MSK Flashcards
1
Q
osteo sarcoma
age group? area?
A
10-20 MC age
**METAPHYSEAL AREA OF LONG BONES**
2
Q
EWING sarcoma
age? location?
A
5-25 y/o
**DIAPHYSES OF LONG BONES, ribs and flat bones**
3
Q
osteoarthritis
what is this? where is it most common? what are the two types? what would you expect to see on a xray?
A
joint disease with protective cartilage on the ends of your bones wears down over time and subchondral bone wears down over time >40 yrs olds THINK ELDERLY, slow developing joint pain
early onset and late onset OA, erosive
hands, hips and knees most common
primary or secondary causes
joint enlargement, red swollen PIP, DIP, weakness and wasting of muscles around joint, deformities
xray: see narrowed asymetric joint space, with osteophyte formation, bony sclerosis
4
Q
what is a osteophyte? what disease is this commonly seen in?
A
a bony outgrowth associated with the degeneration of cartilage at joints.
osteoarthritis
5
Q
what are the characteristics associated with early osteoarthrits? (4 things)
A
1-2 years
morning stiffness lasting
they’re ok, they say they just keep going
red, prominent PIP, DIP joints with normal radiographs
6
Q
what are the characteristics associated with late osteoarthritis?
A
AM stiffness lasting
mechanical stiffness that gets worse with movement, more pain the more they do
claim not to have the same strength they used to (opening jars/doors etc)
little evidence of inflammation
ABNORMAL RADIOGRAPHS
get less symptomatic in non-weight bearing joints AKA many patients have extreme hand deformities but are asymptomatic (once they are deformed they don’t hurt anymore)
7
Q
what is the treatment options for osteoarthritis? (7 things)
A
joint conservation
exercise
weight loss
NSAIDs (caution with ulcers)
COX-2 inhibitor (safer for people with history of ulcers, but still need to watch for cardiac complications)
cartilage replacement (15-55)
total joint replacement
8
Q
primary osteoarthritis is…..
A
idiopathic, arises spontaneously
9
Q
secondary osteoarthritis can come from….
A
- posttraumatic
- congentiral deformation
- endocrinopathy
- neuropathic arthropathy
- padgets disease
- avascular necrosis
- skeletal hyperostosis DISH
10
Q
what is the most common joint disorder in the US?
A
osteoarthritis
11
Q
Osteoarthritis of the hip
what is this? what will you see on the xray? what is the “definitive cure”? what other surgical interventions can you do in younger patients?
A
degredation of articular cartilage, thickening of the subcondral bone
progressive hip pain that often complain of groin pain, “crunching” noises aka crepitus
xray osteophyte formation, decreased joint space, sunchondryl sclerosis and cysts
conservative: same as always
definitive cure: total hip arthroplasty THA (replace joint)
surgical: arthroscopic debridement, femoral head resurfacing in younger patients
12
Q
osteoarthritis of the knee
what is this? what are four presentations you see with this? what is a possible muscle presentation? what is the gold standard for diagnosis? what are the conservative vs surgical treatment options?
A
degredation of the hyaline cartilage of the knee
pain is worse in AM, giving away or locking
joint hypertrophy, and tendernous at the joint line, possivle quadricept atrophy
gold standard: xray…see osteophyte formation, decreased joint space so bone on bone, sunchondral sclerosis
treatment: conservative normals plus cortisone injections and hyaluronic acid injections
surgical: knee arthroscopy, tibial/femoral osteotomy, total knee arthroplasty
13
Q
what are the Early osteoarthritis presentations? (4)
A
1-2 years
morning stiffness lasting !!! “they’re ok, they just keep going!”
red, prominent DIP and PIP joint involvement
normal radiographs
14
Q
osteoarthris…explain what happens in this…
A
normal bone programming
“cartilage scenescence”–we outlive our chondrocytes around 25-30 years old, it frays and falls apart and the chondrocytes become hypertrophic and grow larger, however they produce enzymes MMP and aggrecanases that break down the cartilage and act like growth plate cells where THEY MAKE MORE collagen 1 and 9, BONE THAN BREAK IT DOWN…CARTILAGE CAN’T REGROW SO YOU JUST GET INCREASED BONE GROWTH!!
“progressive loss of articular cartilage and reactive changes at the joint margins from bone rubbing on sunchondral bone rubbing on bone “behaves like a fracture” and stimulates chondrocyte hypertrophy and increased bone growth
15
Q
what are the common presentations of late osteoarthritis? (5)
A
morning stiffness lasting
mechnical stiffness, gets worse with movement, more pain the more they do
not the same strength they used to (opening jars, turning handles)
abnormal radiographs! deformities obviously present, bone hypertrophies
get LESS symtomatic in non weight bearing joints, asymatic once they are deformed because they aren’t able to move them
16
Q
what are the treatment options for someone with osteoporosis?
A
Not much…its a natural bone programming
Its “supposed” to happen
- joint conservation
- exercise low impact
- weight loss to relieve load on joints
NSAIDS and COX-2, total joint replacement, autologous cartilage implantation (not many people qualify)
17
Q
what joints are most commonly effected by osteoarthritis?
A
PIP, DIP, hips, knees
18
Q
infectious (septic) arthritis
how many joints does this involve? what joint is the most common? what is the most common agent? what are the four agents in children? what active people does this often effect and percent? what should you treat with until the cultures come back?
A
involves a single joint, most commonly the knee 90%
then hip, shoulder, anklet
Adults: S. aureus, streptococcus
children: Haemophilis influenzae, E. coli, pseudomonas, borrelia burgdoferi
- sexually activite individuals have increased risk from Neisseria gonnoreah 50%*
xray: may see gas in the joint space, arthrotomy and culture - treat until culture comes back: ceftrixaone, followed by 4 weeks of antibiotic after organism identified*
19
Q
in infectious (septic) arthritis….what must you always do if the hip is involved?
A
arthrotomy….test it and see what it is!!
20
Q
osteoporosis
what is this? who is it most common in? what is the nickname for this disease? what imaging type do you want to preform? what 3 presentations might you find on physical exam?
A
abnormal bone remodeling, decrease in the total volume of bone making it less dense, since less strong it leads to increased fractures!
imbalance between bone formation and reabsorption
most common in menopausal women
“silent disease”
presentation: height loss, kyphosis, severe cervical lordosis dowagers hump
Dexxa scan of spine and hip
21
Q
what is an abnormal DEXA scan result that can indicate osteoporosis?
A
-2.5 and below
22
Q
what are the treatment options for osteoporosis? (3)
A
- bisphosphonates: inhibits osteoclasts (jaw necrosis)
- HRT, estrogen, or progesterone (stroke, breast cancer)
- selective estrogen receptor modulator (serms)
23
Q
what test should you do for herniated disk pulposa?
A
straight leg test
pain at
24
Q
herniated nucleus pulposus
what happens in a herniation? where does this most commonly occur in the vertebrae and in the spinal cord? what will the 3 main symptoms be and what are 3 things a patient will get pain with that are normal things? what do you do for treatment?
A
this is when the nucleus pulposus, the soft gelatinous center is herniated posteriorally since this is where the annulus fibrosis is the weakest!!!
usually occurs in lumbar spine since takes the most load
see motor and sensory manifestation
- tingling, numbness, or burning pain (seen in sagital and axial MRI images)
- pain with coughing, sneezing, and laughing
RICE, NSAIDs, surgery
25
spinal stenosis
## Footnote
what is this caused by? what two conditions for the risk of stenosis increase with? what **unique** thing makes this better, and what makes this worse? what can you see the in the lumbar region? what will you see on the MRI? what can you do for treatments for this?
compression of nerves of spinal cord caused by **narrowing of the spinal cord and foramen**
commonly seen in **spondylosis and degenerative arthritis**
pain increases with walking or axial loading (leaning back), and decreases with _leaning forward, flexion!_
back and leg pain, **soft tissue and thecal narrowing, can see loss of lumbar lordosis**
TX: acetaminophen, weight reduction, pelvic tilt, abdominal exercises....last choice decompressive surgery
26
avascular necrosis
## Footnote
what causes the necrosis? how long can the cells survive? what is a unique sign that you will see? where does the pain present and what happens when the person rests? what are four surgical interventions you can do?
bone death from disruption of blood supply
osteocytes, blasts and clasts, die withing 24-48 hours of oxygen deprivation
reprofusion may regenerate bone growth
_cresent sign: collapse of sunchondral bone_
**often seen pain in groin, thigh, buttock**
**pain typically decreases with rest**
Treatment: NSAIDS, anticoagulants (heparin, coumadin etc) since can thin blood and help it get to the site if there is a clot!!
Surgical intervention: hip resurfacing, core depression, **fibular bone graft**, total hip arthroplasty
27
osteomyelitis
## Footnote
what is this and how does it present? what is the most common organism in this and what are the different potential organisms from adults to children? what can a xray show you? MRI? Labs? How long does this person need to be on antibiotics? what is commonly needed? what needs to be removed?
infection of the bone, bacterial, fungal
symtoms come from inflammatory response, pus inhibits blood flow, causing necrosis, if bacteria gets into the bone itself it can be difficult to eradicate
**S. aureus most common in children and adult**
Adults: S. pyogenes, Pseudomonas, E. coli
Children: Group B strep, E. coli, Streptococcus pyogenes, haemophilis influenzae
**fever, chills, malaise, may have ulcer over effected area**
xray:done destruction/hetertrophic bone formation
Labs: soft tissue involvement
_6 weeks of antibiotic therapy required, can do hyperbaric chamber if not healing, debridement required in most cases and hardware removal, also amputation_
28
where are the 3 most common locations for osteomyelitis in children?
femur, tibia, and humerus
aka the long bones
29
where are the three most common locations for osteomyelitis in adults?
vertebrae, maxilla, pelvis
30
scoliosis
## Footnote
what are the two general shapes of the spine you can see? what age group is this in and what gender? what are two **unique** indicators you can see? what do you see with the shoulder, iliac, scapula and flank? how do you describe the curve? what vertebrae is this most common in? what type of curvature is really rare?
lateral curvature of the spine in **C or S shape, 3-18 years old!**
**cafe au lait spots and tufts of hair present=indicators**
**asymmetric in shoulder and iliac height, asymmetric scapula, flank decrease flexion**
more common in girls during puberty growth spurt and cessation of spinal growth rate at are the greatest risk!
to measure the curvatue you look at the vertebrare at the apex of the curve and then describe relative to that
_most common at T7-T8, left curvatures is rare!_
31
what plane are the abnormalites in scoliosis found?
coronal
32
what are two things you can see on a xray in osteomyleitis?
**late sequestra:** dead bone surround granulation tissue
**involucrum:** (periseal new bone) make take several weeks to months to appeare
but careful when looking at xray.....visible changes on cray lag behind symptoms by **10 days**
33
explain the 2 divisions of patients for _scoliosis_ and what the treatment reccomendations are?
**\>20\* curvatures: back brace and surgery consult**
34
in scoliosis patients, when are increased xrays indicated? what is considered clinically significant for a curvature change using scolimeter?
\>5\* curvature change: increased xray
## Footnote
curve changes: \>15% is signficant!!
35
what would you commonly see sacroilliacitis with?
ankylosing spondylitis
and bamboo spine
36
kyphosis
## Footnote
what vertebrae do you see this in? what other curvature typically accompanies this in the spine? what is the difference in treatments based on the degress of curvature in the spine?
increased curvature of **_thoracic_ vertebrae, commonly associated with scoliosis**
_rounded back appearance, usually accompanied by excessive lordosis_
**if 45-60\* of curvature: PT and bending**
**if \>60\*: _milwakee brace_**
**surgery as last resort**
37
what is the most common spinal deformity evaluated by a clinician?
idiopathic adolescent scoliosis
38
what are four things that can cause kyphosos?
- dengeneration
- osteoporosis
- trauma
- spondylolisthe
39
what is the difference between a strain and a sprain?
**strain**: injury to the **bone-tendon unit at the myotendinous junction or the muscle itself**
_sprain_: involves _collagenous tissue, such as tendons or ligaments_
40
quadriceps/hamstring strain
## Footnote
what motions can cause a strain in both the quads and hamstrings? what do you use to classify the amount of damage done? what do you NEED to make a diagnosis? when do you do a MRI? what might you feel or see? what is the treatment?
quadriceps strain: cause forced hip extension or knee flexion
hamstring strain: forced hip flexion, knee extension
**excessive force causing excessive muscular contraction, causes musculotendous unit stretch or tear**
grading system for type,
_palpable hematoma in muscle belly_, possible defect in muscle or tendon
HX and PE all that are needed to make DX
mri may be helpful if complete tear is suspected
TX: conservative usuals surigcal: hematoma evacuation, repair COMPLETE TEAR tendom/muscle , fasciotomy
41
what are 4 predisposing factors for a strain?
inflexibility
overtraining
poor body mechanics
muscle imbalance
42
ankle sprain
## Footnote
what are the three types that can cause this and which ligaments are included in which types? what are the presents? what exam tests are important to do? what rule do you use to determine if a xray is needed? what is the treatment and what is one exception and how long do these patients need to be immobalized?
inversion injuries (90%), **_anterior talofibular_ (#1), calcaneofibular, posterior talofibular**
eversion (10%), **deltoid lig**
lateral rotation (**high ankle sprain**): **syndesmotic ligs**, anterior tibiofibular joint, high ligs connect the tibia and fibula, pain with _external rotation_, pain just above the ankle _squeeze test of tibia/fibula_
point tender over lig, hypermobility with stress testing
anterior drawer tests
ottowa ankle rule to determine if xray is needed
Tx: conservative even if grade III, surgical repairs but is reserved for chronic instability, crutches 48-72 hours and brace, with *syndesmotic sprain* longer immobalization for 4-6 weeks
43
gout
## Footnote
what happens here? what do the crystal depositions look like? what is effected commonly as a strange presentation in most cases? what are the two ways these crystals accumulate and what are the percentages? what hardened structure can be found within joints of chronic gout? what labs do you do? what is diagnostic? what is the difference between the treatment for acute and chronic treatment?
most common form of inflammatory arthritis in m/w over 40
**acute arthritis (usually at night) by sudden increase and deposition of uric acid crystals in the joint**
**great toe effected in 50% of cases**, but can effect any joint in the body: ankles, knee, hands, wrists
cause: **hyperuricemia, too much in circulation and in 90% of cases there isn't enough secreted from the kidneys** instead of overproduction (10%)
joints contain _tophi, hardened nodules_ (chronic)
Labs: **uric acid levels, may have elevated WBC, _uric acid crystals in joints are diagnostic_,** xray to access joint damage
Acute TX: NSAIDS, colchicine
Chronic: Xanthine oxidase inhibitor, **allopurinol (blocks production) or probenecid (increases uric acid excretion)**
44
what do the crystals in gout look like?
needle like WITHOUT birefringence
45
when does the ratio of men\>women, switch to women\>men who are effected by gout?
after menopause, then it is more common in women
46
what is the name when the big toe is effected by gout?
podogra
47
pseudogout
## Footnote
what is this caused by? what joint is the most commonly effected? what isn't present that is seen in regular gout? where do you see the deposits? what do the crystals look like under the microscope?
acute inflammatory disease caused by **calcium pyrophospate crystals**
calcium pyrophosphate dihydrate disease
**knees most commonly effected**
\*\*\*\*\*no tophi present that differentiates from gout\*\*\*\*
**see calium deposits in the cartilage**
aspiration see _rod shapped crystals with blunt ends and befringement unlike gout_
conservative and excision of chondrocalcinosis
48
what is the most common cause of gout in people?
metabolic syndrome 75%
49
what are three interesting things that increase risk of gout?
alcohol, meat, seafoods
metabolic conditions
50
rotator cuff tear
## Footnote
what four muscles are included as part of the rotator cuff? which is the most common culpriate? what types of pain will you find? what 5 tests do you want to do? what are the three types of images you can use and why are they helpful?
can be **complete** or **partial** tear of musculotendonous complex, +/- muscle atrophy/tendernous/crepitus
includes:
**1. supraspinatus (most common)**
**2. infraspinatous**
**3. teres minor**
**4. subscapularis**
pain/_weakness_ with **elevation and rotation**, **@ night, radiates to mid humerous AROM\>\>PROM PAIN**
testing:
**1. drop arm test**
**2. empty can test (supraspinatus)**
**3. lift off test (subscapularis)**
4. hawkins (think it looks like a bird wing)
5. Neer impingement sign
imaging:
1. xrays (subacromial spur, calcified tendonosis, **head of humerus may migrate forward**
2. MRI-helpful but expensive
3. arthrogram
51
when is a arthrogram used for a patient with a rotator cuff tear?
when pt has an implant and can't have MRI, dye is injected into the joint and you wait to see if the dye leaves the joint
52
what does a "global" tear mean for a rotator cuff tear?
all the four muscle tendons are torn
can be acute (trauma) or gradual (fraying over time)
53
what are the conservative vs aggressive treatment options for someone with a rotator cuff tear? what is important fun fact to know here?
conservative:
1. PT
2. Cortisone Injections (good for elderly)
3. NSAIDS
Surgical:
1. arthroscoptic repair
Fun fact: want to have it repaired in healthy individual because it can lead to **rotator cuff arthritis and arthropathy which leads to total shoulder replacement**
54
adhesive capsulitis
## Footnote
what are 4 risk factors? what causes this? what imaging do you want to do? what is the reccomended treatment and how long can this take to be effective? what is last resort treatment? how do you make the diagnosis?
**sedentary people**, **decreaed volume of the joint capsule and capsular contraction**
**"frozen shoulder",** *insidious onset, gradual progression, pain at night*
**increased risk with: age, obesity, diabetic, middle aged women**
there is a physical "block" preventing motion
xray: rule out other bony deformities
**diagnosis is based on history and PE**
treatment: NSAIDS and stretching, GH cortisone injection, takes patience since it can take up to a year to heal, _manipulation under anesthesia as last chance_
55
elbow dislocation
## Footnote
who is it common in? how does it happen? what must you access for? what do you treat with? what is important to do after reduction?
most common in children, 50% happen from sports
**fall on outstrectched hand, 98% are posterior**
arm held at side in splinted position, unwillingness to move elbow
**obvious deformity, olecranon swelling**
**MUST access neurovascular structures**, MUST perform POST reduction xray!!! two films!
treatment:
1. reduction
2. spint/cast 1-3 weeks
**elbow gets very stiff very fast esp in kids, so want to initiate early ROM exercises to prevent _flexion contracture_**
NSAIDS
56
lateral epicondylitis
## Footnote
what is a nickname for this condition? what muscles specifically does it effect? what does this person have a difficult time doing? what happens with pain and ROM? what are 5 treatment options? what is the last resort treatment and why?
**"****TENNIS ELBOW", dengeneration/inflammation of the *wrist extensor mechanism***
***LATERAL EPICONDYLE, DIFFICULTY LIFTING THINGS WHEN HAND IS PRONATED***
**involves the tendonous insertion of _extensor carpi radialis brevis_**
tennis, golf, weight lifting
pain with repetitive extension and flexion
pain:
1. radiate down the arm
2. **passive wrist flexion**
**3. active and resisted wrist extension**
Treatment:
1. _eliminate aggrevating factors_
2. NSAIDS, ICE, HEAT
3. tennis elbow strap
4. cortisone injection, DONT INJECT TENDON
5. surgical release/faciotomy if all else fails. only successful in 50% of people and longer than 6 months
57
olecranon bursitis
## Footnote
what are the two different causes? what is the difference in treatment between the two? what is the most common organism to cause it? what should you test? and for what two things?
inflammation of olecranon bursitis, can be from resting on the elbows a lot
usually quick onset
can be from infection: septic bursa
**suspect infection if erythema and intense pain on palpation**
send joint fluid for analysis: culture and crystal analysis
treatment for non infectious:
1. padding/compression wrap, NSAIDS, heat, ice
2. cortisone injection **\*\*\*need to make sure 100% not infected if so\*\*\***
treatment for infectious:
1. treat cultured pathogens
2. incision and drainage
**most common organism is S. aureus**
58
carpal tunnel syndrome
## Footnote
what happens? what causes the symptoms? what 4 special tests can you when diagnosing? what is the gold standard of care? what should you do first and for how long? describe the numbness pattern
**most common nerve entrapement syndrome, _median nerve under transverse carpal lig_**
pain and numbness in media distribution (pic), **pain at night**, **weakness in thumb grip strength**
tendernous and tingling at wrist and palmar area
Special tests:
Phalens test w/tingling after 1 min (I think of "flailing hands)
Tinel's sign-taping over transverse lig produces tingling (I think tinel=tingle)
decreased 2 point sensation
electromyography/nerve conduction
**gold standard: surgery**, releases transverse lig, but first try **night splint, NSAIDS for 4-6 weeks before surgery consult**
59
DeQuervain's disease
## Footnote
what is this caused by? who is it more common in? where do you see the localized pain, between what two things? what is 1 special test you want to do? what are the two treatment options?
**extensor pollicus brevis and abductor pollicus longus act to abduct the thumb away from the hand in the radial plane, more common in women and diabetics**
**synovial/tendon sheath** becomes inflammed from OVERUSE
**pain over the CMP joint of first digit, trapezium and metacarpal of thumb**
special test**: finkelstein's test** (place thumbs inside of fist and ulnar deviate which causes pain!!)
tests: xray to rule out other things, labs for gout
treatment:
1. NSAIDS, splint, cortisone injection, symptoms resolve in about a year
2. fasciotomy of 1st dorsal compartment (not as common) but releases overlying lig
60
fibromyalgia
## Footnote
what is it? how long do you need to have it? what are the requirements? what are the 4 presentations? what are the 4 important things you need to rule out? what testing is ok? which arent? what should you NOT treat with? what are 4 potential medical treatments?
**central pain syndrome, pain threshold disorder \>3 months 6:1 females**
**increased activity in somatosensory cortex, posterior insula, and thalamus**
**allodynia** (percieved pain when non, hugging), **hyperplasia** (aplified pain perception)
aggrevated by stress, lack of sleep, activity
1. widespread muskulo pain
2. sleep disturbance
3. no objective physical findings
4. **11/18 trigger points**
* important to test deep tendon reflexes and sensation*
**testing proceed with caution: NEED TO RULE OUT CELIAC DISEASE, IBS, VIT D DEF, HYPOTHYROIDISM**
**DO NOT ORDER RA/ANA**
can order thyroid, electrolytes, vit D, ESR/CRP, Hep C, CPK
Don't treat with: NSAIDS, narcotics
Treat with: Tricylic antipressants (help sleep), selective serotonin reuptake inhibitors (SSRIs), dual acting, lyrica neurontin but SO many side effects
61
what are other therapies important for treating fibromyalgia that aren't medications?
5 things
1. lifestyle modifications
2. **low impact aerobic exercise**
3. sleep hygiene/check for sleep apnea
4. **address depression/stressors**
5. encourage patients to take control
62
fibromyalgia and depression
1. what percent have depression at time of diagnosis?
2. what percent have lifttime incidence of depression?
3. what percent have lifetime incidence of anxiety?
depression at diagnosis: 30%
lifetime depression incidence: 74%
lifetime anxiety incidence: 60%
63
Systemic Lupus Erythematosis (SLE)
## Footnote
who is this common in? what happens? what are the four main body systems you worry about? what are the 11 presentations and how many do they need to have?
**womens disease, 16-55, african american 15:1**
debris from abnormal cell apoptosis promotes polyclonal B cels and autoantibodies, complexes deposit everywhere causing the symptoms
**1. renal** (nepthritis, nephrotic syndrome, tubulointerstitial disease)
**2. neuro** (seizures, psychosis)
**3. hematologic** (hemolytic anemia, leukopenia, lymphopenia ALL GO DOWN)
**4. Immunological (vascular thrombosis)** (antiophospholipid syndrome)
**_malar rash_, _arthritis without erosion just deformity, alopecia, raynauds, photosensitivity, positive ANA_** _arthritis_
must have 4/11 symptoms ANA is the only one that MUST be there
64
what are 8 lab tests seen in SLE?
1. CBC (anemia/cytopenias)
2. BUN/Cr (kidney involvment)
3. UA (proteinuria/ casts)
4. C3/C4 (decreased)
**4. ESR ELEVATED, CRP NORMAL**
**5. positive ANA** with all patterns EXCEPT centromere and SCL70
6. **dsDNA** that is more specific than ANA, *speckled or nucleolar*
65
SLE treatment
1. skin
2. renal
3. other
**Skin/fatigue: hydroxychloroquine**
**renal: high dose corticosteroids and cyclophosphamadine (immunosuppressant)**
other immuno:
azathioprine
mycophenalate
methotrexate
66
the drugs used to treat SLE puts the patients at increased risk for two things? you should treat the side effects of these when treating SLE patients
atherosclerosis
osteoporosis
67
what is an important thing you want to discuss with women who have SLE?
birthcontrol and family planning, Pregnancy is VERY risky!!!
68
what interesting false positive test resulte can SLE create?
false positive syphilis
69
drug induced SLE
## Footnote
what is it? what are 3 drugs that commonly cause it? what pattern does it have?
acts and looks like SLE but is reversible when the drug is discontinued
**minocycline**: most common derm drug for acne
**hydralazine:** for BP
procainamide
histone pattern ANA
70
what two exam tests are important for impingement/bursitis/tendonitis of the shoulder?
hawkins
Neers (impingement sign)
71
inpingement/bursitis/tendonitis
## Footnote
what happens in this? what three things ilicit pain? what degrees do you catch at? what are the movement limitations? what two movement tests should the patient do? what tests do you want to order? what are the five treatment considerations?
**repetitive overhead work**, gradual progression
impingement: subacromial bursa, rotator cuff compressed between humeral head and acromion
inflammation: subacromial bursa, rotator cuff tendons (as it gets more inflammed the space gets smaller and pinches the tendons more)
**pain: lifting or reaching****, night**
_catch at 80-120\*_
DECREASED AROM BUT FULL PROM
**tests: Neers inpingment sign, hawkins manuver** (elbow bent out in front and push down)
xray: A/P/axillary/lateral, MRI rarely indicated
REST, NSAIDS, **naprosen**, PT, corisone injection, surgery
72
what type of surgery do you do for impingment, bursitis, or tendonitis of the shoulder?
arthroscopic subacromial decompression
| (scrapping off the bursa)
73
Pre-patella bursitis
## Footnote
what else is this known as? what do patients get it from? what is the organism that can cause it if infection? what do you want to do for imaging/testing? what do you do for treatment?
roofers, floorers, people who are kneeling down all the time, feels like water on the knee
"housemaids knee"
inflammation of prepatellar bursa, between patella and skin
trauma or repetitive kneeling
*can become infected by micropenetrating trauma **S. aureus***
xray to rule out bony injury, or foreign body in bursa
*joint aspiration* if question of infection, analyze for organism
conservative approach plus *knee pad or cortisone if 100% no infection*
74
Meniscal tear
## Footnote
what two common pt populations does this happen in? how do injuries in these two groups occur? which one is more commonly injured? when does the patient have pain? what are 3 things they may report as feelings? what are the two tests that are important? what are the two next steps after conservative treatment fails? what must be considered?
**older patients:** associated with OA, degenerative tear, chronic complaints
**younger patients:** associated with rotational injury from femur on tibia or trauma
W\>M, **medial more commonly torn**
**pain with rotation/squatting**, fullness behind knee, and _giving way or locking (can't extend knee)_
_joint-line tenderness biggests key_
**mcMurray's test is the gold standard**
**appleys compression tests**
*tears rarely heal on their own, symptoms may get better but they will return*
**repair vs.** **menisectomy**
(dependent on type of tear, zone red vs white, activity demands)
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what does the medial meniscus look like? how much motion is allowed? what does it attach to?
**Medial Meniscus**
"C" shaped
attaches to tibia and MCL
2mm of motion
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what is the shape of the lateral meniscus? how is it attached? how many mm of motion does it have?
**Lateral meniscus**
"o" shaped
loosely attached, decreasing risk for for injury
10 mm of motion as knee flexes
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Reactive Arthritis (Reiter Syndrome)
## Footnote
what is this join infection caused by? what are the two most common routes a person can contract this? what are the 4 symtoms that are included as a part of this tetrad? what do you want to make sure you do? and what test will be negative? what do you treat with?
joint inflammation that presents after PREVIOUS INFECTIONs commonly from **sexually transmitted or gastroenteritis**
_chlamydia urethritis most common pathogen_
**Tetrad presentation:**
1. **urethritis** (difficulty urinating,
**2. conjunctivitis** (eye inflammation)
**3. olioarthritis (1-4 joints)**
**4. mucosal ulcers** (oral, balantitis\*peeling of skin on penis\*, stomatitis \*inflammation of the mouth)
**5. *keratoderma blennhoragicum rash/ulcers on bottom of feet***
want to do a culture, will be RF NEGATIVE!
Treatment: NSAIDS, DMARDS antibiotics not really helpfuly even though infection!
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developmental dysplasia of hip
**4 RF**
1. first child
2. girl
3. breech presentation
4. family hx
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what are te two bacteria seen in _reactive arthritis_ in the sexually transmitted pathway?
chlamydia urethritis
ureaplasma
9:1 Men
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what are the 4 bacteria you should worry about in _reactive arthritis_ that you should worry about in the gastroenteritis pathway?
Yersina
Salmonella
Shigella
Campylobacter
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developmental dysplasia of the hip (DDH)
## Footnote
4 dx?
tx goal?
3 tx and for what age group?
DX:
1. barlow
2. ortalani
3. AP xray
4. _US at 6 weeks if female and breech_
TX:
\*\*goal is to keep the hip located so that the ligaments and bones have time to form and strengthen to hold it in place\*\*
1**_. PAVLIK_** **_BRACE/harness_**
- use under 6 months for 8-12 weeks
- 90-95% successful
2. **_casting if older than 6 months_**
8-12 weeks
**_3. surgical reduction/fixation if older than 2 y/o_**
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developmental dysplasia of hip (DDH)
## Footnote
3 causes?
which side MC? when present?
4 sxs
causes:
1. generalized hip laxity
2. complete hip dislocation
3. acetabular abnormality
MC in left hip, present at birth
SXS:
**1. initally asymptomatic**
**2. then with walking, limp and decreased leg length**
**3. asymetry of the skin folds**
**4. _loss of adduction_**
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slipped capital femoral epiphysis (SCFE)
## Footnote
what is this?
key fact?
age range?
5 potential causes?
slippage of the femoral epiphysis **_usually posteriorly_**
## Footnote
**_most common adolescent hip disorder, 8-16 y/o_**
causes:
1. endocrine disease (GH, hypo/hyper thyroid)
2. inflammation
3. renal disease
4. irradiation
5. mechanical forces
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slipped capital femoral epiphysis (SCFE)
## Footnote
6 sxs?
3 dx test? 2 findings?
SXS:
1. acute or chronic
2. pain with activity
3. pain in hip, groin, knee
4. limp
5. **_decreased hip movement with INTERNAL ROTATION_**
6. **_possible limb shortening_**
DX:
1. AP and FROG LATERAL
2. "fuzzy" irregularities on physis (growth plate)
3. slipping at the physis
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slipped capital femoral epiphysis (SCFE)
## Footnote
2 goals of tx?
1 tx option?
GOALS:
1. stablize the epiphysis
2. cause early closure of the physis
1. surgical fixation
**screw into the epiphysis**
**non weight bearing**
**WILL PROGRESS IF LEFT UNTREAED**
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osgood-schlatters disease
## Footnote
what is this and who do you find it in?
3 causes of this?
inflammation at the tibial tubercle apophysis during periods of growth/athletic children
## Footnote
MC in males!!!
CAUSES:
**_1. repetitive trauma/overuse_**
**_2. jumping/running_**
**_3. repetitive quadriceps use that pull on the insertion_**
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osgood-schlatters disease
## Footnote
4 sxs of this?
dx?
3 tx?
SXS:
1. gradual onset
2. worsens with jumping, running, kneeling
3. **deformity at tibial tubercle with pt tender**
4. often bilateral
DX:
CLINICAL!!!
TX:
1. symptomatic for several months
2. resassurance
3. rarely surgery for tibial tubercle excision
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"nursemaids elbow" subluxation of the radial head
## Footnote
what is this?
what happens?
MC age?
3 sxs?
most common elbow injury in kids caused by increased joint laxity _radial head is wedged in annular ligament_
## Footnote
occurs in 2-3 years old MC
SXS:
1. caused by forceful pronation/extension
2. unwillingness to use arm
3. arm held in extension by side
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nursemaids elbow: sublaxation of the radicular head
## Footnote
2 dx?
tx 2?
DX:
1. pain over the radial head
2. xrays not helpful
TX:
1. **manipulation of the radial head with _PRESSURE ON THE RADIAL HEAD WITH FORCE FLEX AND SOUPINATION_**
2. cast for reccurent dislocations
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Torus fracture
## Footnote
nickname? what is this?
"buckle fracture"
one side of the cortex buckles from compression fracture like falling on outstrected hand
TX: cast 4-6 weeks
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Greenstick fracture
how does this happen?
tx?
occurs in LONG bones when bowing occurs causing break in one side of the cortex
## Footnote
TX: less than 15\* cast, over 15 surgery
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GROWTH PLATE FRACTURES
SALTER HARRIS CLASSIFICATION
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