Diseases Week 5 Flashcards
Prepatellar buristis
AKA “housemaid’s knees” busitis of prepatellar bursa common in people who work on their knees i.e. roofers, floorers, housemaids
Osgood-Schlatter Syndrome
Tenderness and swelling at the site of the infrapatellar tendon insertion into the tibial tubercle. Common.
Symmetric INFLAMMATORY arthritis w/ insidious (sudden) onset, erosive, chronic progressive, disabling disease. Can have systemic comorbidities: sq nodules, pericarditis, inflammatory eye disease, vasculitis. These are well controlled w/ new RA treatments. Serologies: Positive rheumatoid factor (RF) and anti CCP antibody (ACPA’s) (ACPA is more sensitive and specific), elevated CRP and ESR Prevalence: 1% of adult population. Higher in women, whites, and natives. Age of onset: 30-50 Risk factors: smoking, periodontal disease Clinical presentation: Swollen joints (not hips or DIPS), painful, red, immobile, systemic problems, morning stiffness >1hr. Swelling in > 3 joints, Swelling in hands, Symetric swelling, erosions (late), nodules (late), positive serologies, ulnar drift. Therapy: Patient Ed, PT/OT, Exercise/Rest (exercise when swelling is low; rest when high), NSAIDS, Steroids, DMARD’s (Disease Modifying Anti-Rheumatic Drugs), Biological DMARD’s
Rheumatoid Arthritis
Rheumatoid Arthritis
Symmetric INFLAMMATORY arthritis w/ insidious (sudden) onset, erosive, chronic progressive, disabling disease. Can have systemic comorbidities: sq nodules, pericarditis, inflammatory eye disease, vasculitis. These are well controlled w/ new RA treatments. Serologies: Positive rheumatoid factor (RF) and anti CCP antibody (ACPA’s) (ACPA is more sensitive and specific), elevated CRP and ESR Prevalence: 1% of adult population. Higher in women, whites, and natives. Age of onset: 30-50 Risk factors: smoking, periodontal disease Clinical presentation: Swollen joints (not hips or DIPS), painful, red, immobile, systemic problems, morning stiffness >1hr. Swelling in > 3 joints, Swelling in hands, Symetric swelling, erosions (late), nodules (late), positive serologies, ulnar drift. Therapy: Patient Ed, PT/OT, Exercise/Rest (exercise when swelling is low; rest when high), NSAIDS, Steroids, DMARD’s (Disease Modifying Anti-Rheumatic Drugs), Biological DMARD’s
Hallix rigidis
bone spur on first metatarsal. Causes turf toe like symptoms. Need lateral x-rays.
Description: Inflammatory back pain w/ sudden onset before 40. Duration > 3 months. Pain decreases w/ exercise (vs. other low back pain = opposite) Fusion of spine/ bamboo spine. Sacroiliitis/ fusiton. Notable Back inflexibility M>F Positive HLA B27 (90%)
Ankylosing Spondylitis
Most common benign bone neoplasm in children/young adults.
Osteoid Osteoma
Osteoporosis
A type of osteopenia due to bone atrophy caused by an imbalance in bone remodeling process (overactive osteoclasts). Normal lab values. Often a diagnosis of exclusion. Bone density below 2.5. Decreased trabecular bone. “trivial trauma” can cause fractures: hip, colles, wedge after dowager’s hump. Most common in post-menopausal white women. Treat by proper calcium and vitamin d intake in bone building years (up to 30). Weight bearing exercise! Two types: Type 1 = postmenopausal Type 2 = Senile (both sexes) Associations: Excess steroids, hyper parathyroidism, hyperthyroidism, poor nutrition/malabsorbtion, immobilization, hypogonadism. Kidney problems, diminished PTH secretion, increased oc, decreased ob (Be sure to screen treatable causes strictly!) Treatment: bisphosphonates –> decrease oc activity
Overuse injury that is very painful of the plantar fascia. Self healing, long term. Diagnose by pressing anterior calcaneus.
Plantar Fasciitis
Stages: I Mild AC separation II AC disruption III AC and CC disruption
Shoulder seperation
most common primary malignant neoplasm of children/ young adults Destructive neoplasm favoring metaphyseal regions of large long bones. Multiple variants : high grades have high mortality May be linked to paget’s, irradiation, bone infarcts, and retinoblastoma gene defect.
Osteosarcoma / Osteogenic Sarcoma
Plantar Fasciitis
Overuse injury that is very painful of the plantar fascia. Self healing, long term. Diagnose by pressing anterior calcaneus.
Autoimmune (Type III hypersensitivity). Production of antibodies to nucleus. Positive ANA in 95% of pts. (Positive ANA doesn’t mean lupus!!!, but negative likely means no lupus.) Peak incidence: 15-40. Females. Blacks. Clinical symptoms: DIVERSE. Acronym = I’M DAMN SMART: Immunoglobulin, Malar (butterfly) rash, Discoid rash, Ana, Mucositis, Neurologic disorders, Serositis, Hematologic disorders, Arthritis, Renal disorders, Photosensitivity. Tests: positive ANA (sensitive not specific) positive ds DNA ( very specific poor prognosis), positive smith (specific and not prognostic), positive antihistone (drug induced lupus) Therapy: patient ed, NSAIDs, steroids, hydroxychloroquine, methotrexate, Avoid TNF biologics
Systemic Lupus Erythematosus
Presentation: bruising, tenderness, palpable defect, painful limp, weak plantar flexion. Risk factors: Age, previous injury, sedentary, comorbidities, certain activities (tennis, jumping) Treatment: Acute (1-10 days): PRICEMM plus knee brace to limit extension. Subacute (up to 10 days) : ROM exercise, Estim, Ice/heat. Initiate cross training. Remodeling phase (up to 3-4 months) Isotonic then eccentric exercise. Consider brace/sleeve.
Gastrocnemius injuries
Most common are big football players and out of shape older pts. playing explosive sports. Test by squeezing gastroc and observing plantarflexion. Palpation. Partial tears will heal, full tears need surgery.
Torn Achilles Tedon
Ankle inversion sprain
Presentation: swollen, bruised. Pain w/ weight bearing, tendor at injured ligament/tendon. Positive anterior ankle drawer. Anterior Talo-Fibular ligament most common. Calacaneofibular ligament next then posterior talofibular. Fibularis/Peroneous tendons often involved. Treatment: Grade 1/2 Brace, ROM, Strengthening, Proprioception (PT) Grade 3: Consider surgery. Follow Ottowa Ankle rules: get x ray if pain over: posterior tip of medial/lateral malleolus, base of 5th metatarsal, or navicular bone. Be sure there isn’t tibio=talar seperation on x-ray.
Osteromalacia
Decreased bone mineralization w/ excess osteiod. Due to interference w/ calcium, phoshate, or vit. D. Osteopenic Childhood = rickets (widened distorted growth plates, bowed legs, fractures) Intestinal malabsorbtion is the most common cause of Vit. D defeciency in USA –> Celiac’s disease! Can be caused by renal vit. d metab prob too. BioChem profile: high ALP, low Ca or P, Increased PTH, Decrease Vit. D
Decreased bone mineralization w/ excess osteiod. Due to interference w/ calcium, phoshate, or vit. D. Osteopenic Childhood = rickets (widened distorted growth plates, bowed legs, fractures) Intestinal malabsorbtion is the most common cause of Vit. D defeciency in USA –> Celiac’s disease! Can be caused by renal vit. d metab prob too. BioChem profile: high ALP, low Ca or P, Increased PTH, Decrease Vit. D
Osteromalacia
JIA Systemic Onset
Boys = Girls; 1-6yrs old. Symptoms: daily spiking fevers accompanied by an evanescent (quick clearing)salmon colored rash. Systemic features including: lymphadenopaty, hepatosplenomegaly, pericardial/pleural effusions, fatigue, muscle atrophy, weight loss, leukocytosis, anemia –> leukemia is main differential. RA and ANA negative. 20-50% ultimately have severe, chronic arthritis.
PCL prevents the femur from sliding Anterior on tibia and hyperflexion of the knee. Main stabilizer of femur when walking downhill. Positive posterior drawer test. Toughest to find clinically. Remember tendons named for where they attach on tibia. Use finger cross and hold over knees to remember orientation. Index finger is PCL. Inside capsule, but outside synovial membrane
Torn PCL
Tenosynovitis of APL and EPB. Test w/ Finkelstein’s test.
De Quervain’s Tenosynovitis
Psoriatic Arthritis.
7-10% of psoriasis (westra said 33%?). Skin and nail pits, inflammatory eye dises, peripheral arthritis - DIPs, Dactylitis/sausage toes, achilles tendinitis, sacroiliitis, arthritis mutilans (very aggressive and mutitlating form of arthritis) Low % positive HLA B27
Tuberculous osteomyelitis
Secondary to hematogenous spread from lungs. Prefers spine (Pott’s disease) and long bones.
Positive Varus test.
Torn LCL
Deposition of monosodium urate. Joints: acute inflammatory arthritis, Skin: accumulation of crystals (tophi), Kidney: Uric acid urolithiasis, nephropathy. Stages: Asymptomatic, Acute intermittent, chronic tophaceous Causes: Overproduction (10%) (enzyme defects), Uric acid underexcretion (90%) (renal failure, hypertension, obesity, diuretics, low dose aspirin, dehydration, alcohol consumption, cold hands and feet, high protein diet. Symptoms: abrupt onset and extreme pain,redness and swelling, (infx on differential) 50-75% podagra first MTP joint (big toe), other joints (MTPs, mid foot, ankles, heels, kness, wrists, fingers, elbows., cottage cheese like fluid, high serum uric acid (not always), SYNOVIAL FLUID ANALYSIS, negative birufringement, Yellow w/ parallel light and blue w/ perpendicluar, spiny crystals, tophi (helix of ear and periarticular regions) Treament: Acute: lifestyle changes/ NSAIDs and colchicine, Chronic: Allopurinol, probenicid Males > Females
Gout
Congenital disorder of type 1 collagen. Either abnormal or too little. Inadequate collagen for osteoid production. Spectrum from type II (fetal in utero) to type 1 (fx tendency decreases post puberty) Thin, weak, short, curved, bones.
Osteogenesis Imperfecta
Arthritis in 5 or more joints Girls > Boys Symptoms: malaise, weight loss, low grade fever, lymphadenopathy, anemia.
JIA Polyarticular Onset
AKA “clergyman’s knees” bursitis of infrapatellar bursitis.
Infrapatellar bursitis
Caused by twisting motion of ankle. Can tear syndesmosis of tibia/fibula. Longer recovery time. X-Ray for fx and Look for Tibiotalar If yes pt. needs surgery or will have permanently sloppy ankle.
High ankle sprain
Fungal osteomyelitis
Blastomycosis and coccidiodomycosis are most common in non-immunosuppressed. Secondary to hemato spread from lungs. (original pulmonary infx often asymptomatic)
When a loop of bowel protrudes below inguinal ligament just lateral to pubic tubercle.
Femoral hernia
Most common benign bone neoplasm in adults. Especially attacks hand.
Chondroma
Hypecalcemia due to primary hyperplasia or NEOPLASTIC enlargement of parathyroid glands. Spectrum of bony changes due to osteoclastic activity - subperiosteal erosions, diffuse osteroporosis, tumor-like skeletal change. Fractures, metabolic impairment of kidneys, weakness, neuropsych. (all due to hypercalcemia) Renal stone disease. ALWAYS RESPECT A HIGH CALCIUM
Primary hyperparathyroidism
JIA Oligoarticular/Pauciarticular Onset
Occurs in 24-58% of all JIA. 4 or fewer joints (knees, ankles, wrists, elbows. Positive ANA.
Pathological fracture
fracture through diseased bone - tumourous or tumor-like bone. NOT OSTEOPOROSIS
The combo of expanded marrow, high oxygen demand, sluggish circulation means that bone is vulnerable to infarction. Infarcted areas act as loci for infx. Gut devitalizaiton due to intravascular sickling leads to an increased incidence of invasion and bacteremia. Sickle cell patients have reduced bacteriocidal and opsonic activity vs. salmonella and an abnormality in the alternative pathway of complement activation.
Salmonella, Sickle cell, osteomyelitis
Chronic synovial inflammation of unknown cause. Girls > boys. Age < 16. Can cause short jaw stature, and blindness (if not controlled.) Different subtypes: systemic onset, polyarticular onset, puaciarticular onset. Treatments: Patient/Parent Ed, PT/OT, NSAID’s, Steroids, DMARD’s Biologic DMARD’s.
Juvenile Idopathic Arthritis
Osteosarcoma / Osteogenic Sarcoma
most common primary malignant neoplasm of children/ young adults Destructive neoplasm favoring metaphyseal regions of large long bones. Multiple variants : high grades have high mortality May be linked to paget’s, irradiation, bone infarcts, and retinoblastoma gene defect.
bone spur on first metatarsal. Causes turf toe like symptoms. Need lateral x-rays.
Hallix rigidis
JIA Polyarticular Onset
Arthritis in 5 or more joints Girls > Boys Symptoms: malaise, weight loss, low grade fever, lymphadenopathy, anemia.
Torn ACL
ACL prevents the femur from sliding posteriorly on tibia and hyperxtension of the knee. Limits medial rotation of the femur when the foot is on the ground. Important for deceleration. Postive Anterior drawer test and lockman’s test. Test ASAP before swelling sets in. Surgical repair w/ middle third of patellar, pes anserinus tendons, or donor achilles. Remember tendons named for where they attach on tibia. Use finger cross and hold over knees to remember orientation. Middle finger is ACL. Inside capsule, but outside synovial membrane
Gout
Deposition of monosodium urate. Joints: acute inflammatory arthritis, Skin: accumulation of crystals (tophi), Kidney: Uric acid urolithiasis, nephropathy. Stages: Asymptomatic, Acute intermittent, chronic tophaceous Causes: Overproduction (10%) (enzyme defects), Uric acid underexcretion (90%) (renal failure, hypertension, obesity, diuretics, low dose aspirin, dehydration, alcohol consumption, cold hands and feet, high protein diet. Symptoms: abrupt onset and extreme pain,redness and swelling, (infx on differential) 50-75% podagra first MTP joint (big toe), other joints (MTPs, mid foot, ankles, heels, kness, wrists, fingers, elbows., cottage cheese like fluid, high serum uric acid (not always), SYNOVIAL FLUID ANALYSIS, negative birufringement, Yellow w/ parallel light and blue w/ perpendicluar, spiny crystals, tophi (helix of ear and periarticular regions) Treament: Acute: lifestyle changes/ NSAIDs and colchicine, Chronic: Allopurinol, probenicid Males > Females
Limb is medially rotated and shorter (psoas). Knee points medially and leg is medially rotated.
Hip dislocations
Hip dislocations
Limb is medially rotated and shorter (psoas). Knee points medially and leg is medially rotated.
Caused by neisseria gonorrhea or staph aureus. Signs and symptoms: rapid onset, personal history, pain, range of motion restriction (one joint), synovial fluid analysis and culture, positive blood cultures
Acute infectious arthritis
Torn MCL
Positive Valgus test. Remember Valgus = Gum between knees. Pain in medial knee. Instability. Treatment: Crutches, Ice, Rehab. full recovery 4-8 weeks.
Lateral hip pain due to abductors rubbing on trochanteric bursa. “I can’t sleep on my hip.” “I can’t walk up stairs” Treat w/ steroid injections. Arthritis will be more in groin.
Trochanteric bursitis
De Quervain’s Tenosynovitis
Tenosynovitis of APL and EPB. Test w/ Finkelstein’s test.
7-10% of psoriasis (westra said 33%?). Skin and nail pits, inflammatory eye dises, peripheral arthritis - DIPs, Dactylitis/sausage toes, achilles tendinitis, sacroiliitis, arthritis mutilans (very aggressive and mutitlating form of arthritis) Low % positive HLA B27
Psoriatic Arthritis.
Fibroma
Fibrous cortical defect. Most common bone lesion. Non-neoplastic developmental defect. Can be found in 1/3 of children. Often regress spontaneously. Occasionally large enough to compromise bone and cause fx.
Positive Valgus test. Remember Valgus = Gum between knees. Pain in medial knee. Instability. Treatment: Crutches, Ice, Rehab. full recovery 4-8 weeks.
Torn MCL
Twisting motion with foot fixed can result with torn: 1.) ACL 2.) Medial collateral ligament 3.) Medial meniscus (Lateral meniscus actually more commonly torn however medial is technically the triad)
“Unhappy” or “terrible” triad
Force creates tremendous swelling. If compartment is more than 30mmHg we must do fasciotomy. If not fixed result is permanent disability.
Compartment Syndrome
Osteogenesis Imperfecta
Congenital disorder of type 1 collagen. Either abnormal or too little. Inadequate collagen for osteoid production. Spectrum from type II (fetal in utero) to type 1 (fx tendency decreases post puberty) Thin, weak, short, curved, bones.
Acute infectious arthritis
Caused by neisseria gonorrhea or staph aureus. Signs and symptoms: rapid onset, personal history, pain, range of motion restriction (one joint), synovial fluid analysis and culture, positive blood cultures
Gastrocnemius injuries
Presentation: bruising, tenderness, palpable defect, painful limp, weak plantar flexion. Risk factors: Age, previous injury, sedentary, comorbidities, certain activities (tennis, jumping) Treatment: Acute (1-10 days): PRICEMM plus knee brace to limit extension. Subacute (up to 10 days) : ROM exercise, Estim, Ice/heat. Initiate cross training. Remodeling phase (up to 3-4 months) Isotonic then eccentric exercise. Consider brace/sleeve.
Hamstring Injury
Most often upper hamstring tear, possible avulsion, Lateral more common than medial. Risk factors: increasing age, decreased hip flexor flexibility, previous injury, quick burst exercises (think old man softball) Exam findings: Ecchymosis, palpable deformity, pain w/ passive stretch, painful contraction. Avulsion on x-ray. Treatment: Acute (1-10 days): PRICEMM plus knee brace to limit extension. Subacute (up to 10 days) : ROM exercise, Estim, Ice/heat. Initiate cross training. Remodeling phase (up to 3-4 months) Isotonic then eccentric exercise. Consider brace/sleeve.
Paget’s disease (Ostetitis Deformans)
Deforming bone disease of middle-aged to elderly adults. Due to latent viral infx (paramyxovirus?) of osteoclasts in a genetically susceptible person. Anglo-Saxon. Prefer’s large bones. Three phases: lytic (high OC), mixed (OC and OB), sclerotic (High OB) –> results in focal bone resorption followed by haphazard new formation. Widening/bowing of long bones is key radiographically. Chalk-like bone fx’s. BioChemical profile: High ALP, normal serum Ca, no hepatobilliary disease.
Drug induced Lupus
Clinical features are less severe: fever, malaise, arthritis, serositis, rashes. CNS and renal are rare. Antihistone antibody 90% Therapy: Stop offending med!
Calcium pyrophosphate dihydrate crystals (CPPD). Males = Females. Strongest association = aging. Also trauma and metabolic disease. Clincal features: Can be mono, oligo, or poly articular. Knees most common, wrists, hips, shoulders, and ankles too. Chondrocalcinosis shows on x- rays 75%. No tophi, no marker, rhomboid shaped weak birefringement crystals. Blue w/ parallel light and yellow w/ perpendicular. Treatment: NSAIDs, Steroids, Not Colchicine and allopurinol
Pseudogout
Disc herniates central posteriorly and usually occurs at L4-5. Causes saddle anesthesia, bowel or bladder incontinence, significant motor deficits,. Surgical emergency. Six hours to fix otherwise bowel and bladder symptoms become permanent.
Cauda Equina Syndrome
Incompetent valves of perforating veins may result in varicose veins. Flow of blood is obstructed and flows from deep to sueperficial veins.
Varicose veins
Osteopetrosis
Abnormal thickening of bones due to abnormaly high OB activity. Marrow problems and bone weakness. Can fix w/ early marrow transplant.
Most often upper hamstring tear, possible avulsion, Lateral more common than medial. Risk factors: increasing age, decreased hip flexor flexibility, previous injury, quick burst exercises (think old man softball) Exam findings: Ecchymosis, palpable deformity, pain w/ passive stretch, painful contraction. Avulsion on x-ray. Treatment: Acute (1-10 days): PRICEMM plus knee brace to limit extension. Subacute (up to 10 days) : ROM exercise, Estim, Ice/heat. Initiate cross training. Remodeling phase (up to 3-4 months) Isotonic then eccentric exercise. Consider brace/sleeve.
Hamstring Injury
Infx leading to necrosis of SQ. Severe pain is common. Infx should be treated w/ surgery, IV Antibiotics and fluids. Causative agent: Beta-Hemolytic Group A Strep pyogenes or Clostridium Perfingens. Focus of spreading streptococcal infx that casuses bacteremia and systemic inflammatory response syndrome (SIRS). Can result in widespread desquamation of the skin, shock, multiorgan failure, and death. SIRS is caused by specific exotoxins produced at the site of infx that have systemic effects. More than 50% of patients have experienced a recent minor trauma, surgery, or varicella. Clinical signs: high fever, high heart rate, altered mental status, low bp, leukocytosis, positive blood culture. Rapid onset, High CRP, ESR, WBC w/ banded neutrophils, CT imaging could reveal edema of soft tissues. Gram stain the wound, culture the wound and blood, surgical debridement
Necrotizing Fasciitis
Osteoid Osteoma
Most common benign bone neoplasm in children/young adults.
Fat Emboli Syndrome
When you don’t properly fix bones right away bone marrow leaks into system get ARS (acute respiratory syndrome). Petichiae in eye. Used to be more common.
Biolgically, the most aggressive/lethal of all primary bone tumors. Prefers diaphysis of long bones and pelvis. Affects mainly young people. Usually has 11:22 translocation mutation (11+22 = 33 Patrick Ewing’s Jersey Number) Survival around 50%
Ewing’s Sarcoma
Classic Myeloma
Classic example of strictly osteolytic tumor Often associated w/ hypercalcemia. Fractures common. Plamacytoma of bone = localized tumor of plasma cells- eventually tends to evolve towards classic myeloma
Pain Pallor Paresthesia Paralysis Pulselessness
Arterial Occlusion
Clinical features are less severe: fever, malaise, arthritis, serositis, rashes. CNS and renal are rare. Antihistone antibody 90% Therapy: Stop offending med!
Drug induced Lupus
Foot Drop or Steppage Gait
Injury to common fibular nerve produces an inability to dorsiflex and evert foot causing the toes not to clear during swing phase of walking. Paralysis of Anterior and lateral compartments. Trauma to lateral knee, knee dislocation, etc.. Nerve runs very close to head of fibula.
Metastatic prostate cancer
Classic example of strictly osteoblastic tumor.
Infection of the muscle that leads to muscle inflammation. Can be caused by many different microorganisms. Causative agents: clostridium perfingens, staphylococcus aureus, cocksackievirus A&B, Dengue Fever Virus, Taenia solium, Trichinella spiralis
Myositis
Necrotizing Fasciitis
Infx leading to necrosis of SQ. Severe pain is common. Infx should be treated w/ surgery, IV Antibiotics and fluids. Causative agent: Beta-Hemolytic Group A Strep pyogenes or Clostridium Perfingens. Focus of spreading streptococcal infx that casuses bacteremia and systemic inflammatory response syndrome (SIRS). Can result in widespread desquamation of the skin, shock, multiorgan failure, and death. SIRS is caused by specific exotoxins produced at the site of infx that have systemic effects. More than 50% of patients have experienced a recent minor trauma, surgery, or varicella. Clinical signs: high fever, high heart rate, altered mental status, low bp, leukocytosis, positive blood culture. Rapid onset, High CRP, ESR, WBC w/ banded neutrophils, CT imaging could reveal edema of soft tissues. Gram stain the wound, culture the wound and blood, surgical debridement
fracture through diseased bone - tumourous or tumor-like bone. NOT OSTEOPOROSIS
Pathological fracture
Becomes a problem after 6 hours of non returned blood flow after intracapsular fracture of femoral neck both in children and in elderly. Can be due to infarct from fx, corticosteroids, and alcoholism. Caisson’s disease (the bends) Legg-Calve-Perthes = osteonecrosis of femoral head in children in age 4-8.
Avascular necrosis
Systemic Lupus Erythematosus
Autoimmune (Type III hypersensitivity). Production of antibodies to nucleus. Positive ANA in 95% of pts. (Positive ANA doesn’t mean lupus!!!, but negative likely means no lupus.) Peak incidence: 15-40. Females. Blacks. Clinical symptoms: DIVERSE. Acronym = I’M DAMN SMART: Immunoglobulin, Malar (butterfly) rash, Discoid rash, Ana, Mucositis, Neurologic disorders, Serositis, Hematologic disorders, Arthritis, Renal disorders, Photosensitivity. Tests: positive ANA (sensitive not specific) positive ds DNA ( very specific poor prognosis), positive smith (specific and not prognostic), positive antihistone (drug induced lupus) Therapy: patient ed, NSAIDs, steroids, hydroxychloroquine, methotrexate, Avoid TNF biologics
Classic example of strictly osteoblastic tumor.
Metastatic prostate cancer
Occurs in 24-58% of all JIA. 4 or fewer joints (knees, ankles, wrists, elbows. Positive ANA.
JIA Oligoarticular/Pauciarticular Onset
Femoral hernia
When a loop of bowel protrudes below inguinal ligament just lateral to pubic tubercle.
Ewing’s Sarcoma
Biolgically, the most aggressive/lethal of all primary bone tumors. Prefers diaphysis of long bones and pelvis. Affects mainly young people. Usually has 11:22 translocation mutation (11+22 = 33 Patrick Ewing’s Jersey Number) Survival around 50%
Shoulder seperation
Stages: I Mild AC separation II AC disruption III AC and CC disruption
Plantar fasciitis
Inflammation of plantar fascia between heel and forefoot. Sometimes torn in sprinters. Most common in older patients due to elastic fiber loss of elasticity due to sulfhydryl cross linking. Pain especially bad when waking. Treatment: heel cup, stretching and night splints.
Tenderness and swelling at the site of the infrapatellar tendon insertion into the tibial tubercle. Common.
Osgood-Schlatter Syndrome
ACL prevents the femur from sliding posteriorly on tibia and hyperxtension of the knee. Limits medial rotation of the femur when the foot is on the ground. Important for deceleration. Postive Anterior drawer test and lockman’s test. Test ASAP before swelling sets in. Surgical repair w/ middle third of patellar, pes anserinus tendons, or donor achilles. Remember tendons named for where they attach on tibia. Use finger cross and hold over knees to remember orientation. Middle finger is ACL. Inside capsule, but outside synovial membrane
Torn ACL
Inflammation of plantar fascia between heel and forefoot. Sometimes torn in sprinters. Most common in older patients due to elastic fiber loss of elasticity due to sulfhydryl cross linking. Pain especially bad when waking. Treatment: heel cup, stretching and night splints.
Plantar fasciitis
Most common strain. Anterior talofibular ligament is most frequently sprained.
Inversion sprain
Chondroma
Most common benign bone neoplasm in adults. Especially attacks hand.
Turf Toe
Soft tissue inflammation/injury of MP joint of big toe. Can be very painful when toeing off. Common in football and soccer.
Patellofemoral syndrome
Condromalacia patella. Patella slides outward. Often due to knees slighting in. Common in women and tennis players.
Develops after infx. Bowel (campylobacter, salmonella, shigella, yersinia) Genital (Chlymidia) Not septic arthritis; simply inflammatory rxn. Males 20-50. HLA B27 = predisposition = 85%\ Extra articular manifestations: conjunctivitis, urethritis, genital ulcers, rash in palms and sores Therapy: Antibiotics, NSAIDs, Peripheral arthritis (sulfasalazine, methotrexate) Axial arthritis (Biologics for TNF blocking).
Reactive arthitis
Age-related progressive loss of articular cartilage. NOT INFLAMMATORY Symptoms:Gradual onset, intermittent initially. Knees & Hips worse w/ weight bearing (cycle of inactivity), relieved by rest, morning stiffness
Osteoarthritis
Reactive arthitis
Develops after infx. Bowel (campylobacter, salmonella, shigella, yersinia) Genital (Chlymidia) Not septic arthritis; simply inflammatory rxn. Males 20-50. HLA B27 = predisposition = 85%\ Extra articular manifestations: conjunctivitis, urethritis, genital ulcers, rash in palms and sores Therapy: Antibiotics, NSAIDs, Peripheral arthritis (sulfasalazine, methotrexate) Axial arthritis (Biologics for TNF blocking).
Arterial Occlusion
Pain Pallor Paresthesia Paralysis Pulselessness
Trochanteric bursitis
Lateral hip pain due to abductors rubbing on trochanteric bursa. “I can’t sleep on my hip.” “I can’t walk up stairs” Treat w/ steroid injections. Arthritis will be more in groin.
Deforming bone disease of middle-aged to elderly adults. Due to latent viral infx (paramyxovirus?) of osteoclasts in a genetically susceptible person. Anglo-Saxon. Prefer’s large bones. Three phases: lytic (high OC), mixed (OC and OB), sclerotic (High OB) –> results in focal bone resorption followed by haphazard new formation. Widening/bowing of long bones is key radiographically. Chalk-like bone fx’s. BioChemical profile: High ALP, normal serum Ca, no hepatobilliary disease.
Paget’s disease (Ostetitis Deformans)
Varicose veins
Incompetent valves of perforating veins may result in varicose veins. Flow of blood is obstructed and flows from deep to sueperficial veins.
Inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi. causes localized bone pain and tenderness. 80% of infx result from contiguous spread or from open wounds. 3 types: Primary - hematologic spread Secondary - Spread from adjacent tissue (think diabetes) Direct - Compound fracture or arthroplasty Main causative agents: staph aureus, salmonella typhii (think sickle cell), pasteurella multocida (think cat bites) Visualize massive influx of nutrients into bone on bone scan. Signs and Symptoms: fever, high pulse rate, overlying skin warm and red w/ multiple necrotic-appearing lesions. Proximal join normal, High ESR, High CRP, High WBC, High PMNs, some bands, gram stain and cultures of the wound are positive in 75%, blood cultures are positive in 50%. Treat with antibiotics.
Osteomyelitis
Fibrous cortical defect. Most common bone lesion. Non-neoplastic developmental defect. Can be found in 1/3 of children. Often regress spontaneously. Occasionally large enough to compromise bone and cause fx.
Fibroma
Boys = Girls; 1-6yrs old. Symptoms: daily spiking fevers accompanied by an evanescent (quick clearing)salmon colored rash. Systemic features including: lymphadenopaty, hepatosplenomegaly, pericardial/pleural effusions, fatigue, muscle atrophy, weight loss, leukocytosis, anemia –> leukemia is main differential. RA and ANA negative. 20-50% ultimately have severe, chronic arthritis.
JIA Systemic Onset
Secondary to hematogenous spread from lungs. Prefers spine (Pott’s disease) and long bones.
Tuberculous osteomyelitis
Pain in soft tissues between metatarsals. Caused by too small of shoes. Treat w/ metatarsal pad for pressure relief.
Metatarsalgia
AKA “housemaid’s knees” busitis of prepatellar bursa common in people who work on their knees i.e. roofers, floorers, housemaids
Prepatellar buristis
Presentation: swollen, bruised. Pain w/ weight bearing, tendor at injured ligament/tendon. Positive anterior ankle drawer. Anterior Talo-Fibular ligament most common. Calacaneofibular ligament next then posterior talofibular. Fibularis/Peroneous tendons often involved. Treatment: Grade 1/2 Brace, ROM, Strengthening, Proprioception (PT) Grade 3: Consider surgery. Follow Ottowa Ankle rules: get x ray if pain over: posterior tip of medial/lateral malleolus, base of 5th metatarsal, or navicular bone. Be sure there isn’t tibio=talar seperation on x-ray.
Ankle inversion sprain
Chondrosarcoma
Most common primary malignant neoplasm of middle aged/elderly Symptoms: swelling and pain. prefers long bones and central skeleton. may grow to very large size before dx (pelvis) Multiple variants.
Classic example of strictly osteolytic tumor Often associated w/ hypercalcemia. Fractures common. Plamacytoma of bone = localized tumor of plasma cells- eventually tends to evolve towards classic myeloma
Classic Myeloma
A type of osteopenia due to bone atrophy caused by an imbalance in bone remodeling process (overactive osteoclasts). Normal lab values. Often a diagnosis of exclusion. Bone density below 2.5. Decreased trabecular bone. “trivial trauma” can cause fractures: hip, colles, wedge after dowager’s hump. Most common in post-menopausal white women. Treat by proper calcium and vitamin d intake in bone building years (up to 30). Weight bearing exercise! Two types: Type 1 = postmenopausal Type 2 = Senile (both sexes) Associations: Excess steroids, hyper parathyroidism, hyperthyroidism, poor nutrition/malabsorbtion, immobilization, hypogonadism. Kidney problems, diminished PTH secretion, increased oc, decreased ob (Be sure to screen treatable causes strictly!) Treatment: bisphosphonates –> decrease oc activity
Osteoporosis
Primary hyperparathyroidism
Hypecalcemia due to primary hyperplasia or NEOPLASTIC enlargement of parathyroid glands. Spectrum of bony changes due to osteoclastic activity - subperiosteal erosions, diffuse osteroporosis, tumor-like skeletal change. Fractures, metabolic impairment of kidneys, weakness, neuropsych. (all due to hypercalcemia) Renal stone disease. ALWAYS RESPECT A HIGH CALCIUM
Metatarsalgia
Pain in soft tissues between metatarsals. Caused by too small of shoes. Treat w/ metatarsal pad for pressure relief.
Painful neuroma between 3rd and 4th toe. Caused by too small of toe box on shoes.
Morton’s neuroma
High ankle sprain
Caused by twisting motion of ankle. Can tear syndesmosis of tibia/fibula. Longer recovery time. X-Ray for fx and Look for Tibiotalar If yes pt. needs surgery or will have permanently sloppy ankle.
Most common primary malignant neoplasm of middle aged/elderly Symptoms: swelling and pain. prefers long bones and central skeleton. may grow to very large size before dx (pelvis) Multiple variants.
Chondrosarcoma
Inversion sprain
Most common strain. Anterior talofibular ligament is most frequently sprained.
Osteoarthritis
Age-related progressive loss of articular cartilage. NOT INFLAMMATORY Symptoms:Gradual onset, intermittent initially. Knees & Hips worse w/ weight bearing (cycle of inactivity), relieved by rest, morning stiffness
Ankylosing Spondylitis
Description: Inflammatory back pain w/ sudden onset before 40. Duration > 3 months. Pain decreases w/ exercise (vs. other low back pain = opposite) Fusion of spine/ bamboo spine. Sacroiliitis/ fusiton. Notable Back inflexibility M>F Positive HLA B27 (90%)
Abnormal thickening of bones due to abnormaly high OB activity. Marrow problems and bone weakness. Can fix w/ early marrow transplant.
Osteopetrosis
Morton’s neuroma
Painful neuroma between 3rd and 4th toe. Caused by too small of toe box on shoes.
Pott’s fracture
Dislocation occurs when foot is forcibly everted: 1.) pulls on strong medial ligament often tearing off medial malleolus. 2.) Talus moves laterally shearing off the lateral malleolus or more commonly breaking the fibula.
Cauda Equina Syndrome
Disc herniates central posteriorly and usually occurs at L4-5. Causes saddle anesthesia, bowel or bladder incontinence, significant motor deficits,. Surgical emergency. Six hours to fix otherwise bowel and bladder symptoms become permanent.
Torn Achilles Tedon
Most common are big football players and out of shape older pts. playing explosive sports. Test by squeezing gastroc and observing plantarflexion. Palpation. Partial tears will heal, full tears need surgery.
Giant cell tumor
intermediate between benign and malignant states. 50% recurr following simple curettage. Some can metastastize to lungs.
Infrapatellar bursitis
AKA “clergyman’s knees” bursitis of infrapatellar bursitis.
Torn PCL
PCL prevents the femur from sliding Anterior on tibia and hyperflexion of the knee. Main stabilizer of femur when walking downhill. Positive posterior drawer test. Toughest to find clinically. Remember tendons named for where they attach on tibia. Use finger cross and hold over knees to remember orientation. Index finger is PCL. Inside capsule, but outside synovial membrane
Myositis
Infection of the muscle that leads to muscle inflammation. Can be caused by many different microorganisms. Causative agents: clostridium perfingens, staphylococcus aureus, cocksackievirus A&B, Dengue Fever Virus, Taenia solium, Trichinella spiralis
Juvenile Idopathic Arthritis
Chronic synovial inflammation of unknown cause. Girls > boys. Age < 16. Can cause short jaw stature, and blindness (if not controlled.) Different subtypes: systemic onset, polyarticular onset, puaciarticular onset. Treatments: Patient/Parent Ed, PT/OT, NSAID’s, Steroids, DMARD’s Biologic DMARD’s.
Compartment Syndrome
Force creates tremendous swelling. If compartment is more than 30mmHg we must do fasciotomy. If not fixed result is permanent disability.
Injury to common fibular nerve produces an inability to dorsiflex and evert foot causing the toes not to clear during swing phase of walking. Paralysis of Anterior and lateral compartments. Trauma to lateral knee, knee dislocation, etc.. Nerve runs very close to head of fibula.
Foot Drop or Steppage Gait
Salmonella, Sickle cell, osteomyelitis
The combo of expanded marrow, high oxygen demand, sluggish circulation means that bone is vulnerable to infarction. Infarcted areas act as loci for infx. Gut devitalizaiton due to intravascular sickling leads to an increased incidence of invasion and bacteremia. Sickle cell patients have reduced bacteriocidal and opsonic activity vs. salmonella and an abnormality in the alternative pathway of complement activation.
Dislocation occurs when foot is forcibly everted: 1.) pulls on strong medial ligament often tearing off medial malleolus. 2.) Talus moves laterally shearing off the lateral malleolus or more commonly breaking the fibula.
Pott’s fracture
When you don’t properly fix bones right away bone marrow leaks into system get ARS (acute respiratory syndrome). Petichiae in eye. Used to be more common.
Fat Emboli Syndrome
Osteomyelitis
Inflammation and destruction of bone caused by bacteria, mycobacteria, or fungi. causes localized bone pain and tenderness. 80% of infx result from contiguous spread or from open wounds. 3 types: Primary - hematologic spread Secondary - Spread from adjacent tissue (think diabetes) Direct - Compound fracture or arthroplasty Main causative agents: staph aureus, salmonella typhii (think sickle cell), pasteurella multocida (think cat bites) Visualize massive influx of nutrients into bone on bone scan. Signs and Symptoms: fever, high pulse rate, overlying skin warm and red w/ multiple necrotic-appearing lesions. Proximal join normal, High ESR, High CRP, High WBC, High PMNs, some bands, gram stain and cultures of the wound are positive in 75%, blood cultures are positive in 50%. Treat with antibiotics.
Pseudogout
Calcium pyrophosphate dihydrate crystals (CPPD). Males = Females. Strongest association = aging. Also trauma and metabolic disease. Clincal features: Can be mono, oligo, or poly articular. Knees most common, wrists, hips, shoulders, and ankles too. Chondrocalcinosis shows on x- rays 75%. No tophi, no marker, rhomboid shaped weak birefringement crystals. Blue w/ parallel light and yellow w/ perpendicular. Treatment: NSAIDs, Steroids, Not Colchicine and allopurinol
“Unhappy” or “terrible” triad
Twisting motion with foot fixed can result with torn: 1.) ACL 2.) Medial collateral ligament 3.) Medial meniscus (Lateral meniscus actually more commonly torn however medial is technically the triad)
Torn LCL
Positive Varus test.
intermediate between benign and malignant states. 50% recurr following simple curettage. Some can metastastize to lungs.
Giant cell tumor
Blastomycosis and coccidiodomycosis are most common in non-immunosuppressed. Secondary to hemato spread from lungs. (original pulmonary infx often asymptomatic)
Fungal osteomyelitis
Condromalacia patella. Patella slides outward. Often due to knees slighting in. Common in women and tennis players.
Patellofemoral syndrome
Avascular necrosis
Becomes a problem after 6 hours of non returned blood flow after intracapsular fracture of femoral neck both in children and in elderly. Can be due to infarct from fx, corticosteroids, and alcoholism. Caisson’s disease (the bends) Legg-Calve-Perthes = osteonecrosis of femoral head in children in age 4-8.
Soft tissue inflammation/injury of MP joint of big toe. Can be very painful when toeing off. Common in football and soccer.
Turf Toe
Congenital hip dislocations
- Posterior dislocations are the most common
- Due to failure of the acetabulum to deepen during development; femoral head rides up on iliac wing
- Bilateral 50% of time, 8X girls>boys, and 1.5/1000 births
- Pediatric health care providers routinely screen all newborns and infants for hip dysplasia. Early treatment requires a harness that keeps the hip joint in place while the child grows. Harder to correct if diagnosed after 6 months; may require surgery.
Groin pull
- Strains of adductors, usually occurs in sports that require quick starts (ex. short distance racing)
- Strain, stretching, and possibly tearing of the proximal attachments of the adductor muscles of the thigh (and sometimes flexors)
Shin Splints
- Mild compartment syndrome in anterior compartment (tibialis anterior strain)
Ski Boot Syndrome
- Caused by a tight ski boot or other type of shoe (also in sports with running)
- Produces pain in the dorsum of the foot and usually radiates to web space between the 1st & 2nd toes
- Caused by compression of the deep fibular nerve deep to the inferior band of the extensor retinaculum and the extensor hallucis brevis
- Associated with edema in anterior compartment of leg
Meniscal Tears
- Present as tenderness at joint line; tear is usually surgically excised
- Peripheral tears can often be repaired or heal on own because of generous blood supply
- If tear cannot heal or be repaired à remove meniscus
- Pain on lateral rotation of tibia on femur = lateral meniscus injury (vice versa for medial)
Pes Anserinus Bursitis
- Common finding in patients and/or athletes who present with complaints of anterior knee pain
- Usually found in patients who have tight hamstrings, although it also can be caused by trauma
- Self-limiting condition that responds to a program of hamstring stretching & quadriceps strengthening
- Posterior dislocations are the most common
- Due to failure of the acetabulum to deepen during development; femoral head rides up on iliac wing
- Bilateral 50% of time, 8X girls>boys, and 1.5/1000 births
- Pediatric health care providers routinely screen all newborns and infants for hip dysplasia. Early treatment requires a harness that keeps the hip joint in place while the child grows. Harder to correct if diagnosed after 6 months; may require surgery.
Congenital hip dislocations
- Strains of adductors, usually occurs in sports that require quick starts (ex. short distance racing)
- Strain, stretching, and possibly tearing of the proximal attachments of the adductor muscles of the thigh (and sometimes flexors)
Groin pull
- Mild compartment syndrome in anterior compartment (tibialis anterior strain)
Shin Splints
- Caused by a tight ski boot or other type of shoe (also in sports with running)
- Produces pain in the dorsum of the foot and usually radiates to web space between the 1st & 2nd toes
- Caused by compression of the deep fibular nerve deep to the inferior band of the extensor retinaculum and the extensor hallucis brevis
- Associated with edema in anterior compartment of leg
Ski Boot Syndrome
- Present as tenderness at joint line; tear is usually surgically excised
- Peripheral tears can often be repaired or heal on own because of generous blood supply
- If tear cannot heal or be repaired à remove meniscus
- Pain on lateral rotation of tibia on femur = lateral meniscus injury (vice versa for medial)
Meniscal Tears
- Common finding in patients and/or athletes who present with complaints of anterior knee pain
- Usually found in patients who have tight hamstrings, although it also can be caused by trauma
- Self-limiting condition that responds to a program of hamstring stretching & quadriceps strengthening
Pes Anserinus Bursitis
Stress fracture
Overuse injury
Occurs when muscles become fatigued and are unable to absorb shock. Most occur in leg or foot.
Symptoms: pain w/ activity, subsides w/ rest.
Diagnosis - often miss on x -ray; need MRI or bone scan.
Treatmetn = rest
Medial tibial syndrome
Not Well understood pathology of the tibial periostitis. Felt under the insertion of the soleus. Most common is at the dital one third of the medial border of the tibia.
Overuse injury
Occurs when muscles become fatigued and are unable to absorb shock. Most occur in leg or foot.
Symptoms: pain w/ activity, subsides w/ rest.
Diagnosis - often miss on x -ray; need MRI or bone scan.
Treatmetn = rest
Stress fracture
Not Well understood pathology of the tibial periostitis. Felt under the insertion of the soleus. Most common is at the dital one third of the medial border of the tibia.
Medial tibial syndrome
