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Orthopaedics for the Practicing Internist

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

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Orthopaedics for the Practicing Internist

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  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. Chronic Pain • Often lacks a mechanism of injury • Symptoms of gradual onset • Common causes of chronic knee 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

  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 • 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 • Joint above and below • Most painful part last • Gait • Alignment (varus, valgus) • Squat • Inspection • Swelling • Bruising • Deformity

  13. Physical Exam • Palpation • Effusion • Range of Motion • Patellar tracking • Extension (-5 to 5) • Flexion (135-145) • 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 • 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 • 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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