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MSK > Lecture 3: Misc MSK Injuries > Flashcards

Lecture 3: Misc MSK Injuries Flashcards

1
Q

Essentials of diagnosis of Osteomyelitis (4)

A
  • Fever with bone pain and tenderness
  • (+) blood cultures
  • Elevated ESR/CRP
  • Early radiographs are typically negative, esp within 2 weeks

Trending ESR and CRP is much better than WBC due to chronicity

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2
Q

What are the etiologies of osteomyelitis? (3)

A
  • Hematogenous spread
  • Contiguous spread
  • Secondary infection d/t vascular insufficiency or neuropathy
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3
Q

Who is hematogenous osteomyelitis MC in? Where exactly?

A

Children, esp males, in the metaphysis of their long bones

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4
Q

MC primary sites of hematogenous osteomyelitis? (5)

A
  • Urinary tract
  • Skin/soft tissue
  • IV sites
  • Endocardium
  • Dentition

Staph

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5
Q

Biggest RFs for hematogenous osteomyelitis (3)

A
  • IVDU
  • Diabetes
  • IVs

Also similar for spinal epidural abscesses

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6
Q

Who is contiguous spread osteomyelitis MC in and how?

A

Adults, usually post fracture/open wound (diabetic ulcers)

Most commonly polymicrobial

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7
Q

How does osteomyelitis present? (4)

A
  • Gradual onset of S/S
  • Dull pain at site, fever and rigors
  • Tenderness, warmth, erythema, swelling on exam
  • Probing for bone is recommended if ulcer is present
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8
Q

How does vertebral involvement of osteomyelitis present?

A
  • Much slower onset
  • Localized pain/tenderness
  • Pain with percussion over affected area
  • Neurologic symptoms in 1/3 of pts
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9
Q

Dx of osteomyelitis

A
  • Early XR: maybe swelling, loss of tissue planes, periarticular demineralization of bones
  • Later XR: Periosteal thickening or elevation, bone cortex irregularity
  • Ideal: CT or MRI, which is highly sensitive
Moth eaten

Children: 5-7d for changes
Adults: 10-14d for changes

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10
Q

When is CT/MRI indicated for osteomyelitis evaluation?

A
  • Onset < 2 weeks at presentation
  • XR neg but clinical presentation is sus
  • (+) neuro findings on exam

MRI is especially good for feet

Nuclear is alternative.

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11
Q

Who is bone biopsy indicated in for osteomyelitis?

A

Any patient with radiologic evidence without (+) blood cultures.

Do not delay biopsy due to abx use.

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12
Q

What would histology show for a positive bone biopsy for osteomyelitis?

A

Necrotic bone with extensive resorption adjacent to an inflammatory exudate

Must collect through an uninfected site if percutaneous.

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13
Q

Empiric ABX for osteomyelitis

A

MRSA and G- coverage: Vanco + 3rd/4th gen cephalosporin

Typically only used in long-bone infections

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14
Q

How long is staph osteomyelitis?

A

4 weeks

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15
Q

If you want to transition a pt to PO abx for osteomyelitis, what is the combo?

A

After 2 weeks of IV agents at minimum, you can use Levofloxacin/ciprofloxacin + rifampin

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16
Q

When is debridement indicated for osteomyelitis? (4)

A
  • Infection related to open fx or surgical hardware
  • Extensive disease
  • Concomitant joint infection
  • Recurrent/persistent infection
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17
Q

Persistent elevation of what labs over 2 weeks with appropriate ABX is suggestive of a persistent osteomyelitis infection?

A

ESR/CRP

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18
Q

What are the complications of osteomyelitis? (3)

A
  • Pathological fx
  • Chronic
  • Impaired bone growth
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19
Q

What is chronic osteomyelitis?

A

Bone infection over months-years resulting in the development of a sequestrum +/- sinus tract

bone sequestrated/trapped

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20
Q

What is an involucrum?

A

Bone formation in areas where the periosteum was damaged

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21
Q

Where is chronic osteomyelitis MC in? (3)

A
  • Sternal
  • Mandibular
  • Feet
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22
Q

How does chronic osteomyelitis present? (4)

A
  • Pain, erythema, swelling
  • +/- draining sinus tract
  • fever usually not present
  • bone palpation is positive
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23
Q

How do labs differ between chronic vs acute osteomyelitis?

A

Leukocytosis and ESR/CRP are rarely elevated in chronic.

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24
Q

What is a marjolin ulcer?

A

Epithelium of the sinus tract develops squamous cell carcinoma

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25
Q

Management of chronic osteomyelitis (3)

A
  • Debridement
  • Obliteration of dead space
  • Long-term ABX therapy
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26
Q

What is compartment syndrome?

A

Increased pressure within a limited space compromises the circulation and function of the muscles and nerves within that space

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27
Q

What are the 4 compartments of the lower leg?

A
  1. Anterior
  2. Lateral
  3. Superficial posterior
  4. Deep posterior

MC location for compartment is lower leg

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28
Q

What is normal compartment pressure and how long can we tolerate increased pressure?

A
  • 10mm is normal, but we can tolerate up to 20 without damage.
  • After around 8h, we start developing neuropathy.
  • After around 12h, myocytes die and we develop contractures.
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29
Q

Clinical presentation of compartment syndrome? (6)

A
  • Pain out of proportion
  • Pain that worsens with passive stretching
  • Paresthesias within 30min onset
  • Tense to palpation
  • Decreased sensation (use 2 point)
  • Weak pulse in severe

Paralysis is late and pallor is rare

30
Q

How do you measure compartment pressure and what is an elevated pressure? (3)

A
  • Two separate measurements within 5 cm of the site
  • Pressures must be > 45 mmHg
  • Must account for hypotensive patients, aka if DBP is within 30 of their compartment pressure. (DBP of 52 with pressure of 28 = compartment syndrome)

DO NOT USE in hands or feet

31
Q

Management of compartment syndrome? (3)

A
  1. Remove casts/dressings
  2. Elevate affected limb
  3. Surgical fasciotomy if patient has had it within 24h-48h
32
Q

Essentials of rhabdomyolysis (3)

A
  • MCC: Crush injuries
  • Serum elevations in CK and lyte abnormalities
  • Release of myoglobin leads to renal toxicity
33
Q

What is rhabdomyolysis? (2)

A
  • Acute skeletal muscle cell death leading to release of intracellular contents
  • ATN will occur, leading to AKI
34
Q

What causes ATN due to rhabdo? (5)

A

Hypovolemia + myoglobin + uric acid crystals + decreased GFR + ferrihemate (metabolite of myoglobin)

35
Q

Clinical presentation of rhabdomyolysis (4)

A
  • Dark tea colored urine
  • Myalgias and weakness
  • Malaise, low-grade fever
  • N/V, abd pain, and tachy if severe

Similar to a flu patient

36
Q

Dx of rhabdo

A
  • Elevated CK 5x ULN (Most sensitive)
  • UA showing tea color when urine myoglobin is > 100
  • A (+) blood on UA with negative RBC on microscopy = myoglobinuria
  • CMP: Elevated phosphorus, uric acid, BUN/Cr, AST/ALT
  • CBC to monitor potential DIC

A UA cant differentiate blood and myoglobin

37
Q

Management of Rhabdo

A
  • IVF aggressively for first 72h early
  • Monitor I&O to get goal of 200-300
  • Urine alkalization via bicarb

fluids & bicarb

38
Q

When would you treat hypocalcemia in rhabo?

A

Only if hyperkalemia is present

39
Q

Discharge criteria for rhabdo (5)

A
  • Normal renal
  • Normal lytes
  • Alkaline urine
  • Isolated cause of injury
  • No uncontrolled comorbidities
40
Q

Main complications of rhabdo (3)

A
  • AKI
  • Compartment syndrome
  • DIC
41
Q

What is fibromyalgia?

A

Chronic condition characterized by multiple MSK pain with multiple tender points but no objective findings

42
Q

MC demographic for fibromyalgia

A

Women 20-55

43
Q

Presentation of Fibromyalgia (4)

A
  • Chronic fatigue and generalized aching pain
  • Depression
  • Widespread soft tissue tenderness
  • No joint involvement
44
Q

How is fibromyalgia diagnosed? (3)

A

ACR criteria:

  1. Widespread pain index (WPI) > 7 + symptom severity (SS) > 5 or WPI 3-6 with SS > 9
  2. 3 months
  3. No other disorder

Dx of exclusion

45
Q

Management of fibromyalgia

A
  • Patient education
  • CBT
  • Exercise
  • Wt loss if overweight
  • Muscle relaxant: flexeril
  • Antidepressants
  • Neurontin/pregabalin
  • Tramadol

Careful of tramadol addiction

46
Q

Treatment protocol for fibromyalgia

A

On average: start with cyclobenzeprine or amitriptyline QHS

47
Q

What is neurogenic arthropathy/charcot joint?

A

Condition characterized by progressive destruction of bone and soft issues at weight bearing joints

48
Q

What is the hallmark sign of neurogenic arthropathy?

A

Mid-foot collapse, described as a rocker-bottom foot

49
Q

MC etiologies for neurogenic arthropathy (5)

A
  • DM (MC)
  • Cerebral palsy
  • Alcoholic neuropathy
  • Spinal cord injury
  • Syphilis

peripheral neuropathy related things

50
Q

Where does neurogenic arthropathy occur most commonly?

A
  • Foot
  • Ankle
  • Tarsometatarsal joint
  • Ankle articulations
51
Q

Presentation of neurogenic arthropathy (5)

A
  • Unilateral warmth, redness, and edema over joint
  • Hx of minor trauma
  • Pain is present but low severity
  • Loss of arch, bony protrusions
  • 40% have concomitant ulcers
52
Q

Dx imaging of neurogenic arthropathy

A
  • XR with weight-bearing
  • MRI if XR negative OR osteomyelitis is in DDx
53
Q

What 3 things are key to look at for an XR for neurogenic arthropathy?

A
  • Progressive decline of the yellow angle (calcaneal inclination)
  • Equinus deformity (can’t dorsiflex)
  • Destruction of TMT joint (red line)
54
Q

Staging of neurogenic arthropathy (4)

A
  1. Stage 0: early/inflammatory with no radiographic evidence
  2. Stage 1: development with swelling and XR findings
  3. Stage 2: coalescence with decreasing inflammation and healing of XR findings
  4. Stage 3: Remodeling with no inflammation, bony deformities, and mature fracture callus.
55
Q

Tx for stage 0-2 neurogenic arthropathy

A
  • Avoid weight-bearing via casting of foot
  • CROW (charcot restraint orthotic walker) use

before foot remodeling has occurred mostly

56
Q

Tx for stage 3 or failed therapy neurogenic arthropathy

A

Discuss risk/benefit of surgery

57
Q

What is Raynaud’s phenomenon? (2)

A
  • Syndrome of paroxysmal digital ischemia in cold or emotional stress.
  • Vasoconstriction and then rapid vasodilation

MC in the fingers

58
Q

What is primary Raynaud’s & who is it MC in? (3)

A
  • NO vascular structural abnormalities
  • MC in healthy females 15-30
  • FMHx

MC type

59
Q

What is secondary Raynaud’s & who is it MC in? (5)

A
  • Underlying systemic condition leads to Raynaud’s
  • MC in males > 40
  • MC with rheumatologic conditions
  • Frostbite, jackhammers
  • More severe and higher risk of ulceration/gangrene
60
Q

What are raynaud attacks & where do they MC occur? (3)

A
  • Sudden onset of cold digits with demaracation of skin pallor (white attack) or cyanosis (blue attack)
  • Massive erythema when rewarming
  • MC in the index, middle, and ring fingers
Sclerodactylyl, calcinosis
61
Q

What do nailfold capillaries look like in raynaud’s?

A
62
Q

Management of primary Raynaud’s (2)

Normal PE and nailfold capillaries

A
  • Pt Ed
  • Regular f/u
63
Q

Management of secondary Raynaud’s (1)

A

Tx the underlying condition

64
Q

What is the patient education for Raynaud’s? (3)

A
  • Wear mittens and stockings
  • Avoid vasoconstrictors
  • Smoking cessation
65
Q

First-line pharmacologic therapy for Raynaud’s (2)

A
  1. CCBs (amlodipine)
  2. NTG or PDE5 inhibitors

Indicated if failure to control symptoms, vasodilators

If all fails, refer to vascular

66
Q

What is Marfan’s syndrome?

A

Genetic disorder of CT tissue characterized by skeletal, ocular, and CV abnormalities

1 in 5000, bones, eyes, heart

67
Q

Presentation of Marfan’s

A
  • Tall, long arms, and digits (arachnodactylyl)
  • Scoliosis
  • Pectus Carinatum/excavatum
  • Ectopia lentis (eye lens displacement)
  • Myopia (Near sighted)
  • Retinal detachment
  • MVP
  • Aortic root dilation => aortic regurg or dissection
68
Q

How is marfan’s confirmed?

A

Genetic testing showing a mutation in the fibrillin gene (FBN1) on chromosome 15

69
Q

What criteria is used to score marfan syndrome?

A

Ghent criteria

No need to memorize criteria components

70
Q

How do we manage Marfans? (5)

A
  • Annual Ophthalmology
  • Annual Orthopedic
  • Annual Echo/cardio
  • Long term BBs (atenolol/metoprolol)
  • Restriction from vigorous physical exertion

Eye, Bones, Heart

MSK (17 decks)

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