Clin Med MSK - Rheum - Lec 1 Flashcards
Osteoporosis RFs
- postmenopausal women
- Decr in estrogen
- persons ≥ 65 years old
- white & Asian people
- small body frame
What is the 1 year mortality in white women after a hip fracture?
40%
Medical conditions that can lead to osteoporosis
- endocrine disorders
- GI disorders
- hematologic disorders
- rheumatologic & autoimmune disorders
- CNS disorders
- meds (anticoag, hormonal therapy, glucocorticoids, immunosuppressants, lithium)
Common fractures seen w/ osteoporosis
- femoral neck fractures
- pathologic fractures of vertebrae
- lumbar & thoracic vertebral fractures
- distal radius fractures
What is a fragility fracture?
any fall from a standing height or less that results in a fracture
Who is screened for Osteoporosis?
- all women ≥ 65yo & all men ≥ 70yo
- postmeno women < 65yo
- perimeno women & men aged 50-69yo w/clinical RFs for fracture
- any adult w/ fracture after age 50
- any adult w/ condition (such as RA) or meds (such as glucocorticoids ≥ 3 months) assoc. w/ low bone mass or bone loss
What is the T-score used in osteoporosis?
of standard deviations above or below mean for a gender & ethnicity-matched young adult healthy population
Describe the levels of a T-score
- normal (>/= -1)
- low bone mass (osteopenia) (-1 to -2.5)
- osteoporosis (≤ -2.5)
- severe or established osteoporosis (</= -2.5 & >/= 1 fracture)
Osteoporosis Dx - Labs
- Minimal workup: Serum Ca++, 25-hydroxyvitamin D, TSH
- Additional workup (looking for 2ndary causes)
- BUN
- Cr
- Albumin
- Serum Ca++
- Phosphate
- PTH
Osteoporosis Tx
- proper Ca++ & Vit D intake
- Exercise
- stop smoking
- avoid excess alcohol intake
- Bisphosphonates (1st line)
- Other tx: PTH, selective estrogen response modulators, calcitonin
What is FRAX? & what doe it take into account?
Fracture Risk Assessment Tool
- predicts 10 year risk of fracture
- age, weight, height, smoking status, etoh intake, Fx, femoral neck BMD
When do we use FRAX?
to determine if a person w/ osteopenia should go on a bisphosphonate
Ankylosing Spondylitis RFs
- Family History
- Presence of HLA-B27
- Associated w/ IBD, anterior uveitis, psoriasis
Ankylosing spondylitis back pain criteria
back pain lasting > 3 months, in patient aged < 45 years
Characteristics of ankylosing spondylitis pain
- worse upon waking or after rest
- lasts ≥ 30 minutes
- assoc. w/ morning stiffness
- improves w/ activity or exercise, but not w/ rest
- may occur at night, awaking pt
- spinal stiffness & loss of mobility
Ankylosing spondylitis stooped posture may include…
- incr flexion deformity of neck
- incr thoracic kyphosis
- loss of normal lumbar lordosis
Ankylosing Spondylitis Dx Criteria
- pts w/ >/= 3mo back pain & less than 45yo
PLUS - Sacroiliitis on imaging & >/= 1 SpA feature
OR - HLA-B27 & >/= other SpA features
Ankylosing Spondylitis SpA features
- Crohn’s/colitis
- HLA-B27
- Enthesitis (heel)
- Arthritis
- Psoriasis
- Elevated CRP
- Dactylitis
- FHx
- Uveitis
- Good response to NSAIDs
What can be seen on X-ray in Ankylosing Spondylitis?
sacroiliitis & bamboo spine
Ankylosing Spondylitis Tx
- Non-pharmaco Tx: exercise & PT
- Pharmaco Tx: NSAIDs, TNF inhibitors, Interleukin 17 inhibitors
- Spinal surg, hip arthroplasty in severe cases
Fibromyalgia RFs
- 1st degree relative w/ fibromyalgia
- female
- infx (for Lyme dz,hep C)
- stress (ACEs, illness, trauma, psychosocial)
- physical trauma or injury
Associated condition with Fibromyalgia
- women: dysmenorrhea, interstitial cystitis, endometriosis
- Chronic fatigue syndrome, IBS, chronic HA
When should you expect fibromyalgia in a patient?
patients who present w/ multifocal pain that don’t have damage or inflammation in affected
Fibromyalgia Labs
- CBC
- ESR
- CRP
- Creatine kinase
- Metabolic panel
- Thyroid function testing
- Anti-nuclear Ab
- RF
Fibromyalgia Tx
- Goal is to incr quality of life
- Pharmacologic therapies
- Cognitive behavioral therapy (1)
What can be done to increase quality of life in fibromyalgia patients?
- Exercise
- Eat healthy
- Good sleep habits
Which classes of drugs & examples can be used to treat fibromyalgia?
- Muscle relaxants (Cyclobenzaprine)
- Antidepressants (Amitriptyline, Duloxetine, Milnacipran)
- Anticonvulsants (Pregabalin)
- Analgesic (Tramadol)
Describe Budapest Criteria used for complex regional pain syndrome
- continuing pain that is disproportionate to any inciting event
- > /= 1 sign in >/= of the categories
- > /= 1 symp in >/= of the symp list below & >/= 1 sign in >/= 2 signs list below
- No other Dx can better explain S/S
Complex Regional Pain Syndrome Tx
- PT/OT
- Meds: gabapentin, corticosteroids, ketamine
- Cognitive behavioral therapy
Gout dietary factors
- red meat
- seafood
- alcohol, especially beer
- sugar-sweetened beverages (fructose rapidly incr serum urate level)
Uric acids is byproduct of…
the breakdown of DNA/RNA
What conditions will cause underexcretion of uric acid?
- Renal impairment
- HTN
- Diuretics
- Ethanol
What conditions will cause overproduction of uric acid?
- Genetic disorders
- Excessive purine intake
- Sickle cell anemia
Gout Dx
- GS - monosodium urate crystals insynovial fluid analysis
–> Negatively birefringent needle shaped crystals - If it is not possible to get synovial fluid, an incr serum uric acid is a good clue (over 6)
- X-ray: may have ”mouse bite”/punched out erosions
Describe synovial fluid analysis results for gout
Gross appearance:
Volume:
Viscosity:
WBC:
Polymorphonuclear cells:
Crystal analysis:
Glucose []:
Gross appearance: Opaque
Volume: 5 - 50
Viscosity: Low
WBC: 500 - 75,000
Polymorphonuclear cells: >50
Crystal analysis: (-) birefringent
Glucose []: serum glucose
Gout Immediate Tx
- Prednisone (1st line)
- NSAID (indomethacin) (2nd line)
- Pain meds
- Colchicine (4th line)
Gout Prevention Tx
- Allopurinol
- Probenecid
- Colchicine
Pseudogout can affect what joints?
any joint but most commonly the knee
other joints: wrist, hand, pelvis, hip
Is pseudogout monoarthritis or polyarthritis?
monoarthritis (89%) > polyarthritis (11%)
Pseudogout Dx
- definitive dx ID Ca++ pyrophosphate dihydrate crystals insynovial fluid or biopsied tissue - (+) birefringence
- detection of chondrocalcinosis onx-ray
Describe synovial fluid analysis results for pseudogout
Gross appearance:
Volume:
Viscosity:
WBC:
Polymorphonuclear cells:
Crystal analysis:
Glucose []:
Gross appearance: Opaque
Volume: 5 - 50
Viscosity: Low
WBC: 500 - 75,000
Polymorphonuclear cells: >50
Crystal analysis: (+) birefringent
Glucose []: serum glucose
Pseudogout Acute Tx
- Steroids (1st line)
- NSAIDS (2nd line)
- Colchicine -can be used for prevention as well- (3rd line)
What role do proinflammatory chemicals play in RA?
cause development of proteases which break down the cartilage and cause arthritis
In RA, proinflammatory chemicals move through the blood to what other organs causing…?
- Vasculitis
- Lung fibrosis
- Liver disease
- Splenomegaly
RA genetic RFs
- HLA-DRB1 gene
- Epigenetic modifications
RA non-genetic RFs
- smoking
- microbiota
- female
- western diet
- ethnic factors
RA Dx - Labs
- RF (sensitive but not specific)
- Anti-Citrullinated Peptide Antibodies (very specific)
- ESR/CRP high (not specific)
- Arthritis > 3 joints, morning stiffness, disease duration > 6 wks
RA Dx - Imaging
- X-rays: narrowed joint space w/ osteopenia & erosions, deformities
How does the Criteria from American College of Rheumatology work?
6 points needed for Dx
- the more small joint involvement the more points you get
RA Tx
- Target outcome is remission through use of dz-modifying agents (DMARDS)–> methotrexate
- NSAIDS or steroids for acute flares
What is one of the most common chronic dz in children
Juvenile Idiopathic Arthritis (JIA)
Juvenile Idiopathic Arthritis Dx - Labs
- No specific test - Dx of exclusion
- elevated ESR, CRP
- RF (+) in about 15%
Juvenile Idiopathic Arthritis Dx - Imaging
X-ray may show soft tissue swelling, usually no joint damage early in dz
Juvenile Idiopathic Arthritis Tx
- DMARDS - methotrexate - 1st line
- NSAIDS
- Steroid joint injections
Psoriatic Arthritis Dx
- clinical dx in pts w/ joint inflammation, absence of RF, & typical psoriatic skin & nail lesions
Psoriatic Arthritis X-ray findings
“pencil in cup” deformity
CASPAR criteria: joint inflammation + >/= 3 of the following
- current psoriasis, personal Hx of psoriasis, or family Hx of psoriasis
- typical psoriatic nail dystrophy, including onycholysis, pitting & hyperkeratosis
- RF (-)
- current or Hx of dactylitis (sausage fingers)
- radiologic evidence
Psoriatic Arthritis Tx
- Manage skin dz
- NSAIDS, corticosteroids, DMARDS
How long do arthritic symptoms typically last in reactive arthritis?
3 - 5 months
What is keratoderma blenorrhagica?
scaly rash typically on palms, soles, trunk, scalp, and/or scrotum
Reactive Arthritis Dx - Labs
- No universally accepted criteria for dx
- HLA-B27 positive (80%)
- Look for underlying infx (don’t miss gonorrhea/chlamydia)
- ESR/CRP likely elevated
Reactive Arthritis Dx - imaging
X-rays will be normal for 1st several months of dz, then show ill defined erosions
Reactive Arthritis Tx
- Antimicrobial therapy if needed
- NSAIDS
–> If NSAIDS not helping –> methotrexate–> steroids–> Anti TNF - Steroid joint injections can provide pain relief
How long do arthritic symptoms typically last in reactive arthritis?
3 - 5 months
How long will it take for pts to have complete remission in reactive arthritis?
6 - 12 months
SLE Dx
- have 2 or more systems involved
- look at sticky notes on notes
SLE Tx
- minimizing organ damage, reduce flares & optimize quality of life
- Hydroxychloroquine
- NSAIDS
- Steroids
- Methotrexate
Systemic Sclerosis (Scleroderma) Dx
- (+) ANA (non specific)
- (+) anti centromere Ab (more specific to CREST syndrome)
- (+) scleroderma Ab (SCL-70)
Systemic Sclerosis (Scleroderma) Tx
- DMARDS (methotrexate)
- Steroids
- CCB for Raynaud’s
What are the 2 types of scleroderma?
- Limited Cutaneous Systemic Sclerosis (CREST syndrome)
- Diffuse Cutaneous Systemic Sclerosis
What does CREST syndrome stand for
- Calcinosis: calcific nodules in skin
- Raynaud’s phenomenon
- Esophageal dysmotility
- Sclerodactyly
- Telangiectasia
What is the most common type of Scleroderma?
CREST syndrome
CREST syndrome commonly affects…
- face
- neck
- distal elbows & knees
Diffuse Cutaneous Systemic Sclerosis affects…
trunk & proximal extremities
What organs & systems may be involved in SLE?
- kidneys
- skin
- Msk system
- CV system
- CNS & PNS
- blood
Polyarteritis Nodosa Dx
- no lab tests or specific markers specific
- serology for hep B&C virus, parvovirus B19, or other chronic viral infx
- antistreptolysin O titers
- CBC, kidney & liver function
- incr ESR/CRP
- Angiogram will most likely show abnormalities
- BIOPSY at symptomatic site (preferably skin or muscle) to CONFIRM
Polyarteritis Nodosa Tx
- High dose Corticosteroids
- Pulse methylprednisolone for critically ill pts
Polymyalgia Rheumatica Dx
- No specific labs, but will use labs to rule out other dz
- Imaging not routinely needed
Polymyalgia Rheumatica Tx
- Prednisone, 10–20 mg/day PO; if no dramatic improvement w/n 72 hrs, the dx should be revisited
- Weekly methotrexate may incr successful prednisone taper
Polymyalgia Rheumatica Prognosis?
1–2 months
can have flares as prednisone is tapered
Giant Cell Arteritis/Temporal Arteritis Dx
- ESR very elevated
Giant Cell Arteritis
- MRI or CT angiography establishes the dx by demonstrating long stretches of narrowing of the subclavian & axillary arteries
Temporal Arteritis
- May see changes w/ US
- Temporal Artery Biopsy for definitive dx
Giant Cell Arteritis Tx
- Prednisone
- Low-dose aspirin–> reduce stroke & vision loss
- tx last 6mo to >2yrs
Polymyositis Dx
elevated CK, muscle biopsy definitive
Polymyositis Tx
Steroids, methotrexate
Sjogren’s Syndrome Dx
- Rheumatoid factor (+)
- Anti-ro & Anti-la antibodies
- The Schirmer test measures the quantity of tears secreted
- Salivary gland biopsy if other diagnostics unclear
Sjogren’s Syndrome Tx
- symptom relief & prevention of complications
- Pilocarpine can help reduce symptoms
- Artificial tears
Osteosarcoma Dx
Radiographs
- “Codman triangle”
–> New rim of bone forming b/c tumor
- “Sunburst”
–> Inflammation & extra bony growth coming of bone
Osteosarcoma Tx
Immediate referral - MSK oncologist
- Chemo
- Amputation
- Limb salvaging surg (90%)
Ewing’s Sarcoma Dx
- ESR – Elevated
- Bone marrow aspiration & tumor biopsy
Radiographs
- Large lytic lesion of metaphysis or diaphysis of long bone
- Characteristic “onion skin” appearance
Ewing’s Sarcoma Tx
- Refer immediately to a MSK oncologist
- Chemo & irradiation
- Possible surgical resection
Chondrosarcoma Dx
Radiographs
- Intramedullary lesion w/ stippled & ring-like calcification
- Substantial erosion, thickening, & bone destruction
- MRI – more accurate for extent of tumor
Chondrosarcoma Tx
- Refer for surgery
- No chemo usually needed (don’t respond well b/c of slowly differentiating cells)
Osteochondroma Dx
Radiographs
- Compact, pedunculated protuberance of bone
(big outpouching of bone)
Osteochondroma Tx
- May be left untx unless symp
- Analgesics for minor aches
Compartment Syndrome Dx
- Calculate delta pressure
–> check twice
Compartment Syndrome Tx
Referral/Consult for immediate fasciotomy
Osteomyelitis Dx
Radiographs
- Soft tissue swelling
- Osteopenia, bone resorption, new periosteal bone formation
- MRI – TEST OF CHOICE
Osteomyelitis Tx
- ID organism
- Surg debridement (non-hemato)
- Abx therapy
- Consult infx dz & ortho
Osteomyelitis: Children Abx Tx
- Children < 3 mos: IV oxacillin + cefoxatime
- Children > 3 mos: IV oxacillin ± vanc
–> PNC allergic: vanc alone
Osteomyelitis: Adult Abx Tx
Vanc + ceftriaxone
How long is IV Abx Tx for Osteomyelitis?
- Usually IV Abx - 5-10 days or until C&S is back
- Continue for 4-6 weeks
What is the WBC count for Septic arthritis?
> 50,000/mcL
Septic Arthritis Dx
- Aspirate affected joint
–> Cell count w/ diff
–> Gram stain
–> Crystal
–> C&S - Blood cultures
- Radiographs
–>Help to rule out osteomyelitis
Describe what aspirate looks like in septic arthritis.
Gross appearance:
Volume:
Viscosity:
WBC:
Neutrophils:
Gram stain:
Crystals:
- Gross appearance: Yellow/green
Volume: Cloudy/opaque
Viscosity: decr viscosity
WBC: >50,000 WBC count
Neutrophils: >75%
Gram stain: (+)
Crystals: (-)
Septic arthritis Abx Tx
for 6 ish weeks of Abx (2-4 wks IV then 2-3 weeks PO)
- Vanc (1 g IV bid, adjusted for age, weight & renal function) + either:
—> ceftriaxone if concomitant meningitis or endocarditis is suspected)
—> cefotaxime 1 g IV q 8h
—> ceftazidime 1 g IV q 8h
Septic arthritis Non-Abx Tx
- Frequent aspirations (total WBC count is decr, fluid becoming sterile)
- NWB
- Immobilize the joint
- Consult ortho for surg debridement
