Rheumatology and Orthopedics USMLE Flashcards

1 - Exam that elicits pain for Tennis elbow?

Pain with resisted wrist extension and passive flexion

2 - Exam that elicits pain for Golfer's elbow?

Pain with resisted wrist flexion And with passive extension of the wrist

3 - Exam for De Quervain's tenosynovitis?

passive stretching of affected tendons ( passive ulnar deviation of the wrist ) by grasping flexed thumb into the palm with fingers elicits pain. (Finkelstein's test )

4 - Tendons affected in De Quervain's tenosynovitis?

Abductor Pollicious Longus and Extensor Pollicious Brevis

5 - Tendon affected/degenerated in tennis elbow?

Extensor Carpi Radialis Brevis

6 - What is Smith's Fx ? how did it happen?

Distal Radius Fx after falling on Flexed wrist, with anterior displacement of the distal part of the radius

7 - What is Colle's Fx? How did it happen?

distal radius Fx with posterior displacement of the distal part of radius and after fall on an outstretched hand

8 - Prophylaxis for Pseudo-gout ?

colchicine

9 - MCC of Osteomyelitis in SCD pt?

Salmonella

10 - Give 2 Orthopedic Conditions that are Negative Initially on X-ray.?

Scaphoid Fx and AVN

11 - MC location of Osteomyetlis in adults vs. Children?

vertebral body in adults Vs metaphysis of long bones in children

12 - Indication for X-ray in Low Back Pain?

Osteoprosis / compression Fx

Suspect Malignancy

A Spondylitis ( i.e Insidious onset, nocturnal, Pain better with movement )

13 - Indication For MRI in Low Back Pain Pt?

Sensory/ motor deficits

Cauda equina syndrome " urine retention Saddle anesthesia" Suspected epidural abscess /infection (e.g fever IV abuse concurrent infection, hemodialysis )

Abnormal initial X-Ray too

14 - Indication for CT scan in Low Back Pt?

Same Indication For MRI if Pt not able to do MRI

15 - We check what before hydroxychloroquine sulfate? how often do we check that?

baseline ophthalmic exam @ time of start Rx, then annually after 5 years

16 - Pain of Trochanteric bursitis elicited by?

Sleeping / Pressure on the affected Lateral side and Ext rotation and Resisted abduction

17 - MCC of Back pain?

Lumbosacral muscle strain

18 - Confirmatory test for carpal tunnel syndrome?

Nerve conduction study

19 - Exam to Dx Cong Hip Dysplasia?

Barlow and Ortolani

ultrasound after 2 weeks (not before) till 6 months, after six months we can do Xray.

20 - What maneuver to do to treat dislocation of the radial head?

Supination with Flexion Or hyperpronation of the elbow joint

21 - What Joints Spared in Rheumatoid Arthritis?

DIP and Sacroiliac lumbar, thoracic vertebrae

22 - What is Pathergy where to see it?

pustular skin lesions secondary to minor trauma

Behçet disease, Crohn's disease

23 - Skin finding in Reactive Arthritis?

Keratoderma blennorrhagicum & Circinate balanitis

24 - Risk F for Pseudogout ( associated with what Diseases )?

hemochromatosis and hyperparathyroidism hypothyroidism and DM and Wilson

25 - Risk F for torticollis ?

Risk factors Related to crowding in the uterus :

Multiple gestations, breach Position Oligohydrominous

26 - What Conditions/disease Related to intrauterine Position?

Metatarsal Adductus, Congenital Muscular torticollis CHD, and Club foot

27 - Neer test for?

Rotator cuff tendinopathy

28 - Pseudothrombophlibitis has been seen in?

bakers cyst rupture

29 - Hypertension Treatment in Pt with gout?

Losartan

30 - Which stress fracture needs to be treated with surgery?

Anterior tibial, 5th metatarsal

31 - Shin splints vs. tibial stress Fx?

shin splints are anterior leg pain in overweight pt who walk or run.

Vs

stress Fx is seen in underweight Pt and has localized pain.

32 - 2 cases we have to examine the neck before Anesthesia?

Rheumatoid Arthritis, Down Syndrome

33 - Rx of gout in Renal F Patient?

Intraarticular Steroid

34 - What is the most common stress fracture?

2nd metatarsal " March Fx "

35 - Which stress fracture needs to be treated with surgery?

Anterior tibial, 5th metatarsal

36 - Risk F for AVN?

Sickle cell

Caisson disease "decompression sickness"

Steroids

SLE,, steroid, antiphospholipid Antibodies syndrome "APLAS", alcohol,

37 - Nerve compressed in CTS Vs TTS?

Median N Vs Tibila N

38 - Staph Aureus tend to Affect Epiphysis T/F?

F Metaphysis

39 - Osteosarcoma Vs Ewing sarcoma Arise from?

Metaphysis vs diaphysis

40 - MCC of Acute prepatellar bursitis is?

Staph Aureus

41 - Anterior Ischemic Optic Neuropathy seen As A SE of Viagra? T/F

F we see it in GCA

42 - Drugs to avoid in myasthenia vs drugs to avoid in gout?

Aminoglycosides, BBs, Azithromycin, quinolones,

Vs

Thiazides and Aspirin.

43 - What is the site where giant cell tumors in the bone arises from?

Epiphysis

44 - What is Monteggia Fx ?

proximal 1/3 ulnar fracture with associated radial head dislocation/instability

45 - What is Galeazzi Fx ?

distal 1/3 radius shaft fx AND

associated distal radioulnar joint (DRUJ) injury

46 - What are the malignancy associated with dermatomyositis?

Ovarian, colon, pancreas lung stomach

47 - Medications Causing Drug-induced SLE with negative Anti histone?

Minocycline, Statin, Propylthiouracil

48 - What is the most accurate test to diagnose Sarcoidosis?

lymph node biopsy

49 - What is the treatment for renal osteodystrophy?

low phosphate diet, phosphate binders like sevelamer ( ca carbonate).Ca and vit D

50 - We provide CBT as Rx for Fibromyalgia T/F?

T 

Distal Ulnar Fracture

distal ulnar oblique fracture

Legg-Calve-Pethes disease

Legg-Calve-Pethes disease is characterized by osteonecrosis of the femoral head. It typically present in boys age 4-10 years with insidious-onset hip or knee pain and an antalfic gait.

Developmental dysplasia of the hip (DDH)

Definition

• A spectrum of disorders ranging from complete dislocation of the femoral head to a reduced hip joint with acetabular dysplasia

Types:

1. Complete hip dislocation.

2. Partial hip subluxation.

3. Hip dysplasia (incomplete development).

Risk factors:

• family history - may reflect laxity of ligaments
• Race- common in white 
• Breech  presentation - Exaggerated positioning in acute flexion and adduction in utero may occur
• Female sex - the presence of maternal relaxin in the fetal circulatory system
• large fetal size 
• First born child

Galeazzi's test

• With the child is lying on a flat surface, flex the hips and knees so the heels rest flat on the table, just distal to the buttock . 
• A dislocated hip is signaled by relative shortening of the thigh compared with the normal leg, as shown by the difference in knee height level. 
• This test is almost always useless in children under 1 year of age and is negative if dislocation is bilateral.

Barlow's test

• This is a provocative test that picks up an unstable but located hip; it is unsuitable for a dislocated hip. 
• Thighs are gently grasped in the hand, with the thumb at the lesser trochanter and fingers at the greater trochanter . The hip is adducted slightly and gently pushed posteriorly with the palm. 
• Detection of "pistoning," or the sensation of the femoral head subluxating over the posterior rim of the acetabulum, is a positive finding.

Ortolani's test:

• This test detects hips that are already dislocated. 
• The flexed limb is grasped as in Barlow's test. The hip is abducted while the femur is gently lifted with the fingers at the greater trochanter. 
• In a positive test, there will be a sensation of the hip reducing back into the acetabulum. 

Clinical Manifestations

In newborn:

• We can diagnose DDH in this period by positive Ortolani’s test or Barlow’s test.
• Asymmetry of the skin fold may help, but its not specific. 
• Shortening of the limb at this age doesn’t exist.
• We cant use X-rays because the acetabulum and proximal femur are cartilaginous and wont be shown on X-ray.
• USG is the best method to Dx.

In the early childhood:

• Parents notice asymmetry of creases of groin, limitation of movement of affected hip or click every time hip is moved

In older children:

• Complaints of limping, waddling gait (bilateral DDH), Trendelenburg’s gait (unilateral DDH), lumbar lordosis, limitation of hip abduction, etc…

X-ray

Von Rosen view:

hips abducted 45º & medially rotated.

Anteroposterior.

We draw a line through the central axis of the femoral shaft.

        in normal hip ( ossific nucleus )will be inside the acetabulum.

        in dislocated hip it will be above acetabulum.

Delayed development of ossific nucleus / smaller

Horizontal line of Hilgenreiner:

   drawn between upper ends of tri-radiate cartilage of the acetabulum.

Vertical line of Perkins:

  drawn from the lateral edge of the acetabulum vertical to horizontal line.

4 quadrants:

Normal hip: the ossification center of the femoral hip lower medial quadrant.

Dislocated hip: upper lateral quadrant.

Acetabular index:

    angle between horizontal line of Hilgenreiner and the line between the two edges of the acetabulum.

    normal hip 20º-300 

    dilocated or dysplastic hip ≥ 30º

Shenton’s line:

    semicircle between femoral neck and upper arm of obturator foramen, in dislocated hip this line is broken.

Treatment:

The earlier the better. 

Exact treatment depends on patient age at presentation and degree of involvement

Goal is to:

1.Flex and abduct hips.

2.Reduce femoral head and maintaining it.

Reduction can be achieved by closed manipulation , traction followed by closed reduction and opened reduction  

 maintenance can be done using plaster cast(frog leg or Batchelor) or splint (von Rosen’s splint)

• Acetabular reconstruction procedure
• Salter’s osteotomy
• Chiari’s pelvic displacement osteotomy 
• Pemberton’s pericapsular osteotomy

• From (0-6 months)  

A dislocated hip at this age may spontaneously reduce over 2-3 weeks if the hip is held in a position of flexion. 

Reduction by closed manipulation and maintained with plaster cast or splint

• From 6 months -2 year

Gentle closed reduction of the dislocation under a general anesthetic and maintenance of a located position for 2-3 months in a hip spica cast usually stabilize the joint

• From the age of 2-6 years:

open reduction with osteotomy

• 6-10 years

No treatment for bilateral
Open reduction with reconstruction for unilateral

• After 10 years

Only indication for treatemnt is pain. If only one hip affected total hip replacement may be done.

Conditions affecting Shoulder (Impingement syndrome)

Impingement syndrome

• Painful condition of the rotator cuff due to impingement 
• Repetitive compression or rubbing of tendons supraspinatus under coracoacromial arch
• Passively, when the internally rotated shoulder is moved into forward flexion, the patient will experience discomfort (Neer impingement sign)
• Thickening of ACJ, OA spurs, Swelling of cuff, bursa

• Any prolonged repetitive overhead activity such as tennis, pitching, golf, or swimming may compromise the space between the humeral head and the coracoacromial arch that includes the acromion, coracoacromial ligament, and the coracoid process
• Localised edema and swelling – tendinitis
• Scarring, Fibrosis, Calcification
• Incomplete and complete tear
• Secondary Arthropathy – Milwaukee shoulder

Clinical Features

• Depends upon the stage of disease
• Tendinitis - less than 40 years of age, anterior shoulder pain after activity, tenderness anteriorly at supraspinatus 
• Painful arc, Impingement sign,
• Chronic tenditis : 40 – 50 yrs , repeated attacks of shoulder pain, pain more at night, cannot lie on affected side, stiffness
• Tear: greater than 45 yrs, Partial/ complete, difficulty in abduction, local injection, atrophy

• Diagnosis: History, Physical examination, Imaging  X-ray, arthrography, USG, MRI

Treatment:

•         Conservative: Rest, avoiding painful activities, warm packs, physiotherapy, NSAIDs, Local steroids
•         Surgical: Acromioplasty, Debridement, Rotator cuff repair

ADHESIVE CAPSULITIS

• Frozen shoulder
• Condition characterised by progressive pain and stiffness of shoulder which resolves spontaneously in 18 to 24 months.
• Idiopathic, Fibroblastic proliferation, Association with DM, Dupuytrens disease, hyperthyroidism
• Clinical features:40 – 60 yrs, h/o trauma +/-, progressively increasing pain in shoulder and arm, night pain, Gradual stiffness and decreasing pain, Gradual regain of motion
•     Wasting of muscles, ROM- decreased in all direction

X-rays Normal, to exclude other diseases

• Diagnosis: Not every stiff shoulder is frozen shoulder
• Other causes of stiffness ruled out, painful restriction of movement with normal x rays and natural progression in three stages

Treatment:

•      Conservative: NSAIDs, ROM exercises Pendulum exercises, Local steroid injection, Large volume injection and manipulation under anaesthesia,
•     Surgical: No definitive role.

Legg Calve Perthes Disease

Definition.  

• It is degenerative disease of the hip joint, where growth/loss of bone mass that leads to some degree of collapse of the hip joint and to deformity of the ball of the femur and the surface of the hip socket
• The disease is characterized by idiopathic avascular osteonecrosis of the capital femoral epiphysis of the femoral head leading to an interruption of the blood supply of the head of the femur close to the hip joint 

Epidemiology

• Disorder of the hip in young children
• Usually ages 4-8 years
• Boys:Girls= 4:1
• Usually unilateral

Blood supply

Age related changes in blood supply to Epiphysis

Age < 4

Receives blood from the metaphyseal vessels

Age 4-8

Blood from separate epiphyseal vessels as the physis is barrier to blood flow

Age > 8

The ligamentum teres has increasing significance in supply (20%)

Radiographic Stages

Four Waldenstrom stages:

1) Initial stage

2) Fragmentation stage

3) Reossification stage

4) Healed stage

Initial Stage

Early radiographic signs:

• Failure of femoral ossific nucleus to grow
• Widening of medial joint space
• Irregular physeal plate
• Blurry/ radiolucent metaphysis

Fragmentation Stage

• Bony epiphysis begins to fragment
• Areas of increased lucency 

Reossification Stage

• Normal bone density returns
• Alterations in shape of femoral head and neck evident

Healed Stage

• Left with residual deformity from disease and repair process
• Differs from AVN(avascular necrosis) following Fx or dislocation

Presentation

• Often insidious onset of  limp
• C/O pain in groin, thigh, knee
• The typical patient has a flexion contracture of 0-30 degrees, loss of abduction compared with the opposite side and loss of internal rotation of the hip.
• Can have an acute onset
• Patients frequently have younger skeletal age than cohorts

Physical Exam

• Decreased ROM, especially abduction and internal rotation
• Trendelenburg test often positive
• Adductor contracture
• Muscular atrophy of thigh/buttock/calf
• Limb length discrepency

• Imaging

AP pelvis

Frog leg lateral

Key= view films sequentially over course of dz

Arthrography

Differential Diagnosis

• Important to rule out infectious etiology (septic arthritis, toxic synovitis)

Others:

-JRA

-Sickle Cell

-Osteomyelitis

-Traumatic AVN

-Neoplasm  

-Medication-steroid

Non-operative Tx

• Improve ROM 1st
• Bracing:

-casts

-Hips abducted and internally rotated for containment

• Wean from brace when improved x-ray healing signs

Bracing

Operative Tx

• If non-op tx cannot maintain containment

Surgical options:

• Excise lat extruding head portion to stop hinging abduction
• Acetabular (innominate) osteotomy to cover head
• Varus femoral osteotomy
• Arthrodesis 

Varus Osteotomy

Late Effects of LCP

• Physeal arrest patterns 
• Irregular head formation

Congenital Talipes Equinovarus(Clubfoot)

The term talipes is derived from of the Latin words for ankle(talus) & foot (pes).

The term refers to the gait of severely affected
patients, who walked on their ankles.

• Clubfoot  is a severe fixed deformity of the foot characterized by fixed ankle plantar flexion (equinus), inversion of the subtalar (talocalcaneal) joint (varus), and medial subluxation of the talonavicular and calcaneocuboid joints (adductus)

Etiopathogenesis 

• Idiopathic majority , some  secondary to muscle pathology 
• All the tissues of the foot i.e. bone, joint,ligaments and muscles have developmental abnormality
• Bone: smaller in size, neck of talus is angulated so that head of talus is directed downwards  and medially. Calcaneum is small and concave  medially
• Joints: equinus deformity  occurs primarily at ankle joint. Inversion deformity occur  in subtalar joint. Adduction occurs in midtarsal joints
• Muscles and tendons: muscles of calf are underdeveloped.
• Capsule and ligament: all the ligamentous structure on the postero-medial side of the foot shortened
• Skin shows adaptive change
• Callosities and bursae over  bony prominences on the lateral side

Congenital Talipes Equinovarus

• Bilateral in 60%. 
• General examination to rule out other deformities
• Normally, the foot of newborn can be dorsiflexed until the dorsum touches the anterior aspect of shin of tibia
• Components of the deformity:
• Equinus.
• Varus.
• Adduction.

X-ray

• AP view and a lateral view in a position of maximum dorsiflexion. 
• Kite angle is the angle subtended by the long axes of the calcaneus and the talus on the AP view. 
• This angle is normally between 20 and 40 degrees. 
• In the clubfoot, this angle is less than 20 degrees with relative parallel alignment of the talus and calcaneus. 
• The relationship of the talus and calcaneus should also be assessed on the lateral view. Again, in the clubfoot, this shows relative parallel alignment compared with the normal foot

Treatment 

Nonoperative :

• Best results are achieved with early manipulation.
• (as early as first week of life) and serial casting (changed every 2 week).  Adduction deformity is corrected first followed by inversion and then equinus deformity. If this sequence is not followed rocker bottom foot may result 

Wearing Of Dennis-Browne(DB) splints for maintenance.

Good results may be achieved if previous technique is applied.

Operative Technique :

• In less than 3 years only soft tissue release may be sufficient while older children require  bony operations.
• Indicated for manipulation failure cases, recurrence and neglected cases
• Posteromedial soft tissue release (PMSTR)
• Tendon transfer
• Dwyer’s osteotomy- open wedge osteotomy  of calcaneus
• Dilwyn-Evan’s procedure : PMSTR with calcaneo-cuboid fusion
• Wedge tarsectomy
• Triple arthrodesis

Approach to limping child

Differential diagnoses:

0 to 5 years old

• Septic arthritis
• Osteomyelitis
• Transient hip synovitis
• DDH
• Perthes disease
• Toddler's fracture
• Nonaccidental injury (child abuse)
• Tumors (ALL)
• Neuromuscular disorders (cerebral palsy, Duchenne's Muscular Dystrophy)
• Discitis
• Juvenile rheumatoid arthritis

5 to 10 years old

• Septic arthritis
• Osteomyelitis
• Transient synovitis
• Perthes
• Limb length difference
• Tumor (ALL, Ewing sarcoma, benign bone tumors)
• Neurologic disorders (hereditary motor sensory neuropathy)
• Discitis
• Juvenile rheumatoid arthritis

10 to 15 years old

• Osteomyelitis
• Slipped capital femoral epiphysis (SCFE)
• Tumor (osteosarcoma, Ewing's sarcoma, benign bone tumors)
• Perthes disease
• Hip dysplasia
• Idiopathic chondrolysis

History

• Acuteness of onset, pain, history of trauma or injury, constitutional symptoms such as fever, malaise, chills; early morning stiffness and motor milestone development (walked by 15-18 months).
• Past medical history, Birth history and any previous surgery, injuries, or illnesses.
• Family history of childhood lower extremity conditions such as developmental dysplasia of the hip (DDH).

Physical examination

• An antalgic gait is characterized by a decreased stance period on the affected limb as well as a trunk shift over the affected limb during stance.
• Evaluation for limb length difference: palpate the anterior superior iliac spine (ASIS) with the patient standing. Then, with the patient supine, compare lengths of the lower extremities with the legs extended. Also, compare lengths of the femurs by flexing the hips and comparing the relative heights of the knees.
• Physical exam should also include the back, sacroiliac (SI) joints, and abdomen as well as the entire extremity involved.
• Palpate the entire length of the limb.
• Range of motion of the hip, knee, and ankle joints. Particular attention should be paid to any erythema, warmth, joint effusion, or focal tenderness.
• A thorough neurologic examination should also be completed.

Investigation 

• Radiographic evaluation. Anteroposterior (AP) and lateral plain radiograph (x-ray) of the entire length of bone involved, including joint above and below the area of concern. Referred pain describes pain attributed to one site or location by the patient but the source of the pain is at a different site (e.g., knee pain in a patient with an SCFE involving the hip joint). 
• Laboratory studies. Complete blood count (CBC) with differential, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP). If rheumatologic conditions or spondyloarthropathies are being evaluated, include rheumatoid factor (RF), antinuclear antibody (ANA), anti-streptolysin (ASO) titer, Lyme titer, and HLA B-27.
• Additional imaging studies.
• Magnetic resonance imaging (MRI). Very sensitive and specific. Able to identify areas of bone marrow edema, soft tissue edema, or fluid collections such as abscesses.
• Ultrasound. Useful to look for hip joint effusions, subperiosteal or soft-tissue abscesses. May also help guide aspiration of hip joint or soft tissue abscess.
• CAUTION: If septic arthritis is suspected, a joint aspiration should be performed without wasting time waiting for the availability of other additional imaging studies.

Ulnar tunnel syndrome

Motion:

 >  Dorsiflexion- 0-50

Palmarflexion 0-60

Radial deviation 0-15

Ulnar deviation 0-50

Supination/Pronation 75-80 each

        

ULNAR TUNNEL SYNDROME

Compression of sensory, motor or both in Guyons canal at wrist

Guyons canal fibro-osseous triangular space ulnar aspect of volar wrist, roof volar carpal ligament and pisohamate ligament, lat. Wall TCL and hook of hamate, medial wall pisiform and fibrous structures

Ulnar nerve and artery

Causes- SOL like ganglions, aneurysms, lipoma

# hook of hamate, repeated trauma vibration tools, long distance cyclists

Symotoms – numbness and tingling ring and little finger, weakness of intrinsic muscles, pain at wrist

Sensory deficit – sparing of dorsal hand

Motor – weak intrinsics, clawing, Froments sign, confrontation test, Egawa test

Diagnosis – history, clinical tests, Tinels sign, Nerve Conduction study

Treatment – Cessation of provocative activities,  NSAID, Local steroid injection, Surgery

CARPAL TUNNEL SYNDROME

Compression of median nerve at wrist in carpal tunnel

Carpal tunnel three sides by carpal bones, roof by Transverse Carpal Ligament

Causes– Secondary, Idiopathic

Clinical features:

aching and burning pain along median nerve distribution, night symptoms, aggravated by elevation, repetitive activities and prolonged wrist flexion, clumsiness of hand, female predominance

Physical signs :

Sensory loss, Motor weakness and atrophy

   

PROVOCATIVE TESTS

Phalen's test

Carpal compression test

Tinel's test

Diagnosis

History, Physical findings, Provocative tests, NCV study

Treatment:

Avoiding aggravating activities and posture, Splinting, NSAIDS, Local steroid, Surgery

De QUERVAINS DISEASE

• Tenosynovitis of 1st compartment – APL, EPB
• Overuse, spontaneous
• Woman, 40-50 yrs, pain radial side, swelling over radial styloid, tenderness

Finkelstein's test

Treatment

• Crepe bandage and slab application
• Analgesics
• Local steroid injection
• Chronic case  excision of part of tendon sheath