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Malignancy, age > 50, progressive and night time sx, unintentional wt loss, IVDU, steroid use, immunocompromised,trauma, caudal equine sx ( progressive weakness, saddle anesthesia, and urinary retention or incontinence of bowel and bladder.

What are the red flags for back pain?

90% improve in 3 mo. 10% go on to chronic LBP > 3 mo. Only 1% will need surgery.

What is the natural hx of LBP?

L1-3: thigh pain, decrease patellar reflex. L4-5: knee pain, decrease patella reflex and dorsiflexion, S1: Post leg pain, decrease achilles and plantar flexion.

What are the sx of sciatica?

PE as tolerated, core strength,yoga, PT, NSAID or Tylenol Muscle relaxants no better than NSAIDS, and Opioids correlate with prolonged disability. Acupuncture, massage and chiropractor all help.

What is the treatment of mechanical back pain?

Radiculopathy > 6 wk or Red Flags. Consider epidural steroid injection if no better 6 wk. Epidural good for spinal stenosis and radiculopathy.

When do you image LBP with MRI? offer steroid injection?

Consider physiatrist or OT referral or Pain clinic Stress management with CBT and treatment of depression Goal is to increase function, manage pain and cope NSAIDS/Tylenol/Cyclobenzaprine/Heat 20 min TCA and SNRI ( Duloxetine 60 mg/d better than TCA) ) Gabapentin/ Topomax ( No big role)

How do you treat chronic LBP?

Osteoporosis, but if wt loss suspect malignancy

What is the most common cause of thoracic compression fx?

Work up with DEXA, CMP, TSH, Vit D. If suspect malignancy, check CBC, Alk Phos. SPEP and UPEP and CRP and bone scan. Treat with Tylenol 650 mg bid or Naproxen 500mg bid. If persistent pain consider Calcitonin 200 U spray, and if pain > 3 mo consider MRI to look for bone marrow edema and consideration for vetebroplasty.

How do you treat compression fx. ?

Chronic pain, morning stiffness, worse at night, pain relief with activity, Causes: Psoriasis, Reiter of Ankylosing spondylitis, sacroilitis or joint inflammation.

How does inflammatory back pain present and what are the causes?

Failed conservative treatment 6 wk, Cauda Equina Mylopathy: Babinski, clones, hyperreflexia Disc with radicular sx. spondylolithesis.

What are indication for surgery with back pain?

Loss of vision, stroke, paralysis, meningitis, steroid myopathy, hyperglycemia and mood disorder.

What are the side effects of Epidural?

Grade 1: swelling pain , no laxity Grade 2: Moderate pain and swelling , no laxity Grade 3: Laxity

How do you grade ankle sprains?

Ottawa Rule: 1. bone tenderness at distal lateral or medial malleolus or over 5th metatarsal bone. 2. Inability to bear wt., 3. Over 18, Treatment: RICE, support brace, crutches with mod-severe sprain, walking boot cast 3-6 wk or until pain free.

How do you treat ankle sprain? What is Ottowa ankle rule?

Age > 55, inability to bear wt with 4 steps, Inability to flex leg 90 degrees, Point tenderness over fibula and patella.

What are the Ottawa rule for knee pain?

2nd, 3rd, and 5th metatarsal pain and swelling. Check Vit D level. Treat with non weight bearing cast or walking boot for 6 wk or surgery.

Stress fracture in foot where is most common?

Ligament injury ( medial and lateral)ACL ( Lockman) Meniscal injury( McMurray) and Apley OA Patellofemoral Tendonitis ( Pes anserine, iliotibial band and patellar quadriceps)

What are the common causes of knee pain?

Bilateral Non wt bearing AP, Lateral, and Oblique For OA check standing wt bearing. Sunrise view for patellar femoral arthritis.

What type of xray do you order for knee pain?

No improvement with 3 wk pt, Large complex tear on MRI, Persistent effusion 4-6 wk, Locking.

Indication for referral for knee pain with possible arthroscopic surgery.

Overuse, Trauma, malalignment, weakness, tightness and leg length discrepancy

What are the common causes of patellofemoral syndrome?

Distal radius fracture caused by fall on outstretched hand. Rx: External reduction with brace of cast 6 wks. F/u with xray 1 wk.

What is Colles fracture? How do you treat it?

Tender in anatomic snuff box in young person. Rx: Thumb spica cast and immobilize 2-3 mo. Recheck xray in 2 wk. Referr if proximal fx due to possible avascular necrosis.

What is Scaphoid bone fracture? How do you treat it?

Splint until swelling subsides, then walking boot for 4-6 wk.

How do you manage lateral malleolus fracture?

All dislocated fx, joint instability, neuromuscular injury, open or extension into joint.

Which fractures do you refer?

Referr if cannot fully extend elbow.

Olecranon fx treatment

Radial N. : Thumb up sign Median N: OK sign Ulanar N: Peace sign Rx Sugar tong splint and sling Xray weekly until union May take up to 14 wk to heal. Brace can be removed when callous seen on xray and can start OT and strengthening exercises.

Humerus Fracture Evaluation and Treatment

If multiple can have intra-abdominal injury( liver and spleen laceration) First three rib fx can be associated with mediastinal or aortic injury ( hemothorax, pulmonary contusion, pneumonia)

Rib Fracture associated injuries/complications?

NSAIDS , Opiates, Intercostal blocks, Incentive spirometry. Repeat Xray if persistent pain. May take 6 wk to heal.

How do you treat rib fracture?

OA ( anterior / groin) Trochanteric bursitis ( Lateral) back pain (posterior) also piriformis syndrome and SI joint dysfunction

What are the common causes of hip pain?

NSAIDS, Tyleonl PT, Steroid injection, Consider Colchicine 0.6 mg bid 3-6 mo if resistant to NSAIDS

How do you treat hip OA?

PT x 6 wk, RICE, NSAIDS, Avoid activities which exacerbate sx. Steroid infection after 12 wk PT, Stop smoking, Consider surgery if > 50% tear.

Rotator Cuff tears. treatment

RCT, DM, subarachnoid bursitis, bicipital tendonitis, trauma and poor exercise Initially painful for up to 9 mo,, then frozen for up to 12 mo then resolution for up to 24 mo. Exercises ROM , stretch, NSAIDS, Tylenol, Oral or injectable steroids. If not improvement in 3 mo surgery for release.

Cause and treatment of frozen shoulder?

Thumb Spica splint 3-4 wks, NSAID, stretches and steroid injection.

How do you treat Dequervian tenosynovitis?

MRI if neuropathy sx and weakness.

When do you image chronic neck pain?

Ulnar collateral ligament sprain Thumb spica s;oint for 3 wk.s. If laxity referr to Ortho.

What is Gamekeepers thumb and how do you treat it?

Flexor tendon swollen and fixed in flexion. RF: DM Rx: Immobilization with buddy tape 4-6 wk or steroid injection. Stretches

Trigger finger cause and treatment?

Herniation of synovial tissue from joint capsule Dx: Transilluminate or US. 40% will resolve on own with no treatment Surgical excision is best with 5% recurence. Steroid injection not recommended.

Ganglion cyst of wrist

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