Ch 13 MDT Musculoskeletal System Flashcards
Chest pain is “reproducible”
Able to exacerbate pain with palpation on physical exam
Likely secondary to viral illness and other causes of inflammation
-Other rheumatic diseases such as fibromyalgia a common cause of chest wall pain
Costochondritis
Diagnostic tests for Costochondritis
Clinically
-Rads/Labs used to rule out other sources of chest pain
Treatment for Costochondritis
Improves in the course of 2 weeks
- NSAIDS
- Home Stretching
- Activity modification
Osteoarthritis
Affects an Estimated ____ million people
30 million
Osteoarthritis
Knee joint accounts for ___% cases
80%
Risk factors for Osteoarthritis
Age (>50)
Female (1.7x more likely than males)
Family history
Joint injuries
Chronic inflammation
Obesity
Occupation
Heavy workload
Common sites of Osteoarthritis
Hips
Knees
Spine
Hands
Joint Pain that is exacerbated with use, alleviated with rest
Pain is aching, deep in later stages
Sharp pain in beginning stages
- Bony swelling
- Joint line tenderness, crepitus
- Limited ROM on affected joint
Osteoarthritis
Diagnostic tests for Osteoarthritis
Plain films
-Joint space narrowing, osteophytes, subchondral sclerosis, cysts
Treatment for Osteoarthritis
NSAIDs/Tylenol
Activity/Lifestyle modification (weight loss)
Rehabilitation
Osteoarthritis
Loss of 10% of body weight is associated with __% reduction in pain over 18 months
50%
Includes rheumatoid arthritis, reactive arthritis, psoriatic arthritis, ankylosing spondylitis
Inflammatory Arthroses
Autoimmune disorder
Mostly small joints and bilateral: hands, finger, wrist, feet, ankle
Insidious onset, distal joints first (DIP of hands are spared)
Extra-articular manifestations (pulmonary, CV, eyes)
Rheumatoid Arthritis (RA)
Rheumatoid Arthritis (RA)
Diagnosed if they meet 4 of the 7 ACR criteria which involves:
Morning stiffness (1 hour for 6 weeks)
Arthritis (>/= 3 joints for 6 weeks)
Swelling of hand joints (6 weeks)
Symmetrical joint swelling (6 weeks)
Rheumatoid nodules
Positive Rheumatoid factor
Erosions or osteopenia in hand X-Ray
May have myelopathy with C1-C2 involvement
Nodules (elbow mostly)
Swelling/hypertrophy
Swan neck deformity
Lateral drift of toes
- Boggy sensation
- ROM diminished and painful
- Reduced grip strength
- Numbness and tingling in affected nerve
Rheumatoid Arthritis (RA)
Lab tests for Rheumatoid Arthritis (RA)
Rheumatoid Factor (RF)
Antibody to cyclic citrullinated peptide (Anti-CCP)
C-reactive Protein (CRP)
Erythrocyte Sedimentation Rate (ESR)
Radiologic studies for Rheumatoid Arthritis (RA) that can show osteopenia and mild soft tissue swelling along with erosions
Plain films
Treatment for Rheumatoid Arthritis (RA)
MEDADVICE
NSAIDs/Tylenol
-Disease-Modifying Anti-Rheumatic Drug (DMARD)
Physical Therapy/Surgery
Disease-Modifying Anti-Rheumatic Drug (DMARD)
Etanercept
Methotrexate
Hydroxychloroquine
Cyclosporine
Spondylarthropathy that is preceded and precipitated by infection in the body
-Urinary Tract Infection, Diarrheal illness, STIs
Incidence 10 per 1,000
Interval of days to weeks between infection and onset of pain
Reactive Arthritis
Clinical manifestations 1-4 weeks after infection, include:
- Peripheral arthritis
- Enthesitis
- Dactylitis
- Lower Back pain
- Extra articular manifestations (nail changes, conjunctivitis, uveitis, oral lesions
Reactive Arthritis
Diagnosis of Reactive Arthritis
Exclude other etiologies
-Lyme, Septic joint, RA, Psoriatic arthritis
Test for:
- Arthrocentesis (joint effusion)
- Stool cultures (diarrhea)
- UA and STD panel (GU symptoms)
Treatment for Reactive Arthritis
Treat active infection
Self limited symptoms (up to 6 months)
NSAIDs for pain
Refer to specialist in severe cases
Inflammatory arthritis associated with psoriasis
Common inflammatory skin disease
Most common manifestation: well demarcated erythematous plagues with silver scale
1-2 per 1,000
Psoriatic Arthritis
Joint stiffness sometimes alleviated by physical activity
SI joint, large joints (knee), small joints (DIP)
Pain may precede lesions
Soft tissue inflammation: Enthesitis, dactylitis, tenosynovitis
Nail Lesions
Ocular involvement
Psoriatic Arthritis
Diagnosis and Treatment for Psoriatic Arthritis
Made clinically in a patient who has both psoriasis and classic arthritis
Refer to rheumatology and dermatology
NSAIDs
DMARDs
Inflammatory arthritis of the spine
More common in men
Back pain in almost all patients
Ankylosing spondylitis
Back pain. “Bamboo spine”: Severe restriction in back mobility seen in about half of patients in later stages.
Large joints involved: Sacroiliac joint, spine, hip shoulder
-Peripheral arthritis common, chest wall inflammation, enthesitis, dactylitis
Ankylosing spondylitis
Treatment for Ankylosing spondylitis
Recognize and refer
NSAIDs
DMARDs after rheumatology referral
Minimize damage to spine and other manifestages
Psychological screening and surveillance
Monosodium urate crystal deposition in joints and tissues (tophi)
-Uric acid deposition
Most patients have hyperuricemia
Monoarticular 80% of the time
Common sites:
-1st toe, ankle, knee, wrist, fingers, elbow
Intense pain, redness, swelling
Occurs in hours to days
Gout
Swelling, erythema, tophi
Severe tenderness even to light touch
ROM: Limited and guarded
1st toe, ankle, knee, wrist, fingers, elbow
Gout
Lab tests for Gout
Uric acid
Chem panel
TSH, Iron panel
WBC
Rads for Gout, look for:
Erosion and peripheral spurs; soft tissue swelling
Treatment for acute episode of Gout
NSAID (Indomethacin)
Colchicine (N/V/D, bone marrow suppression, neuropathy
Steroids
Prophylaxis of Gout
Allopurinol (overproducers)
Probenecid (underexcreters; UA <600mg/day)
Diet modification for Gout
Avoid: Meat, seafood, alcohol, high-fructose corn syrup
Referral consideration for a Gout patient if:
Joint deformity or destruction
Large tophaceous masses
Metabolic problems
All patients should see MO for consideration of prophylaxis
Similar clinical presentation to gout
- Intensely painful, joint swelling, erythema
- Large joints such as the knee often affect
URIC ACID levels are NORMAL
Pathophysiology is based on calcium pyrophosphate deposition (CPPD)
Pseudogout
Pseudogout is differentiated from gout by lab, which show:
Analysis of joint aspiration reveals rhomboid shaped crystals
Treatment for Pseudogout
NSAIDs
-No preventive treatment
Infection of the joint space
-Direct inoculation, hematogenous spread, or from a bone infection
Staph aureus is the most common cause
Severe, pain, swelling, decreased mobility
Difficulty bearing weight
Fever, tachycardia
-Post surgical patients, history of STI
Septic Arthritis
Erythema, effusion, discharge, skin changes, wound
Warm and tender to touch
Restricted passive ROM, Guarded active ROM
Septic Arthritis
Diagnostic tests for Septic Arthritis
CBC, ESR, CRP
Joint fluid aspirate (Gram stain, Culture, Crystal Analysis)
Plain films
MRI
Treatment for Septic Arthritis
Supportive if having shock (IV, monitors, O2, VS, Bolus of IVF)
IV Antibiotics (Ceftriaxone, Vancomycin)
MEDEVAC
Venous clot formation, often in lower extremities
Virchow’s Triad:
-Hypercoagulability, Venous stasis, Endothelial Damage
Deep Vein Thrombosis
Risk factors for Deep Vein Thrombosis
MSK Surgery
Polytrauma
Spinal cord injuries
History of blood clots
Immobilization
Cancer history
Certain genetic conditions predisposing for clots
Estrogen use
Smoking
Diabetes
Obesity
Age
Venous thrombosis will become a ________ in most cases
Pulmonary embolism
Used as a clinical assessment to evaluate risk of PE
Wells Criteria
Pain in the limb, edema, erythema
Palpable veins, fever
Homans sign
PE
Disruption in the bone from repetitive or forceful trauma
Severe pain, swelling, decreased mobility
Limited weight bearing
Numbness, tingling, pallor, ecchymosis, deformity
Tenderness, crepitus, palpable deformity
ROM: Limited or Guarded
Fracture
Fracture
In anatomic alignment
Non-displaced
Fracture
Not in anatomic alignment; described as a percentage
Displaced
Fracture
Distal fragment overlaps proximal fragment
Bayonetted
Fracture
Fragments are separated
Distracted
Fracture
Deviation at an angle
Angulation
Diagnostic tests for a Fracture
Plain films (AP, Lat, Oblique) above and below joint -Repeat if suspicion is high but image is normal
Consider CT, MRI, U/S, or Bone Scan
Adverse outcomes of a fracture
Delayed union
Nonunion
Malunion
Joint contractures
Osteonecrosis
Osteomyelitis or infection
Neurovascular injury
Compartment syndrome
Treatment for Fracture revolves around what four R’s?
Recognition
Reduction
Retention of reduction while achieving union
Rehabilitation
Fracture
Factors that increase healing
Skeletal immaturity
Transverse fractures
Presence of adjacent bone for support
Anatomic alignment
Fracture
Factors that decrease healing
Smoking
Skeletal maturity
Oblique/Comminuted/Segmental Fractures
Marked displacement
Intraarticular fracture
Spondylarthropathy that is preceded and precipitated by infection in the body
-Urinary Tract Infection, Diarrheal illness, STIs
Incidence 10 per 1,000
Interval of days to weeks between infection and onset of pain
Reactive Arthritis
