CLINICAL CARE OF THE MUSCULOSKELETAL SYSTEM Flashcards

1
Q

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

A

Costochondritis

Most cases improve course of few weeks:
(1) NSAIDS
(2) Home stretching program
(3) Activity modification

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2
Q

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

A

80%

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3
Q

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

A

1) older
2) 50
3) females
4) males
6) Joint

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4
Q

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

A

Osteoarthritis
Treatment
(1) Control pain
(a) NSAIDS
(b) Tylenol
(2) Stop insult to cartilage
(3) Rehabilitation

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5
Q

What is considered to Stop insult to cartilage when treating osteoarthritis

A

(a) Activity/lifestyle modification
(b) Weight reduction
(c) Loss of 10% body weight associated with 50% reduction in pain over 18 months

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6
Q

Common examples of Inflammatory arthroses are

A

-rheumatoid arthritis
-reactive arthritis
-psoriatic arthritis
-ankylosing spondylitis

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7
Q

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

A

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

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8
Q

Diagnostic Tests for suspected Rheumatoid arthritis

A

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

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9
Q

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

A

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

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10
Q

What is Enthesitis

A

Inflammation of insertion sites of ligaments, tendons, fascia

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11
Q

what is Dactylitis

A

Sausage digits

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12
Q

Reactive Arthritis
In a patient with active infection consider testing
1) Joint effusion: _____
2) Active diarrhea: ______
3) GU symptoms: ________

A
  1. Arthrocentesis
  2. Stool cultures
  3. UA and STD panel
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13
Q

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

A

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

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14
Q

What issue?
(a) Common inflammatory skin disease
(b) Most common manifestation: well demarcated erythematous plaques with silver scale

A

psoriasis

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15
Q

True/False
Diagnosis for Psoriatic Arthritis made in patient who has both psoriasis and classic arthritis pattern

A

true

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16
Q

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

A

Ankylosing Spondylitis

17
Q

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

A

b) NSAIDs
c) DMARDs
f) Psychological

18
Q

What is defined as Monosodium urate crystal deposition in joints and tissues.

A

Gout

19
Q

Most patients with gout have ______

A

hyperuricemia (elevated uric acid)

20
Q

True/False
Gout is Multiarticular 80% of the time

A

FALSE
MONOARTICULAR

21
Q

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

A

Gout
(1) Acute Episode
-(a) NSAID (Indomethacin)
-(b) Colchicine (n/v/d; bone marrow suppression, neuropathy)
-(c) Steroids
(2) Prophylaxis
(3) Diet modification

22
Q

What are the prophylaxis meds for Gout.

A

(a) Allopurinol (overproducers)
(b) Probenecid (underexcreters; UA <600mg/day)

23
Q

Diet modification for Gout pts
Avoid:

A

1) Meat
2) Seafood
3) Alcohol
4) High-fructose corn syrup

24
Q

Referral Decisions Gout
(1) _______ deformity or destruction
(2) Large _____ masses
(3) Metabolic problems
(4) All patients should see MO for consideration of _______

A

1) Joint
2) tophaceous
4) prophylaxis

25
Q

Gout Laboratory Tests

A

(a) Uric acid
(b) Chem Panel
(c) TSH, Iron Panel
(d) WBC
(e) NEEDLE SHAPED, NEGATIVE BIREFRINGENT

26
Q

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)

A

Pseudogout

27
Q

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

A

Septic Arthritis
Treatment
(1) Supportive if having shock (IV, monitors, O2, VS, bolus of IVF)
(2) IV antibiotics (ceftriaxone, vancomycin)
(3) MEDEVAC

28
Q

Fractures are Classified by:

A

Location
orientation
extent of fracture line
displacement
skin integrity

29
Q

Fracture classification Displacement
(1) Non-displaced - ____
(2) Displaced - ___________________
(3) Bayonetted - ____________________
(4) Distracted - ___________________
(5) Angulation - __________________

A
  1. in anatomic alignment
  2. not in anatomic alignment; described as a percentage
  3. distal fragment overlaps proximal fragment
  4. fragments are separated
  5. deviation at an angle
30
Q

Treatment for Fractures 4R’s

A

(a) Recognition
(b) Reduction
(c) Retention of reduction while achieving union
(d) Rehabilitation

31
Q

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

A
  1. Traction
  2. Sling
  3. pelvic fractures
  4. comfort
32
Q

Treatment for Fx

A

(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

33
Q

True/False
Oblique/Comminuted/Segmental fractures heal faster than transverse fractures.

A

Falst

34
Q

True
Smoking slows healing for fractures

A

True