Orthopedics in Primary Care

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Anonymous
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214924
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Orthopedics in Primary Care
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2013-04-21 20:44:26
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Orthopedics Primary Care
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Musculoskeletal exam
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  1. Straight leg raise (SLR)
    L4/L5

    Pt. lying in supine position, relaxed, raise a straightened leg until pain/paresthesia felt.

    (+) in Sciatica or irritation of sciatic nerve - pain radiates (radicular) down buttocks, posterior thigh, and/or below knee level.
  2. Femoral nerve stretch
    Opposite of sciatic nerve stretch.

    Pt. lying prone and relaxed, raise straight leg in hyperextension. 

    Tests L3 (femoral nerve)

    (+) produces radicular sx from anterior thigh to anterior knee
  3. Patrick's Maneuver
    A.K.A. LaFebere Test

    "Figure-of-4" test; pt. supine, flex knee and place ankle above contralateral knee. 

    Apply downward force onto the flexed knee to stress lower back, SI joint & hip.

    **Pain points to source of pathology**
  4. PRICES acronym  (Universal Orthopedic Treatment)
    Protection

    Rest

    Ice

    Compression

    Elevation

    Support
  5. FIRST: r/o these malignant problems, in musculoskeletal complaints
    1. Infection - septicemia (usually staph or strep)

    2. Neoplasm - pain worse when lying down

    3. Aneurysm - AAA -> abdominal bruits/masses, check distal pulses

    4. Cauda Equina syndrome - MEDICAL EMERGENCY - ask if any loss of bowel or bladder function.
  6. RED FLAGS (in musculoskeletal complaints)
    • - recent trauma
    • - hx of osteoporosis
    • - Abd. pain that radiates through to back
    • - Fever
    • - IV drug use
    • - Unexplained weight loss
    • - Hx of CA
    •         - pain worse at night
    •         - pain unrelieved by in the supine pos.
    •         - pain that wakes pt. from sleep
    • - Bowel/bladder dysfunction
    • - saddle area paresthesia
    • - weakness
  7. Differentiating back pain: Spondylogenic
    Ex: herniated disc

    Assoc. with radiculopathy (burning, deep toothache, below knee, paresthesia, known dermatome)

    Weakness

    Positive tests

    Clinical correlation

    Increased pain when bending TO affected side and valsalva
  8. Differentiating back pain: Mechanical
    Ex: lumbar back strain

    Assoc.w/ referred pain above knee, sharp/dull/achy, no paresthesia

    back pain only

    no neurologic deficits (no weakness)

    Negative tests

    Increased pain with bending AWAY from affected side and mechanical movement
  9. Diagnostic Imaging: Plain radiographs
    • - not initially < 50yrs old
    • - order only if suspected fracture, < 20 yrs old, or > 50yrs old
  10. Dx Imaging: MRI
    For tissue imaging, r/o neoplasm, herniated disc

    For surgery decisions

    • * Beware of false positives
    •        - < 60 years: 20%
    •        - > 60 years: 57%
  11. CT
    Visualizes bone the best

    FASTEST

    Not ordered in FP usually
  12. CT myelogram
    Gold standard for multi-level with radiculopathy

    Not ordered in FP; used for pre-op mapping
  13. Other diagnostic tests
    EMG/NCS - symptoms 2-3 weeks before positive

    ESR - nonspecific, but sensitive.  Inflammatory marker (cancer, arthrotides (RA), autoimmune, infection)

    Nuclear bone scan - Cancer, occult fractures, osteomyelitis **HIGH RADIATION**

    others to r/o non-spinal etiology (pelvic)
  14. Treatment of Musculoskeletal complaints
    1st line: acetaminophen (but no anti-inflammatory properties)

    NSAIDS - oral/topical

    Muscle relaxants - sedating (flexeril), non-sedating (skelaxin)

    Ice - < 20min. TID x 48hrs, then moist heat

    Steroids (prednisone 60mg/day in divided doses, x 3 days)

    Exercise &/or PT

    Trigger injection

    Sufficient analgesia - tramadol, toradol, narcotics prn



    **90% GET BETTER IN 90 DAYS WITH NO INTERVENTION**
  15. Cervical Spine pain causes
    5 causes:

    • 1. Discogenic 
    • 2. Radiculogenic
    • 3. Myelogenic
    • 4. Spondylogenic
    • 5. Combination
  16. Shoulder: Impingement Sign
    (+) suggests AC Impingement syndrome

    pt. to raise arm (palm side down) straight up in arc to side. 

    Pt. will flip hand palm side up and/or drop contralateral shoulder to avoid pain of the AC impingement
  17. Shoulder: Drop arm test
    Test for rotator cuff tear

    2 Methods:

    1. Pt. holds arm out to side, you firmly tap wrist, arm collapses with full tear.

    2. Pt. raises arm laterally as far as they can and then SLOWLY lowers, arm collapses on way down if full tear
  18. Shoulder: Empty can test
    Pt. holds arm out in front w/ thumb down (like emptying a can), then raise the arm up with you applying resistance

    If produces shoulder pain = rotator cuff/supraspinatus injury or tendonitis
  19. Shoulder: Hawkin's test
    Arm at 90 degrees abduction & elevation (hangman)

    Stabilize elbow as you pull the wrist/hand down to stress the shoulder

    More sensitive than empty can test, more specific to AC joint
  20. Shoulder treatment
    Ice, then moist heat

    Early & brief immobilization

    NSAIDs

    Muscle relaxants?

    Sufficient analgesia

    PT - AROM early to avoid frozen shoulder

    Injection (usually immediate relief, but if unable to move arm after injection, consider complete supraspinatus rupture). Rule of 3: No more than 3 injections, no closer than 3 months apart in a lifetime.

    Surgery
  21. Biceps tendon rupture
    "popeye" muscle

    Longhead rupture from chronic tendonitis (degeneration)

    Loud snap, painless

    < 5% loss of strength

    Distal bulge (proximal rupture) - Ludington's

    Refer (treat) only: proximal bulge (distal rupture) or sign. loss of strength
  22. Cozen's Sign
    Eval. lateral/medial epicondylitis

    • Lateral: Tennis elbow
    •           Pt. with arm out straight, pushes back      of hand up against your resistance. Causes pain at lateral epicondyle.

    • Medial: Golfer's Elbow
    •           Pt. pushes their hand down against resistance; causes pain at medial epicondyle
  23. Olecranon Bursitis
    Swelling (sometimes pain) over tip of ulna at elbow, may be traumatic

    Tx with RICE and NSAIDs

    R/O infection, tx with keflex (stat referral to ortho if osteomyel.)

    Aspiration/injection rarely needed, high risk of gram + infection

    surgery
  24. DeQuervain's tenosynovitis
    Navicular pain of hand, often work-related, assoc. with arthrotides, Mostly females age 30-60

    Finkelstein's maneuver - hold pts thumb in palm of their hand, pressing in, then pull hand down to stretch. Causes pain.

    wrist splint w/ thumb abductor

    NSAIDs

    injection prn

    surgery
  25. Greater trochanteric pain syndrome
    Bursa in line with pubis rarely the cause

    PT w/ iontorphoresis

    Injection

    Rarely surgery
  26. Piriformis Anatomy (hip)
    Origin: pelvic surface of sacrum

    Insertion: medial surface of greater trochanter

    Action: lateral (external) rotation of extended thigh; abducts a flexed thigh

    Innervation: S1 & S2

    Compresses sciatic nerve, can cause sciatica
  27. Piriformis stress test
    Have pt. cross leg of affected extremity over contralateral knee.  Then have pt. push & pull against resistance (your hand).

    (+) will reproduce sciatic radicular symptoms - suggests piriformis syndrome.  SLR will be negative.

    Confirm with traction.
  28. Stretching exercise for piriformis syndrome
    Cross affected leg over, above contralateral knee, pull unaffected knee up to chest, apply gentle pulling pressure against affected ankle.
  29. Piriformis syndrome treatment
    • NSAIDs
    • stretching exercises
    • correct shoes
    • body mechanics
    • PT

    Injections - may need MRI guided, neuroradiologist
  30. Examination of the knee: Theater sign
    patellofemoral syndrome

    cannot sit for the length of a movie without knee pain, or can't lie on side with legs together in bed (anserine bursitis, OA, varus abnl)
  31. Anterior drawer/Lachman's
    Anterior drawer, in sitting position, pull tibia away from femur, if lax, ACL tear

    Lachman's: anterior drawer done at 30 degrees to disengage quadriceps

                -more sensitive test
  32. Varus and Valgus stress
    Valgus- stabilize lower leg & push lateral knee joint towards midline- looking for instability of MCL (medial)

    Varus- stabilize lower leg & push medial knee joint laterally- look for instability of LCL (lateral)
  33. McMurray's maneuver
    Extend and twist lower leg - inward and outward rotation, stress the knee menisci

    popping, clicking, catching = (+) and may be painful

    Suggests meniscal tear, medial or lateral
  34. Apley Grind
    prone

    place weight on bent 90degree leg on foot

    Twist leg to 'grind' the knee meniscus

    More sensitive than McMurray's, clicking, catching, pain, meniscal tear
  35. Chondromalacia
    A type of anterior knee pain, crepitus, x-ray will reveal softening (degeneration) of posterior patella

    chronic
  36. Patello-Femoral syndrome
    anterior knee pain; esp. w/ stairs

    no crepitus, exam objectively normal

    typically adolescent female, overweight

    good patellar tracking

    "Wimpy" quadriceps

    quad strengthening/stretch exercises

    Injection
  37. Common knee treatments
    PRICES & NSAIDS

    Knee sleeve (not immobilizer), except instability (use crutches)

    Specialty braces: hinged brace with collateral tear; ACL brace prn, unweightening brace

    PT

    Arthrocentesis/injection

    Refer to ortho: Grade II or greater meniscal tear, persistent beyond 60-90 days, fractures/dislocations.
  38. Plantaris tendon rupture
    Tiny muscle between gastrocnemius (calf) & soleus, medial to achilles.

    Runner's injury

    Sudden sharp pain w/ no loss of calf strength

    THEN hurts only with step-off of walking

    Thompson negative

    Ace/crutches x 1-2 weeks
  39. Achilles' tendon injury
    palpate achilles

    range of motion, strength

    Medial malleolus swelling/echhymosis

    Thompson's test (+ is pathologic)

    Homan's sign (r/o DVT)

    Refer achilles rupture STAT (posterior gutter with plantar flexion)

    Otherwise NSAID, stretching
  40. Sprained ankle tests: Drawer sign
    try to pull heel off leg, instability check
  41. sprained ankle test: Talar tilt test
    stabilize leg & invert foot, instability check
  42. Tx of ankle sprains
    PRICES

    Moist heat after 48 hrs

    analgesia

    NSAIDS

    aircast ankle splint, bledsoe fx boot

    crutches prn if no weight bearing (if severe)

    rehab w/ alphabet exercises
  43. Metatarsalgia
    capsulitis

    often pain is nontraumatic

    r/o stress fx (post-op shoe vs. referral)

    mechanics of injury (hi-heels, tight achilles, tight shoes)

    NSAIDs, warm soaks, loose shoes

    Metatarsal bars

    occasionally surgery

    Consider Freiberg's infarction (osteonecrosis 2nd MT head), MRI/refer

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