Transcript Hand and Wrist Exam Cont

Duke Internal Medicine Residency Curriculum
Wrist, Hand, Ankle, and Foot
Glen Xiong, MD
Christopher Meyer, MD
Gordon Reeves, MD
Amir Kahn, MD
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Learning Objectives
• Demonstrate the basic elements of the wrist and hand
exam and understand the clinical implications of findings.
• Understand the diagnostic approach to and management
of carpal tunnel syndrome.
• Understand and be able to apply the Ottawa Ankle Rules.
• Understand the basic management of foot fractures
including indications for emergent and non-emergent
referrals.
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Wrist and Hand
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Hand and Wrist Exam
• Inspection
– Start with hands open and palms facing down
• Evaluate alignment of digits, muscular
atrophy (thenar eminence), bony
enlargement, swelling
– Inspect nails
• Pitting, onycholysis, brown yellow
discoloration (Psoriasis)
• Redness and telangectasias of nail-fold
capillaries (connective tissue disease)
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www.nymidtownorthopedics.c
om/ knee.html
www.vandemarkortho.com/
patient/pated/wrist
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Hand and Wrist Exam Cont
• Hand Function
– Ask patient to open and close the hand
• Look for smooth and full movement
– Grip strength
• Objective measurement of strength of
hand and forearm muscles
• Can be estimated by gripping of the
examiner’s fingers
• Dynometer is more accurate and
reproducible
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Hand and Wrist Exam Cont.
• Hand Function continued
– Evaluate range of motion of wrist and
all hand joints
– Evaluate sensation of the hand
•Pulp of index finger – median nerve
•Pulp of the 5th finger – ulnar nerve
•Dorsal web space between the
thumb and index finger – radial
nerve
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Hand and Wrist Exam Cont
• DIP and PIP joints
– Palpate by squeezing the joints
medially and laterally between the
thumb and index finger
– Evaluate for enlargement, tenderness
and/or synovial thickening
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Hand and Wrist Exam Cont
• MCP Joint
– Palpate by squeezing the joint from between
the thumb and fingers
– Swelling seen as fullness in the “valleys”
normally found between the knuckles
– Pain with squeezing or swelling
• Single joint
– Trigger finger, posttraumatic arthritis
• Multiple joints
– RA (symmetric), psoriatic arthritis
(asymmetric or symmetric)
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Hand and Wrist Exam Cont
• Palpate the eight carpal bones by
squeezing between your index finger and
thumb
• Palpate the wrist with thumb over dorsal
aspect and fingers beneath
– Palpate the groove of the wrist, the
distal radius and ulna
– Palpate the anatomic snuff box
•More visible with lateral extension of
the thumb away from the hand
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Hand and Wrist Exam Cont
• Palpate flexor tendons
– Feel for tenderness or cyst formation
– Pain with passive stretching of the tendon in
extension indicates active tenosynovitis
• Palpate palmar fascia
– Feel for nodularity
– Nodularity may indicate palmar fibrosis,
which leads to Dupuytren’s contractures
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Hand and Wrist Exam Cont
• Inspect the dorsum of the hand
– Evaluate for mucinous cysts
• may indicate herpetic whitlow, foreign
body reaction, abscess or dermatofibroma
– Ask patient to actively extend DIP
joints against resistance
• Deficiency in patients with repeated blows
to the tip of the finger
– Mallet finger
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Mallet Finger
www.emedicinehealth.com/
articles/5404-9.asp
www.handuniversity.com/
topics.asp?Topic_ID=19
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Clincal Pearls
• Bony enlargement of PIPs (Bouchard’s node) and/or DIPs
(Heberden’s Node) with minimal inflammation – likely OA
www.healthinplainenglish.com/.
../osteoarthritis/
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Clincal Pearls
• Symmetric deformity/inflammation in MCPs,
PIPs, wrists over several weeks – likely RA
– If DIP involvement and/or asymmetric with
nail changes consider psoriatic arthritis
• Thenar atrophy – likely median nerve
compression from carpal tunnel syndrome
• Hypothenar atrophy – ulnar nerve compression
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Clinical Pearls Cont.
• Loss of smooth motion of trigger finger + flexor
tendon tenderness over MCP + pain with
extension of the finger = likely trigger finger
• Flexion contractures of the ring, 5th, and 3rd
fingers – think dupuytren’s contractures
• Inability to flex tip and characteristic deformity
= mallet finger
• Tenderness over “snuffbox” – consider scaphoid
fracture
• Tenderness over over ulnar styloid – consider
Colles’ Fracture
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Carpal Tunnel Syndrome10
ACP medicine (Online) ACP medicine [electronic resource]. New York, N.Y. : WebMD
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Carpal Tunnel Syndrome3,4
• Pain and loss of hand function due to median nerve
compression as it passes through the carpal tunnel in the
wrist
• Prevalence – approx 3% of the adult population.
• Women more than men approx 3:2 or 1.
• Associated conditions (up to 1/3 of cases)
– Pregnancy, diabetes, hypothyroidism, inflammatory arthritis,
amyloidosis, Colle’s fracture, use of corticosteroids and
estrogens.
• Associated occupations (repetitive wrist/hand activities)
– Food processing, manufacturing, construction, logging
• Natural History is variable – can lead to permanent nerve
damage and hand dysfunction or be self-limiting.
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CTS – Diagnosis4
• Little to no data on physical diagnosis in pts presenting to
PCP – studies generally based on referral population.
• Three tests most predictive of electrodiagnosis:
– Hand symptom diagrams (pt fills in hand diagram depicting
symptoms): +LR 2.4, -LR 0.5
• Classic or probable pattern: at least 1 of digits 1,2,3; wrist pain
radiating proximally; palmar pain unless solely ulnar.
– Hypalgesia: +LR 3.1, -LR not significant
• Diminished sensation to painful stimuli on the palmar aspect
index finger
– Weak thumb abduction strength testing: +LR 1.8, -LR 0.5
• Weakness in mov’t of thumb to right angle of hand.
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CTS – Diagnosis cont4
• May be helpful but not well validated
– Square wrist sign (requires calipers),
– Flick sign (ask pt to show you what they do when symptoms at their worst –
pt flicks wrist)
– Close fist sign (symptoms reproduced when open and close fist x 60 sec).
• Phalen and Tinel signs found to be of limited utility.
• Thenar atrophy – low sensitivity but specific. Likely represents
advanced disease.
• Electrodiagnosis
– Although used as the gold standard for diagnosis in most studies of
clinical diagnosis has false positives and false negatives.
– Best used in symptomatic pts to confirm diagnosis, e.g. prior to
surgery, or to identify nerve entrapment at other locations.
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CTS – Treatment5,6
• Conservative treatment
– Wrist splints – neutral position; relieve symptoms in up to
80% of pts.
– NSAIDs
• Not supported by evidence, but typically done in practice
– Activity modification
– Corticosteroid injections – after above treatments have failed
• Short-term (1-3 months) improvement in symptoms compared
to placebo or oral steroids. Long term not studied.
• No improvement compared to splinting + NSAIDs in one study
– Ineffective or mixed results
• Likely ineffective - Diuretics, pyridoxine, non-steroidal antiinflammatory drugs, yoga and laser-acupuncture
• There is conflicting evidence for the efficacy of ultrasound and
oral steroids.
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CTS – Treatment cont7,8
• Surgical division of transverse carpal ligament
– Although response to conservative treatment is initially
good, most have recurrence.
– Failure of conservative treatments or thenar atrophy are
indications for referral.
– Surgery provides better relief than splinting at 3mo and 1yr
f/u.
– Good results with low complication rates
– Can require weeks of missed work to recover
– Various techniques can be open or endoscopic
• alternatives to standard open carpal tunnel release not clearly
better.
• Conflicting evidence if endoscopic carpal tunnel release allows
quicker return to ADLs/work.
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Common causes of foot pain9,10
• Forefoot
– Hallux valgus, hammer toe (PIP flexion), claw toe (PIP and
DIP), and mallet toe (isolated DIP)
• Footwear with greater forefoot width and depth, orthoses, rarely
surgery
– Morton neuroma: entrapment neuropathy of the interdigital
nerve, esp between 3rd and 4th metatarsal heads
• Orthoses, glucocarticoid injection, surgical excision.
• Midfoot
– Arthritic changes or arch deformity
– Tarsal tunnel syndrome – post tib nerve entrapment
• Pain and paresthesia over plantar and distal foot, + Tinel sign
• Splinting, NSAIDs, steroid injection, surgical decompression.
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Ankle & Foot
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Lateral view of tendons and ligaments responsible for maintaining ankle
articulation.
Wexler RK. The Injured Ankle. Am Fam Physician. 1998 Feb 1;57(3):474-80.
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Medial view of tendons and ligaments responsible for maintaining ankle
articulation.
Wexler RK. The Injured Ankle. Am Fam Physician. 1998 Feb 1;57(3):474-80.
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Common Causes of Foot Pain10
ACP medicine (Online) ACP medicine [electronic resource]. New York, N.Y. : WebMD
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Common causes of foot pain9,10
• Hindfoot
– Plantar fasciitis – most common cause (up to 15% of foot
symptoms requiring medical attention)
• Runners, military, obesity, prolonged standing, pesplanus,
reduced ankle ROM
• Pain over plantar heel to midfoot.
• Most pts improve regardless of therapy in 6-12 months.
• Orthoses, avoid barefoot walking, plantar and heel cord
stretches, NSAIDs, steroid injections, surgery.
– Achilles tendonitis or associated bursitis
• Running/sports, ankylosing spondylitis, Reither syndrome,
fluoroquinolones (also associated with rupture), steroid use
• Orthoses - particularly heel lifts, NSAIDs.
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Plantar Fasciitis Exercises
• Towel Stretch
Sit on the floor with your legs stretched out in front of you.
Loop a towel around the top of the injured foot. Slowly pull
the towel towards to keeping your body straight. Hold for
15 to 30 seconds then relax - repeat 10 times.
(http://www.plantarfasciitisbraces.com/plantar_fasciitis_str
etching_exercises.html)
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Plantar Fasciitis Exercises
• Calf/Achilles Stretch
Stand facing a wall place your hands on the wall chest
high. Move the injured heel back and with the foot flat on
the floor. Move the other leg forward and slowly lean
toward the wall until you feel a stretch through the calf,
hold and repeat.
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Plantar Fasciitis Exercises
• Stair Stretch
Stand on a step on the balls for your feet, hold the rail or
wall for balance. Slow lower the heel of the injured foot to
stretch the arch of your foot.
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Ottawa Ankle Rules
• Clinical "decision rules" to predict fractures, allowing
radiography to be used more selectively
• 750 adult patients were evaluated in two emergency
departments after presenting with acute blunt ankle
injuries
• Follow-up study by applying the rules during evaluation of
2,342 patients with acute ankle injuries
Stiell et al. Implementation of the Ottawa ankle rules. JAMA 1994;271:827-32.
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Ottawa Ankle Rules
An ankle radiographic series is required only if patient has
pain in malleolar zone and any one of the following
findings:
1. Bone tenderness at the posterior edge or tip of the
lateral malleolus
2. Bone tenderness at the posterior edge or tip of the
medial malleolus
3. Inability to bear weight both immediately and in
emergency department
Stiell et al. Implementation of the Ottawa ankle rules. JAMA 1994;271:827-32.
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Ottawa Foot Rules
A foot radiographic series is required only if patient has
pain in midfoot zone and any one of the following
findings:
1. Bone tenderness at the base of the fifth metatarsal
2. Bone tenderness at the navicular
3. Inability to bear weight both immediately and in
emergency department
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Ottawa Ankle & Foot Rules
http://www.healthservices.gov.bc.ca/msp/protoguides/gps/anklex.
pdf
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Toe Fractures
• Most common type of foot fracture
– Estimate to account for 9% of all fractures seen in the primary
care setting
• Commonest etiologies: axial loading (“stubbing” toe),
hyperabduction, or crush injury
• Clinical presentation usually localized pain; although also with
difficulty fitting into shoe or altered walking
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Toe Fractures: Clinical Presentation
• Ecchymosis and edema within first hours after injury
• Point tenderness characteristic of underlying fracture; however
diffuse soft tissue inflammation and tenderness is common
• Rotational deformity of nail bed (relative to adjacent nail beds)
indicative of displacement
• Distal phalynx fracture can present as subungal hematoma
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Toe Fractures: Diagnosis
• Plain films should be obtained with AP, oblique and lateral views
• Remember to evaluate for additional fractures after identifying one
fracture site is important—often multiple phalanges involved
• Distal phalynx fractures commonly are comminuted
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Toe Fractures: Indications for Referral
• Emergent referral for open proximal phalanx fractures, fractures
associated with gross contamination, or circulatory instability
• Dislocation of great toe, instability of reduced great toe fracture, or
displaced intra-articular fractures (can lead to DJD)
• Management of open fractures in diabetics or immunosuppressed
patients
• Complications from toe fractures (nonunion, chronic pain,
osteomyelitis)
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Toe Fractures: Primary Care Mgmt
• “Buddy taping” (taping fractured to adjacent toe) with cushioning
agent in between to prevent maceration (gauze, etc) mainstay of
treatment
– Pain unrelieved with buddy taping may require further
immobilization via short leg walking cast with foot plate
• APAP or NSAIDs usually adequate analgesia
• Continue immobilization until point tenderness resolves (usually 46 weeks)
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Metatarsal Fractures
• Second most common type of foot fracture after toe fractures
• Risk factors include osteoporosis, sedentary lifestyle,
benzodiazepine use, diabetes (particularly in patients with >25
years of disease or increased physical activity)
• Twisting or direct blows are most common mechanism of
traumatic injury
– First metatarsal infrequently injured due to increased relative
stability
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Metatarsal Fractures: Stress Fracture
• First described in 1855 as "march fractures" due to predilection for
military recruits
• In contrast to traumatic fractures, occur with repeated
administration of forces not powerful enough to cause fracture with
single occurrence
• Second most common type of stress fracture in athletes (other
than tibial stress fracture)
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Metatarsal Fractures: Presentation
• Traumatic fractures present typically with localized pain and
difficulty ambulating
• Contrastingly stress fractures more sub-clinical
– Dull aching pain during or immediately after activity
– May present with poorly localized forefoot pain
• Pain with axial loading (applied pressure perpendicular to
phalanx) differentiates fracture from soft tissue injury
• Greater pain with direct palpation compared to resisting
plantar/dorsiflexion differentiates from tendon injury
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Metatarsal Fractures: Referral Indications
• Tenderness of the tarsometatarsal joint (Lisfranc joint)
• Compartment syndrome rarely occurs
– Pain with passive toe flex/extension early sign
– Pallor, parasthesia, out of proportion pain, tense swelling
should prompt consideration
– Diminished or absent pulse is late finding
• Other indications include displaced 1st metatarsal fractures,
multiple fractures, intraarticular fractures, displaced fractures near
metatarsal head
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Metatarsal Fractures: Management
• Obtain AP, lateral, oblique plain film views
• Minimally displaced/nondisplaced fractures: non weight bearing
for 3-5 days, elevation and ice for 24 hrs; then progressive weight
bearing
– After point tenderness resolves and callus formed on f/u plain
film injury considered healed--usually at least six weeks
• Displaced fractures (greater than 3-4 mm or 10 deg angulation in
dorsal or plantar plane) reduced with regional block and
placement of toes in Chinese finger trap
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Metatarsal Fractures: Management
• Initial mgmt of displaced fractures followed by placement in
bivalved cast for 1-3 weeks, then converted to short-leg walking
cast with progressive weight bearing
• Stress fracture usually treated only with cessation of inciting
activity for 4-8 weeks followed by gradual reintroduction
– Fifth metatarsal stress fractures are exception due to high
rates of nonunion and should be referred to orthopedics
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Question 1
1. Based on available data, which combination of clinical
findings is most likely to have electrodiagnostic testing
consistent with CTS?
a. Hand pain in all digits, diminished thumb abduction,
and diminished sensation to sharp.
b. Pain in fourth and fifth digits only, positive Phalen sign,
positive Tinel sign
c. Positive Flick sign, positive close fist sign, positive
square wrist sign (a-p diameter/mediolat dimension at
distal wrist crease > 0.7)
d. Asymptomatic 55 yo female, works in the logging
industry.
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Answer
1. a. Correct. Each of these clinical findings are predictive of
carpal tunnel syndrome confirmed by electrodiagnostic
testing.
b. Incorrect. This is an unlikely pattern of pain for CTS.
Although classically used to diagnose CTS, the Phalen and
Tinel signs have not been shown to be predictive of the
electrodiagnosis in studies.
c. Incorrect. These are potentially predictive of CTS but
lack sufficient validation at this time.
d. Incorrect. Although a middle aged female lumberjack
may be at increased risk for CTS based on epidemiology,
she is asymptomatic and electrodiagnostic testing would
be inappropriate. If she did have a positive test, this
would likely represent a false positive.
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Question 2
All of the following are associated with Carpal Tunnel
Syndrome EXCEPT
A. Traumatic arthritis and hyperthyroidism
B. Diabetes Mellitus and corticosteroid use
C. Pregnancy and use of estrogens
D. Manufacturing work and amyloidosis
E. Female gender and h/o Colle’s fracture
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Answer
A. Correct – Neither of these conditions are associated with
CTS. Inflammatory arthritis and hypothyroidism are.
B. - E. Each of these has been associated with CTS
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Question 3
Which of the following is best supported by evidence for the
initial management for CTS?
A. Referral for surgery
B. Corticosteroid injections
C. NSAIDs
D. Wrist splints
E. Diuretics or Yoga
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Answer
A. Incorrect: Surgery is effective but is generally not done
as initial therapy unless the pt presents with evidence of
advanced disease (e.g. thenar atrophy).
B. Incorrect: Has been shown to provide at least short term
relief, but is generally only considered after more
conservative measures have failed.
C. Incorrect: Although typically used in practice, the use of
NSAIDs has not been supported by evidence.
D. Correct: Wrist splints provide relief of symptoms in most
patients with CTS.
E. Incorrect: Unlikely to be helpful.
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Question 4
When evaluating the sensation of the hand, the
following anatomical areas correlate with which
nerve?
A) Pulp of index finger – ulnar nerve
B) Pulp of the 5th finger – radial nerve
C) Dorsal web space between the thumb
and index finger – radial nerve
D) Pulp of index finger – radial nerve
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Question 4 Answers
A &D) Incorrect: The pulp of index finger is innervated by
the median nerve.
B) Incorrect: The pulp of the 5th finger is innervated by
the ulnar nerve
C) Correct: You are so smart! The dorsal web space
between the thumb and index finger is innervated by the
radial nerve.
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Question 5
A 65 y/o woman presents with pain in a few of
her fingers. Physical exam reveals bony
enlargement with little or no inflammation of
the affected PIPs and DIPs. What is her most
likely diagnosis.
A)Rheumatoid Arthritis
B)Psoriatic Arthritis
C)Osteoarthritis
D)Who cares? Refer to Rheumatology.
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Question 5 Answers
A) Incorrect: Rheumatoid arthritis rarely affects the DIPs
and the joint exam would be consistent with
inflammation.
B) Incorrect: Psoriatic Arthritis can affect both the DIPs and
PIPs, but is also associated with inflammation. She would
also likely have a hx of psoriasis or active lesions at the
time of diagnosis. Nail changes would also provide a
clue.
C) Correct: Osteoarthritis has little to no evidence of
inflammation on physical exam and does affect both the
PIPs and DIPs causing bony enlargement (Bouchards and
Heberdens nodes).
D) Although Rheumatologists are nice people, you can
probably handle this one on your own.
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Question 6
Which of the following is NOT a common causes of plantar
fascitis (the most common cause of heel pain)?
A. Prolonged standing
B. Obesity
C. Poor flexibility of calf muscles or reduced ankle range of
motion
D. Too much stretching
E. Lack of arch support
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Answer
D. Too much stretching. Plantar and heel cord stretches is
actually one of several ways to treat heel spur (plantar
fascitis). Other treatments include orthoses, rest,
NSAIDS, and even surgery. The other answers contribute
to development of plantar fascitis.
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Question 7
A 47-year-old man fell from a ladder at work and presents
to urgent care. He report 10/10 ankle pain and is
convinces that he has fractured his ankle. He requests
Percocet and a work excuse note. He has been
ambulatory since the fall. Which of the following is the
BEST next step?
A. Order an ankle serious to rule out fracture
B. Prescribe Percocet
C. Perform a careful ankle exam and focus on the tarsal
zone
D. Write a work excuse citing unsafe work environment
E. Screen the patient for narcotic abuse
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Answer
C. The best next step would be to exam the foot carefully for
bony tenderness alone the poster and tip of both lateral
and medial malleoli. If the patient does not have
tenderness in these areas and since he is ambulatory,
ankle x-ray would not be necessary. The other answer
could be options depending on the specific situation, they
would not be the next best step.
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Question 8
What of the following about Toe fractures is FALSE?
A. Causes include crush injury, hyperabduction, and axial
loading.
B. They are the MOST common cause of foot fracture.
C. They are never emergent.
D. “Buddy taping” is the usual treatment.
E. Point tenderness is present and may be accompanied by
soft tissue swelling and tenderness.
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Answer
C. Emergent referral for toe fractures are indicated for open
proximal phalanx fractures, fractures associated with
contamination or circulatory instability. The other
answers are features of toe fracture.
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Question 9
Which of the following is NOT a risk factor for metatarsal
fractures.
•
•
•
•
•
Hypertension
Diabetes
Sedentary lifestyle
BZP use
Osteoporosis
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Answer
A. Hypertension is not a risk factor for metatarsal fractures.
Diabetes, especially >25 years is on of the major risk
factors. Other risk include sedentary lifestyle, BZP use,
and osteoporosis. Repeat direct trauma is a common
cause of stress metatarsal fractures.
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Question 10
When treating patients with metatarsal fractures, the
following should be carefully considered EXCEPT.
A. Early immobilization for 3-5 days
B. Early weight bearing for 24 hours
C. Follow-up exam should focus on pain and point
tenderness
D. Displaced fractures should be reduced with regional block
E. Stress fracture is usually treated by 4-8 weeks of
cessation of inciting activity
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Answer
B. Early weight bearing is discouraged for fractures in
general and immobilization is used primarily to help with
fracture healing and prevention of complications such as
displacement or non-union. Early immobilization for 3-5
days is the general rule for metatarsal fractures. Followup exam should focus on point tenderness and follow-up
x-ray should exam callus formation at the fracture site.
Most stress fractures could be management by rest.
However, 5th metatarsal stress fracture require orthopedic
referral due to high complication rate.
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References
1. Bickley L: Bates’ Guide to Physical Examination and History Taking 7th
Edition. Lippincott Williams & Wilkins. 1999.
2. Klippel J: Primer on Rheumatic Diseases, Edition 12. Arthritis Foundation,
2001.
3. Katz JN, Simmons BP.Related Articles, Links Clinical practice. Carpal
tunnel syndrome. N Engl J Med. 2002 Jun 6;346(23):1807-12. Review.
4. D'Arcy CA, McGee S.Related Articles, Links The rational clinical
examination. Does this patient have carpal tunnel syndrome? JAMA.
2000 Jun 21;283(23):3110-7. Review.
5. O'Connor D, Marshall S, Massy-Westropp N. Non-surgical treatment
(other than steroid injection) for carpal tunnel syndrome. Cochrane
Database Syst Rev. 2003;(1):CD003219. Review.
6. Marshall S, Tardif G, Ashworth N. Local corticosteroid injection for carpal
tunnel syndrome. Cochrane Database Syst Rev. 2002;(4):CD001554.
Review
7. Verdugo RJ, Salinas RS, Castillo J, Cea JG. Surgical versus non-surgical
treatment for carpal tunnel syndrome. Cochrane Database Syst Rev.
2003;(3):CD001552. Review
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Duke Internal Medicine Residency Curriculum
References Cont.
8. Scholten RJ, Gerritsen AA, Uitdehaag BM, van Geldere D, de Vet HC,
Bouter LM. Surgical treatment options for carpal tunnel syndrome.
Cochrane Database Syst Rev. 2004 Oct 18;(4):CD003905. Review.
9. Essentials of musculoskeletal care / American Academy of Orthopaedic
Surgeons, American Academy of Pediatrics ; Letha Yurko Griffin,
editor. Rosemont, IL : American Academy of Orthopaedic
Surgeons, 2005.
10. ACP medicine (Online) ACP medicine [electronic resource]. New York,
N.Y. : WebMD
11. Fracture care by family physicians. A review of 295 cases Fam Pract
1994 Mar;38(3):238-44
12. Fracture care by family physicians -- J Am Board Fam Pract 1993 MarApr;6(2):179-81
13. DeLee: DeLee and Drez's Orthopaedic Sports Medicine, 2nd ed.,
Copyright © 2003 Saunders
14. www.uptodate.com
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