PANCE Blueprint Musculoskeletal (10%)

PANCE Blueprint Musculoskeletal (10%)

PANCE Blueprint Musculoskeletal (10%)

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

Lessons

  1. Musculoskeletal Flashcards (Members Only)

    1. Musculoskeletal Quick Cram

  2. Musculoskeletal Comprehensive Exam (Members Only)

  3. MRI Imaging of the Spine (Lecture)

  4. Disorders of the shoulder (PEARLS)

    1. Shoulder Fractures/dislocations (ReelDx + Lecture)

      • Shoulder Dislocation
        • Anterior dislocation is the most common - 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 lesionfracture 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 most common.
        • Most can be treated conservatively - sling and swathe.
        • Begin PT after 4 weeks with light strengthening after 6 weeks.
      • 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 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 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 shoulder is held down to prevent shrugging.
        • (+) HawkinsElbow/shoulder flexed at 90 degrees with sharp anterior shoulder pain with internal rotation.
        • (+) Drop arm test: pain with inability to lift 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 often not associated with trauma. Pain on 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 humeral head.
        • NSAIDS, physical therapy, corticosteroid injectionsTotal shoulder  arthroplasty if unresponsive to nonoperative treatment.
    1. 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
        • Most common pediatric elbow fracture - accounts for 41% of all serious pediatric elbow injuries.
        • Usually occurs from fall to an outstretched hand.
        • X-ray demonstrates anterior fat pad sign = dark area 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 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.
        • 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 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 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.
    2. Soft tissue injuries of the forearm, wrist and hand (ReelDx)

      • 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 fist with 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 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 sudden blow to tip of extended finger with forced flexion.
        • Patient is unable to straighten distal finger (flexed at 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 tip of partially extended digit (jammed finger) - hyperflexion of middle joint (flexion at PIP and extended at DIP) causing disruption of extensor tendon at base of middle phalanx.
        • The deformity is characterized by PIP flexion and DIP extension.
        • Elson test: bend PIP 90° over edge of a table and extend middle phalanx against resistance. In presence of central slip injury there will be weak PIP extension and the DIP will go rigid.
        • Radiographs are not required in 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: Abscess in tip of finger.
        • Herpetic whitlow: Herpes virus infection around the fingernail (thumb sucking).
  5. Disorders of the Back and Spine (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. 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.
    3. 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.
    4. 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 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
      • 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. 
      Cervical radiculopathy 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 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.
    5. 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.
    6. Lower back pain

    7. 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°
    8. 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 (sittingleaning 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.
  6. Disorders of the hip (PEARLS)

    1. 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 radiolucency of 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

      Hip Fractures → Femoral head and neck fracture will present with severe hip, groin, or thigh pain often with a history of recent trauma or fall.
      • 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 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.
  7. Disorders of the Knee (PEARLS)

    1. Fractures and dislocations of the knee

      • 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).
      • Knee Osteoarthritis
        • Degenerative disease of synovial joints that causes progressive loss of articular cartilage.
        • Pain worse with activities, swelling, stiffness, sticking and grinding - palpable crepitus on exam.
        • Radiographs - weight-bearing views of affected joint - joint space narrowingosteophytessubchondral sclerosis.
        • Acetaminophen is considered first-line treatment. If acetaminophen fails, NSAIDs can be prescribed.
        • Total joint replacement may be indicated in advanced cases.
    2. 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.
      • 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 weekCorticosteroid 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 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 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 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 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 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: 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. Disorders of the Ankle and Foot (PEARLS)

    1. Fractures and dislocations of the ankle and foot

      • Ottawa ankle rules - order an X-ray if any of the following apply:
        • Pain along lateral malleolus, medial malleolus.
        • Midfoot pain, 5'th 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 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, military - due to overuse.
        • Most common in 3'rd 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 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 as 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.
    2. Soft tissue injuries of the ankle and foot (ReelDx)

      • Ankle Sprains
      • 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 deformity of bursa over 1st metatarsal. History of poorly-fitted shoes, pes planus (flat feet), or rheumatoid arthritis.
        • Difficulty with shoe wear due to medial eminence, pain over prominence at MTP joint 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.
    1. Staphylococcus aureus - most common cause overall. Pasteurella multocidaseen 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)

      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).
  9. Musculoskeletal Neoplastic Disease (PEARLS)

    1. Bone cysts and tumors (Lecture)

      • 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.
    2. Noncancerous mucin-filled synovial cyst caused by either trauma, mucoid degeneration or synovial herniation.
      • Usually on the hands, especially on the dorsal aspect of the wrists.
      • Median or ulnar nerve compression and hand ischemia due to vascular occlusion may be caused by volar ganglion.
      • Firm and well circumscribed often fixed to deep tissue but not to overlying skin, transilluminates. Allen's test to ensure radial and ulnar artery flow.
      • Usually, observation, aspiration second line, and excision.
  10. 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 nodesswelling of the distal interphalangeal joints.
    • Bouchard nodes: Swelling of the proximal interphalangeal joints.
    • Treat with stretching, acetaminophen, NSAIDs (oral and topical), joint replacement surgery.
  11. Osteoporosis

    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.
  12. Compartment Syndrome (Lecture)

    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.
  13. Rheumatologic Conditions (PEARLS)

    1. Fibromyalgia (Lecture)

      • Pain on palpation with a 4-kg force in 11 of the following 18 sites (9 bilateral sites, for a total of 18 sites).
        • Occiput: at the insertions of one or more of the following muscles: trapezius, sternocleidomastoid, splenius capitis, semispinalis capitis.
        • Low cervical: at the anterior aspect of the interspaces between the transverse processes of C5 to C7.
        • Trapezius: at the midpoint of the upper border.
        • Supraspinatus: above the scapular spine near the medial border.
        • Second rib: just lateral to the second costochondral junctions.
        • Lateral epicondyle: 2 cm distal to the lateral epicondyle.
        • Gluteal: at the upper outer quadrant of the buttocks at the anterior edge of the gluteus maximus muscle.
        • Greater trochanter: posterior to the greater trochanteric prominence.
        • Knee: at the medial fat pad proximal to the joint line.
      • Treat with Tricyclics (TCAs) - Cymbalta, SSRIs, Neurontin, and exercise. Pregabalin (Lyrica) is the only drug FDA approved to treat fibromyalgia.
    2. Gout/pseudogout (Lecture)

      Gout: accumulation of uric acid in the soft tissue of joints and bone.
      • Inflammatory joint pain. The great toe is often first affected.
      • 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), 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. 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.
    5. Polymyositis (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 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.
    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. 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.
    8. 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.
      • Joint inflammation 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).
    9. 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, 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).
    10. 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).
    11. 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.

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