12. Rheum/Ortho/Sports Flashcards by Evelyn Qin

Define negatively birefringent in gout

Yellow when parallel to polarizing axis
Blue when lying perpendicular
Will see yellow and blue crystals perpendicular to each other
Note: CPPD cyrstals are smaller and rhomboid

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Supracondylar fracturs are assoc with injury to what?

Median nerve, brachial artery

Note: ARM mneumonic. Axillary nerve, radial nerve, median nerve from top to bottom

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Painful, red or violaceous, subcutaneous nodules on the anterior lower legs is what? Next step in management?

Erythema nodosum

CXR to look for sarcoidosis or Tb. These are assoc with EN

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Psuedogout is an acute inflam arthritis d/t calcium pyrophosphate crystals. Often in setting of surgery or medical illness! Dx?

Synovial fluid shows rhomboid-shaped, pos birefringent crystals
Radiographic evidence of chondrocalcinosis (calcified articular cartilage!!)

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MCC of asymptomatic elevation of alkaline phosphatase in an elderly patient?

Paget disease of the bone - freq incidental finding

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Elderly patient with advanced osteoporosis can get acute back pain following minimal trauma? What is the cause?

Vertebral compression fracture - common complication of advanced osteoporosis. Pain inc with standing, walking or lying on back. Tenderness at affected level.

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Immune complex deposition in small to medium sized blood vessels leading to endothelial injury and end-organ damage. Presents with fatigue, nonblanching, palpable purpura, arthralgias, renal disease, and peripheral neuropathies. Dx? Confirm? What is it assoc with?

Mixed cryoglobulinemia syndrome
confirm serologically with low complement levels or skin/renal bx
Assoc with CHRONIC HEP C, HIV, SLE

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Elevated alk phos, skull with thickened cortices with mixed lytic and osteoblastic lesions suggests what? Management?

Paget disease of bone

Bisphosphonates (eg Alendronate) - inhibit osteoclasts

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Scaphoid fractures may present with initially neg Xrays. What’s the best next step in management if you suspect a scaphoid fracture?

CT scan or MRI of the wrist.

OR - can immobilize the wrist in thumb spica and repeat imaging in 7-10 days

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What imaging can confirm a rotator cuff tear?

MRI

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Exam findings of osteoarthritis?

Bony enlargement and tenderness, crepitus with movement, and painful or dec ROM
Note: worse after actiity at the end of the day

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What is anserine bursitis/pes anserinus pain syndrome?

Localized pain and tenderness over the anteromedial tibia. Sx occur over weeks to months, and pain worse overnight/in the morning. Strongly assoc with diabetes

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What should you suspect in a young patient with Down syndrome who presents with UMN findings (hyperreflexic, positive Babinski), ataxic, dizzy, and refusal to do usual activities

Atlantoaxial instability - excess laxity in posterior transverse ligament –> inc mobility bw C1 (atlas) and C2 (axis)

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What is effective initial therapy for fibromyalgia? In what type of patients is FM seen in?

TCAs - amytriptyline

Young to middle-aged women - fatigue, widespread pain, and cognitive/mood disturbances

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How do you manage a peds patient with radial head subluxation (nursemaid’s elbow)?

Gently hyperpronate the forearm OR supinate the forearm and flex the elbow1

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Whats the best way to prevent future gout attacks?

ETOH cessation. Weight loss also helpful.

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Slipped capital femoral epiphysis (SCFE) occurs in obese, early-adolescent boys. Tx?

Surgical pining of the slipped epiphysis to lessen risk of avascular necrosis of the femoral head and chondrolysis

Acute knee pain assoc with catching or reduced ROM suggests a meniscal injury. If sx persist, how should you evaluate it?

MRI - surgery is advised in younger patients to relieve pain and reduce risk of further joint injury.

cervical spondylosis affects 10% of people >50yo. Hx of neck pain is typical. Limited neck rotation and lateral bending is d/t osteoarthritis. What causes sensory deficits?

Osteophyte-induced radiculopathy.
Radiographs show bony spurs and sclerotic facet joints. Specificity of these findings are low since osteoarthritic changes are common in asymp patients.

Idiopathic avascular necrosis of the femoral capital epiphysis is also known as what? who does this most commonly affect?

Legg-calve-Perthes disease. Boys bw 4-10yo.
Sx: hip, groin, or knee pain + antalgic gait.
manage conservatively with observation and bracing.

What injury usually presents with rapid onset of pain and swelling with hemarthrosis in joint?

ACL injury - common esp in young female athletes in sports

If SLE is suspected, what should be tested first (ie most sensitive)?

ANA - very sensitive, but nonspecific

If elevated, then tests more specific autoantibodies (eg anti-dsDNA).

MOA of succinylcholine? What is the greatest risk of use?

MOA: binds to postsynaptic Ach receptors to trigger Na influx and K efflux –> temporary paralysis (delayed repol of skeletal mm).
Can cause life-threatening cardiac arrhythmia d/t severe hyperK

Primary SE/consequences of:

Halothane
Etomidate
Nitrous oxide
Propofol

acute liver failure - hepatoxic intermediary compounds
adrenal insufficiency (inhibits 11B-hydroxylase)
neurotoxicity (inactivates Vit B12) - peripheral neuropathy
Myocardial depression –> hypotension

What conditions are the following abs assoc with? 1. Anticardiolipin antibodies 2. Anti-CCP 3. Antimitochondrial 4. ANCA 5. Anti-smooth muscle 6. Anti-topoisomerase I

1. antiphospholipid syndrome (thrombosis and miscarriages) 2. more specific marker for RA than Rheumatoid factor 3. Primary biliary cholangitis/cirrhosis 4. Wegeners, autoimmune vasculitis 5. Autoimmune hepatitis 6. Systemic scleroderma

Patient with hx of ankylosing spondylitis falls and has midline tenderness over upper lumbar region and restricted spinal motion. Exam also shows aortic regurg. What is the most likely cause of the pain?

Vertebral fx - pts with AS dev osteopenia/osteoporosis dt inc osteoclast activity in setting of chronic inflam. Inc risk of fx Note: Ankylosing sponylitis and AR is a common finding

What condition is commonly assoc with ca pyrophosphate dihydrate crystal deposition in joints --> chondrocalcinosis, pseudoguout, and chronic arthropathy? Diabetes and liver disease is common in these patients as well. How do you dx and confirm?

Hereditary hemochromatosis Dx - Fe studies (Fe overload) Confirm: genetic tests

What condition presents with symmetrical proximal mm weakness and erythematous rash over the dorsum of the fingers and/or upper eyelids?

Dermatomyositis =can be due to a paraneoplastic syndrome in malignancy

Morning stiffness, MCP joint involvement, nontender nodules on the elbow, high ESR suggests what? What part of the axial skeleton does it predominantly affect?

Rheumatoid arthritis Cervical spine - can lead to cervical spine subluxation --> spinal cord compression. Can cause radicular pain. Hyperreflexia

MCC of AL amyloidosis vs AA amyloidosis?

AL - multiple myeloma | AA - rheumatoid arthritis (renal involvement is characterized by NEPHROTIC synd - congo red and apple green)

In patients with systemic sclerosis, what does esophageal manometry show if the esophagus is involved?

Hypomotility incompetence of the LES/dec in LES pressure Note: achalasia also has aparistalsis in the distal esophagus, but has inc LES pressure

What is the drug of choice for relief of pain in osteoarthritis and does not alter the progression of the disease?

NSAIDS (eg diclofenac)

Bone Xray findings showing lytic lesion, onion skin periosteal reaction, and moth-eaten appearance is classic for what? Tx?

Ewing sarcoma Tx - surgery, radiation, chemo Note: can be mistaken for osteomyelitis symptomatically, but xray differentiates the two

Differentiate polymyositis from polymyalgia rheumatica in terms of sx and dx

Polymyositis: prox mm weakness (hard to climb stairs) - dx with mm bx (endomysial infiltrate, patchy necrosis), inc mm enzymes, ANA, anti-Jo1 Note: similar to dermatomyositis but without skin finding Polymyalgia rheum: >50yo, stiffness more in pain shoulders, hip girdle, neck, assoc with temporal arteritis! Inc ESR, CRP. Improve with glucocorticoids

Differentiate primary vs secondary Raynauds

Primary: women <30, no tissue injury, neg ANA and ESR, tx with CCB. SYMMETRIC Secondary: Caused by CT dz, drugs, nicotine, occlusive vascular conditions, men >40, tissue injury or digital ulcers seen, CCB for sx, aspirin to reduce risk for digit ulceration. ASYMMETRIC

Diabetic with joint pain showing loss of cartilage, osteophyte development and loose bodies is characteristic of what?

``` Neurogenic arthropaty (charcot joint) due to peripheral neuropathy (nerve damage) Can also be seen with syringomyelia, SCI, vit B12 def, or tabes dorsalis. ```

Sudden onset of low back pain and dec spinal mobility after bending, coughing, or lifting and tenderness at the affected level in an elderly patient is a sign of what?

Vertebral compression fracture - MCC of nontraumatic VCF is osteoporosis. Can also be caused by osteomalacia, infx, bone mets, hyperparathyroidism.

When is a hip ultrasound done vs a hip x-ray done in a child with signs concerning for developmental dysplasia of the hip? Tx?

Age 2wk-6mo: hip US 4-6mo: hip xray Tx: Pavlik hip harness

What are a common MSK complaint in kids that occurs mainly at night, affects lower extremities bilaterally, but allows for normal physical exam and activity?

Growing pains Age 2-12 y. Tx: education and reassurance. Massage, stretching, exercises, heat.

Patient with multiple white nodules in the hands and hx of painful arthritis in the fingers and feet has what?

Tophaceous gout. Confirm with arthrocentesis showing inflammatory effusion with uric acid crystals.

SCFE is a common hip disorder in overweight adolescents. How do you manage?

Urgent surgical fixation to prevent avascular necrosis of the hip