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Orthopedic APEA Test Questions with
Correct Answers Graded A+
OA
Description (2) ✔✔- Progressive destruction of the articular cartilage and subchondral bone accompanied by osteophyte formation and sclerosis. (bone on bone)
- Confined to the joints (Synovial joint) OA RF (5) ✔✔- Obesity
- Age>
- Trauma
- FX hx
- Overuse OA SX ✔✔- Asymmetrical joint pain
- Morning stiffness <30mins/ 1hr
- Limited ROM
- Tenderness at joint line
- Bony swelling
- Instability Most common joints affected by OA? (6) ✔✔- Knees
- Hips
- Cervical spine
- Lumbar spine
- Finger joints DIP & PIP
- First CMC & MTP joints Joint Pain Red Flags SX (5) ✔✔- Abdominal pain (intensity or duration unusual for OA; persistent)
- Knee effusion
- Age <50 y (non-menopausal women) swelling of fingers/hands
- Isolated MCP involvement and or psoriasis
- Several joints affected OA DX (8) ✔✔* Based on Hx
- Joint pain
- Age >
- AM stiffness <30min
- XR = joint narrowing or osteophyte
- Tenderness along joint line
- Limited ROM
- Joint deformity
- Instability
OA NonRX (5) ✔✔- Exercise (Mainstay*)
- Braces
- Wt loss
- Pt. education
- Fatigue RA DX Criteria (4 domains) ✔✔1. Number of sites involved joints (3 or more)
- Stereological abnormality (RF or anti-CPP): anticitrullinated peptide/protein AB
- Elevated ESR or CRP ( C reactive protein) good measure for active disease
- Symptoms persist at least 6 weeks
6/10points RA Autoantibody Test (2) ✔✔1. RF (20%)
- Anti-CCP/ACPA (detects RA earlier) RA TX goal ✔✔Goal is to achieve inactive disease clinically and structurally. RA NonRX ✔✔- Exercise
- Mediterranean diet
- Avoid sugar
- Heat/cold
RA RX (3) ✔✔- Methotrexate (1st line) DMARD start ASAP
- Glucocorticoids may be used but not long-term
- Biologic therapy if tx failure
REFER!
Gout Description Uric acid level? ✔✔- Deposition of monosodium urate (MSU) crystals in joints and other connective tissues cause acute or chronic inflammation and pain manifested as acute or chronic arthritis, tophi, nephropathy, and/or renal stones.
- Uric acid level>6.8 mg/dL (occurs when crystals form) may not be elevated Gout Etiology (4) ✔✔- Underexcretion may be due to renal insufficiency, acidosis, or use of diuretics, aspirin, or cyclosporine
- Overproduction may be due to enzyme deficiencies, psoriasis, or hematologic malignancies
- Dietary excess of purines
- Alcoholism is a contributing factor in both overproduction and underexcretion of urate Gout Incidence/why? RF (5) ✔✔- Increasing in US (due to the use of diuretics, & ASA) RF
- High purine diet
- Diuretic use
- ASA use
3. NSAIDS
- COX-2 inhibitors Gout: Consider urate-lowering therapy in patients (4) ✔✔1. With prior urate renal stones
- With recurrent attacks; more than two per year
- With at least stage 2 chronic kidney disease (CDK)
- If tophi present Gout RX Preventive ✔✔1. Allopurinol (Zyloprim) 1st line- Decreases production of uric acid
- Febuxostat (Uloric) 1st line- Xanthine oxidase inhibitor Gout: Expected Course Follow-Up ✔✔- Acute attacks usually subside without treatment in approximately 1-2 weeks
- Assess serum uric acid levels monthly until desirable level (<6 mg/dL) is reached, then annually on long-term therapy 5th Metatarsal Fracture concern? ✔✔Does not always heal in an ideal manner due to lack of blood supply. Monitor the healing process Grades of Sprains (3) ✔✔I: minimally torn ligament, stable joint (stretch)
II: incomplete tear, painful weight bearing (partial rupture) III: completely torn ligament; severe pain, swelling, tenderness (complete rupture) Most common sites of sprains are? (3) mechanism? ✔✔- Ankle
- Knee
- Wrist fall, twist, blow Ankle Sprain ✔✔- Stretching or partial tearing of the lateral or deltoid ligaments of the ankle
- Ligaments connect bone to bone Eversion Ankle Sprains (4) ✔✔- Less common
- Sprain resulting in tears in the deltoid ligament
- More severe
- Refer Inversion Ankle Sprains ( 3) ✔✔- More common (85%)
- Sprain resulting in tears in the lateral ligament
- Less severe Sprain Management (3) ✔✔- RICE (2-3 days)
- Early mobility w/ splints, braces!!!!
- Analgesics! Sprain Referral? (3) ✔✔- Orthopedist if Grade III sprain or eversion sprain
Fracture physical assessment ✔✔Palpate entire area around fracture site, adjacent bones, and joint above and below injury Fracture clinical pearls (4) ✔✔- Splint where it lies" unless no vascular fracture not intact
- One view is no view
- Orthogonal= X-rays taken at 90-degree angle (minimal is AP/Lateral)
- AANP exam: casting, splinting, diagnosis interpretation of X ray Fracture Reporting Tool (5) ✔✔1. Orientation: transverse, oblique, spiral
- Fragmentation: comminuted, segmental
- Side: medial, lateral, etc.
- Location: epiphysis, diaphysis, ect
- Bone: femur, tibia, ect. The shoulder joint: Differential dxx based on... ✔✔- Location of pain.
- Know your anatomy (Clavicle - >AC joint--> acromion --> subacomial bursa--> supraspinatus tendon) 3 most common causes of Anterior Lateral Shoulder Pain? ✔✔1. Impingement Syndrome (IS)
- Rotator Cuff Tendinopathy (RCT)
- OA 2 most common causes of posterior shoulder pain? ✔✔1. Cervical Strain
- Cervical Radiculopathy (make pt move neck in all directions, if pain occurs think cervical etiology) What is Extrinsic Shoulder Pain? Causes? (4) ✔✔- Pain outside the shoulder and often poorly localized
- Cervical nerve root compression
- MI
- Splenic injury
- Ectopic pregnancy Others Impingement Syndrome (IS) Description Etiology ✔✔- Compression of rotator cuff tendons and the subacromial bursa
- Overuse, trauma, OA, RA Impingement Syndrome (IS) Neer Test Drop-arm test Cross-arm test
Rotator Cuff Tendinopathy (RCT) Description 4 SITS muscles? ✔✔- A spectrum of injuries involving any of the four rotator cuff muscles (SITS muscles)
- Supraspinatus (most common) --> abduction 2. Infraspinatus--> external rotation
- Subscapularis --> internal rotation
- Teres minor--> external rotation Rotator Cuff Tendinopathy (RCT) Etiology (4) ✔✔* Tears may occur as a result of:
- Acute injury
- Degeneration
- Chronic muscle impingement
- Inadequate blood supply to the tendons Rotator Cuff Tendinopathy (RCT) RF (3) ✔✔- Advancing age
- Repetitive use of upper extremities/shoulders
- Overhead activity in work or sport Rotator Cuff Tendinopathy (RCT) SX (12) ✔✔- Pain, often at night
- Pain may be referred down deltoid
- Increased pain with overhead movement
- Tenderness over rotator cuff area
- Weakness with abduction or forward flexion
- Pain during abduction motion (painful arc)
- Positive impingement signs (Hawkins, Neer, empty can, lift-off tests)
- Limited active range of motion (ROM)
- Grating sensation at tip of shoulder when lifting the arm
- Positive "drop arm" test may indicate a full-thickness cuff tear
- Cross-arm test to identify acromioclavicular joint disease
- Ensure that discomfort is not referred pain from neck** Rotator Cuff Tendinopathy (RCT) ✔✔- Xray (AP, Lateral, and Y view of shoulder
- MRI Rotator Cuff Tendinopathy (RCT) NonRX(3) RX (2) ✔✔Non RX
- Rest
- Ice
- PT RX
- NSAIDS
- Subacromial steroid injection Lateral Epicondylitis (Tennis Elbow) Description (2) Incidence ✔✔- Inflammation of the common tendinous origin of the extensor muscles of the forearm on the lateral humeral epicondyle.
- 10 x more common than medial epicondylitis
- Change to a bigger tennis grip
- Deep massage
- Surgical if unresponsive to 6-12 months Lateral Epicondylitis RX (4) ✔✔- NSAIDS / cream Refer:
- Steroid injections (usually avoided due toolbar nerve proximity)
- Botulinum injection
- Platelet-rich plasma injection Medial Epicondylitis (Golfer's Elbow) Description ✔✔Inflammation of the common tendinous origin of the flexor muscles of the forearm at the medial humeral epicondyle Medial Epicondylitis (Golfer's Elbow) Etiology RF ✔✔- Repetitive overuse
- Activities that require forceful extension of the elbow against resistance with the forearm supinated and the wrist dorsiflexed:Golf Pitching Medial Epicondylitis (Golfer's Elbow) SX (5) ✔✔- Pain to the region of the medial epicondyle
- Reproducible by forcefully extending the elbow against resistance with the forearm supinated and the wrist dorsiflexed
- Pain may radiate down the flexor surface of the forearm
- Point tenderness over the medial epicondyle
- No swelling or erythema Medial Epicondylitis (Golfer's Elbow) TX ✔✔-RICE
- NSAIDS
Scaphoid Fracture Description Purpose of the scaphoid bone (2) ✔✔- Small break in a bone on the thumb side of your wrist.
- The scaphoid (navicular) is the most important carpel bone
- t is important in stabilizer of the midcarpal joint Scaphoid Fracture Mechanism Incidence ✔✔- Fall forward
- Most common wrist fracture Scaphoid Fracture SX DX (2) ✔✔- Snuffbox Tenderness
- XR- If negative, consider immobilization and repeat x-ray in 5-7 days. or
- Consider CT, MRI if pt can not wait Scaphoid Fracture TX (4) ✔✔- Thumb spica splint
- PT/OT
- Surgery?
- Refer to ortho
- Positive Phalen's test (Hold flexed fingers against each other with wrists flexed at a 90° angle for 60 seconds Considered positive if paresthesia occurs High specificity, low sensitivity)
- Positive Tinel's test (Percuss over the median nerve on the volar aspect of the wristConsidered positive if paresthesia occursHigh specificity, low sensitivity) Carpal Tunnel Syndrome DX ✔✔- Nerve conduction studies
- Description of sx
- Physical test: Phalens & Tinels Carpal Tunnel Syndrome NonRX (3) ✔✔- Avoid triggers
- Splint the wrist w/ fingers free (wear mostly at night, or during day PRN)
- Surgical decompression Carpal Tunnel Syndrome RX (2) ✔✔- NSAIDS
- Steroid injections (ok for pregnancy) De Quervains Tenosynovitis Description ✔✔A tendinopathy of the wrist that produces pain and/or tenderness at the base of the thumb on the radial side of the wrist. De Quervains Tenosynovitis Etiology ✔✔- Unknown
- repetitive overuse of thumb
- Pinching twisting movements of thumb De Quervains Tenosynovitis SX (4) ✔✔- Pain on abduction of the thumb
- Pain may extend up the forearm with grasping movements
- Pain on ulnar deviation
- Tenderness and/or swelling directly over the tendon sheath De Quervains Tenosynovitis DX ✔✔- Point of exquisite tenderness
- Positive Finkelstein maneuver: Have the patient make a fist with the fingers folded over the thumb. Deviate the wrist ulnarly. Pain at the radial styloid suggests De Quervain's. De Quervains Tenosynovitis NonRX (4) ✔✔- Rest (halt Inflammation)
- Ice TID x 20mins
- Thumb spica splint PRN, or short arm splint
- Decompression surgery De Quervains Tenosynovitis RX ✔✔-NSAIDS
- Steroid injection at the tendon sheath De Quervains Tenosynovitis Expected Course (2) ✔✔- Recovery expected in 4-6 weeks, but can persist longer
90% cure rate with surgery, when indicated
