CLINICAL CARE OF THE MUSCULOSKELETAL SYSTEM Flashcards
What issue? how would you treat?
Major cause of chest pain in the ambulatory setting
(1) Reported ranges of 10-50% of patients
(2) Chest pain is said to “reproducible”
(3) Able to exacerbate pain with palpation on physical exam
(4) Causes of this syndrome poorly studied and documented
(5) Likely secondary to viral illness and other causes of inflammation
(6) Other rheumatic diseases such as fibromyalgia a common cause of chest wall pain
Costochondritis
Most cases improve course of few weeks:
(1) NSAIDS
(2) Home stretching program
(3) Activity modification
Osteoarthritis affects an estimated 30 million people in the US:
(1) Knee joint accounts for approximately ___% of cases
(2) Also affects:
- a) Hand
- (b) Spine
- (c) Hip
80%
Risk factors are numerous and include:
(1) Age: More common in ____ population
(2) In general population age over __ y/o
(3) Gender: Greater risk in _____
(4) 1.7 times as likely as ____
(5) Family history
(6) ____ injuries
(7) Chronic inflammation
(8) Obesity
(9) Occupation
(10) Heavy workload
1) older
2) 50
3) females
4) males
6) Joint
What dx/Tx Symptoms (1) Pain that is exacerbated with use, alleviated with rest (2) Pain is aching, deep in later stages (3) Sharp pain in beginning stages Physical Exam (1) Visual = Bony swelling possible (2) Palpation = Joint line tenderness, crepitus (3) ROM = Limited (4) Muscle Test = Unremarkable (5) Neurovascular = Unremarkable (6) Special Test = Depends on affected joint
Osteoarthritis Treatment (1) Control pain (a) NSAIDS (b) Tylenol (2) Stop insult to cartilage (3) Rehabilitation
What is considered to Stop insult to cartilage when treating osteoarthritis
(a) Activity/lifestyle modification
(b) Weight reduction
(c) Loss of 10% body weight associated with 50% reduction in pain over 18 months
Common examples of Inflammatory arthroses are
- rheumatoid arthritis
- reactive arthritis
- psoriatic arthritis
- ankylosing spondylitis
What Dx/Tx
(1) Unknown etiology
-(a) Autoimmune disorder
-(b) Mostly small joints and bilateral: hands, finger, wrists, feet, ankle
-(c) Insidious onset, distal joints first (DIPJ of hands are spared)
-(d) Extra-articular manifestations (pulm, CV, eyes)
Symptoms
-(a) 4 of 7 ACR criteria:
-(b) Morning stiffness (1 hour for 6 weeks)
-(c) Arthritis (>/= 3 joints for 6 weeks)
-(d) Swelling of hand joints (6 weeks)
-(e) Symmetrical joint swelling (6 weeks)
-(f) Rheumatoid nodules
-(g) Positive RF factor
-(h) Erosions or osteopenia in hand XR
-(i) May have myelopathy with C1-C2 involvement
Physical Exam
(a) Visual
-1) Nodules (elbow mostly)
-2) Swelling/hypertrophy (esp PIP early sign)
-3) Swan neck deformity
-4) Lateral drift of toes
(b) Palpation = Boggy sensation
(c) ROM = Diminished and painful
(d) Muscle Test = Reduced grip strength
(e) Neurovascular = Numbness and tingling in the affected nerve
(f) Special Test = None
Rheumatoid Arthritis
Treatment
(a) MEDAVICE with GMO or refer to Internal Medicine
(b) Typical medications used:
1) NSAID/Tylenol
2) DMARD (Disease-Modifying Anti- Rheumatic Drug)
a) -Ab, , etanercept, methotrexate, hydroxychloroquine, cyclosporine
(c) Physical Therapy/Surgery
Diagnostic Tests for suspected Rheumatoid arthritis
Laboratory studies 1) Rheumatoid Factor (RF) 2) Antibody to cyclic citrullinated peptide (Anti-CCP) 3) C-reactive Protein (CRP) 4) Erythrocyte Sedimentation Rate (ESR) Plain Films
Clinical Manifestations
(a) Acute onset of joint pain 1-4 weeks after infection
(b) Peripheral arthritis in Knees, Small joints of hands/wrists
(c) Enthesitis - Achilles tendon commonly involved
- -1) Inflammation of insertion sites of ligaments, tendons, fascia
(d) Dactylitis (“sausage digits”)
(e) Lower back pain
(f) Extra articular manifestations:
- -1) Nail changes
- -2) Conjunctivitis, anterior uveitis
- -3) Oral lesions
Reactive Arthritis Treatment (a) Treat infection if active (b) Symptoms self-limited, May last up to 6 months (c) NSAIDS for pain (d) Severe cases -1) Refer to specialist -2) DMARDS/steroids considered
What is Enthesitis
Inflammation of insertion sites of ligaments, tendons, fascia
what is Dactylitis
Sausage digits
Reactive Arthritis In a patient with active infection consider testing 1) Joint effusion: \_\_\_\_\_ 2) Active diarrhea: \_\_\_\_\_\_ 3) GU symptoms: \_\_\_\_\_\_\_\_
- Arthrocentesis
- Stool cultures
- UA and STD panel
What Dx/ Tx
Associated with a derm issue
Clinical Manifestations
(a) Pain and stiffness in affected joints
–1) Stiffness sometimes alleviated by physical activity
(b) Asymmetric distribution of joint pain
–1) SI joint, large joints (such as knee), small joints (such as DIP)
(c) Majority have skin lesions prior to pain
–1) Pain may precede lesions
(d) Soft tissue inflammation: Enthesitis, dactylitis, tenosynovitis
(e) Nail lesions
(f) Ocular involvement
Psoriatic Arthritis Do not attempt to manage 1) Refer to rheumatology and dermatology 2) Treat symptoms in the interim 3) NSAIDs 4) DMARDs to be considered by specialist
What issue?
(a) Common inflammatory skin disease
(b) Most common manifestation: well demarcated erythematous plaques with silver scale
psoriasis
True/False
Diagnosis for Psoriatic Arthritis made in patient who has both psoriasis and classic arthritis pattern
true
What issue? Clinical Symptoms (a) Back pain in almost all patients (b) “Bamboo spine”: severe restriction in back mobility seen in about half of patients in later stages of disease progression Large joints involved: (a) Sacroiliac joint, spine, hip, shoulder (b) Peripheral arthritis common (c) Chest wall inflammation (d) Enthesitis (e) Dactylitis
Ankylosing Spondylitis
Tx for Ankylosing Spondylitis
a) For our purposes, recognize and refer
(b) Initial pain relief with _____
(c) Expect use of _____ after rheumatology referral
(d) Minimize damage to spine
(e) Minimize other manifestations
(f) _______ screening and surveillance
b) NSAIDs
c) DMARDs
f) Psychological
What is defined as Monosodium urate crystal deposition in joints and tissues.
Gout
Most patients with gout have ______
hyperuricemia (elevated uric acid)
True/False
Gout is Multiarticular 80% of the time
FALSE
MONOARTICULAR
What issue/ Tx usually monoarticular involvement Common sites of involvement (a) 1st toe, ankle, knee, wrist, fingers, elbow (5) Intense pain, redness, swelling (6) Occurs in hours to days b. Physical Exam (1) Visual = Swelling, erythema; tophi (2) Palpation = Severe tenderness even to light touch (3) ROM = Limited and guarded (4) Muscle Test = Unremarkable (5) Neurovascular =Unremarkable (6) Special test = None
Gout
(1) Acute Episode
- (a) NSAID (Indomethacin)
- (b) Colchicine (n/v/d; bone marrow suppression, neuropathy)
- (c) Steroids
(2) Prophylaxis
(3) Diet modification
What are the prophylaxis meds for Gout.
(a) Allopurinol (overproducers)
b) Probenecid (underexcreters; UA <600mg/day
Diet modification for Gout pts
Avoid:
1) Meat
2) Seafood
3) Alcohol
4) High-fructose corn syrup
Referral Decisions Gout
(1) _______ deformity or destruction
(2) Large _____ masses
(3) Metabolic problems
(4) All patients should see MO for consideration of _______
1) Joint
2) tophaceous
4) prophylaxis
Gout Laboratory Tests
(a) Uric acid
(b) Chem Panel
(c) TSH, Iron Panel
(d) WBC
(e) NEEDLE SHAPED, NEGATIVE BIREFRINGENT
What Issue?
Similar clinical presentation to gout
(a) Intensely painful, joint swelling, erythema
(b) Large joints such as the knee often affected
Uric acid levels are NORMAL
(a) Pathophysiology is based on calcium pyrophosphate deposition (CPPD)
Pseudogout
What Issue / Tx
Infection of the joint space from or more of the following
(1) Direct inoculation, hematogenous spread, or from a bone infection
(2) Staphylococcus aureus most common
(3) Severe pain, swelling, decreased mobility
(4) Difficulty bearing weight
(5) Fever, tachycardia
(6) Post-surgical patients
(7) Previous STI
b. Physical Exam
(1) Visual = Erythema, effusion, discharge, skin changes, wound
(2) Palpation = Warm and tender
(3) ROM = Restricted passive ROM; Guarded active ROM
(4) Muscle Test = Limited
(5) Neurovascular = Unremarkable
(6) Special test = None
Septic Arthritis
Treatment
(1) Supportive if having shock (IV, monitors, O2, VS, bolus of IVF)
(2) IV antibiotics (ceftriaxone, vancomycin)
(3) MEDEVAC
Fractures are Classified by:
Location orientation extent of fracture line displacement skin integrity
Fracture classification Displacement
(1) Non-displaced - ____
(2) Displaced - ___________________
(3) Bayonetted - ____________________
(4) Distracted - ___________________
(5) Angulation - __________________
- in anatomic alignment
- not in anatomic alignment; described as a percentage
- distal fragment overlaps proximal fragment
- fragments are separated
- deviation at an angle
Treatment for Fractures 4R’s
(a) Recognition
(b) Reduction
(c) Retention of reduction while achieving union
(d) Rehabilitation
Splinting
(1) Check pulses and sensation before and after a splint
(2) _____ for femoral fractures
(3) Spine board/C-Collar for spine fractures
(4) _____ for clavicular fractures
(5) Pelvic binder for ______
(6) Position of _____ and natural positioning
(7) Loosely to allow for swelling; well-padded
- Traction
- Sling
- pelvic fractures
- comfort
Treatment for Fx
(1) Pain control
(2) Rule out other more life threatening injuries
(3) Copious irrigation for open fractures
(4) Tetanus prophylaxis
(5) Broad-spectrum antibiotics
(6) MEDEVAC
True/False
Oblique/Comminuted/Segmental fractures heal faster than transverse fractures.
Falst
True
Smoking slows healing for fractures
True
