Karp Skeletal Flashcards
Inflammatory conditions - men 18-34
Spondyloarhtropathies
Gonococcal arthritis
Gout
Non inflammatory conditions - men and women - 18-34
Injury, overuse
Low back pain
Inflammatory conditions - women 18-34
Gonococcal arthritis
RA
SLE
Non inflammatory conditions - men 35-65
Low back pain
Overuse or injury
OA
Entrapment syndromes
Inflammatory conditions - men 35-65
Bursitis
Gout
Spondyloarthropathies
Inflammatory conditions - women 35-65
Bursitis
RA
Non inflammatory conditions - women 35-65
Osteoporosis Low back pain Injury or overuse Fibromyalgia Entrapment syndromes OA Raynauds
Noninflammatory condition - men >65
OA
Low back pain
Osteoporosis
Fracture
Inflammatory conditions - men >65
Bursitis Gout RA Pseudo gout Poly myalgia rheumatica Septic arthritis
Non inflammatory conditions - women >65
Osteoporosis OA Fibromyalgia Low back pain Fracture
Inflammatory conditions - women >65
Bursitis RA Gout Pseudogout Poly myalgia rheumatica Septic arthritis
What is the time line between acute and chronic time course?
6 weeks
How does mono/oligo arthritis differ from poly articular?
> 3 joints affected
What are inflammatory symptoms?
Joint pain - activity and rest Soft tissue swelling in joint Sometimes erythema and warmth Prolonged (>60 min) morning stiffness Systemic symptoms common ESR and CRP increased Hemoglobin normal or low Synovial fluid WBC >2000 Synovial fluid % PMN >75
What are non inflammatory symptoms?
Joint pain - activity only
Bony swelling in joint if anything
No erythema and warmth
Variable (<75
What is the most common lab feature of inflammation?
Acute phase response
IL-6 made
CRP is a direct measure - more specific than ESR that can be elevated with other things like age
What is a big general difference between Articular and non articular disorders?
Non articular characterized by pain on active movement only and can be localized no specific non articular structure
What are pain or tenderness symptoms in articular vs. non Articular disorders?
A - localized to joint, deep or poorly localized, specific referral patterns
N - localized to extra articular structure, point tenderness, superficial
What are symptoms of pain on movement in articular vs. non articular disorders?
A - active and passive movement, in many planes, localized to joint
N - active movement only, in specific planes, rarely localized
What are the symptoms of swelling in articular vs. non articular diseases?
A - common, synovial effusion or thickening, bony enlargement
N - maybe, not limited to articular structure
What are limitation of motion symptoms in articular vs. non articular diseases?
A - passive and active range of motion, related to mechanical derangement or joint pain
N - maybe but only with active, related to extra articular mechanical abnormality, diffuse pain or weakness
What may be present in articular disease but is not present in a nonarticular disease?
Crepitation
Instability
Locking of joint
Deformity - only in NA if antecedent trauma
What are the local and widespread etiologies of non articular disorders?
Local - fracture, septic bursitis, bursitis, tendonitis
Widespread - fibromyalgia, hypothyroidism, osteoporosis
Aching and discomfort in subdeltoid region associated with night pain and aggravated with abduction
Hx of repetitive and strenuous upper limb activity - may be absent in elderly
Onset acute or chronic in any age group
Subacromial bursitis (rotator cuff tendinitis) Suspect rotator cuff tear when weakness or wasting is present
Pain over anterior aspect of shoulder exacerbated by restricted elbow flexion or supination, occurs at any age, night pain is rare, associated with overuse
Bicipital tendinitis
Pain and tenderness poorly localized to lateral epicondyle impairing grip, aggravated by resisted dorsiflexion of wrist, often from overuse in person over 30 years
Tennis elbow (lateral epicondylitis)
Pain and tenderness poorly localized to medial epicondyle, aggravated by wrist flexion, associated with overuse
Golfers elbow (medial epicondylitis)
Deep aching pain on lateral aspect of hip and thigh, aggravated by activity often present at night related to position, more frequent in women
Trochanteric bursitis - movement of hip is usually normal
Circumscribed painful swelling anterior to patella
Pre patellar bursitis - related to recent trauma, may be infected
Pain over the medial aspect of upper tibia
Anserine bursitis
Pain on under surface of heel on weight bearing, aggravated by dorsiflexion of foot
Plantar fasciitis - radiographs may show a plantar spur, related to repetitive trauma
When should an arthrocentesis be indicated?
Acute monoarthritis
Trauma with effusion
Anytime you suspect infection, blood, or crystals
ONLY get cell count and differential, gram stain and culture, and crystal analysis (chocolate agar if gonorrhea suspected)
What do colors of synovial fluids mean?
Clear - not inflammatory
Translucent or opaque - inflammatory
White and chalky - gout
What are the four types of joint fluid?
Normal - clear, viscous, WBC 2000 WBC and >75% neutrophils - septic arthritis, RA, gout spondyloarthritis
Hemorrhagic - indicates trauma with or without fracture or coagulopathy
What can a WBC alone not do?
Differentiate between inflammatory and septic
Chronic oligo articular arthritis of lower extremities, possible knee effusion
Lyme arthritis
What are the three stages of Lyme disease?
1 - 3-4 days after transmission - fever, malaise, myalgias, arthralgias, no true arthritis, hallmark is erythema chronicum migrans (ECM)
2 - weeks to months - myalgias and arthralgias, carditis and AV block, meningitis CN vii palsy, conjunctivitis Ns iritis
3 - 5-7 months - arthritis, chronic CNS symptoms of cognitive and memory dysfunction, radiculopathy
How is Lyme disease diagnosed?
ElLISA assay for IgG to spirochete confirmed by western blot
What causes gout and psuedogout?
Gout - monosodium urate
Psuedogout - calcium pyro phosphate dihydrate
Acute extremely painful monoarthritis, cutaneous erythema/tendonitis, fever, leukocytosis, spontaneous resolution in 3-5 days usually, mean time to first recurrence - 11 months
Early gout
Granulomatous urate deposits, finger, wrists, knees, olecranon bursa, ears, pressure points involved
Late gout - usually - 10 years after first attack, remissions shorten, chronic inflammation
What is the relationship between hyperuricemia and gout?
Alone doesn’t imply gout but is always in gout
More likely with elevated uric acid but levels can be normal during acute attack
90% have decreased uric acid secretion - idiopathic, CKD, drugs
10% have overproduction (800mg/24hrs) - idiopathic or overproduction
How is gout diagnosed definitively?
Demo monosodium urate crystals in joint fluid
Birefringence - yellow urate parallel, blue perpendicular (opposite with CPPD)
What are radiographic features of gout?
Tissue swelling early with preservation of joint spaces
Erosions with overhanging edge at end of capsule (not in joint) late in disease
Little peri articular osteopenia
Elderly male with onset of knee swelling and severe pain over hours to days, can be in wrist, shoulder, or ankle
Psuedogout (chondrocalcinosis) - mimics gout
Elderly female with symptoms in 2nd and 3rd mcp joints of hand, picture of osteoarthritis with inflammation imposed
Chronic CPPD arthropathy - can also have pseudo rheumatoid with synovitis and pseudo neuropathic with destruction of joint
Calcification of knee menisci, triangular cartilage of the wrist, and symphysis pubis, degenerative changes similar to osteoarthritis, inflammatory or blood tinged joint fluid
Chondrocalcinosis
What are features of osteoarthritis?
Pain with use, little morning stiffness Pain and stiffness with inactivity (churchgoers knee) Sensation of locking or giving away Crepitus with passive movement No useful lab tests
What is one of the earliest radiographic feature of OA?
Bone marrow edema on MRI
What is the most common cause of osteonecrosis?
Trauma
Particularly fracture of femoral neck
Progressive bone pain, often worse at night or with use and weight bearing, pain on movement of affected joint, no inflammation
Osteonecrosis - no lab tests for diagnosis
Early signs on MRI include bone marrow edema
What is the boutonnière sign in RA?
Flexion of PIP and hyper extension of DIP
What is the swan neck sign in RA?
Flexion of DIP and hyper extension of PIP
What are lab features of RA?
Rheumatoid factor (anti IgG)
Anti CCP
Normochromic normocytic anemia
Nothing diagnostic by itself
What are common viral infections associated with arthritis?
Parvovirus B19
Rubella
Hep b and c
HIV
What are extra articular manifestations of RA?
Rheumatoid nodules Keratoconjunctivitis sicca Episcleritis/scleritis Vasculitis Pulmonary nodules/fibrosis
What is the use of anti CCP tests in RA?
Same sensitivity for RA as RF
utility in diagnosing early RA or differentiating RA from another condition with RF
What are general features of seronegative spondyloarthropathy?
Chronic and inflammatory
Oligo articular
Asymmetric, often involves axial skeleton
Strongly associated with HLA B27
Axial arthritis, enthesitis, arthritis of hips and shoulder, peripheral arthritis, flexed forward posture
Ankylosing spondylitis
What are general features of ankylosing spondylitis?
Onset in early adulthood before age 40 Men affected more than women Back Pain typically first symptom Insidious onset Duration more than three months Morning stiffness
What are the extra articular manifestations of ankylosing spondylitis?
Anterior uveitis - tearing, pain, photophobia, blurry vision, corneal inflammation and edema, monocular
Aortitis, aortic insufficiency, heart block
Spinal cord damage - spinal fracture, cauda equina syndrome
What are the radiographic features of ankylosing spondylitis?
Erosion, sclerosis and fusion of sacroiliac joints
Erosion at sites of tendon attachment
Ossification of annulus fibrosis, apophyseal joints, and intervertebral ligaments = bamboo spine
Bone spurs bridge edges of vertebral bodies
Arthritis involving large joints of lower extremities or interphalangeal joints, looks like RA but with DIP involvement, involvement of axial skeleton with or without peripheral joint disease, nail ridging and pitting
Psoriatic arthritis
What are x ray and lab features of psoriatic arthritis?
Sausage digits
Joint space loss
Marginal erosion of DIP and PIP joints
ESR and CRP elevated but autoantibodies negative
What is Reiter’s syndrome?
Triad of urethritis, conjunctivitis, and arthritis
= reactive arthritis
What pathogens are associated with reactive arthritis?
Shigella, salmonella, campylobacter, yersinia, chlamydia
2-4 weeks after infection, additives asymmetrical, oligo articular, lower more than upper limb involvement, digits of hands and feet diffusely inflamed (dactylis), enthesitis, radiographic sacroiliitis
Reactive arthritis
What are non articular manifestations of reactive arthritis?
Keratoderma blenorrhagicum Circinate balanitis Oral ulcers Anterior uveitis Aortitis Nail dystrophy without pitting
