Misc MSK injury trigger Flashcards
MC in Children, esp males, in their metaphysis in long bones
hematogenous osteomyelitis
fever with bone pain and tenderness. Associated elevations in ESR, CRP and negative radiographs
osteomyelitis
may also see positive blood cultures!!
Urinary tract, skin/soft tissue, IV sites, endocardium, dentition are MC originations for what?
hematogenous osteomyelitis
MC in vertebral column LS>TS>CS in adults
hematogenous osetomyelitis
can be caused by prosthetic devices, neurosurgery, septic arthritis or open fractures/trauma
contiguous osteoarthritis
pt presenting with gradual onset of dull plantar foot pain and fever/chills 1 week ago. Ankle shows tenderness, warmth, erythema and swelling. what labs/imaging would you order in this patient? if imaging/labs are positive what would you see and what would be your next step?
suspected dx: osteomyelitis
labs: blood cultures (+), CBC (^WBC), ESR (^), CRP (^), BMP (just to assess renal/liver prior to meds)
Imaging: jump straight to MRI/CT d/t onset being <2 weeks and it being in the foot.
next step: consult ID/Ortho.
if + for staph start cefazolin, nafcillin or oxacillin (vanc for MRSA or PCN allergy) for 2 weeks followed by 4-6 wks of levo/cipro + rifampin
(slides say typically only use abx in long bone infections but i guess you could give abx)
Pt presents with 6 wk hx of localized pain over her lumbar area. pain is increased with percussion to the area. she has also been complaining of headaches and suffered a seizure en route to the hospital. what is your suspected dx? what imaging would you get in this patient?
osteomyelitis w vertebral involvement
remember neuro s/s can be seen in 1/3 of pts!
if you see neuro s/s you can jump straight to MRI/CT!
Xray shows loss of tissue planes and periarticular demineralization of bones
early osteomyelitis
Xray shows periosteal thickening or elevation and bone cortex irregularity
later osteomyelitis
if a pt has suspected osteomyelitis with radiologic evidence but their blood cultures are negative what is the protocol
bone biopsy
histology shows necrotic bone with extensive resorption adjacent to inflammatory exudate
osteomyelitis
(ceftaz/ceftriaxone/cefepime) + vanc is for what
empiric ABX for osteomyelitis (typically only used in long bone infections)
cefazolin/nafcillin/oxacillin is used when? when would vanc be used instead?
abx regimen for staph osteomyelitis
use vanc for MRSA or PCN allerg
levo/cipro + rifampin is used when? what are alternatives to this
PO abx that can be used for osteomyelitis after 2 weeks of IV abx.
alternatives are bactrim, doxy or clinda.
what suggests a persistent osteomyelitis infection
persistent elevation of ESR/CRP over 2 weeks of appropriate ABX
can lead to chronicity, pathological fracture, and impaired bone growth
complications of osteomyelitis
formation of cloaca, necrosis, sequestrum and involucrum are all associated with what condition
chronic osteomyelitis
MC in sternum, mandible and feet
chronic osteomyelitis
what physical exam and lab findings may differentiate chronic and acute osteomyelitis
fever is NOT usually present in chronic.
chronic may have a draining sinus tract.
chronic - ESR/CRP and WBC are not elevated usually
chronic is developed over months to years!!
when the epithelium of an osteomyelitis sinus tract develops squamous cell carcinoma it is known as what
marjolin ulcer
in compartment syndrome, how long before myocytes die and we develope contractures
12 hours
develope neuropathy after 8 hours
after a suspected fracture of her tibia, a patient begins having increased pain out of proportion to her pain 20 minutes ago. on exam her skin is tense to palpation over the injury and she reports she is starting to experience deceased sensation and paresthesias. what is the diagnostic of choice in this pt and, if positive, what is the tx
dx: compartment syndrome
diagnostic: two separate pressure readings withiin 5cm of the site. if over 45 mmHg its positive
tx: elevate limb. remove restrictive dressings. consult if sugrical fasciotomy is needed. admit!
pt presents with myalgias, weakness, and a low grade fever. she reports swelling and tenderness of her left lower extremity. she also has dark colored urine.
what lab findings would you see in this patient?
rhabdomyolysis
labs:
treat with aggressive IVF for 72 hours with a goal of 200-300 mL/hr of urine output.
when would you use bicarb in this patient? when would you be concerned about hypocalcemia?
this is rhabdomyolysis.
use bicarb to alkalize urine only if:
CK levels are higher than 5,000
acidemia
dehydration
underlying renal disease
only treat hypocalcemia if hyperkalemia is present!
complications can include compartment syndrome, DIC and AKI
rhabdomyolysis
widespread soft tissue tenderness with chronic fatigue and generalized aching pain. often with associated depression. no joint involvement
fibromyalgia
when do you treat with neurontin or lyrica
fibromyalgia with severe sleep disturbance
when do you treat with cymbalta/savella
fibromyalgia patients with severe fatigue
initial tx for this dz is cyclobenzaprine or amitriptyline at bedtime
fibromyalgia
Condition characterized by progressive destruction of bone and soft issues at weight bearing joints
neurogenic arthropathy/ charcots joint
MC in pts with DM, cerebral palsy, syphilis, spinal cord injury and alcoholic neuropathy
neurogenic arthropathy
pt presents and reports pain that is a 2/10 of her right foot onset 2 weeks ago after stumbling and stepping on a rock. on exam you see unilateral warmth, redness and edema over the dorsal and plantar aspects of the foot. she reports the pain is low severeity but constant. she has a hx of DM, alcoholism and syphilis. what could the diagnosis be and how would it present if it is not treated.
neurogenic arthropathy.
could see bony protrusions of the plantar foot and loss of arch leading to charcots foot.
when would you want to use a weight bearing xray
neurogenic arthropathy ( probs to assess the arch of the foot)
what stage of neurogenic arthropathy includes bony changes such as fx, subluxation/dislocation and bony debris
stage 1 developement
swelling/redness/warmth from stage 0 will persist throughout stage 1 as well
what stage of neurogenic arthropathy do clinical inflammatory signs begin to decrease and fractures and bony debris begin to heal with new bone formation
stage 2 coalescence
what stage of neurogenic arthropathy do you see stable or unstable bony deformity but no signs of inflammation. xray may show fracture callus and decreased sclerosis
stage 3 remodeling
when do you use a charcot restraint orthotic walker?
stage 0-2 neurogenic arthropathy treatment in addition to avoiding weight bearing.
for stage 3 discuss surgery
MC in males > 40 and in those with rheumatologic conditions. can also be seen d/t frostbite or jackhammer use
secondary raynauds (Increased risk of gangrene and ulceration compared to primary)
when do you use amlodipine as first line and nitro or PDE5 inhibitors as second line? what do you do if all of these fail
raynauds phenomenon
refer to vascular surgery if they dont work
what heart conditions are assocaited with marfans
MVP
aortic root dilation leading to aortic regurgitiation or dissection
what visual problems are associated with marfans sydnrome
myopia (near sighted)
ecotopia lentis (eye lens displacement)
retinal detatchement
what is the gene for marfans
fibrillin gene FBN1 on chromosome 15
what is the ghent criteria used for
marfans syndrome
Long term BB is used in management for what disease. What other management guidlines are there
marfans
annual ophthalmology, orthopedic, cardio checkups.
restrict from physical exertion
