Clin Med 2 Flashcards
STS epidemiology
peak onset at 15yo, male > female, rhabdomyosarcoma > osteosarcoma > Ewing’s sarcoma
is there screening for STS?
NO
STS ddx part 1
enchondroma (benign but can turn to chondrosarc), osteoid osteoma (prox femur –> NSAID), myositis ossificans (post traumatic)
STS ddx part 2
bone cyst, gout, brown tumors of hyperparathyroid (primary –> parathyroid adenoma, secondary –> chronic renal dz), osteomyelitis (Brodie’s abscess - hematogenous spread), Paget’s (endo dz)
STS risk factors
prior rad therapy, genetic ca syndromes
genetic ca syndromes: li fraumeni syndrome
germline mutation in TP53 tumor suppressor gene –> STS, osteosarc, RMS, fibrosarc, UPS; get whole body MRI
genetic ca syndromes: familial adenomatous polyposis (FAP)
auto dom colorectal ca syndrome, germline mutation in APC gene on chrm 5q21 –> adenomatous colon polyps –> CRC by 35-40yo
genetic ca syndromes: Gardner syndrome
variant of FAP w/ extracolonic manifestations like osteomas, skin cysts, hypertrophy of retinal epith, desmoid tumors/fibromatosis
genetic ca syndromes: Carney-Stratakis syndrome vs Hereditary retinoblastoma vs neurofibromatosis
auto dom –> GISTS, paragangliomas vs germline mutation in retinoblastoma tumor suppressor gene RB1 vs mutation in neurofibrin 1/2 gene (NF1/2) –> malig peripheral nerve sheath tumors
STS anatomic sites
extremities > visceral > retroperitoneum > trunk > head and neck
where are osteosarcs vs Ewing’s sarcs?
metaphyseal vs diaphyseal
STS diagnostic imging
XR (esp in children to min rad), MRI (gold standard), CT (sm cortical lesion, lung windows/metastases), angiogram (for vasc, resectability)
STS diagnostic bx
pre-tx core needle bx before diagnosis and grading; bx needs to be along future resection axis w/ minimal dissection and careful attn to hemostasis –> don’t do it yourself –> call the surgeon who’ll be operating to do bx; DON’T do needle aspiration/FNA
STS general tx
multidiscip care; spare limbs –> need good margins, neoadjuvant chemo +/- XRT if primary resection = difficult; allograft/rotationplasty/reconstruction; external beam rad, intraoperative RT, proton beam therapy
STS specific tx: osteosarc vs Ewing’s sarc vs chondrosarc
radio resistant, chemo sensitive –> neoadjuvant/preop chemo before surgery; recurrence in lung vs radio and chemo sensitive vs radio and chemo resistant
presentation: osteosarc vs Ewing’s sarc vs chondrosarc
painful swelling around knee/humerus, night pain and limping, firm/soft mass fixed to underlying bone, high ALP vs pain and constitutional sxs like osteomyelitis/sarc, can metastasize vs pain at lesion/mass (shoulder), can become high grade or de-differentiate
radiology: osteosarc vs Ewing’s sarc vs chondrosarc
Codman’s triangle vs onion skinning vs mass w/ matrix appearance
pathology: osteosarc vs Ewing’s sarc vs chondrosarc
osteoblasts secreting osteoid, cotton candy vs round and blue, no osteoid –> no cotton candy vs chondrocytes secreting cartilage
how does liposarcoma occur?
from adipocytes and has fatty tissue around sacromatous elements (spindle shaped sarcoma cells), develop from well-differentiated tumors in retroperitoneum then limbs
when does angiosarcoma occur?
can appear after rad therapy, assoc w/ chronic lymphedema; not good if >5cm or metastatic
GIST. tx?
GI stromal tumor that can occur anywhere in the GI tract, metastasize to liver. cKIT, PDGF, VEGF = inhibited by sm molec tyrosine kinases; adjuvant therapy for 3 y
Describe elbow
Links forearm and upper arm in concert w/ shoulder; uni-axial hinge joint
elbow stabilizers: static vs dynamic
bony structures vs muscles, ligaments, capsules
3 joints in elbow: humeroulnar vs humeroradial vs proximal radioulnar
True elbow joint, modified hinge joint for fl/ex vs combined hinge and pivot joint, some fl/ex and more rotation of radial head on capitulum of elbow vs rotation for supination and pronation
2 ligaments of elbow fxns: medial/ulnar collateral and lateral/radial collateral
Resists and prevents excessive ab/dduction; does not impede supination/pronation
what are the growth plates of elbow?
CRITOE/CRMTOL: Capitulum, radial head, internal/medial epicondyle, trochlea, olecranon, external/lateral epicondyle
Carrying angle. Cubitus valgus vs varus
Nmlly 15 degrees; female > male. >15 degrees d/t forearm deviating outwards vs <15 degrees d/t forearm deviating inwards
describe ulnar collateral ligament vs radial collateral ligament
has ant/post/transverse bundles, fan shaped ligament, impt stabilizer of valgus stress vs impt secondary stabilizer in fl/ex
Mechanism and sxs of lateral vs medial epicondylitis
overusing wrist extensor –> microtears of tendon at lat epicondyle —> tennis elbow; aches at region, difficulty wrist/mid finger extension and ADL vs overusing wrist flexors —> microtears of tendon at med epicondyle —> golfer’s elbow; tenderness at region, inc pain w/ resisted wrist flexion and forearm pronation, neg Tinnel’s at cubital tunnel
how to dx vs tx lat/med epicondylitis?
XR shows calcium deposits in extensors d/t microtears and chronicity of condition vs rest/ice, forearm splint/trap, OMM, rehab, acupuncture, steroid injection, surgery last resort
MCL/ulnar collateral sprain
repetitive valgus stress –> microtears or rupture –> gradual onset of pain, tenderness of humeroulnar joint, ulnar nerve irritation
how to dx vs tx MCL/ulnar collateral sprain
pain in valgus stress test and milking maneuver vs rest 2-4wks, NSAIDs, OMM/OT/PT, prolotherapy, surgery for persistent sxs
medial apophysitis
repetitive valgus stress –> microtears or rupture –> gradual or fast onset of pain at medial epicondyle w/ swelling or bruising, pain in late cocking or acceleration
how to dx vs tx vs prevent medial apophysitis
XR shows widening of apophyseal line –> partial or complete separation vs rest 2-3mo, NSAIDs, rehab vs pitch counts
primary injury vs secondary injury
trauma directly injuring cells vs body’s response to trauma (vasoconstriction –> dec blood flow and O2 –> cell death –> histamine release –> capillary permeability for fluid –> swelling and edema)
tissue injury and repair: phase I/days vs phase II/wks vs phase III/months
inflamm: red/heat/swell/pain/loss of fxn, neu/macs, vasodil/bleed, edema, phag; 2-4d vs fibroblastic repair: angiogenesis & type III collagen unorganized deposition –> weak scar tissue; day3-2wks vs maturation remodeling: wound contracture, type I collagen reorganization –> improve tensile strength to 80%; months
muscle injury vs tendon injury
ruptured myofibers ctx and gap filled w/ edema and scar tissue –> satellite cells/stem muscle cells prolif and regen –> new myofibers project into developing connective tissue scar vs tenocytes = reparative cells in tendons that activate collagen prod; tendons have less vascularity –> less O2 and nutrition supply –> slower to heal than muscles
goals of muscle rehab
dec pain, inflamm, effusion; return to full active & pain-free ROM, muscular strength/power/endurance, asx fxnal activities at preinjury lvl
acute vs subacute/intermediate vs chronic phase of muscle rehab
R (to manage inflamm), I (for vasoconstriction), C (limit edema), E (help lymphatic system move extracellular tissue away from injury site) vs emphasis on restoring fxn –> flexibility training, strengthening exer, re-est neuromuscular ctrl via proprioceptive exer vs healed connective tissue for tensile strength 80%, inc intensity strengthening exer
what does anterior interosseous n. innervate?
flexor digitorum profundus, flexor pollicis longus, pron quadratus
meds for pain/edema
analgesics, acetaminophen, NSAIDs (ibuprofen, naproxen), corticosteroids
when/why use heat vs ice vs electrical stimulation
for vasodil –> bad in phase I vs for vasoconstriction –> good in phase I vs analgesic, anti-edema
how does radial nerve split?
superficial branch => sensory; deep branch/posterior interosseous => motor, passes thru Arcade of Frohse where it’s most susceptible to injury
how to regain motion?
passive ROM, involuntary; active assisted ROM (assistance w/ unaffected extremity or device); active ROM, voluntary
osteochondritis dessicans of elbow
repetitive loading, limited blood supply –> subchondral fx, articular cartilage fx –> loose body formation from capitulum –> lat elbow pain, stiffness, locking, catching
how to tx osteochondritis dessicans of elbow
activity restriction/mods, OT/PT, NSAIDs, elbow arthroscopy w/ removal of loose bodies
valgus extension overload syndrome
medial laxity –> medial pain; lat compression near radial capitular joint –> lat pain; impingement posteriorly –> loss of extension and posterior pain, olecranon spurring
how to regain strength: isometric vs concentric vs eccentric ctx
joint doesn’t move, load stays in place but still has muscle ctx vs muscle shortens against resistance, isotonic (constant load) & isokinetic (constant vel) vs muscle lengthens against resistance, isotonic & isokinetic; restores strength and fxn in athletes w/ tendonitis
neuromuscular ctrl. goal?
for joint stability, not strength; requires afferent/proprioceptive input to produce efferent/muscle ctx output. counteract post-injury inhibition to allow more nml use of surround musculature
neuromuscular ctrl exer: early vs late vs much later
AROM, wobble board vs rhythmic stabilization vs plyometrics
when to use therapeutic modalities?
in adjunct to rehab; don’t use independently
thermotherapy
using heat or cold –> arterial blood flow (inc blood flow/vasodil or dec blood flow/vasoconstrict) or collagen extensibility (inc tendon extensibility and collagenase activity or dec enzyme activity)
what temp injures tissue?
<32 degrees F or >113-122 degrees F
examples of conduction vs convection in cryotherapy
cold packs, ice massage, cold-compression device vs vapocoolant spray, cold water immersion
factors determining heat-absorbing capacity of cold modalities
pt’s mass, size of contact area, diff in temp b/w modality and tissue (greater ability of cold modality to absorb heat –> greater potential for reducing tissue temp), distance across which heat = transferred
indications vs precautions for cryotherapy
acute injuries to minimize inflamm, ctrl pain and neuromuscular inhibition vs cold intolerance/hypersensitivity, Raynaud’s dz, arterial insufficiency, impaired sensation, cog deficits/inability to communicate, cardiac/resp involvement b/c it raises bp
which phase of injury&repair to do heat modalities? therapeutic effects?
after acute phase of inflamm/phase I. dec muscle spasm, pain, joint stiffness; inc circ
conduction vs convection vs radiation of heat therapy w/ examples
transfer heat b/w 2 bodies at diff temps thru direct contact; hot pack, heating pad, parraffin bath vs transfer heat via fluid circ over surface of body; fluidotherapy (air), hydrotherapy (water, whirlpool) vs transfer heat thru conversion of electromagnetic radiation into heat energy; radiant heat
indications vs precautions for heat therapy
arthritis, chronic pain vs ischemia, bleeding d/o, impaired sensations, cog deficits/inability to communicate, malignancy, edema
superficial vs deep heat therapy
<2cm vs >2cm; US, nonthermal shortwave diathermy, microwave diathermy
deep heat therapy: therapeutic vs thermal vs nonthermal US
use acoustic energy above hearing range –> 1-3MHz (medical US uses 1-10MHz); improve healing or alter fxn vs inc tissue temp to 40-45 degrees C; you’ll heat more bone > tendon > skin/muscle/fat; <40C –> no change, >45C –> tissue dmg vs repair/regen dmged tissue; acoustic cavitation: gas bubbles oscillate and burst –> disrupt tissue, acoustic streaming: unidirectional movement from US waves
therapeutic US: phonophoresis
use sound waves to drive whole molec thru skin into underlying tissue; transport limited by stratum corneum (permeability depends on hydration, abrasions inc drug absorption, follicles primarily transport –> heat skin –> better drug absorption)
electrotherapy
use electricity to generate AP –> alter sensory input or cause muscle ctx –> inc joint ROM, muscle strength, circ; dec muscle atrophy and spasm; release polypeptides & neurotransmitters; inhibit pain fibers; transport meds
indications vs precautions of electrotherapy
pain, arthritis ROM, joint effusion, muscle stimulation/education, muscle disuse atrophy, meds delivery vs stimulation over carotid sinus & heart, preg, sz, acute fx, hemorrhage, impaired sensation, malignancy
3 categories of nerve injuries: neurapraxia-focal vs axonotmesis vs neurotmesis
dmg of myelin sheaths around axon vs dmg to axon itself vs complete disruption of axon
electrotherapy: iontophoresis
use electric current to transport meds thru skin; meds must dissociate into electrically charged ions in soln; tx lasts 10-20min
indications vs precautions of axial/spinal traction
reduction of nerve or disc compression, pain/muscle spasm, loosening adhesions in dural sleeve vs congenital spine deformity, cervical spine (ligamentous instability, vertebrobasilar insufficiency), lumbar spine (preg, AAA), osteopenia/porosis, infxn
electrotherapy: transcutaneous nerve stimulation (TENS)A
pulse, sensory lvl stimulation to interfere transmission of pain signals in spinal cord –> placebo, gateway theory, release of endogenous opioids; 30-60min for 8hrs/d
electrotherapy: neuromuscular electrical stimulation (E-Stim). indications vs precautions
electrical stimulation above motor activation threshold to cause muscles ctx. strengthen muscle and maintain muscle mass, enhance voluntary muscle ctrl vs stimulation over heart & neck, pacemakers, preg, sz, impaired sensation, malignancy, infxn
low lvl laser therapy. precautions?
use laser to tissues up to 36.5 degrees C => “cold laser”. w/in 6mo of rad therapy, preg, unfused epiphyseal plates/small children, over-cancerous areas, eyes, hemorrhage
dry needling
thin filiform needle to penetrate skin and stimulate underlying myofascial trigger points, muscular and connective tissues for neuroMSK pain and movement impairments –> release tension
adverse effects vs precautions of dry needling
pneumothorax vs local skin lesions/infxn, severe hyperalgesia, metal allergies, abnl bleeding, vasc dz, 1st trimester
acupuncture
stimulate specific points/meridians to balanc emovemnt and restroe ehalth; for acute and chronic med problems
massage. indications vs precautions
applying hands to soft tissue to improve circ and break down soft tissue adhesions. muscle cramps, stress/tension, edema vs local infxn, inflamm arthritis, open wounds, bleeding d/o, malignancy, entrapment neuropathy
extracorporeal shockwave therapy. indications vs adverse effect
noninvasive high energy pulse thru skin to target tissue –> induc inflamm to initiate nml healing. plantar fasciitis, calcific tendinopathy of shoulder, Achilles’ tendinopathy, patellar tendinopathy vs discomfort
bacteria causing osteomyelitis
s. aureus/epi, H. flu, salmonella in sickle cell, Pseudomonas in IVDU
acute vs subacute vs chronic osteomyelitis
“great pretender”, direct contiguous (neg), hematogenous (50%), periosteal pus cx (75%); no fever, erythema, drainage vs Brodie’s abscess: round radiolucency w/ thick surrounding sclerosis; no fever, constitutional sxs; pus cx –> s. aureus vs sequestrum (necrotic bone), involucrum (thick bony collar to wall of infxn), cloaca (defect in involucrum)
complications of osteomyelitis
pathologic fx, septic arthritis, growth disturbance, sq cell ca, amyloidosis
bacteria causing acute vs chronic septic arthritis
pyogenic bacteria or virus vs non-Candida fungi, mycoTB, spirochetes
toxins vs sxs vs dx vs tx of gonococcal septic arthritis
lack Opa proteins, protein 1A, antigenic LPS vs dermatitis, tenosynovitis, polyarthralgia, fever/chills vs NAAT, Thayer Martin, blood cx, synovial fluid cx, low glu vs ceftriaxone
what kind of distribution does nongono arthritis affect? how does it spread?
bimodal (1-5yo and >60yo). from contiguous infected foci (epiphyseal osteomyelitis); from neighboring soft tissue infection (like skin infxn); Direct inoculation of bacteria through joint interventions or surgery (like prosthetic joints)
toxins by nongono arthritis
s. aureus have fibrinogen binding protein and MSCRMMS, K. kingae have pili, s. agalactiae have fibrinogen binding adhesin
which joints are infected in IVDU?
sternoclavicular and sternomanubrial joints
pathology of nongono arthritis
purulent synovial fluid, ulceration of cartilage –> irreversible joint loss, inflamm of pannus, Exposure of subchondral bone, Obliteration of the joint space by fibrous ankylosis
sx vs dx vs tx of nongono arthritis
fever, malaise, dec ROM vs synovial fluid cx, blood cx, leukocytosis w/ L shift, low glu vs parenteral abx therapy
bacteria causing prosthetic joint infxn. how?
s. aureus/epi, gram neg bacilli. direct inoculation, biofilm
early vs delayed vs late onset of prosthetic joint infxn
s. aureus –> acute fulm illness vs s. epi –> long indolent course vs dental (viridans), GI/U (E coli, Pseudomonas), pyogenic (s. aureus/epi)
dx vs tx of prosthetic joint infxn
synovial fluid analysis (pathogen must be found in 2 periprosthetic samples), tissue bx vs device removal, 2-stage exchange arthroplasty
early local vs early dis vs late dis vs PTLLS lyme dz
EM vs EM, acute meningitis w/ neck stiff and HA, facial palsy, transient AV block vs pauciarthralgia vs warm joints w/ large effusion, radiculoneuritis; late stage dz in txed pts, no bacteria found
dx vs tx lyme dz
ELISA + West blot vs doxy, amox, cefuroxime
polyarthritis w/ RF. dx vs tx
polyarticular, migratory. Synovial fluid analysis: sterile inflammatory fluid vs resolves its own
clostridial vs strep myonec
C. septicum enter body via mucosal lining or bowel wall; ABCDE strain/toxin; purple skin, gas prod, fever/tachy; leukocytosis w/ L shift, hemolytic anemia, inc ESR/CK/aldolase/LDH/potassium, gas in tissue; surgical debride, piperacillin + clindamycin vs S. pyogenes enter prox muscles of LE; Spe pyrogenic toxins bind to both macrophages and CD4 T cells → high levels of cytokines; early (NVD, flu like sxs), intermediate (muscle pain/spasm), late (hypoTN, tachy, organ failure); leukocytosis w/ L shift, inc ESR/CK, abnl liver and renal fxn, CT/MRI: muscle thickening/edema/lymphadenopathy; penicillin + clindamycin
complications of calcaneal fx
wound dehiscence, lost talar motion, dystrophy/CRPS, inc heel width
Maison fx
prox 1/3 of fib, tear in syndesmosis/inteross mem, GET KNEE XR
How to tx Charcot joint?
nonop: splint/cast/edema ctrl
op: fusion/osteotomies/amputation
what does bone scan vs MRI show for LCP?
dec uptake w/ dec blood flow vs bone marrow changes
