
      • Acute- indomethacin, Chronic- allopurinol.
      Pseudogout: accumulation of crystals of calcium pyrophosphate dihydrate (CPPD) in the connective tissues.
      • Inflammatory joint pain (knee most common) is often associated with hyperparathyroidism.
      • Joint fluid analysis: Rhomboid-shaped calcium pyrophosphate crystals, positive birefringent crystals.
      • Corticosteroids are 1st line, NSAIDs, Colchicine (prophylaxis).

    3. Juvenile rheumatoid arthritis (Lecture)

      A group of rheumatic diseases that begin at or before age 16. Evening fever spikes, salmon pink maculopapular rash, and Koebner’s phenomenon.
      • There are three types:
        • Oligoarticular JIA (60%) is the most common form and usually affects young girls. Involvement of ≤ 4 joints during the first 6 mo of disease.
        • Polyarticular JIA is the second most common form. It affects ≥ 5 joints at onset and is divided into two types: RF negative and RF positive.
        • Systemic JRA is Still’s disease: it is the least common form and involves fever and systemic manifestations.
      • Treatment involves NSAIDs, intra-articular corticosteroids, and disease-modifying antirheumatic drugs - methotrexate.

    4. Osteoporosis (Lecture)

      DEXA in all women ≥ 65 and all men ≥ 70 years of age
      • Osteoporosis T-score ≤ -2.5
      • Osteopenia T-score -1 to - 2.4
      • Z score: same age/gender <-2.0 - search underlying cause
      • Oral bisphosphonates are taken on an empty stomach with a full glass of water and remain upright for 30 min. Associated with osteonecrosis of the jaw

    5. Polyarteritis nodosa (Lecture)

      Systemic vasculitis of medium and small arteries affecting men in their 40-50's.
      • Various combinations of symptoms, such as unexplained fever, arthralgia, subcutaneous nodules, skin ulcers, pain in the abdomen or extremities, new footdrop or wrist drop, or rapidly developing hypertension.
      • Livedo reticularis and palpable purpura.
      • Associated with Hepatitis B/C (20%).
      • Diagnostic studies: ↑ ESR, ↑ CRP, ANCA negative, and definitive diagnosis with vessel biopsy.
      • Treatment includes steroids +/- cyclophosphamide if refractory.

    6. Polymyalgia rheumatica (Lecture)

      Chronic and inflammatory rheumatic disease characterized by pelvic girdle and shoulder pain and stiffness. Severe after rest. Stiffness is more prominent in the morning.
      • Difficulty rising out of the chair or lifting arms above head.
      • Normal muscle strength, reduced active and passive range of motion, joint swelling may be appreciated.
      • Associated with temporal arteritis - headache may indicate giant cell arteritis.
      • ESR: >50 mm/hr.
      • Treatment: Steroid taper for 2 years.

    7. Polymyositis and Dermatomyositis (ReelDx + Lecture)

      Polymyositis: autoimmune myopathy characterized by symmetric proximal muscle weakness and no rash.
      • Proximal muscle weakness in the shoulders and hips: difficulty combing hair, difficulty raising arms, difficulty rising from a chair.
      • Associated with malignancy.
      • Muscle biopsy showing perimysial inflammation, anti-Jo antibodies, ↑ creatinine phosphokinase (CPK or CK), ↑ creatine kinase-MB (CK-MB).
      • Treat with steroids, followed by long-term immunosuppression.
      Dermatomyositis: autoimmune myopathy characterized by symmetric proximal muscle weakness and characteristic cutaneous findings.
      • Gottron's papules: raised violaceous, slightly scaly plaques on bony prominences of the hands and elbows
      • Shawl or V-sign: a photosensitive pink rash of the neck and trunk. Often appears as sunburn with a v-neck t-shirt
      • Heliotrope rash: purple/lilac or red rash around eyes and on eyelids
      • Muscle biopsy showing endomysial inflammation.
      • Treat with steroids, followed by long-term immunosuppression.

    8. Reactive arthritis (Reiter syndrome) Lecture

      Autoimmune response to infection in another part of the body.
      • The classic triad of urethritis, conjunctivitis, and oligoarthritis (can’t see, can’t pee, can’t climb a tree).
      • After recent infection with Gonorrhea, Chlamydia, Shigella, Salmonella, Yersinia, or Campylobacter.
      • HLA-B27 positive (80%), synovial fluid is aseptic with negative bacterial cultures.
      • NSAIDs are the mainstay of therapy, antibiotics to treat the underlying genitourinary infection if still present.

    9. Rheumatoid arthritis (Lecture)

      Chronic autoimmune inflammatory disease with persistent symmetric polyarthritis with bone erosion, cartilage destruction, and joint structure loss
      • Small joint (MCP, PIP, wrist, knee, MTP, shoulder, ankle) morning stiffness >30 mins that is worse with rest and improves through the day (vs. osteoarthritis, which gets worse throughout the day and, if morning stiffness is present, will be < 30 minutes)
      • Joint inflammation is visible. 3+ symmetrical joints - DIP joint usually spared
      • Boutonniere deformity: flexion at PIP, hyperextension of DIP
      • Swan neck deformity: flexion at DIP with joint hyperextension at PIP
      • Rheumatoid factor (RF) (sensitive but not specific), anti-CCP (most specific for RA)
      • Joint fluid analysis: Yellow to white fluid, 2,000-50,000 leukocytes, 50% neutrophils, no organisms
      • Treat with DMARDs. Methotrexate is usually first. (Contraindicated in pregnancy)

    10. Sjögren syndrome (Lecture)

      Multisystem autoimmune disease characterized by dryness due to exocrine gland destruction.
      • Patients complain of xerostomia (dry mouth), xerophthalmia (dry eyes), and have joint involvement in the form of arthritis.
      • Schirmer’s tear test is positive if < 5 mm lacrimation in 5 minutes.
      • Diagnosis can be made via testing for anti-SS-B (La) and anti SS-A (Ro) antibodies.
      • Treat with artificial tears, pilocarpine (cholinergic) for xerostomia.

    11. Systemic lupus erythematosus (Lecture)

      Systemic autoimmune disease characterized by acute flares, commonly presenting with the triad of joint pain, fever, and malar (butterfly) rash.
      • Multiple organ systems are involved - Serositis, Oral ulcers, Arthritis, Photosensitivity, Blood disorders, Cardiac disease, and Renal involvement.
      • Often drug-induced: procainamide, hydralazine, INH, quinidine.
      • Antibodies: anti dsDNA (best test), ANA (not specific), anti-Smith.
      • Treat with sun protection, hydroxychloroquine (for skin lesions), NSAIDs or acetaminophen for arthritis. Pulse dose steroids; cytotoxic drugs (methotrexate, cyclophosphamide).

    12. Systemic sclerosis - Scleroderma (ReelDx + Lecture)

      Systemic connective tissue disorder causing thickened skin (sclerodactyly), lung, heart, kidney, and GI tract.
      • CREST Syndrome: Calcinosis, Raynaud’s phenomenon, Esophageal dysfunction (GERD), Sclerodactyly, and Telangiectasis.
      • Antibodies: Anti-centromere (limited) and anti-topoisomerase (systemic)
      • Acute management with DMARDs and steroids. Treat Raynaud's with vasodilators (CCBs and prostacyclin).

  15. Spinal Disorders (PEARLS)

    1. Ankylosing spondylitis (Lecture)

      Seronegative spondyloarthropathy that primarily affects the sacroiliac joint and spine.
      • Presents as chronic low back pain and morning stiffness with paint that decreases with exercise and activity.
      • Associated with psoriasis, inflammatory bowel disease, anterior uveitis, and aortic regurgitation.
      • HLA-B27 positive.
      • Radiography: bamboo spine - squaring of vertebral bodies.
      • Treat with NSAIDs, PT and tumor necrosis factor (TNF) inhibitors.

    2. Cauda equina syndrome (Lecture)

      Rare condition usually involving a large midline disk herniation that compresses several nerve roots, usually at L4-L5 level.
      • Leg pain, numbness, saddle anesthesia, bowel/bladder dysfunction and/or paralysis.
      • This is a surgical emergency requiring immediate referral.

    3. Herniated nucleus pulposus (Lecture)

      Cervical radiculopathy is most commonly posterolateral at C5-C6, C6-C7.
      • C4
        • May affect the levator scapular and trapezius muscles, resulting in weakness in shoulder elevation. There is no reliable associated reflex.
      • C5
        • Weakness of the rhomboid, deltoid, bicep, and infraspinatus muscles. Patients may have weakness of shoulder abduction and external rotation. The bicep reflex may be diminished.
      • C5-C6
        • Affects the C6 nerve root and produces pain at the shoulder tip and trapezius with radiation to the anterior upper arm, radial forearm, and thumb, and sensory impairment in these areas. C6 radiculopathy can easily be confused for C5 or C7 radiculopathy. Weakness can overlap with the C5 or C7 muscles. Muscles affected include infraspinatus, bicep, brachioradialis, pronator teres, and triceps. Weakness involves flexion at the elbow, or shoulder external rotation. The bicep or brachioradialis reflex may be diminished.
      • C6-C7
        • Affects the C7 nerve root and produces pain at the shoulder blade, pectoral area, and medial axilla with radiation to the posterolateral upper arm, dorsal elbow and forearm, index and medial digits or all of the fingers, and sensory impairment in these areas. C7 radiculopathy can result in weakness of the triceps, pronator teres, flexor carpi radialis. Weakness involves the elbow extensors and forearm pronators. There may be a diminished triceps reflex.
      • C7-T1
        • Causes C8 radiculopathy. Weakness can be present in the opponens pollicis, flexor digitorum profundus, flexor pollicis longus, and hand intrinsic muscles. Clinically, patients present with symptoms similar to an ulnar or median motor neuropathy and can have weakness of finger abductors and grip strength; they may also have findings suggesting median motor neuropathy. No reliable reflex test is available.

      Lumbar radiculopathy most commonly involves either the L5 or S1 root.

      • L1
        • Rare - symptoms involve pain, paresthesia, and sensory loss in the inguinal region.
      • L2, L3, and L4
        • In older patients with spinal stenosis. They are generally considered as a group because of the marked overlap of innervation of the anterior thigh muscles. Acute back pain is the most common presenting complaint, often radiating around the anterior aspect of the thigh down into the knee.
      • L5
        • The most common radiculopathy affecting the lumbosacral spine. It often presents with back pain that radiates down the lateral aspect of the leg into the foot. On examination, strength can be reduced in foot dorsiflexion, toe extension, foot inversion, and foot eversion. Reflexes are generally normal.
      • S1
        • Pain radiates down the posterior aspect of the leg into the foot from the back. On examination, strength may be reduced in leg extension (gluteus maximus) and plantar flexion. Sensation is generally reduced on the posterior aspect of the leg and the lateral foot. Ankle reflex loss is typical.
      • S2, S3, and/or S4
        • Patients can present with sacral or buttock pain that radiates down the posterior aspect of the leg or into the perineum. Weakness may be minimal, with urinary and fecal incontinence as well as sexual dysfunction. 

    4. Kyphosis (Lecture)

      • Increased convex curvature of the thoracic spine.
        • Curves of 45 - 60 degrees should be observed every 3-4 months and exercise prescribed for lumbar lordosis.
        • Curves > 60 degrees or with significant pain should be treated with bracing (Milwaukee brace). Surgery is sometimes indicated.
      • Scheuermann's Kyphosis: A rigid thoracic hyperkyphosis of childhood defined by > 45 degrees curvature.
        • Curves < 60°: most patients fall in this group and can be treated with observation alone.
        • Curves 60°-80°: bracing with an extension-type orthosis.
        • Curves > 75 degrees : Operative treatment.

    5. Scoliosis (Lecture)

      Defined as a lateral spinal curvature with a Cobb angle of 10° or more.
      • On Adams forward bending asymmetry in scapular height is noted.
      • Radiographs standing PA and lateral.
      • > 20° refer to orthopedics may need bracing, observation in most cases.
      • Bracing or surgery if > 40°

    6. Spinal stenosis (Lecture)

      Pain in elderly that increases with extension (walking downhill and standing upright) and is relieved with flexion at the hips and by leaning forward (sitting, leaning over shopping cart).
      • Neurogenic claudication: pain, numbness, and weakness in the calves, buttocks, and/or thighs during walking or weight bearing - a symptom of nerve root compression.
      • Kemp sign - Unilateral radicular pain from foraminal stenosis made worse by extension of the back.
      • Straight leg raise (nerve root tension sign) is usually negative.
      • MRI show spinal stenosis.
      • Treat NSAIDS, physical therapy, weight loss and bracing - epidural injection of steroids or decompression laminectomy.

    7. Back strain and sprain (ReelDx)

      Cervical strain (Whiplash)
      • Injury occurs as a result of a rear impact, with rapid extension followed by flexion of the cervical spine (usually after MVA or fall).
      • Stiffness and pain in the neck.
      • Will present with paraspinal muscle tenderness and spasm and a positive Spurling test.
      • Treatment includes a soft cervical collar (2 to 3 days), application of ice or heat, analgesics, and gentle active ROM very soon after injury.
      Back strain
      • Most common cause of back pain - associated with activity.
      • Characterized by stiffness and difficulty bending.
      • The patient will present with axial back pain and no radicular symptoms.
      • The patient should resume activity as tolerated.
      • Patients who have not improved in 4-weeks should be re-evaluated. 
      • In the absence of 'red-flag' symptoms, treat conservatively with NSAIDs, heat or ice, PT, and home-based exercises (avoid bed-rest). May include a muscle relaxant such as cyclobenzaprine or short-term use of a benzodiazepine.

    8. Thoracic outlet syndrome

      Thoracic outlet syndrome affects the space between the collarbone and first rib (thoracic outlet)
      • Common causes include trauma, repetitive injuries, pregnancy, and anatomical defects, such as having an extra rib
      • Symptoms include pain in the shoulders and neck and numbness, weakness, and coldness in the fingers
      • Provocative test: Adson's maneuver
      • Diagnose with x-ray, EMG, MRI, U/S, and angiography
      • Treatment involves physical therapy and pain relief. In rare cases, surgery may be needed to relieve the compression

    9. Torticollis

      Torticollis is a postural deformity due to abnormal contraction of the sternocleidomastoid muscle
      • Torticollis can be inherited and is seen soon after birth or acquired
      • The best initial step is neck radiograph to rule out acquired causes including retropharyngeal abscess and atlantoaxial subluxation
      • Ultrasonography can be used to visualize muscle tissue and is preferred in newborns
      • Treatment includes physical therapy, botulinum toxin, muscle relaxants, and surgery

    11. Lower back pain (ReelDx)

      15 mins

    1. Shoulder Fractures/dislocations (ReelDx + Lecture)

      • Shoulder Dislocation
        • Anterior dislocation is the most common - the arm is abducted and externally rotated
        • Differentiate from posterior dislocation in which the arm is held adducted and internally rotated
        • Squaring of the shoulder: loss of rounded appearance (humeral head) and sharp prominence of the acromion (squaring)
        • Axillary nerve injury: May present with numbness or tingling over the lateral shoulder
        • Bankart lesion: fracture of the anterior inferior glenoid following impaction of the humeral head against the glenoid.
        • Hill-Sachs lesion: dent in the humeral head
        • Reduce, postreduction films, sling, and swath, physical therapy
      • Clavicular fractures
        • Swelling, erythema, and tenderness on the anterior aspect of her right shoulder.
        • Middle third fracture is the most common.
        • Most can be treated conservatively - sling and swathe.
        • Begin PT after 4 weeks with light strengthening after 6 weeks.

    2. Soft tissue injuries of the shoulder (Lecture)

      • AC Joint Separation
        • elevation of the clavicle (step-off deformity) and point tenderness and pain with cross-chest testing.
        • Sling and analgesia. More severe injuries usually will require operative repair.
      • Biceps Tendonitis
        • Pain with resisted supination of the elbow.
        • MRI: can show thickening and tenosynovitis of proximal biceps tendon - increased T2 signal around biceps tendon. A "Popeye" deformity - indicates a rupture.
        • Treat with NSAIDs, PT strengthening, and steroid injections. Surgical release is reserved for refractory cases.
      • Rotator cuff tendinopathy/tear
        • Shoulder pain exacerbated by sleeping on the affected shoulder, and reaching overhead. 
        • Severe focal tenderness at the insertion of supraspinatus (anterolateral shoulder) and decreased active elevation with a normal passive range of motion.
        • Magnetic resonance imaging (MRI) is the most accurate test.
        • Treat with physical therapy (for all patients), NSAIDs, steroid injections, and surgical repair for patients with complete tears.
      • Adhesive Capsulitis (frozen shoulder)
        • Insidious onset of shoulder stiffness and pain at rest and with movement. Decreased active and passive range of motion.
        • MR arthrogram - loss of axillary recess indicates contracture of the joint capsule.
        • Apley scratch test: the patient tries to bring hands together on the back while one hand comes from above and the other from below. Positive test - restriction with movement.
        • Treat with NSAIDs, physical therapy, and intra-articular steroid injections.
      • Subacromial Impingement
        • Pain with reaching or lifting and pain with overhead motions. Crepitus with range of motion.
        • (+) Neer test: arm fully pronated (thumbs down) with pain during forward flexions while the shoulder is held down to prevent shrugging.
        • (+) Hawkins: Elbow/shoulder flexed at 90 degrees with sharp anterior shoulder pain with internal rotation.
        • (+) Drop arm test: pain with inability to lift the arm above shoulder level or hold it or severe pain slowly lowering arm after shoulder abducted to 90 degrees.
        • Rest, ice, activity modification, NSAIDs, and corticosteroid injections.
      • Subacromial Bursitis
        • Pain is often not associated with trauma. Pain in motion and at rest can cause fluid to accumulate.
        • Treatment includes prevention of the precipitating factors, rest, NSAIDs, and Cortisone injections.
      • Glenohumeral Joint Osteoarthritis
        • Pain at night and pain with activities involving shoulder motion.
        • Radiographs demonstrate subchondral sclerosis and osteophytes at the inferior aspect of the humeral head.
        • NSAIDs, physical therapy, corticosteroid injections. Total shoulder arthroplasty if unresponsive to nonoperative treatment.

    3. Fractures and dislocations of the forearm, wrist and hand (ReelDx + Lecture)

      • Humerus Fractures
        • Accounts for approximately 3% of all fractures - increasing incidence in the elderly.
        • Humerus fractures are the most common site of radial nerve injury (common exam question).
        • Proximal, midshaft, and distal (less common) - posterior fat pad or sail sign.
        • Supracondylar in children (above the growth plate) – worry about compartment syndrome and the brachial artery.
        • Treat with sugar tong splint (distal) coaptation splint(shaft) with ortho follow up in 24-48 hours.
      • Supracondylar fracture
        • The most common pediatric elbow fracture - accounts for 41% of all serious pediatric elbow injuries.
        • Usually occurs from a fall to an outstretched hand.
        • X-ray demonstrates anterior fat pad sign = dark area on either side of the bone.
        • Make sure to check for neurologic or vascular involvement - may cause median nerve and brachial artery injury, as well as radial nerve injury.
        • Long arm posterior splint followed by long arm casting - open reduction with internal fixation for all displaced fractures.
      • Radial Head Fracture
        • The most common cause of a radial head fracture is falling with an outstretched arm. Elbow in extension + forearm in pronation - most force transmitted from wrist to radial head. Treat with a sling, long arm splint at 90 degrees, open reduction, and internal fixation.
      • Radial head subluxation (Nursemaid's elbow)
        • Common upper extremity injury in infants and young children.
        • Generally occurs with a pulling upward type of motion while the child has an outstretched arm.
        • The child refuses to move the arm on presentation.
        • The supination-flexion technique is the classic method of reducing a subluxed radial head. It has a success rate of 80-92%.
        • Always ensure the child spontaneously uses the arm after reduction before discharging to confirm success.
      • Nightstick Fracture (Isolated fracture of the ulna)
        • Isolated fractures of the ulna, typically transverse and located in the mid-diaphysis and usually resulting from a direct blow.
        • Functional brace with good interosseous mold for isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx). ORIF if displaced.
      • Monteggia Fracture (Proximal ulnar shaft fracture with radial head dislocation)
        • Proximal ulnar shaft fracture with radial head dislocation.
        • Traumatic injury - Fall On an OutStretched Hand (FOOSH) or a direct blow to the ulna.
        • Radial nerve injury with wrist drop in 17% of patients.
        • Treat with open reduction and internal fixation.
      • Galeazzi Fracture
        • Distal radial shaft fracture with dislocation of the ulnar-radial joint.
        • Following a direct blow to the dorsolateral forearm, Fall On an OutStretched Hand (FOOSH), falling on a pronated forearm.
        • Mid distal radial shaft fracture with dislocation of the radioulnar joint.
        • Unstable fracture needs ORIF, long arm splint.
      • Colles Fracture - Distal Radial Fracture (Posterior Angulation)
        • Refer to dorsally angulated extra-articular distal radius fractures.
        • Most common forearm fracture - considered 1 of 3 common "fragility fractures" associated with osteoporosis.
        • Fall On an OutStretched Hand (FOOSH) causes distal radial fracture and dorsal (posterior) angulation "dinner fork" deformity (Mom “Colles” you for dinner).
        • Need lateral X-ray to make the correct diagnosis; may cause extensor pollicis longus tendon rupture.
        • Treat with a sugar tong splint/cast.
      • Smith Fracture - Distal Radial Fracture (Anterior Angulation)
        • Reverse Colles fracture is an extra-articular metaphysical fracture of the radius with volar angulation and displacement - garden spade deformity.
        • Results from a fall with palm closed, hands flexed, or blow to the back of the wrist.
        • 3D's (dorsal displacement of the distal fragment).
        • Median nerve injury is common (over time, can develop into carpal tunnel).
        • Reduction/surgery or casting, PT for ROM and strengthening.
      • Scaphoid Fracture (Snuffbox tenderness)
        • Fall on an outstretched hand.
        • Pain along the radial surface of the wrist at anatomical snuffbox.
        • The fracture may not be evident for up to 2 weeks.
        • A complication is avascular necrosis.
        • Treat with 10-12 weeks of casting with a thumb spica splint.
      • Boxer's Fracture
        • Fracture at the neck of the 5th ± 4th metacarpal.
        • Usually caused by a punch with a clenched fist.
        • Look for associated carpal fractures.
        • Treat with an ulnar gutter splint with joints at least 60 degrees flexion.
      • Bennett fracture (intra-articular)
        • Intracellular fracture through the base of the 1st metacarpal (thumb) with large distal fragment dislocated radially and dorsally by abductor pollicis longus muscle.
        • This is an unstable fracture which requires open reduction and internal fixation.
      • Rolando fracture (intra-articular)
        • Comminuted intra-articular fracture of base of 1st metacarpal characterized by intra-articular comminution.
        • This is an unstable fracture and requires open reduction and internal fixation.

    4. Soft tissue injuries of the forearm, wrist and hand (ReelDx + Lecture)

      • Medial Epicondylitis (Golfer's/Pitcher's elbow)
        • Overuse syndrome that results in pain in the myotendinous junction between the wrist flexors and medial epicondyle also known as "golfer's elbow."
        • Pain with resisted wrist flexion and pronation.
        • Pain at the medial elbow epicondyle that may radiate to the wrist.
        • Treat with activity modification, physical therapy, corticosteroid injections - orthopedic surgery in patients who failed physical therapy for 4-6 months.
      • Lateral Epicondylitis (Tennis elbow)
        • Overuse syndrome that results in pain in the myotendinous junction between the wrist extensors and lateral epicondyle, also known as "tennis elbow."
        • Pain with wrist extension or forearm supination.
        • Treat with activity modification, counterforce bracing, physical therapy, and corticosteroid injections - orthopedic surgery in patients who failed physical therapy for 4-6 months.
      • Olecranon Bursitis (Scholar's Elbow)
        • Elbow swelling.
        • Nonseptic bursitis: acute trauma or repetitive trauma causes inflammation of the olecranon bursa.
        • Septic bursitis: infection from microorganisms transferred via trauma to the skin overlying the bursa. Pain or fever may suggest an infectious etiology - R/O septic or gout – aspirate.
        • Treat with PT, rest and ice, systemic antibiotics based on culture if septic, NSAIDS, injected corticosteroids, and joint, operative bursectomy.
      • Cubital/Ulnar Tunnel Syndrome 
        • Caused by ulnar nerve compression at the elbow.
        • Ulnar tunnel syndrome: caused by ulnar nerve compression at the wrist in Guyon's canal.
        • Symptoms are the same for both cubital and ulnar tunnel syndrome.
          • Paresthesias over the small finger and ulnar half of 4th finger and ulnar dorsum of the hand.
          • Exacerbating activities include cell phone use (excessive flexion).
          • Night symptoms caused by sleeping with the arm in flexion.
        • Tinnel sign positive over cubital tunnel.
        • Treat with NSAIDS, activity modification, and nighttime bracing. Operative - ulnar nerve decompression.
      • Carpal Tunnel Syndrome
        • Pain or paresthesia in the median nerve distribution - the first 3 digits and radial half of 4th digit. Symptoms are typically worse at night.
        • + Phalen (pushing backs of hands together) and + Tinel test (tapping over nerve) 
        • The diagnosis can be clinically made; however, it is confirmed by nerve conduction studies.
        • Splint (particularly at night), corticosteroid (oral or injection), surgical decompression for severe median nerve injury
      • De Quervain's Tenosynovitis
        • Pain and swelling at the base of the thumb often radiates into the radial aspect of the forearm.
        • + Finkelstein (make a fist with the thumb inside, then ulnar deviate)
        • Treat: thumb spica splint x 3 weeks, NSAIDs x 10-14 days, steroid injections and PT
      • Thumb Collateral Ligament Injury - Gamekeeper's Thumb & Skier's Thumb
        • Ulnar collateral ligament injury. Result from a fall on an abducted (hitchhiker) thumb.
          • Gamekeeper's thumb for chronic injury.
          • Skier's thumb for acute injury.
        • Laxity and pain with valgus stress.
        • Radiographs to evaluate for avulsion injury. MRI can aid in diagnosis if exam is equivocal.
        • Immobilization (thumb spica splint) for 4 to 6 weeks for partial tears or ligament repair.
      • Dupuytren Contracture (Claw hand)
        • A benign fibroproliferative disorder characterized by contracture of the palms and palmar nodules.
        • Associated with alcoholic cirrhosis.
        • Painless nodules on palms, contractures may limit function - patients often have difficulty wearing gloves or doing household chores like washing dishes or cleaning.
        • Tabletop test is positive if the patient is unable to lay their palm completely flat against the table.
        • Most cases are diagnosed clinically.
        • First-line therapies include injected collagenase and/or steroids. Fasciotomy or fasciectomy if patients are refractory to first-line therapies.
      • Mallet (Baseball) finger - Tear at DIP joint
        • Avulsion of extensor tendon - with a sudden blow to the tip of the extended finger with forced flexion.
        • The patient is unable to straighten the distal finger (flexed at the DIP joint), commonly associated with an avulsion fracture of the distal phalanx.
        • Radiographs - usually see bony avulsion of distal phalanx.
        • Splint DIP uninterrupted extension x 6 weeks or surgical pinning.
      • Boutonniere Deformity - Tear at PIP joint (jammed finger)
        • Sharp force against the tip of partially extended digit (jammed finger) - hyperflexion of the middle joint (flexion at PIP and extended at DIP) causing disruption of the extensor tendon at the base of the middle phalanx.
        • The deformity is characterized by PIP flexion and DIP extension.
        • Elson test: bend PIP 90° over the edge of a table and extend the middle phalanx against resistance. In the presence of a central slip injury, there will be weak PIP extension, and the DIP will go rigid.
        • Radiographs are not required in the evaluation and treatment of Boutonniere deformity.
        • Splint PIP in extension x 4-6 weeks with hand surgeon evaluation.
      • Infections of the hand
        • Cellulitis: usually strep or staph
        • Paronychia: infection next to fingernail anywhere around the eponychium
          • Acute = bacterial
          • Chronic = fungal
        • Felon: infection of the pulp space of the fingertip, usually with staphylococci and streptococci
        • Herpetic whitlow: Herpes virus infection around the fingernail (thumb sucking)

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