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MSK Flashcards

1
Q

What are some inflammatory markers?

A

Elevated ESR and CRP

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2
Q

In joint disease, what is the first line anti-inflammatories used?

A

NSAIDs

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3
Q

MOA of NSAIDs

A

block cytokine synthesis, specifically prostaglandins

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4
Q

Which NSAIDs inhibit both COX-1 and COX-2?

A

ibuprofen, naproxen

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5
Q

Why do some NSAIDs cause increase risk of peptid ulcers?

A

COX-1 inhibition decreases prostaglandin synthesis in gut

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6
Q

Which type of NSAIDs have fewer GI side effects?

A

selective COX-2 inhibitors

drugs ending in “-coxib” (eg. Celecoxib/Celebrex)

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7
Q

Types of inflammatory arthritis

A

RA, spondyloarthritis, infection, crystal-induced

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8
Q

Types of non-inflammatory arthritis

A

osteoarthritis, trauma, hemarthrosis

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9
Q

Inflammatory vs non-inflammatory symptoms

A

Inflammatory - aggravated by rest (eg. prolonged morning stiffness), relief with use, symmetric

Non-inflammatory - aggravated by use, relieved by rest, asymmetric

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10
Q

AC joint connects what?

A

acromion to the clavicle

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11
Q

What are muscles of the rotator cuff? What are their actions?

A 
"SITS"
Supraspinatus – abduction
Infraspinatus – ER
Teres minor – ER
Subscapularis – IR
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12
Q

Which rotator cuff muscles is most often injured?

A

suprapinatus

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13
Q

PE findings of AC joint osteoarthritis

A

Tenderness over AC joint

Cross-arm test (pain cause by flexion and adduction of arm)

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14
Q

Pathophysiology of rotator cuff impingement

A

rotator cuff pinched underneath acromion

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15
Q

Patient comes in because increasing shoulder pain and weakness. Says she can’t lift arm above her shoulder to brush her hair. Likely dx?

A

Rotator cuff tear or impingement

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16
Q

Test that isolates supraspinatus? How is it done?

A

Empty can test: elevate and abduct shoulders with thumbs down. Push down on patient’s arms.

Pain = rotator cuff tear of supraspinatus

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17
Q

What are some PE tests for shoulder impingement?

A

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

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18
Q

How is apprehension test done? What does it test?

A

anterior instability

Arm abducted to 90 deg while examiner externally rotates arm and applies anterior pressure to humerus

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19
Q

Test indicating positive labral tear

A

“clunk sign”
O’Brien test
Speeds (bicep tendonitis)

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20
Q

Test that shows complete rotator cuff tear

A

Drop arm test

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21
Q

Pathophysiology of carpal tunnel syndrome

A

median nerve compression as it runs through carpal tunnel

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22
Q

What forms the carpal tunnel?

A

carpal bones and flexor retinaculum

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23
Q

Which fingers are affected in carpal tunnel?

A

median nerve distribution - thumb, index, middle, radial half of ring finger

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24
Q

What is a sign of severe cases of carpal tunnel?

A

atrophied thenar eminence

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25
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
26
Diagnostic testing for carpal tunnel
EMG testing
27
Carpal tunnel treatment
``` Avoid repetitive movements (typing) Night splint NSAIDS Steroid injection If symptoms constant than need surgical release of flexor retinaculum ```
28
Lateral epicondylitis aka _________ and medial epicondylitis aka _________.
``` lateral = tennis elbow medial = golfers elbow ```
29
Epicondylitis treatment
``` Rest ice Injection Stop repetitive activity Counterforce brace Physical Therapy ```
30
Etiology of lateral epicondylitis caused by what repetitive movement?
wrist supination and extension * medial is pronation and flexion
31
Causes of AC joint separation injury
Direct blow | FOOSH
32
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
33
Most common shoulder dislocation
anterior dislocation (95%)
34
Tests for shoulder dislocation
Positive apprehension sign | Positive sulcus sign
35
How is shoulder dislocation treated?
manual reduction
36
What is a Boxer's fracture?
fracture of 5th metacarpal
37
Boxer's fracture treatment
Ulnar gutter splint Closed reduction pinning ORIF
38
What is a Colles fracture?
distal radius fracture with dorsal angulation of hand and wrist = dinner fork deformity FOOSH most common wrist injury
39
Colles fracture treatment
Closed reduction and immobilization Surgical correction if unable to achieve a stable satisfactory reduction.
40
Gamekeeper's Thumb is an injury to what structure?
ulnar collateral ligament of thumb | tear or avulsion at insertion on proximal phalanx
41
Signs of Gamekeeper's Thumb
Instability of the metacarpal joint of the thumb Weak pinch or grasp Swelling or bruising of the thenar eminence
42
Treatment of Gamekeeper's Thumb
Minor tears: thumb spica Significant tears: surgical repair
43
Most commonly fractured carpal bone
scaphoid
44
Hallmark finding of scaphoid fracture
painful palpation of anatomical snuffbox
45
Diagnostic imaging for scaphoid fracture
MRI, may be missed on XR
46
Treatment of scaphoid fracture
Treat if suspected! Thumb spica cast Surgical correction
47
subluxation of radial head past annular ligament =
Nursemaid's elbow
48
Nursemaid's elbow mechanism of injury
pulling on extended arm of child
49
Treatment of Nursemaid's elbow
Reduction: supinate wrist and extend the elbow while applying pressure over radial head
50
What does a fat pad sign indicate on XR?
occult elbow fracture
51
Time duration of acute vs chronic MSK conditions
acute less than 6 wks | chronic more than 12 wks
52
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
53
What is the narrowing of the spinal canal resulting in compression of spinal cord or nerve roots?
spinal stenosis
54
Causes of spinal stenosis
``` Herniated disc Osteoarthritis Compression fractures Trauma Tumor Inflammation Congenital - narrow spinal canal ```
55
Define radiculopathy
pain, weakness or numbness radiating down a particular nerve distribution
56
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
57
Most herniated discs occur where?
L4/L5 and L5/S1
58
Patient comes in because of… Saddle anesthesia Bowel or bladder incontinence Sexual dysfunction Pain in the lower extremities
Cauda equina syndrome
59
What nerves make up the caudal equine ("horse tail")?
L2-L5 S1-S5 coccygeal nerve
60
Treatment of caudal equina
Acute onset is an emergency requiring immediate surgical decompression
61
Chronic inflammatory disease resulting in vertebral fusion =
Ankylosing spondylitis
62
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)
63
XR findings of ankylosing spondylitis
Bamboo spine
64
Ankylosing spondylitis treatment
``` NSAIDs Opioids DMARDS TNF-alpha antagonists PT Surgery ```
65
Serum positive for HLA-B27. DDX?
Ankylosing spondylitis Psoriatic arthritis Reactive arthrites (Reiter's Syndrome)
66
Medical term for humpback
kyphosis
67
Epidemiology of ankylosing spondylitis
M > F | young adults
68
Treatment of kyphosis
Bracing Physical therapy Kyphoplasty
69
Clinical definition of scoliosis
spinal curvature of more than 10 degrees from side to side
70
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
71
Treatment of scoliosis
Based on Cobb angle - Less than 20: watchful waiting, bracing may arrest further deformity - Over 50: posterior spinal fusion surgery
72
What is the minimum you should wait to order imaging on a patient with generalized low back pain and no significant history?
4 weeks
73
All open fractures should include what treatment?
Irrigation and debridement within 8 hrs of injury Empirical abx: 1st gen cephalosporin (cephalexin, keflex)
74
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 ```
75
Symptoms of avascular necrosis of femoral head
groin pain | difficulty walking
76
Treatment of avascular necrosis of femoral head
Core decompression | Total hip replacement
77
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
78
Developmental dysplasia of the hip treatment
Bracing and splinting | Surgical correction and possibly total hip
79
How does leg present on PE when there is a proximal femur fracture?
injured leg is short and externally rotated
80
Treatment of proximal femur fracture
Needs surgical repair
81
Typical patient with slipped capital femoral epiphysis
13 yo overweight male
82
Symptoms of slipped capital femoral epiphysis
groin and knee pain | limping a little for few months
83
What of hip is most comfortable for patient with slipped capital femoral epiphysis?
ER of hip pain with IR, abd, and flexion
84
XR views for hip
AP and frog leg
85
Treatment of slipped capital femoral epiphysis
Surgical correction, consider bilateral
86
patella fracture treatment
Displaced - ORIF | Non-displaced - extension brace x 6 wks (CANNOT FLEX)
87
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
88
Complication of tibial plateau fracture
compartment syndrome
89
What test to do if patella fracture suspected?
SLR
90
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
91
Treatment of Osgood-Schlatter disease
NSAIDs Self-limiting, but not until growth plates close RICE PT
92
Function of medial and lateral meniscus
provide cushion and stability for knee
93
Mechanism of acute meniscus injury
twisting of knee with planted foot
94
PE findings of meniscal injury
``` Joint line tenderness Joint effusion pain/click with McMurray Apply Thessaly ```
95
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
96
ACL prevents anterior translation of ______.
tibia
97
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
98
Single best choice to test for ACL tear
Lachman test
99
Likely injury in MVA when knee hits dashboard
PCL tear
100
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
101
How to test integrity of MCL?
apply valgus stress to knee at 30 degrees of flexion
102
Treatment for most knee injuries
RICE PT Surgery
103
Most common structure injured in ankle sprain
ATFL = anterior talofibular ligament
104
What is a Jones fracture?
fracture at metaphyseal-diaphyseal junction of 5th metatarsal
105
Risk factors for Achilles tendon rupture
elderly, florquinolones (cipro), CS tendon injections, sports with explosive jumping
106
What test differentiates Achilles tendonopathy from a full rupture?
Thompson's test positive in rupture (squeeze calf and foot doesn't move)
107
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
108
Treatment of corns
Salicylic acid pads or plaster | Debulk or pare in office with scalpel
109
Pathophysiology of plantar fasciitis
Thickened fibrous aponeurosis under calcaneus
110
Common presentation of plantar fasciitis pain
Worse in morning Improved w/ activity, but returns so after Pain with dorsiflexion
111
Which fifth metatarsal fracture has a high rate of nonunion?
Jones fracture
112
Most common pathogen of osteomyelitis? Most common in sickle cell anemic patient?
staph aureus sickle cell - Salmonella
113
infection of the bone = | infection of the joint =
osteomyelitis | septic arthritis
114
Treatment of osteomyelitis and septic arthritis
At least 6 weeks of antibiotics Surgical debridement Remove any hardware (plates, screws etc)
115
Causes of septic arthritis and osteomyelitis
Hematogenous (blood) pathway from another infection Penetrating trauma or surgery
116
Most common pathogen of septic arthritis
staph aureus
117
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
118
How is septic arthritis dx'd?
Arthrocentesis (joint aspiration) with WBC > 50,000
119
Most common primary malignancies that metastasize to the bone?
prostate, breast, lung cancers
120
Malignant bone tumor commonly in age 10-20 yo? Where is it likely to occur?
osteosarcoma; most in knee
121
Most common primary malignant bone tumor in any age
Multiple Myeloma
122
Hallmark diagnostic test for Multiple Myeloma
serum electrophoresis showing Bence-Jones proteins
123
Multiple Myeloma XR findings
"moth eaten" lytic lesions (skull, spine, long bones, ribs) | diffuse osteopenia
124
Prognosis of multiple myeloma
death in 4-6 yrs
125
Sunburst lesion on XR =
osteosarcoma or Ewing's sarcoma
126
What should you be suspecting with fatigue, weight loss, and pathologic fractures?
Bone tumors
127
Imaging to see spread of bone cancer
Bone scan | PET
128
Treatment of bone tumors
Chemo and radiation work well on Ewing's sarcoma | Surgical resection of tumor, including amputation
129
What lab is elevated in bone tumor and why?
Alk phos elevated due to bone remodeling
130
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
131
Joint fluid that collects behind knee
Baker's cyst (popliteal)
132
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)
133
XR findings of osteoarthritis
Joint space narrowing Osteophytes Bone cysts Subchondral sclerosis
134
Osteoarthritis treatment
``` Weight loss PT and moderate exercise Tylenol NSAIDS Steroid injection Hyaluronic acid injection Surgery: Removal of osteophytes, Joint replacement ```
135
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. ```
136
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
137
Screening recommendations for osteoporosis
all women over 65
138
Mainstay medical treatment for osteoporosis
Bisphosphonates
139
When is compartment syndrome typically seen?
after surgery or other trauma, usually tibial fractures
140
6 P's of compartment syndrome
``` Pain is often the first sign Paresthesia Paralysis Pulselessness Pallor Poikilothermia – cold limb ```
141
Dx study for compartment syndrome
measurement of intracompartmental pressure
142
Treatment of acute compartment syndrome
Fasciotomy
143
Fibromyalgia is frequently associated with what other conditions?
depression, anxiety, PTSD
144
Possible treatment for fibromyalgia
Cognitive behavioural therapy Antidepressants Exercise
145
Red, hot, tendery metatarsal joint of great toe
gout
146
Joint fluid in gout will contain what?
negatively birefringent crystals
147
Diet that helps prevent gout
Limit alcohol, organ meats, animal protein Drink lots of water
148
Acute and chronic gout treatment
Indomethacin (NSAID of choice) or steroid injection to reduce inflammation Acute attacks: Colchicine Long term tx: Allopurinol
149
MOA of Allopurinol
decreases production of uric acid
150
Diagnostic criteria for gout
uric acid over 8 * 1/2 of gout patients will be below this level
151
How is pseudogout different than gout?
joint has deposits of calcium pyrophosphate (positive axis) instead of uric crystals (negative, needle-shaped)
152
_______ means more tan 5 joints involved in JRA and _______ is fewer than 5.
polyarticular oligoarticular
153
Systemic JRA has what hallmark signs
Rash Fever Hepatosplenomegaly Hepatits
154
Epidemiology of juvenile rheumatoid arthritis
Age less than 16 | Girls > Boys
155
What additional features are seen in oligoarticular subtype of JRA?
eye issues
156
JRA treatment
NSAIDs | PT/OT
157
Epidemiology of polyarteritis nodosa
Men 3x more | 40-60 yo
158
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
159
Enzymes elevated but not specific to Polymyositis
CPK, AST/ALT, LDH, myoglobin
160
Tissue biopsy of polyarteritis nodosa will show what?
vasculitis of medium and small vessels
161
Treatment of polyarteritis nodosa
high dose steroids
162
Treatment of Polymyositis
high dose steroids
163
Dx test of Polymyositis
muscle biopsy
164
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
165
Temporal arteritis commonly associated with what rheumatologic pathology?
Polymyalgia rheumatica (PMR)
166
How is Polymyalgia rheumatica differentiated from other muscle conditions?
pain in many muscles often symmetrical weight loss fever
167
Polymyalgia treatment
Low dose corticosteroids (10-20 mg prednisone) for several years Exercise
168
What two pathologies have butterfly facial rash?
Lupus | Polymyositis
169
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"
170
Pathophysiology of Reactive arthritis
autoimmune response; immune system doesn't stop fighting a GI or GU infection even when infection is cleared
171
RF and HLA-B27 results of Reiter's Syndrome
RF- | HLA+ in most
172
Treatment of Reiter's Syndrome
Treat underlying infection, usually GI or GU (urethritis of Chlamydia) NSAIDs Steroids
173
60 yo females comes in with stiff, swollen joints in hands and feet especially in the morning. Likely dx?
Rheumatoid arthritis
174
Swan neck deformity
PIP hyperextension with DIP flexion
175
Boutonniere deformity
PIP flexion and DIP hyperextension
176
Immunologic studies for RA eval
RF+ (rules in, but RA pt may be RF-) ANA ACPA
177
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
178
Treatment for RA apart from NSAIDs
COX-2 inhibitors (Celebrex) | DMARDS: Methotrexate first line (teratogenic!)
179
______ is always seen in Lupus, but not specific.
ANA
180
Systemic lupus treatment
NSAIDs Hydroxychloroquine Steroids
181
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 ```
182
Signs of Raynaud's
hands turn blue and white in cold weather
183
CREST syndrome
Seen in scleroderma ``` Calcinosis (nodules under skin) Raynaud's Esophageal problems Sclerodactyly Telangiectasias ```
184
Signs of scleroderma
CREST syndrome + joint pain and decreased ROM
185
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
186
Dx tests for Sjogren Syndrome
Schirmer's test for dry eyes Rose Bengal test for lacrimal gland function ANA RF
187
Pathophysiology of Sjogren Syndrome
destruction of salivary and lacrimal glands
188
Sjogren Syndrome treatment
Symptomatic treatment - NSAIDs, eye drops, vaginal lubricants, regular dental care
189
Which type of arthritis affects DIP joints of hand? and which affects PIP and MCP?
osteoarthritis - PIP, DIP | RA - MCP, PIP
190
Which pathologies cause polyarticular arthritis?
RA Hep B/C SLE
191
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
192
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
193
Galeazzi Fracture
``` - Triad: o Radius Fracture o Radius Shortening o Radio-ulnar dislocation - Rare in children - Surgery required ```
194
Mallet finger treatment
STAX spint to hold DIP in hyperextension x 6wks
195
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)

PANCE review (18 decks)

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