MSK Flashcards
What are some inflammatory markers?
Elevated ESR and CRP
In joint disease, what is the first line anti-inflammatories used?
NSAIDs
MOA of NSAIDs
block cytokine synthesis, specifically prostaglandins
Which NSAIDs inhibit both COX-1 and COX-2?
ibuprofen, naproxen
Why do some NSAIDs cause increase risk of peptid ulcers?
COX-1 inhibition decreases prostaglandin synthesis in gut
Which type of NSAIDs have fewer GI side effects?
selective COX-2 inhibitors
drugs ending in “-coxib” (eg. Celecoxib/Celebrex)
Types of inflammatory arthritis
RA, spondyloarthritis, infection, crystal-induced
Types of non-inflammatory arthritis
osteoarthritis, trauma, hemarthrosis
Inflammatory vs non-inflammatory symptoms
Inflammatory - aggravated by rest (eg. prolonged morning stiffness), relief with use, symmetric
Non-inflammatory - aggravated by use, relieved by rest, asymmetric
AC joint connects what?
acromion to the clavicle
What are muscles of the rotator cuff? What are their actions?
"SITS" Supraspinatus – abduction Infraspinatus – ER Teres minor – ER Subscapularis – IR
Which rotator cuff muscles is most often injured?
suprapinatus
PE findings of AC joint osteoarthritis
Tenderness over AC joint
Cross-arm test (pain cause by flexion and adduction of arm)
Pathophysiology of rotator cuff impingement
rotator cuff pinched underneath acromion
Patient comes in because increasing shoulder pain and weakness. Says she can’t lift arm above her shoulder to brush her hair. Likely dx?
Rotator cuff tear or impingement
Test that isolates supraspinatus? How is it done?
Empty can test: elevate and abduct shoulders with thumbs down. Push down on patient’s arms.
Pain = rotator cuff tear of supraspinatus
What are some PE tests for shoulder impingement?
Neer test – Move fully pronated arm in forced flexion (SUBACROMIAL)
Hawkins test – arm is forward elevated to 90 degrees, then forcibly internally rotated (SUPRASPINATUS)
Pain with either is indicative of impingement
How is apprehension test done? What does it test?
anterior instability
Arm abducted to 90 deg while examiner externally rotates arm and applies anterior pressure to humerus
Test indicating positive labral tear
“clunk sign”
O’Brien test
Speeds (bicep tendonitis)
Test that shows complete rotator cuff tear
Drop arm test
Pathophysiology of carpal tunnel syndrome
median nerve compression as it runs through carpal tunnel
What forms the carpal tunnel?
carpal bones and flexor retinaculum
Which fingers are affected in carpal tunnel?
median nerve distribution - thumb, index, middle, radial half of ring finger
What is a sign of severe cases of carpal tunnel?
atrophied thenar eminence
Positive tests for carpal tunnel
Tinel’s sign - pain and tingling with percussion of flexor retinaculum
Phalen’s Test - press back of hands together (full wrist flexion) and hold, reproduces sx’s within 60 seconds *more accurate than Tinel’s
Diagnostic testing for carpal tunnel
EMG testing
Carpal tunnel treatment
Avoid repetitive movements (typing) Night splint NSAIDS Steroid injection If symptoms constant than need surgical release of flexor retinaculum
Lateral epicondylitis aka _________ and medial epicondylitis aka _________.
lateral = tennis elbow medial = golfers elbow
Epicondylitis treatment
Rest ice Injection Stop repetitive activity Counterforce brace Physical Therapy
Etiology of lateral epicondylitis caused by what repetitive movement?
wrist supination and extension
- medial is pronation and flexion
Causes of AC joint separation injury
Direct blow
FOOSH
When should AC joint separation be surgically corrected?
Type I, II: non-surgical; sling, analgesics, ice
Type III: possible surgery in athletes and heavy laborers
Type IV, V, VI: refer
Most common shoulder dislocation
anterior dislocation (95%)
Tests for shoulder dislocation
Positive apprehension sign
Positive sulcus sign
How is shoulder dislocation treated?
manual reduction
What is a Boxer’s fracture?
fracture of 5th metacarpal
Boxer’s fracture treatment
Ulnar gutter splint
Closed reduction pinning
ORIF
What is a Colles fracture?
distal radius fracture with dorsal angulation of hand and wrist = dinner fork deformity
FOOSH
most common wrist injury
Colles fracture treatment
Closed reduction and immobilization
Surgical correction if unable to achieve a stable satisfactory reduction.
Gamekeeper’s Thumb is an injury to what structure?
ulnar collateral ligament of thumb
tear or avulsion at insertion on proximal phalanx
Signs of Gamekeeper’s Thumb
Instability of the metacarpal joint of the thumb
Weak pinch or grasp
Swelling or bruising of the thenar eminence
Treatment of Gamekeeper’s Thumb
Minor tears: thumb spica
Significant tears: surgical repair
Most commonly fractured carpal bone
scaphoid
Hallmark finding of scaphoid fracture
painful palpation of anatomical snuffbox
Diagnostic imaging for scaphoid fracture
MRI, may be missed on XR
Treatment of scaphoid fracture
Treat if suspected!
Thumb spica cast
Surgical correction
subluxation of radial head past annular ligament =
Nursemaid’s elbow
Nursemaid’s elbow mechanism of injury
pulling on extended arm of child
Treatment of Nursemaid’s elbow
Reduction: supinate wrist and extend the elbow while applying pressure over radial head
What does a fat pad sign indicate on XR?
occult elbow fracture
Time duration of acute vs chronic MSK conditions
acute less than 6 wks
chronic more than 12 wks
How to test for herniated disc?
+ SLR
L5 nerve effects: decreased ankle and great toe strength, numb medial foot
S1 nerve effects: numb posterior calf and lateral foot, weak plantar flexion, diminished Achilles reflex
What is the narrowing of the spinal canal resulting in compression of spinal cord or nerve roots?
spinal stenosis
Causes of spinal stenosis
Herniated disc Osteoarthritis Compression fractures Trauma Tumor Inflammation Congenital - narrow spinal canal
Define radiculopathy
pain, weakness or numbness radiating down a particular nerve distribution
What is shopping cart sign? What does it indicate?
relief of back pain when bending forward and pushing a shopping cart
sign of spinal stenosis
Most herniated discs occur where?
L4/L5 and L5/S1
Patient comes in because of…
Saddle anesthesia
Bowel or bladder incontinence
Sexual dysfunction
Pain in the lower extremities
Cauda equina syndrome
What nerves make up the caudal equine (“horse tail”)?
L2-L5
S1-S5
coccygeal nerve
Treatment of caudal equina
Acute onset is an emergency requiring immediate surgical decompression
Chronic inflammatory disease resulting in vertebral fusion =
Ankylosing spondylitis
Schober’s test
Mark L5 with patient standing
Mark 5 cm below L5 = point 1
Mark 10 cm above L5 = point 2
With the patient bending over, the distance between point 1 and 2 should be greater than 20 cm. If not, this indicates decreased flexion of spine (seen in ankylosing spondylitis)
XR findings of ankylosing spondylitis
Bamboo spine
Ankylosing spondylitis treatment
NSAIDs Opioids DMARDS TNF-alpha antagonists PT Surgery
Serum positive for HLA-B27. DDX?
Ankylosing spondylitis
Psoriatic arthritis
Reactive arthrites (Reiter’s Syndrome)
Medical term for humpback
kyphosis
Epidemiology of ankylosing spondylitis
M > F
young adults
Treatment of kyphosis
Bracing
Physical therapy
Kyphoplasty
Clinical definition of scoliosis
spinal curvature of more than 10 degrees from side to side
What is evaluated on XR of scoliosis?
Cobb angle: line parallel to superior endplate of one vertebra and another line parallel to inferior plate of another vertebra; angle at which these two lines intersect is Cobb angle
Treatment of scoliosis
Based on Cobb angle
- Less than 20: watchful waiting, bracing may arrest further deformity
- Over 50: posterior spinal fusion surgery
What is the minimum you should wait to order imaging on a patient with generalized low back pain and no significant history?
4 weeks
All open fractures should include what treatment?
Irrigation and debridement within 8 hrs of injury
Empirical abx: 1st gen cephalosporin (cephalexin, keflex)
Risk factors for Avascular necrosis of femoral head
Long term steroid use Alcoholism Trauma Arterial embolism Sickle cell anemia Autoimmune disorders like Lupus or RA
Symptoms of avascular necrosis of femoral head
groin pain
difficulty walking
Treatment of avascular necrosis of femoral head
Core decompression
Total hip replacement
PE tests done in infants to assess for developmental dysplasia of the hip
Barlow maneuver – flex hips and knees to 90 deg. Abduct and IR hips while applying pressure to knees in effort to dislocate hips
Ortolani maneuver – flex hips and knees to 90 deg and ER hips while applying pressure over greater trochanters. Done after Barlow to reduce hip if dislocated; positive if clunk
Developmental dysplasia of the hip treatment
Bracing and splinting
Surgical correction and possibly total hip
How does leg present on PE when there is a proximal femur fracture?
injured leg is short and externally rotated
Treatment of proximal femur fracture
Needs surgical repair
Typical patient with slipped capital femoral epiphysis
13 yo overweight male
Symptoms of slipped capital femoral epiphysis
groin and knee pain
limping a little for few months
What of hip is most comfortable for patient with slipped capital femoral epiphysis?
ER of hip
pain with IR, abd, and flexion
XR views for hip
AP and frog leg
Treatment of slipped capital femoral epiphysis
Surgical correction, consider bilateral
patella fracture treatment
Displaced - ORIF
Non-displaced - extension brace x 6 wks (CANNOT FLEX)
What fractures are likely to occur from a fall from heights where patient lands on feet?
tibial plateau tx
calcaneus fx
lumbar compression fx
Lis-Franc fx/dislocation
Complication of tibial plateau fracture
compartment syndrome
What test to do if patella fracture suspected?
SLR
13 yo male basketball player comes to clinic complaining of anterior knee pain. On PE you note enlarged tibial tubercle and pain with resisted knee extension. Likely dx?
Osgood-Schlatter disease
Treatment of Osgood-Schlatter disease
NSAIDs
Self-limiting, but not until growth plates close
RICE
PT
Function of medial and lateral meniscus
provide cushion and stability for knee
Mechanism of acute meniscus injury
twisting of knee with planted foot
PE findings of meniscal injury
Joint line tenderness Joint effusion pain/click with McMurray Apply Thessaly
How is McMurray test done?
Pt lies supine with knee completely flexed. Passively extend while rotating leg and applying pressure to side of knee
IR for lateral meniscus
ER for medial meniscus
ACL prevents anterior translation of ______.
tibia
PE tests for ACL integrity
Anterior drawer: patient supine with knee flexed to 90. You sit on foot and pull on tibia
Lachman test: knee at 30 deg flexion; push down on distal femur and pull up on proximal tibia
Single best choice to test for ACL tear
Lachman test
Likely injury in MVA when knee hits dashboard
PCL tear
Postitive PE tests if PCL tear
Posterior sag sign: hip and knee flexed to 90. see tibial step off
Posterior drawer test: knee flexed to 90 and push proximal tibia
How to test integrity of MCL?
apply valgus stress to knee at 30 degrees of flexion
Treatment for most knee injuries
RICE
PT
Surgery
Most common structure injured in ankle sprain
ATFL = anterior talofibular ligament
What is a Jones fracture?
fracture at metaphyseal-diaphyseal junction of 5th metatarsal
Risk factors for Achilles tendon rupture
elderly, florquinolones (cipro), CS tendon injections, sports with explosive jumping
What test differentiates Achilles tendonopathy from a full rupture?
Thompson’s test positive in rupture (squeeze calf and foot doesn’t move)
Patient says “feels like I’m standing on a marble” or “there’s a pebble in my shoe.” This makes you think what dx?
Morton’s neuroma
Treatment of corns
Salicylic acid pads or plaster
Debulk or pare in office with scalpel
Pathophysiology of plantar fasciitis
Thickened fibrous aponeurosis under calcaneus
Common presentation of plantar fasciitis pain
Worse in morning
Improved w/ activity, but returns so after
Pain with dorsiflexion
Which fifth metatarsal fracture has a high rate of nonunion?
Jones fracture
Most common pathogen of osteomyelitis? Most common in sickle cell anemic patient?
staph aureus
sickle cell - Salmonella
infection of the bone =
infection of the joint =
osteomyelitis
septic arthritis
Treatment of osteomyelitis and septic arthritis
At least 6 weeks of antibiotics
Surgical debridement
Remove any hardware (plates, screws etc)
Causes of septic arthritis and osteomyelitis
Hematogenous (blood) pathway from another infection
Penetrating trauma or surgery
Most common pathogen of septic arthritis
staph aureus
Patient comes in because of leg pain and difficulty walking. There is an open, foul smelling wound on his upper leg. What must you r/o? How?
osteomyelitis; bone scan and biopsy
How is septic arthritis dx’d?
Arthrocentesis (joint aspiration) with WBC > 50,000
Most common primary malignancies that metastasize to the bone?
prostate, breast, lung cancers
Malignant bone tumor commonly in age 10-20 yo? Where is it likely to occur?
osteosarcoma; most in knee
Most common primary malignant bone tumor in any age
Multiple Myeloma
Hallmark diagnostic test for Multiple Myeloma
serum electrophoresis showing Bence-Jones proteins
Multiple Myeloma XR findings
“moth eaten” lytic lesions (skull, spine, long bones, ribs)
diffuse osteopenia
Prognosis of multiple myeloma
death in 4-6 yrs
Sunburst lesion on XR =
osteosarcoma or Ewing’s sarcoma
What should you be suspecting with fatigue, weight loss, and pathologic fractures?
Bone tumors
Imaging to see spread of bone cancer
Bone scan
PET
Treatment of bone tumors
Chemo and radiation work well on Ewing’s sarcoma
Surgical resection of tumor, including amputation
What lab is elevated in bone tumor and why?
Alk phos elevated due to bone remodeling
Patient with bump on back of wrist full of clear fluid. DX and treatment?
Ganglion cyst
Tx: Nothing or can treat with aspiration or surgical excision
Joint fluid that collects behind knee
Baker’s cyst (popliteal)
65 yo patient comes in with decreased ROM and pain in hip. Difficulty walking if weight bearing. XR shows joint space narrowing and osteophytes. Likely dx?
Osteoarthritis (Degenerative joint disease)
XR findings of osteoarthritis
Joint space narrowing
Osteophytes
Bone cysts
Subchondral sclerosis
Osteoarthritis treatment
Weight loss PT and moderate exercise Tylenol NSAIDS Steroid injection Hyaluronic acid injection Surgery: Removal of osteophytes, Joint replacement
Risk factors of osteoporosis
Age Female (drop in estrogen) Family history Excess alcohol Malnutrition Inactivity Tobacco smoking Many diseases - Cushing’s, Crohn’s, Cystic fibrosis, Marfans, Renal insufficiency, etc.
Gold standard for osteoporosis dx. How is it used to assess severity?
DEXA scan
Use T-score to determine severity
- Normal = more than -1
- Osteopenia = -1 to -2.5
- Osteoporosis = less than -2.5
Screening recommendations for osteoporosis
all women over 65
Mainstay medical treatment for osteoporosis
Bisphosphonates
When is compartment syndrome typically seen?
after surgery or other trauma, usually tibial fractures
6 P’s of compartment syndrome
Pain is often the first sign Paresthesia Paralysis Pulselessness Pallor Poikilothermia – cold limb
Dx study for compartment syndrome
measurement of intracompartmental pressure
Treatment of acute compartment syndrome
Fasciotomy
Fibromyalgia is frequently associated with what other conditions?
depression, anxiety, PTSD
Possible treatment for fibromyalgia
Cognitive behavioural therapy
Antidepressants
Exercise
Red, hot, tendery metatarsal joint of great toe
gout
Joint fluid in gout will contain what?
negatively birefringent crystals
Diet that helps prevent gout
Limit alcohol, organ meats, animal protein
Drink lots of water
Acute and chronic gout treatment
Indomethacin (NSAID of choice) or steroid injection to reduce inflammation
Acute attacks: Colchicine
Long term tx: Allopurinol
MOA of Allopurinol
decreases production of uric acid
Diagnostic criteria for gout
uric acid over 8
- 1/2 of gout patients will be below this level
How is pseudogout different than gout?
joint has deposits of calcium pyrophosphate (positive axis) instead of uric crystals (negative, needle-shaped)
_______ means more tan 5 joints involved in JRA and _______ is fewer than 5.
polyarticular
oligoarticular
Systemic JRA has what hallmark signs
Rash
Fever
Hepatosplenomegaly
Hepatits
Epidemiology of juvenile rheumatoid arthritis
Age less than 16
Girls > Boys
What additional features are seen in oligoarticular subtype of JRA?
eye issues
JRA treatment
NSAIDs
PT/OT
Epidemiology of polyarteritis nodosa
Men 3x more
40-60 yo
I came in to see my physician assistant because of…
Insidious onset of proximal muscle weakness
Difficulty going up stairs and getting up from a chair
Dysphagia
Butterfly facial rash
Polymyositis
Enzymes elevated but not specific to Polymyositis
CPK, AST/ALT, LDH, myoglobin
Tissue biopsy of polyarteritis nodosa will show what?
vasculitis of medium and small vessels
Treatment of polyarteritis nodosa
high dose steroids
Treatment of Polymyositis
high dose steroids
Dx test of Polymyositis
muscle biopsy
I came in to see my physician assistant because of…
Constitutional symptoms -fever, weight loss, fatigue
Abdominal pain
Neuropathy
Skin issues
Rashes
Ulcers
Livedo reticularis – a mottled purple skin discoloration
Polyarteritis nodosa
Temporal arteritis commonly associated with what rheumatologic pathology?
Polymyalgia rheumatica (PMR)
How is Polymyalgia rheumatica differentiated from other muscle conditions?
pain in many muscles
often symmetrical
weight loss
fever
Polymyalgia treatment
Low dose corticosteroids (10-20 mg prednisone) for several years
Exercise
What two pathologies have butterfly facial rash?
Lupus
Polymyositis
Patient with recent Chlamydia infection comes to clinic c/o joint pain in random places. You note conjunctivitis on EENT exam. Likely dx?
Reiter’s Syndrome (Reactive arthritis)
“Can’t see, can’t pee, can’t climb a tree”
Pathophysiology of Reactive arthritis
autoimmune response; immune system doesn’t stop fighting a GI or GU infection even when infection is cleared
RF and HLA-B27 results of Reiter’s Syndrome
RF-
HLA+ in most
Treatment of Reiter’s Syndrome
Treat underlying infection, usually GI or GU (urethritis of Chlamydia)
NSAIDs
Steroids
60 yo females comes in with stiff, swollen joints in hands and feet especially in the morning. Likely dx?
Rheumatoid arthritis
Swan neck deformity
PIP hyperextension with DIP flexion
Boutonniere deformity
PIP flexion and DIP hyperextension
Immunologic studies for RA eval
RF+ (rules in, but RA pt may be RF-)
ANA
ACPA
Synovial fluid of inflammatory vs non-inflammatory arthritis
Inflamm: cloudy, WBC >2,000 (>75% PMN), +/- crystals, low viscosity
Non-inflamm: clear, WBC under 2,000, high viscosity
Treatment for RA apart from NSAIDs
COX-2 inhibitors (Celebrex)
DMARDS: Methotrexate first line (teratogenic!)
______ is always seen in Lupus, but not specific.
ANA
Systemic lupus treatment
NSAIDs
Hydroxychloroquine
Steroids
Diagnostic criteria for SLE
mnemonic: “SOAP BRAIN MD”
Serositis Oral ulcers Arthritis Photosensitivity Blood disorders Renal involvement Antinuclear antibodies Immunologic phenomena (eg, dsDNA; anti-Smith [Sm] antibodies) Neurologic disorder Malar rash Discoid rash
Signs of Raynaud’s
hands turn blue and white in cold weather
CREST syndrome
Seen in scleroderma
Calcinosis (nodules under skin) Raynaud's Esophageal problems Sclerodactyly Telangiectasias
Signs of scleroderma
CREST syndrome + joint pain and decreased ROM
Scleroderma treatment
No cure - symptomatic therapy
Warmer weather and vasodilators (CCBs, alpha blockers) for Raynauds
Steroids for joint pain
Antacids for esophageal sx’s
ACE-I for kidney issues
Dx tests for Sjogren Syndrome
Schirmer’s test for dry eyes
Rose Bengal test for lacrimal gland function
ANA
RF
Pathophysiology of Sjogren Syndrome
destruction of salivary and lacrimal glands
Sjogren Syndrome treatment
Symptomatic treatment - NSAIDs, eye drops, vaginal lubricants, regular dental care
Which type of arthritis affects DIP joints of hand? and which affects PIP and MCP?
osteoarthritis - PIP, DIP
RA - MCP, PIP
Which pathologies cause polyarticular arthritis?
RA
Hep B/C
SLE
Salter-Harris Fracture Classification
fractures in children = “SALTER”
I: Separated
II: Above growth plate (plate and metaphysis)
III: Lower than growth plated (plate and epiphysis)
IV: Through all three
V: cERush injury of plate
Torus Fracture
- “Buckle Fracture”
- Compression fracture of a long bone
- Typically in children and near metaphysis
- Can splint, cast or removable Velcro splint x 3wks
Galeazzi Fracture
- Triad:
o Radius Fracture
o Radius Shortening
o Radio-ulnar dislocation
- Rare in children
- Surgery requiredMallet finger treatment
STAX spint to hold DIP in hyperextension x 6wks
6 types of AC separations
Type I – Minimal to no displacement (sprain)
Type II- Partial separation with complete tear of the acromioclavicular (AC) ligament
Type III- Complete tear of the AC ligament with partial tear or sprain of the coracoclavicular ligaments, a small defect or bump may be seen on physical exam
Type IV- Complete tear of the AC ligament with complete tear of the coracoclavicular ligaments and posterior displacement of clavicle
Type V- Complete tear of AC and coracoclavicular ligaments with 100% displacement superiorly just under skin
Type VI- Complete tear of the AC and coracoclavicular ligaments with displacement inferiorly under the coracoids (not very common)
