FM ITE MSK

• For patients undergoing major orthopedic surgery, the American College of Chest Physicians recommends outpatient thromboprophylaxis for a duration of up to 35 days.
• Older recommendations for 10–14 days of prophylaxis were based on studies performed when this was the usual hospital stay.
• This is still recommended as the minimum length for prophylaxis, but a longer period of time is preferred.

Dupuytren’s disease

•  characterized by shortening and thickening of the palmar fascia.
• It is initially asymptomatic, but may progress and cause difficulty with function of the hand, and may eventually lead to contracture.
• Early asymptomatic disease does not require treatment.
• A series of cortisone injections over a period of months may lead to disease regression, and is useful in patients with mild to moderate symptoms.
• Surgery is indicated if a metacarpal joint contracture reaches 30°, or with a proximal interphalangeal joint contracture of any degree.
• If surgery is delayed, irreversible joint contracture may occur.
• There is a strong association between diabetes mellitus and Dupuytren’s disease, with up to a third of diabetic patients having evidence of the disease.
• It is also associated with alcohol use and smoking. 

Elderly Falls

Based on U.S. Preventive Services Task Force recommendations, what intervention has the strongest evidence for preventing falls in community-dwelling older adults at increased risk for falls?

• Exercise interventions provides a moderate net benefit in fall prevention in community-dwelling adults 65 years of age or older who are at increased risk for falls

Osteoporosis

When is osteoporosis treatment indicated?

• In those with high risk of fracture or those with osteoporosis (T-score of -2.5 or less) OR osteopenia (T-score -1 to -2.5) and a 10-year probability of hip fracture of at least 3% using the FRAX tool.
  
• Treatment beyond 5 years has NOT shown to result in further decreases in rates of clinical vertebral fx, nonvertebral fx, or mortality.

Scoliosis

Scoliosis treatment

• Definition: lateral curvature of the spine (Cobb angle) is at least 10 degrees in the absence of underlying congenital or neuromuscular abnormalities.
• For Cobb angle of:
• 10-19 degrees – radiograph every 6 months and observation recommended.
• 20-29 degrees – radiography every 6 months with Risser grading, refer for consideration of bracing and physical therapy esp. at Risser grade 0 or 1*
• 30-39 degrees – refer to specialist for bracing and/or PT
• >40 degrees (severe scoliosis) – refer for surgery

Tibial Stress Fracture

You suspect a patient has a tibial stress fracture. What imaging modality is preferred to identify the stress fracture?

• Initial imaging modality choice is x-ray, then a follow-up x-ray in 3 weeks. If x-ray is inconclusive and you still suspect stress fracture, MRI is the most specific and has the most ability to inform alternate diagnoses.

Ankle

Ottawa Ankle Rules

• Ankle film if:
  -Bone tenderness at lateral malleolus
  -Bone tenderness at medial malleolus
  -Inability to to walk 4 steps after injury and in ER

• Foot films if:
  -Bone tenderness at base of 5th metatarsal
  -Bone tenderness at navicular bone
  -Inability to to walk 4 steps after injury and in ER