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Orthopaedics for the Practicing Internist

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Presentation on theme: "Orthopaedics for the Practicing Internist"— Presentation transcript:

1 Orthopaedics for the Practicing Internist
American College of Physicians 2013 Ohio Chapter Scientific Meeting Columbus, OH October 11, 2013 Paul J. Gubanich, MD, MPH Assistant Professor of Internal Medicine/Sports Medicine Team Physician, Ohio State University Athletics, Ohio Machine, Columbus City Schools

2 Disclosures I do not have a conflict of interest associated with the material contained in this presentation.

3 An Approach to the Patient with Knee Pain
Most common complaints Pain Instability – (ligament injury, OA) Stiffness – (effusion, OA) Swelling Locking (meniscal) Weakness Most diagnosis made by: History Physical exam Imaging

4 Important Historical Components
Age Chronology, onset Pain level, characteristics Exacerbating positions/ movements Relieving factors Activity level or recent change, occupation Previous injuries, surgeries Exercise history, goals Previous treatments

5 Chronology of Symptoms
Acute Pain Sudden onset Specific mechanism of injury Direct trauma (fall, collision, MVA) Landing, pivoting Common acute injuries Fractures (distal femur, patella, proxmial tibia, fibula) Dislocations Meniscal injuries Ligamentous injuries Musculotendious strains Contusions

6 Common causes of chronic knee pain Chronic Pain
Arthritis Tumors (night pain) Osteosarcoma (adolescents) Chondrosarcoma (adults) Giant cell tumor (benign) Metastatic disease is uncommon Sepsis (rare, can be bursal) Bursitis (overuse) Tendonitis Anterior knee pain Chronic Pain Often lacks a mechanism of injury Symptoms of gradual onset

7 Location, Location, Location

8 Medial Knee Joint line – meniscus, OA, osteochondral defect, osteonecrosis, medial collateral ligament Tibial plateau – (osteoporosis, post menopausal) Pes bursa

9 Anterior Knee Anterior Quad tendon or insertion Anterior to patella
Patellar origin, tendon, insertion Tibial tubercle

10 Lateral Knee Pain Lateral Femoral condyle – suggests IT band
Joint line – meniscus, OA, OCD, lateral collateral ligament

11 Posterior Knee Meniscus – posterior medial, lateral corner
Posterior lateral – Baker’s/popliteal cyst, aneurysm

12 Physical Exam Exam both sides Gait Inspection Joint above and below
Most painful part last Gait Alignment (varus, valgus) Squat Inspection Swelling Bruising Deformity

13 Physical Exam Palpation Range of Motion Strength Functional tests
Effusion Range of Motion Patellar tracking Extension (-5 to 5) Flexion ( ) Crepitus, etc. Strength Hamstring Quad Functional tests

14 Physical Exam – Special Maneuvers
Apprehension sign – patellar instability Apley grind test – meniscus McMurray circumduction test, SN 16-58% SP 77-98% (Evans 1993, Fowler 1989, Kurasaka 1999, Anderson 1986)

15 Physical Exam – Special Maneuvers
Valgus stress test – MCL SN 86-96% Varus stress test – LCL SN 25%

16 Physical Exam – Special Maneuvers
Lachman’s – ACL SN 80-99% (various authors and conditions)

17 Physical Exam – Special Maneuvers
Anterior/posterior drawer – ACL/PCL Posterior Sag Sign

18 Radiology Plain x-rays often considered part of exam X-ray views
Helps rule out competing diagnosis X-ray views Standing AP views of both knees (for comparison) Lateral Tunnel at 45 degrees Merchant/Sunrise – to evaluate PF joint

19 Radiology MRI often not needed initially Surgical planning tool
Failure of treatment Identify ligamentous/cartilage injuries of acute or surgical nature Risk stratification

20 General Treatment Pearls
Match disease severity/limitations with treatment options Escalate based on time, response in a stepwise fashion Set realistic expectations for progress and follow-up Align treatment goals with patient goals/expectations when possible Time is a great healer

21 Common Treatment Recommendations
Activity modification, rest Mechanical devices – braces, crutches, lifts, orthotics, etc. Ice, pain medication Nsaids Acetaminophen Others Physical therapy – early motion progressing to strengthening and then functional drills Injection therapy Aspiration Corticosteroids Hyaluronic acid supplents (OA) Glucosamine (OA) Surgical considerations Consider additional imaging options as needed MRI Bone scan CT

22 Red Flags Night pain Abnormal x-ray findings Mechanical symptoms
Fractures, tumor, cartilage lesions, etc. Mechanical symptoms Severe pain, swelling, loss of motion, or weakness High grade ligament injuries Fail to respond to standard treatments Multiple joints involved (Rheum)

23 Summary History and Physical Exam are vital to generating a working differential diagnosis Imaging may complement/confirm working diagnosis Treatment should match symptoms and severity and progress based on progress Questions?

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