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Clinical Medicine I > MSK > Flashcards

MSK Flashcards

1
Q

Bone Cell Types

A
  • osteoprogenitor cells
    • unspecialized that develop into osteblasts
  • osteoblasts
    • form new bone, role in calcification and protein synthesis
  • osteoclasts
    • resorbing and breaking down bony matrix
  • osteocytes
    • mature osteoblasts in the bony matrix
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2
Q

Medical History

A
  • age- problems vary by age (dislocation, overuse, etc)
  • gender
  • occupation/recreation
  • family history (autoimmune, CA, osteoporosis)
  • onset and progression of symptoms
    • injury vs. “wear and tear”
    • joint symptoms (stiffness, movement limitations)
    • muscular symptoms
    • skeletal symptoms (limb length discrepancy)
    • joint pattern (how many affected, symmetrical or not)
    • inflammatory vs non-inflammatory
      • warmth and swelling
      • morining stiffness (“gel phenomenon”)
      • non: worsening w/ activity
    • extra-articular vs. systemic
      • usually autoimmune
      • lung, kidney, etc. problems
  • how disabling- ADLs
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3
Q

Physical Exam Components

A
  • evaluate symmetrically and systematically
  • inspection- deformity, swelling, erythema, asymmetry
    • look at skin!
  • palpation- tenderness, crepitation, warmth, synovial thickening
  • ROM- active and passive, limited d/t muscle/nerve injury
  • manual muscle testing- strength/resistance
  • special testing
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4
Q

9 Categories of MSK Disorders

A
  1. local and regional
  2. cartilage degeneration
  3. inflammatory synovitis
  4. crystalline arthropathies
  5. enthesopathy
  6. joint space disease
  7. osteoarticular disease
  8. inflammatory myopathy
  9. general conditions
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5
Q

Local and Regional Conditions

A
  • tendonitis, bursitis
  • sprains- injury to ligaments
    • I: partial tear, no instability
    • II: partial tear, some instability
    • III: complete tear
  • strains- injury to muscle
    • I: few torn fibers, fascia intact
    • II: moderate amount of m. fibers torn, fascia intact
    • III: tear all m. fibers w/ fascia intact
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6
Q
  • loss of articular cartilage
  • formation of osteophytes
A

cartilage degeneration

  • primary
    • biomechanical abnormalities leading to micro-fisures in the articluar cartilage
  • secondary
    • infection, autoimmune
    • trauma or hypermobility of joint
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7
Q
  • pigmented vilonodular synovitis (PVNS)
    • thickening vascular swelling and infiltration of synovia
  • autoimmune disease
A

inflammatory synovitis

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8
Q
  • monosodium urate
  • calcium pyrophosphate
  • hydroxyapatite
A

crystal-induced synovitis

  • gout
  • pseudogout
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9
Q
  • disorder of transition zone where tendons, ligaments and joint capsule attach
A

enthesopathy

  • hallmark: spondyloarthropathies
  • enthesis affected
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10
Q
  • microorganisms in the joint
  • extremely painful
A

joint space disease

  • septic arthritis
    • perform joint aspiration and fluid analysis, gram stain, cultures
    • hemarthrosis
      • blood in joint (can occur w/ ACL tear)
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11
Q

Osteoarticular Disease

A
  • osteopenia
  • osteoperosis
  • osteonecrosis (typically w/ joint separation)
  • periostitis
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12
Q
  • painless inflammation and weakness of proximal skeletal muscles
A

inflammatory myopathy

  • increased creatine kinase (CK) levels
  • abnormal electromyography (EMG)
  • histological abnormalities w/ biopsy
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13
Q

General Conditions

A
  • polymyalgia rheumatic
  • fibromyalgia
  • complex regional pain syndrome
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14
Q

Initial Imaging Technique

A

x-ray

  • tissue densities:
    • air- black or dark gray
    • fat- gray (lighter than air and darker than muscle or blood)
    • water (blood and soft tissue)- shades of gray
    • calcium in bone- white
    • metal and contrast agents- bright white
  • 2 views at right angles
  • compare with old or bilateral views
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15
Q

X-ray Requirements

A
  • Pt identification
    • name, age, sex, birth date, medical record number
  • location to image
  • technical quality
    • positioning of body part
    • quality
    • contrast
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16
Q
  • continuous x-ray imaging
  • used w/ procedures
  • assess joint motion
A

flouroscopy

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17
Q
  • used to evaluate joint soft tissue, muscle pathology, marrow structures, tumors
A

MRI

  • expensive
  • difficult to see bone, actually seeing fat in marrow
  • T1:
    • fat- bright
    • water- dark
  • T2:
    • fat- dark
    • water- bright
    • blood, edema, CSF- white
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18
Q

MRI with contrast

A

MRI Arthrogram

  • Gadolinium conatrast injected IV or intra-articular
  • helps visualize small structure damage- labral tear
  • C/I
  • cochlear implants, some heart valves, pacemakers, spinal implants, brain aneurysm clips, metalic fragments in eye (some joint prosthesis- some made of non-magnetic materials)
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19
Q
  • imaging joints not seen well with x-ray
    • SI joint, vertebral bodies
  • intra-articular fractures
  • bony abnormalities in joint
  • high radiation
  • 360 degree x-ray 3-D reconstructions
A

CT scan

  • contrast used to determine if mass is solid or cystic
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20
Q

Other Imaging

  • test to measure bone mineral density (lumbar spine and proximal femur- T score and Z score)
  • measure muscle function w/ needle inserted into muscle
  • stimulate sensory/motor nerve w/ electrical impulse to measure conduction
  • sometimes used to evaluate disc herniation or spinal cord compression
  • increased blood flow w/ radionucleotide to ID tumors, fracures
A
  • DEXA scan
  • electromyography test
  • nerve conduction study test
  • myelogram
  • nuclear medicine (Bone/PET scan)
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21
Q
  • imaging using sound waves
  • typically for prodedures- injections
A

Ultrasound

  • images are grayscale
  • high water = darker image (hyperechoic)
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22
Q

Common Ortho Labs

  • inflammation markers
  • autoantibody test
  • antinuclear antibodies (ANA)
  • cryoglobulins
  • metabolic markers
A
  • inflammation:
    • C-reactive protein (CRP)
    • Erythrocyte sedimentation rate (ESR)- sed rate
    • CBC w/ diff
  • autoantibody
    • Rheumatoid factor (RF)
    • antibodies to anti-cyclic citrulinated proteins (anti-CCP)
  • anti-nuclear antibodies (ANA)
    • Abx to DNA or pospholipids
  • cryoglobulins (normally done by rheumatology)
  • metabolic markers
    • calcium, phosphorus, Vit D 25-dihydroxy, alkaline phosphatase
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23
Q

Synovial Fluid Analysis

A
  • to ID cause
    • septic arthritis, hemarthrosis, crystal arthritis, differentiate inflammatory vs. non-inflammatory arthritis
  • r/o infection
  • analyze:
    • appearance (color)
      • normal- clear, straw, wbc <200, PMN <25%
      • noninflamm- clear, straw+, wbc 200-1000, PMN <50%
      • inflamm- cloudy, yellow/green, wbc 1K-75K, PMN >50%
      • septic- opaque, variable, wbc >50K, PMN >90%
      • hemorrhagic- red
    • volume
    • wet prep
      • cells, fibrin, collagen, cartilage, synovial fragments, rice bodies, crystals
    • polarized light microscopy: ID crystals
      • monosodium urate- gout
      • calcium pyrophosphate dehydrate (CPPD)- pseudog
      • hydroxyapatite- osteoarthritis
    • RBCs, WBCs
    • gram stain (an/aerobic, fungal)
      • gonococcal (most common young adults)
      • G+ s. aureus, s. pyogenes, s. pneumonia
      • G- enterobacterieae, pseudomonas
      • fastidious hemophilus, neisseria meningitides
    • crystals
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24
Q

Joint Injection for Inflammation Reduction Drugs

A

Glucocorticoids

  • stop production of inflammatory mediators: leukotrienes and prostaglandins
  • max 3 injections per year
  • increases pts blood sugar
  • dexamethoasone sodium phosphate
    • 1-2h onset, 12d duration
  • hydrocortisone acetate
    • 1-2d onset, 1-4w duration
  • methylprednisone acetate (Depo-Medrol)

triamcinolone acetonide (Kenalog)

triamcinolone hexacetonide (Aristospan)

  • 1-3d onset, 2-4m duration
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25
Q

Steroid Injection Contraindications

A
  • joint infection
  • overlying skin infection
  • systemic bacteremia
  • thrombocytopenia/bleeding disorders
  • prosthetic joints
  • osteonectrosis or fracture
  • uncontrolled DM
  • psoriatric plaques
  • steroid allergy
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26
Q

Joint Injection for OA Pain

A

hyaluronate preparation

  • hyaluronic acid is in synovial fluid- provides shock absorption
  • brand names:
    • Synvisc, Orhovisc, Euflexxa
  • C/I
    • infection
    • overlying skin disease
    • chicken/egg allergy
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27
Q

Complications of Corticosteroid Injections

A
  • joint
    • infection, hemorrhage, flare, steroid arthropathy (joint breakdown w/ too much steroid use)
  • systemic
    • facial flush
    • worstening diabetic control
    • supression of HPA axis
    • iatrogenic Cushing syndrome
  • local
    • leakage along steroid tract
    • atrophy of subcutaneous fat, depigmentation
    • misplaced injections
    • tendon rupture, nerve damage, cartilage injury, abscess
  • rare
    • pancreatitis
    • hypersensitivity rxns
    • uterine bleeding
    • osteonecrosis
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28
Q

MSK Treatment Approaches

A
  • conservative
    • RICE- rest, ice, compression, elevation
    • rehab
    • meds
      • Rx: NSAIDs, corticosteroids, pain relievers
      • herbal: glucosamine and conjointin
      • topical (except over surgical sites!)
    • aspiration/injection
    • bracing
    • activity modification
  • surgical
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29
Q

inflammation in subacromial space

(subacromial bursa, suprapsinatus tendon, acromion, coracoacromail ligament, biceps tendon)

  • d/t overuse, repetition
  • extremely common
  • increases w/ age >30
  • s/s, tests, dx
A

shoulder impingement

  • s/s
    • insidious onset or mild trauma
    • deltoid/upper arm aching; dull at rest or sleeping
    • rc pain referred to deltoid
    • normal/near normal ROM
    • full strength or mild weakness d/t inflammation
  • tests
    • Neer sign
    • Hawkins-Kennedy sign
    • x-ray (+/- bone spur), MRI (r/o tears, tendinosis)
  • diagnosis: clinical
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30
Q

inflammation of long head of biceps

(frequently diagnosed w/ rotator cuff or superior labral patho)

A

bicipital tendinitis

  • role of bicep: supination
  • unknown cause
  • s/s
    • pain in bicep through bicipital groove
    • rupture causes “Popeye muscle” deformity
  • tests
    • Speed’s sign
    • Yerganson’s test
  • tx
    • conservative: PT, ice, subacromial/bicep injection, activity modification, NSAIDs
    • surgical: arthroscopy w/ 6-8w recovery
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31
Q

impingement signs

  • age >40-45
  • +/- injury
  • s/s, tests, dx
A

rotator cuff tear

  • supraspinatus muscle torn typically- cuff arthropathy: humeral head rides up superiorly
  • s/s
    • gradually worsening pain, NIGHT PAIN
    • +/- weakness
  • tests
    • drop arm
    • empty can
    • x-ray (+/- spur, cuff arthropathy)
    • MRI
    • possible US
  • tx
    • based on size, acuity, dysfunction, activity level
    • no symptoms = no tx
    • conservative
      • rest, ice, NSAIDs, +/- injection, PT
      • NO SLING- will get frozen shoulder
    • surgery
      • arthroscopic or open repair
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32
Q

shoulder pain, unable to move arm, deformity

  • s/s, tests, dx
A

glenohumeral instability/dislocation

  • s/s
    • dislocation/subluxation vs. generalized- doesn’t affect just the shoulder
    • may be trauma or genetic (adolescent)
    • may have numbness or tingling
      • check axillary n. (CN XI) - feel for deltiod contraction
      • ALWAYS do neurovascular check before reduction/procedure
  • Bankart Lesion- labrum torn w/ dislocation
  • tests
    • x-ray pre/post reduction to check for fractures- MUST HAVE AXILLARY VIEW
    • for recurrent instability
      • apprehension test (anterior/posterior)
      • sulcus sign (inferior)
      • load and shift test (anterior/posterior)
  • tx
    • traction/counter traction
    • Stimpson hanging arm technique
    • 1st- immobilize 2-3w, PT >4w, maybe surgery
    • recurrent- arthroscopy vs. open surgery
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33
Q

common injury w/ overhead/throwing athletes, fall on outstreched arm or traction injury, increased tension on bicep tendon

  • s/s, tests, dx
A

SLAP tear (Superior Labrum Anterior to Posterior)

  • s/s
    • pain anterior and deep
    • +/- clicking
    • weakness/pain w/ overhead activity
    • normal ROM and strength
  • tests
    • O’Brien test
    • Crank test
    • GIRD: glenohumeral internal rotation deficit- lose ROM
    • MR arthrogram (gold standard)- plain films will be normal
  • tx
    • grade 1-2: rest, ice, PT w/ scapular stabilizers, throwing protocol, core strengthening
    • grade 3+: SLAP repair if <30-35; tenotomy or tenodesis if >35
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34
Q

progressively worsening pain, pain with ACROSS BODY ADDUCTION, rest of exam normal

  • s/s, tests, dx
A

AC joint sprain/dislocation, OA/osteolysis

  • sprain
    • always lateral shoulder trauma (AC joint +/- CC ligs)
    • tx:
      • immobilize w/ sling ~2d, rest, ice, NSAIDs, PT
      • surgery rare (grade 4+ only)
  • OA/osteolysis
    • conservative vs. open or arthroscopic excision/resection
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35
Q

pain, freezing and loss of motion of arm (external rotation)

  • s/s, tests, dx
A

adhesive capulitis

  • s/s
    • freezing -> plateau -> thawing
    • trauma, immobilization, thyroid disease, diabetics, women
    • adhesions and thickening of joint capsule
  • tests
    • x-ray to r/o other causes
    • NO MRI
  • tx
    • conservative: rest, ice/heat, PT, GH injection, NSAIDs, pain meds
    • surgery:
      • manipulation under anesthesia
      • arthroscopy for lysis of adhesions
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36
Q

Shoulder Joint Injections

A
  • subacromial space
    • seated w/ forearm on lap
    • inject ~1cm below posterior border of acromion
    • directed medially, anteriorly, slightly superiorly 2-3cm
  • glenohumeral joint
    • posterior 2 fingers medial and posterior acromion border
    • directed anteriomedial toward coracoid process
  • bicipital tendon sheath
    • sitting or supine
    • externally rotate arm and mark point of max tenderness
    • insert 30-45 deg into sheath AVOIDING tendon
  • AC (acromioclavicular) joint
    • seated w/ forearm in lap
    • superior approach insert ~.5cm
  • SC (sternoclavicular) joint
    • sitting or supine
    • anterior approach ~0.5cm
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37
Q

compression of brachial plexus +/- subclavian vessels

  • s/s, tests, dx
A

thoracic outlet syndrome

  • s/s:
    • women 20-50
    • trauma or mechanical stress, conginital: cervial rib, long C7 transverse process, fibrous tissue in thoracic outlet
    • vague: neck, trapezious, shoulder/arm, supraclavicular pain or aching
    • parasthesia (ulnar nerve commonly)
    • color changes in arm
    • fatigue
    • WORSENING w/ ARM OVERHEAD
    • bruits
  • tests
    • Adson’s maneuver
    • elevated arm stress
  • tx
    • conservative
      • rest, meds: NSAIDs, muscle relaxers, PT w/ postural awareness
    • surgery- rare
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38
Q

Elbow Physical Exam

A
  • inspection
    • edema, deformity, ecchymosis, atrophy
  • palpation
    • bony landmarks
  • ROM at elbow
    • flexion, extension, supination, pronation
  • strength testing
  • special tests
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39
Q

pain w/ use and TTP over tendon origin, pain with grip strength

  • s/s, tests, dx
A

medial/lateral epicondylitis

  • s/s
    • overuse injury
    • +/- weakness
    • lateral pain- tennis elbow (common extensor)
    • medial pain- golfer’s elbow (common flexor)
  • tx
    • conservative
      • rest, ice, NSAIDs, +/- cortisone, injection bracing
    • surgery (not common)
      • drill holes in bone to advance healing
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40
Q

pain in medial joint line

  • types, s/s, tests, dx
A

collateral ligament injury

  • radial collateral ligament (LCL)
    • rare, usually associated w/ fracture or dislocation
  • ulnar collateral ligament (MCL)
    • repeated valgus stress (pitching), injuries rare
    • s/s
      • acute- pop then medial elbow pain
      • chronic- no specific injury, just progressing pain
      • ulnar paresthesia (ring/little finger)
      • pain w/ ecchymosis
    • tests
      • valgus stress test
      • MR arthrogram
    • tx
      • conservative: rest, NSAIDs, PT, throwing mechanics
      • surgery- “Tommy John” UCL repair
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41
Q

tender mass at tip of elbow

  • s/s, tests, dx
A

olecranon bursitis

  • s/s
    • acute or gradual
    • direct blow, gout or crystalline deposits (gritty on palpation), infection (septic) bursitis requires surgery
    • swollen, painful, sometimes red posterior elbow
    • warm to touch
    • remainder of exam benign
  • tests
    • aspirate and analyze WBC, crystals, gram stain/culture
  • tx
    • I&D and Abx
    • NSAIDs, elbow pad, cortisone injection if no infection
    • surgical excision (not common)
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42
Q

aching over medial elbow, numbness/tingling, claw hand

  • s/s, tests, dx
A

cubital tunnel syndrome (ulnar neuritis)

  • s/s
    • medial elbow aching
    • atrophy of hand
    • direct blow vs. leaning on elbows or holding flex position
    • check for deformity/carrying angle
  • tests
    • elbow flex test
    • positive Tinel’s sign
    • vibration and light touch perception- 2pt discrimination
    • manual muscle testing
      • finger abduction and adduction
    • x-rays
    • EMG/NCS
  • tx
    • conservative
      • rest, avoid flexion, night extension splint
    • surgery
      • ulnar nerve decompression
      • transposition- move nerve out of cubital tunnel
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43
Q

pain and ecchymosis in antecubital fossa, “pop”,

“reverse Popeye” deformity

  • s/s, tests, dx
A

distal bicep tendon rupture

  • s/s
    • pain and palpable defect in antecubutal fossa
    • musce belly retracts w/ elbow flexion
    • weakness w/ supination
  • tests
    • x-ray
    • MRI
  • tx
    • surgery w/in 2 weeks of injury
    • consider conservative if elderly, nondominant, partial
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44
Q

extreme swelling, pain, and inability to move elbow

  • s/s, tests, dx
A

elbow dislocation

  • s/s
    • FOOSH
    • terrible triad- dislocation w/ fracture of coronoid and radial head
    • 80% posterior
      • LCL always disrupted
      • brachial a., median and ulnar nn. injured
  • tests
    • neurovascular check
    • x-ray
    • +/- CT scan
  • tx
    • reduction and splint under conscious sedation
    • ROM start in 5-7d
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45
Q

Elbow Injections

A
  • olecranon bursa
    • elbow flexed, poserior 1cm distal to olecranon bursa
    • 18g needle w/ 10ml syringe
    • grasp bursa w/ other hand
  • elbow joint
    • seated w/ 45 degree elbow flex
    • palpate center of lateral epicondyle, radial head, tip of olecranon triangle
  • lateral epicondylitis
    • seated w/ elbow flexed 90 degrees
    • 1cm distal to epicondyle, point of max tenderness
    • 22g needle
  • medial epicondylitis
    • seated w/ elbow extended 20 degrees
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46
Q

Wrist and Hand Exam

A
  • inspection
    • scars, atrophy, edema, erythema, deformity
  • palpate
    • bony and soft tissue
  • ROM- active and passive
    • especially if suspect tendon injury
  • strength
  • special testing
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47
Q

compression of median nerve

  • s/s, tests, dx
A

carpal tunnel syndrome

  • s/s
    • female, repetition, DM, thyroid, RA, pregnancy
    • 1st, 2nd, 3rd finger numbness and tingling
    • worse at night
    • muscle weakness- loss of grip and motor dexterity
  • tests
    • Tinel’s sign
    • Phalen’s sign (*most useful)
    • 2pt discrimination loss
    • muscle atrophy
    • EMG and nerve conduction studies
  • tx
    • conservative
      • NSAIDs, activity modification, bracing, injection
    • surgery
      • open vs endoscopic
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48
Q

swelling/stenosis in tendon sheath of snuff box

(abductor pollicis longis/extensor pollicis brevis)

-s/s, tests, dx

A

DeQuervain’s Tenosynovitis

  • s/s
    • pain +/- mild edema
  • tests
    • Finkelstein test
  • tx
    • injection, +/- bracing, PT
    • rarely surgical release
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49
Q

“bump” on dorsum of wrist, volar radial wrist, base of finger

  • s/s, tests, dx
A

ganglion cyst

  • s/s
    • fluid leaks from joint capsule/tendon synovial sheath
    • vary in size +/- pain
    • transilluminate
    • can compress medial nerve and radial artery
  • tx
    • conservative
      • NSAIDs, rest, wrist splint
      • aspiration- WATCH radial artery
    • surgical
      • if recurrent painful cyst or N/V compromise
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50
Q

finger/thumb deformity with pain, swelling, ecchymosis after injury

  • s/s, tests, dx
A

thumb/finger dislocations

  • s/s
    • tearing of collateral ligament/volar capsular ligament
    • check for joint stability 1-2w later
  • tests
    • x-ray to r/o fracture
  • tx
    • conservative- taping
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51
Q

forced abduction of thumb

  • s/s, tests, dx
A

gamekeeper’s (skier’s) thumb

  • s/s
    • tear of ulnar collateral ligament (UCL) of MC joint
    • pain, swelling, ecchymosis
  • tests
    • valgus stress test
    • x-ray to r/o fracture
    • +/- MRI if suspect rupture
  • tx
    • conservative vs. surgical if UCL ruptured
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52
Q

finger “feels locked” and palpable nodule with flex/extension

  • s/s, tests, dx
A

trigger finger

  • s/s
    • pain and catching
    • thickening of flexor tendon sheath- a1 pulley
    • mostly long and ring finger
    • female, RA/DM
    • worse after inactivity
  • tx
    • conservative vs. surgical
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53
Q

finger flexion weakness following injury

  • s/s, tests, dx
A

flexor tendon injuries

flexor digitorum profundus (FDP) & digitorum sublimis (FDS)

  • s/s
    • “Jersey finger”- ring finger most common
    • swelling, ecchymosis
    • TTP at distal phalanx
    • associated w/ RA/OA
  • tests
    • test flexion at PIP and DIP
  • tx
    • surgical repair
    • *** DOCUMENT evaluation with every finger/hand cut ***
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54
Q

flexed PIP and hyperextended DIP

  • s/s, tests, dx
A

boutonniere deformity

  • s/s
    • rupture extensor central slip
  • tests
    • x-ray to r/o fracture
  • tx
    • extension splint to PIP
    • 6w if youger, 3w if older
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55
Q

blunt trauma to finger tip w/ swelling, ecchymosis, deformity

  • s/s, tests, dx
A

mallet finger

  • s/s
    • rupture to extensor tendon at DIP
  • tests
    • x-ray to r/o fracture
  • tx
    • RICE
    • extensor splint all times for healing
    • surgery for large avulsion
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56
Q

hyperextension of PID/flexion of DIP

  • s/s, tests, dx
A

swan neck deformity

  • s/s
    • weakening of volar plate
    • RA/nerve disorders
    • pain and swelling
  • tests
    • x-ray
  • tx
    • conservative vs. surgical
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57
Q

infection of soft tissue around fingernail

  • s/s, tests, dx
A

paronychia

  • s/s
    • pain and swelling around nail
  • tx
    • digital block and drainage
    • oral abx
      • cephalexin (Keflex) 500mg po q6h 10d
      • tmp/smx (Bactrim DS) 1 po q12h 10d
      • clindamycin (Cleocin) 300mg 1 po q8h 10d
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58
Q

finger pulp infection

  • s/s, tests, dx
A

felon

  • s/s
    • puncture wound (usually thumb or index)
    • sever pain and swelling
    • tense, red, swollen, very tender
  • tests
    • S. aureus pathogen
  • tx
    • digital block w/ surgical drainage
    • abx: Keflex or Bactrim
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59
Q

fight bite in index, middle, ring finger

  • s/s, tests, dx
A

septic flexor tenosynovitis

  • s/s
    • puncture wound
    • Kanavel’s 4 cardinal signs
      1. intense pain w/ extension
      2. flexion posture
      3. fusiform swelling
      4. tenderness along flexor tendon sheath
  • tests
    • CBC, ESR, sed rate
    • x-ray
  • tx
    • call hand service
    • SURGICAL EMERGENCY **DO NOT MISS
    • Abx
    • poor prognosis- usually residual stiffness, loss of ROM
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60
Q

clear fluid filled vesicles on finger

  • s/s, tests, dx
A

herpetic whitlow

  • s/s
    • pain, swelling
  • tests
    • herpes simples 1 or 2
  • tx
    • conservative- DO NOT DRAIN these
    • +/- antivirals
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61
Q

Lower Extremity Physical Exam

A
  • inspection
    • LL length/alignment, deformity, muscle atrophy, pelvic obliquity, Q-angle
      • Q-angle:
        • female 17 deg, male 14 deg
        • angle of ASIS to middle patella to mid tibia
        • stresses medial side of knee + foot pronation
    • gait analysis
  • palpation
    • bony prominences, soft tissue, joint line
  • ROM
  • manual muscle testing (MMT)
  • special tests
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62
Q

Hip Anatomy Terminology

A
  • ischial tuberosity
  • anterior tilt- downward tilt w/ hip extension
  • posterior tilt- hip flexion
  • lateral tilt
  • pelvic rotation w/ walking
  • diarthroidal- movement in 3 planes
  • hip pain- anterior to seam line of pants
  • back pain- posterior to seam line of pants
  • femoral neck angle
    • anteversion- smaller angle than normal (foot in)
    • retroversion- larger angle than normal (foot out)
    • coxa vara- inclination <125 degrees
    • coxa valga- inclination >125 degrees
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63
Q

Hip Exam Special Tests

A
  • Trendelenburg Test/Sign
    • hip drop opposite affected gluteus medius/minimus
  • Thomas test
    • hip flexor contracture/psoas tightness (knee to chest)
  • log roll test
    • pain w/ internal leg rotation- acetabular/femoral neckpathology
  • FABER (Patrick) test
    • flexion-abduction-external rotation (cross leg while lying)
    • SI joint or hip problem
  • Hamstring flexibility
    • passive SLR 80 degrees
    • knee extension should be 5-15 degrees of straight
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64
Q

pain and swelling of thigh, +/- ecchymosis, +/- palpable defect

  • s/s, tests, dx
A

hip strain

  • s/s
    • TTP
    • pain with stretching or resistance to MMT
  • tx
    • RICE, NSAIDs, pain relievers, PT
    • surgery- avulsion injuries
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65
Q

lateral hip/thigh pain

  • s/s, tests, dx
A

hip bursitis - trochanteric bursitis

  • s/s
    • most common hip bursitis
    • lumbar spine OA/scoliosis, length discrepancy, trauma
    • runner, female, middle age to elderly
    • pain at rest and activity
    • difficulty ambulating
    • TTP greater trochanter
    • pain w/ abduction
  • tx
    • RICE
    • cortisone injection
    • NSAIDs, pain reliever
    • weight loss
    • rehab: stretch/strengthen gluteus medius and IT band
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66
Q

buttock, labial/scrotal pain

  • s/s, tests, dx
A

piriformis syndrome

  • s/s
    • pain w/ sitting or getting out of bed
    • pain w/ hip adduction
    • difficulty sitting
    • absent neurological signs
    • TTP SI joint, gluteal muscles, greater sciatic notch
  • tests
    • piriformis test
    • Lasegue sign- leg lifted and straight, flex knee and cross
    • x-ray, MRI, CT to r/o other causes
    • EMG to differentiate btw piriformis and herniated disk
  • tx
    • NSAIDs, PT, +/- injection
    • surgery?
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67
Q

clicking, popping, locking hip with lateral pain

“C sign”

  • s/s, tests, dx
A

femoral acetabular impingement

  • s/s
    • osseous deformity of acetabular rim, femoral head/neck junction
    • causes labral tear and articular cartilage microtrauma
    • from overuse
  • tests
    • decreased flex and IR
    • +FIDDIR
    • x-ray (AP and lateral)
    • MR arthrogram
  • tx
    • conservative vs. surgical
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68
Q

high trama impact to leg in seated position

  • s/s, tests, dx
A

hip dislocation

  • s/s
    • obvious deformity
  • tests
    • check distal pulses and nerve status, knee
    • x-rays (AP and lateral)
    • CT if fracture suspected
  • tx
    • reduction ASAP
    • if no fracture w/ PWB and advance as tolerated
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69
Q

pain in groin, lateral hip or buttock; worse w/ weight bearing; catching/popping sensation

  • s/s, tests, dx
A

osteonecrosis

  • s/s
    • bone death- collapse of femoral head
    • risks: corticosteroid use, alcohol abuse, trauma, sickle cell, RA, lupus
    • Trendelenburg gait
    • decreased/painful ROM
  • tests
    • pain w/ straight leg raise
    • +log roll
    • x-ray, MRI or CT
  • tx
    • w/out collapse
      • core decompression
      • vascularized fibular grafting
    • w/ collapse
      • arthroplasty (replacement)
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70
Q

loss of articular cartilage in hip

  • s/s, tests, dx
A

hip osteoarthritis

  • s/s
    • childhood disease, trauma, osteonecrosis, infection
    • anterior groin/thigh pain (worse at night)
    • pain w/ activity and progresses to constant pain
    • popping, catching grinding
    • fixed external rotation and flexion contracture
  • tests
    • x-rays
  • tx
    • conservative
      • pain control, activity modification, assistive devices
    • surgery
      • osteotomy
      • total hip arthroplasty
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71
Q

ASIS compression

  • s/s, tests, dx
A

lateral femoral cutaneous nerve entrapment

  • s/s
    • pain and dysethesia of lateral thigh
    • decreased sensation but pressure or tapping over nerve increases symptoms
    • no muscle or abnormal reflexes
  • tests
    • plain films- r/o abnormalities
    • CT/MRI- r/o pelvic or abdominal masses
  • tx
    • weight loss, loosening tigh clothing
    • meds
    • cortisone injection
    • surgical release of nerve rarely done
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72
Q

Knee Physical Exam Technique

A
  • inspection
    • gait, alignment, feet, discoloration, effusion, atrophy
  • palpation
    • quad/patellar tendon, joint line, MCL/LCL, bursa, popliteal fossa
  • ROM
    • knee flexion 0-130 degrees (up to 10 percent of hyperextension)
  • manual muscle testing
    • grading scale
  • special test
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73
Q

Knee Special Tests

A
  • apprehension test
    • move patella laterally: +if pain, apprehension, quad contraction
  • J sign
    • excessive lateral patellar shift in terminal extension (up and out)
  • McMurray’s test- meniscus
    • leg lifted w/ knee at 90 degree angle then…knee out/foot in to knee in/foot out
    • try to catch popping or catching
  • anterior drawer/Lachman’s test- ACL
    • ACL prevents anterior translation of tibia and posterior translation of femur
  • posterior drawer/posterior sag sign- PCL
  • valgus stress test- tests MCL
    • knee pressed in, ankle pressed out
  • varus stress test- tests LCL
    • knee pressed out, ankle pressed in
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74
Q

swelling, redness, pain decreased ROM, +/- atrophy in knee

  • s/s, tests, dx
A

bursitis

  • s/s
    • pre-patellar- inflamed (trauma related) or septic
    • pes anserine- early medial compartment OA
    • overuse, injury, break in skin
  • tx
    • aspirate to r/o infection
    • NSAIDs, activity modification, compression
    • surgery rarely to resect (normally resolves on own)
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75
Q

anterior knee pain w/ running, jumping, kicking

A

tendinitis

  • quadriceps tendon- above patella
  • patellar tendon- “jumper’s knee”, inferior patella
  • s/s
    • TTP on bony prominences/tendon
    • pain w/ resisted knee extension
    • full ROM
    • +/- swelling
  • tests
    • plain films
  • tx
    • RICE, NSAIDs, activity modification, PT (hamstring stretches), knee strap/sleeve
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76
Q

knee effusion (giving off liquid), palpable defect, can’t extend leg against gravity when seated or straight leg raise when lying

  • s/s, tests, dx
A

tendon ruptures (quad, patella fracture, patellar)

  • s/s
    • fall on partially flexed knee
    • pain, swelling, inability to ambulate
    • discoloration
  • tests
    • plain films to r/o fracture
    • MRI
  • tx
    • surgery
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77
Q

diffuse anterior knee pain, worse after long sitting, stairs, jump/squat, catching or grinding behind patella

  • s/s, tests, dx
A

patellofemoral syndrome

  • s/s
    • overuse of overloading of joint
    • worse w/ activities the load front of joint
    • chondromalacia- pathologic changes of articular cartilage (softening of cartilage)
    • observe alignment while weight bearing- foot pronation, femoral anteversion, genu valgum, vastus medialis oblique atrophy
  • tests
    • Q-angle, J sign, patellar apprehension sign
    • assess hamstring tightness and quad strength- weak quads put more sheer force across patellofemoral joint
    • plain films
  • tx
    • activity modification, NSAIDs, bracing
    • PT- flexibility and strengthening
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78
Q

severe knee pain, inability to ambulate, patella lateral

  • s/s, tests, dx
A

lateral patellofemoral instability

  • s/s
    • direct contact or sudden change in position
    • usually spontaneously relocates
    • deformity, swelling
  • tests
      • apprehension sign
    • TTP medial patella
    • plain films
    • MRI to r/o soft tissue damage
  • tx
    • conservative
      • RICE
      • +/- aspiration
      • braced in extension
      • NSAIDs, pain meds
      • PT- quad strengthening, flexibility
    • surgery
      • if recurrent dislocation or conservative failure
      • MPFL repair
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79
Q

intermittent pain in knee w/ catching, locking, popping, giving out that can come and go

  • s/s, tests, dx
A

meniscus tears

  • s/s
    • acute w/ twisting, squatting, change in position
    • swelling
    • joint effusion and joint line tenderness
    • decreased ROM- EMERGENCY IF CANNOT EXTEND
    • +/- quad atrophy (quad shuts down w/ knee injury)
    • +/- locked knee
  • tests
      • McMurray test
    • plain films- weight bearing
    • MRI
  • tx
    • conservative
      • RICE, pain control, PT
    • surgery
      • meniscectomy vs. meniscal repair
      • inner cut out (no circulation) while outer stitched
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80
Q

excessive joint fluid tracts to popliteal bursa

  • s/s, tests, dx
A

baker’s cyst

  • s/s
    • most common cyst in knee
    • associated w/ degenerative meniscal tears
    • popliteal swelling/fullness and pain
    • calf pain and swelling if ruptures (may think DVT)
  • tests
    • plain films
    • MRI other pathlology suspected
  • tx
    • conservative
    • rarely surgery for fear of transecting popliteal nerve
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81
Q

knee pain, immediate joint effusion, instability, decreased ROM, hemearthrosis - deceleration, hyperextension

  • s/s, tests, dx
A

ACL tear

  • s/s
    • effusion
    • decreased muscle strength
    • antalgic gait
    • +/- “pop”
  • tests
    • +Lachman’s exam
    • pivot shift test
    • anterior drawer
    • plain films, MRI
  • tx
    • RICE, ROM
    • surgical reconstruction if younger, active (need full ROM before surgery)
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82
Q

force to anterior tibia w/ flexed knee

  • s/s, tests, dx
A

PCL tear

  • s/s
    • pain, joint effusion, +/- instability
    • decreased ROM
  • tests
      • posterior drawer test
    • posterior sag
    • x-ray/MRI
  • tx
    • depends upon degree of instability
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83
Q

valgus or varus grade I / II / III

evaluated and 0 and 30 degrees extension (more play at 30 deg)

  • s/s, tests, dx
A

collateral ligament sprain

  • s/s
    • pain, swelling, stiffness, +/- instability or mechanical symptoms
    • TTP over ligament/attachment
  • tests
    • plain films, MRI
  • tx
    • MCL- conservative if isolated or grade 1-3
    • LCL- conservative grade 1-2, surgical grade 3
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84
Q

pain, mechanical symptoms, creptius in knee, +/- effusion

  • s/s, tests, dx
A

chondral/osteochondral defect (OCD)

  • s/s
    • direct trauma, articular cartilage injuries
  • tests
    • plain films to check for loose bodies, MRI
  • tx
    • conservative
    • surgical
      • microfracture- punch holes in bone
      • OATS- punches of outer articular cartilage place on points of greater weigth bearing
      • autologous chondrocyte implantation
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85
Q

Foot and Ankle Exam

A
  • inspection
    • gait analysis, hindfoot analysis
  • palpation
    • anterior joint line, malleoli, sinus tarsi, achilles tendon, metatarsals, peroneal tendons, posterior tibial tendon
  • ROM
  • manual muscle testing
  • special tests
    • anterior drawer test
      • draw foot anteriorly
    • Thompson test
      • feet hanging off bed, calf squeezed, foot should move if achilles intact, torn if no movement
    • inversion stress test
      • foot inverted while holding ankle
    • eversion stress test
      • foot everted while holding ankle
    • interdigitation neuroma test
      • foot squeeze test
      • web space compression tenderness test
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86
Q

pain, swelling, ecchymosis in ankle w/ inversion or eversion

  • s/s, tests, dx
A

ankel sprain

  • s/s
    • inversion: anterior/posterior talofibular lig, calcaneofibular lig, tibiofubular lig, subtalar lig
    • eversion: deltoid lig
    • TTP
    • palpate/assess 5th MT ALWAYS- don’t miss Jones fx
    • palpate/assess achilles tendon ALWAYS
  • tests
    • anterior drawer
    • squeeze test
    • external rotation test
    • x-ray, MRI, MR arthrogram (looking for uniformity around talus)
  • tx
    • goal: prevent chronic instability and pain
    • conservative- rehab
    • surgical- rare
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87
Q

sudden/severe pain near heel, “someone kicked me in the ankle”

  • s/s, tests, dx
A

achilles tendon rupture

  • s/s
    • swelling, ecchymosis, difficulty ambulating
    • palpable tendon defect
  • tests
    • Thompson’s test (most reliable w/in 48 hrs)
    • plain films, ?MRI
  • tx
    • non-surgical: serial casting
    • surgical
      • tendon retraction- based on activity level, age, risk
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88
Q

vague paresthesis of plantar foot, compression of tibial nerve

  • s/s, tests, dx
A

tarsal tunnel syndrome

  • s/s
    • worse after walking/exercise
    • relieved w/ rest
    • night pain
    • TTP over tarsal tunnel (posterior to medial malleolus)
    • decreased sensation
  • tests
      • Tinel sign
    • plain films
    • MRI to r/o other patho/space occupying lesions
    • EMG/NCS not accurate at ankle and below
  • tx
    • conservative
      • injection, orthotics
    • surgical- poor outcomes
89
Q

insideous onset heel/foot pain w/ worse “start up pain”

  • s/s, tests, dx
A

plantar fasciitis

  • s/s
    • increased pain w/ standing and walking
    • TTP medial calcaneal tuberosity
    • toe dorsiflexion increases pain
  • tests
    • plain films
    • entheseophyte- heel spur (but not source of pain)
  • tx
    • conservative
      • orthotics, night splint, PT, NSAIDs, injections, acupuncture
    • rarely surgical
90
Q

posterior tibial tendon dysfunction

  • s/s, tests, dx
A

pes planus - flat foot

  • s/s
    • classic presentation- mid 50, female, overweight
    • RF: corticosteroid injections, DM, HTN, prev foot injuries
    • insidious onset pain and swelling in media ankle
    • ankle rolls and lost arch
    • sinus tarsi pain
    • hindfoot valgus- “too many toes”
    • unable to toe raise
  • tests
    • plain films, ?MRI - thickening of tendon
  • tx
    • conservative
      • casting, orthotics, PT
    • surgical
      • tendon transfer / osteotomy
91
Q

forefoot pain

  • s/s, tests, dx
A

metatarsalgia

  • s/s
    • abnormal metatarsal lengths, toe deformities: claw/hammer
    • pain w/ activity
    • callus formation- intractable plantar keratosis
    • pain, swelling, MTP joint stability
    • digital nerve function
  • ddx
    • plantar wart: anywhere on sole, punctate hemorrhage, fibrillated texture
  • tests
    • plain films
  • tx
    • conservative
      • metatarsal pad, removal of callus, orthotics, PT, shoe wear
    • surgical
      • realign toes and/or metatarsal heads
92
Q

perineural fibrosis of common digital nerve

  • s/s, tests, dx
A

interdigital (Morton) neuroma

  • s/s
    • 3rd-4th toe webspace
    • plantar forefoot pain
    • dysesthesias of 2 affected toes
    • rarely at night
    • “feels like walking on marble”
  • tests
      • squeeze test
    • assess MTs
    • sensory exam (ANYTIME a nerve is involved)
    • plain films, MRI/US to r/o other causes
  • tx
    • conservative
      • metatarsal pad, shoe change, corticosteroid injection
    • surgical
      • excision
93
Q

lateral deviation of great toe at MTP joint

  • s/s, tests, dx
A

hallux valgus (“bunion”)

  • s/s
    • pain, swelling, numbness or tingling
  • tests
    • plain films
  • tx
    • conservative
      • shoe wear, orthotics, PT- biomechanical evaluation
    • surgery
94
Q

1st MTP joint sprain

  • s/s, tests, dx
A

turf toe

  • s/s
    • pain, swelling, ecchymosis
    • +/- ligamentous
    • common in athletes
    • hyperextension of MTP
  • tests
    • plain films
    • MRI to r/o other causes
  • tx
    • conservative
      • orthotic devices, stiff soled shoes
    • surgical (rare)
      • only if displaced intra-articular or avulsion fracture
95
Q

Toe Deformities

A
  • hammer toe
    • PIP flexion deformity (no DIP or MTP deformities)
  • claw toe
    • MTP extension w/ PIP flexion
  • mallet toe
    • DIP flextion
  • s/s
    • swelling, pain, deformity, shoe calluses
  • tests
    • evaluate sensory and motor of lower extremity
  • tx
    • conservative
      • shoe wear, splints
    • surgical
      • fix deformities
96
Q

brachial plexus innervations

A
97
Q

lumbar plexus innervations

A
100
Q

cervical spine test

A

spurling test

  • narrows neural foramen
  • increases/reproduces redicular symptoms
101
Q
  • pain
    • base of skull to thoracic region
    • SCM / trapezious muscles
    • < ROM
  • headache
  • sleep disturbances
  • fatigue
  • difficulty concentrating
  • +/- radicular symptoms
    • pain, numbness, tingling
A

cervical sprain / strain

  • PE
    • +/- swelling, tenderness, limited ROM
    • neurologic exam usually normal
  • tests
    • x-rays
  • Tx
    • meds: NSAIDs, pain meds, muscle relaxers, steroids
    • +/- cervical collar or neck roll
    • massage, stretching, PT
    • DISCUSS tx options (time off, rest, ice/heat, chiro)
    • self limited (4-6w)
    • whiplash (6-12m)
102
Q

lumbar spine tests

A
  • straight-leg raise
    • check for herniated disk
    • pain w/ lifting asymtomatic leg
  • seated straight leg raise
    • creates sciatic tension
    • patient will lean back to reduce pain (+)
  • _​_FABER test
    • flexion-abduction-external rotation (figure 4 postion)
    • hip and SI joint pathology
103
Q

tests for “non-organic” pain

A

Waddell signs

  • non-organic tenderness
  • axial simulation/torso rotation
  • seated straight-leg raise
  • sensory examination
104
Q

neural foramen narrowing, disc herniation, bone spur

  • limited mobility
  • chronic neck pain - worse w/ upright activity
  • paraspinous muscle spasm
  • headaches
  • radicular symptoms
  • interference w/ ADLs
  • myelopathy symptoms

PE, tests, Tx

A

cervical spondylosis

  • PE
    • tenderness, decreased ROM w/ pain, gait/sensory analysis
  • tests
    • Spurling, Babinski, Brudzinski-Kernig, ankle clonus
    • x-ray, MRI, CT myelogram
  • Tx
    • degeneration will continue w/ time
    • conservative vs. surgical
      • decompression and fusion
105
Q
  • LBP
  • radicular pain to buttocks/posterior thigh
  • difficulty ambulating, sleeping, finding comfortable position
  • bowel or bladder dysfunction (S2-S4)
  • saddle anesthesia
  • weakness in lower exremeties

PE, tests, Tx

A

cauda equina syndrome

(compression of n. roots distal to conus medullaris)

  • PE
    • unable to heel toe walk
    • anal sphincter tone
  • tests
    • MRI, CT myelogram
  • Tx
    • IMMEDIATE decompression surgery
107
Q

neurogenic pain in nerve roots

  • +/- associated numbness, weakness, loss of reflexes
  • neck and radiating pain w/ numbness and tingling
  • muscle spasms
  • muscle weakness
  • headaches
  • relief when hand raised over head
A

cervical rediculopathy

  • can be caused by disc herniation or degenerative changes
108
Q
  • abrupt vs. insidious
  • LBP w/ unilateral radicular leg pain
  • exacerbated w/ walking, sitting, standing, coughing
  • radiates from buttocks to foot or follows dermatome to anterior aspect of thigh not past knee

PE, tests, Tx

A

lumbar herniated disk

  • PE
    • list/trunk shift
    • sciatica
      • seated asymptomatic leg raise (specific to herniated disk)
  • tests
    • plain films - degenerative changes
    • MRI if neurologic changes/intolerable pain
  • Tx
    • conservative
      • NSAIDs, rest, PT
      • epidural steroid injections
      • manipulative therapy, traction, acupuncture
    • surgical
      • microdiscectomy, laminectomy
109
Q

neurological deficit d/t compression of spinal cord

  • gradual onset
  • long-tract signs
    • palmar parathesia
    • decreased finger dexterity
    • subtle gait disturbances
    • abnormal urinary function
    • lack of pain
    • loss of vibration/position sense

tests, PE, Tx

A

myelopathy

  • tests
    • Babinski sign
    • Brudzinski-Kernig test (head lift - leg lift/abduct)
    • ankle clonus (foot dorsiflex)
    • x-ray, MRI, CT myelogram, EMG/NCS (neuropathy vs compression)
  • PE
    • TTP, decreased ROM, decreased lordosis, +/- Spurling
    • shoulder pain does not radiate past elbow (cervical)
  • Tx
    • delayed leads to paralysis, weakness, chronic pain
    • conservative
      • spontaneous resolution in 2-8w
      • NSAIDs
      • cervical traction
      • NO SPINAL MANIPULATION (no chiropractor)
112
Q

general low back or SI joint tenderness

  • doesn’t radiate past the knee

PE, tests, Tx

A

lumbar sprain/strain

  • PE
    • decreased ROM, motor/sensory exam (L4-S1), special tests to r/o other structures
  • tests
    • +/- plain films
    • MRI not indicated
  • Tx
    • conservative
      • pain control, PT/HEP, pt education
      • provide options for shared decision
      • get them back to work
113
Q

LBP > 90 days (3m)

  • LBP radiating to 1 or both buttocks
  • worse w/ bending, lifting, stooping, twisting
  • stiffness
  • intermittent pain down leg
    • relief w/ lying

PE, tests, Tx

A

chronic low back pain

  • PE
    • TTP lumbar and/or SI joint, decreased ROM, normal motor/sensory exam, positive SLR
  • tests
    • plain films (look for degenerative changes)
    • MRI (evaluate structural changes)
  • Tx
    • pt education
    • pain management (watch narco abuse)
      • psychological testing
      • injections
      • biofeedback
      • cognitive/behavior conditioning
      • psychotherapy
      • detoxification programs
115
Q

4 cervical vetabrae fractures

PE, tests, Tx

A
  • Jefferson fracture / C1 burst fracture
  • Hangman’s fracture (C2 pedicles)
  • Clay-shoveler’s fracture
    • C7 > C6 > T1
  • Avulsion fracture
  • PE
    • MOI specific: severe neck/back pain, paraspinous muscle spasm, bony tenderness, +/- neurologic
  • tests
    • plain images: AP, lateral, odontoid
  • Tx
    • immobilization
    • Methylprednisone 30mg/kg bolus, then 5.4mg/kg/h drip 23h
    • conservative vs. surgical intervention
116
Q

neurogenic claudication

  • fatigue and weakness from proximal to distal
  • sitting or lying relieves pain
  • narrowing of lumbar spine w/ nerve root compression
  • order of commonality: L3/4 -> L4/5 -> L2/3

PE, tests, Tx

A

spinal stenosis

  • PE
    • +/- proprioception, reflexes, urine/bowel (spincter tone rarely affected)
  • tests
    • Romberg test (balance lost w/ eyes closed)
    • x-rays to T10
    • MRI
    • EMG/NCS
  • Tx
    • conservative
      • pain control, PT, water therapy, body mechanics
    • surgical
      • quality of life
      • decompression and spinal fusion
117
Q

lumbar fracture

A
118
Q
  • stabbing, knife-like pain in buttocks/posterior leg(s)
  • worse w/ prolonged sitting, twisting, rotating
  • trauma, leg-length inequality, tight iliopsoas, scoliosis, hip OA, pregnancy

PE, tests, Tx

A

SI joint dysfunction

  • PE
    • TTP
    • normal motor/sensory findings
  • tests
    • FABER test
    • compression test (push on ASIS and rock patient)
    • plain films
    • CT scan
  • Tx
    • conservative
119
Q

tailbone pain

  • pain w/ sitting, BM, sexual intercourse

PE, tests, Tx

A

coccydynia

  • PE
    • TTP rectally
    • GI/gynocological exams
  • tests
    • plain films
    • MRI to r/o other
  • Tx
    • conservative
      • PT, change activity, nerve block, 6m-1y recovery
    • surgical
      • coccygectomy
120
Q

pars interarticularis defect / forward translation of vertebrae

  • repetetive hyperextension
  • back pain w/ movement
  • radiculopathy

PE, tests, Tx

A

spondylolysis / spondylolisthesis

  • PE
    • loss or lordosis
    • decreased strength after walking
      • SLR
  • tests
    • x-ray
  • Tx
    • conservative
      • weight loss
    • surgical
      • stabilize defect if skeletally immature
121
Q

lateral curvature in spine

  • +/- pain
  • radiculopathy (L4/5 common)
  • extensor hallicis longus weakening
  • getting shorter/developing hump
  • cardiopulmonary decompensation rarely

PE, tests, Tx

A

scoliosis

  • PE
    • neuro exam for reflexes, motor, sensory function
    • gain analysis
  • tests
    • full-length PA and lateral films
    • EMG (radiculopathy vs. neuropathy)
  • Tx
    • skeletally immature
      • observation, bracing (25-45 deg), fusion (>45 deg)
      • Milwaukee or Boston brace
    • mature
      • conservative tx, surgical if curve >50-60 deg
122
Q
  • back pain w/ weight bearing activities relieved by rest
  • pain a night
  • +/- constitutional symptoms (weight loss, fever, decreased appetite, night sweats, fatigue)

PE, tests, Tx

A

metastatic disease

  • PE
    • inspect for deformity
    • TTP
    • neuro exam
  • tests
    • AP/lateral plain films
    • bone scan to ID other areas of mets
  • Tx
    • dependent on tumor
    • decompression and stabilization w/ postop radiation
124
Q

these spinal fracture uccur mostly d/t osteoporosis/weakening

A

thoracic vertebral fractures

126
Q

vertebral fracture goal, type, tx

A
  • goal - prevent neurologic injury, restore stability/normal fx
  • types
    • avulsion
    • compression
    • fracture/dislocation
  • tx
    • spinal fusion
    • cervical
      • soft collar, Philadelphia collar, rigid orthosis, halo
    • thoracic
      • corset, 3-point orthosis, clamshell
    • lumbar
      • elastic belt, corset, rigid orthosis
127
Q

crystal deposition disease characteristics & 2 types

A
  • sudden onset of severe joint pain and swelling
  • usually 1 joint
  • crystals found in synovium, cartilage, surrounding tissue
  • types
    • gout - monosodium urate crystals (MSU)
    • calcium pyrophosphate dehydrate crystals (CPPD)
      • pseudogout - synovitis
      • chondrocalcinosis - deposits in soft tissue
128
Q

disease / 4 phases / causes

  • urate saturation in blood/body fluids
  • hypertension, metabolic syndrome, obesity
  • thiazide diuretics / low dose ASA
  • diet:
    • high purine: organ meat, select seafood
    • high-fructose corn syrup
    • excessive alcohol: beer/distilled liquors
    • protective:
      • Vit C, coffee, cherries
A

hyperuricemia

  • phases
  1. asymptomatic (>7mg/dL)
  2. acute gouty flare
  3. intercritical gout (intervals between attacks)
  4. chronic tophaceous gout
  • causes
    • underexcretion (90%)
      • kidney, HTN, obesity, lead, drugs
    • overproduction
      • diet, obesity, psoriasis, nicotinic acid (B3)
129
Q

gout

s/s, test, tx

A
  • s/s
    • sudden onset, cardinal signs inflammation, +/- constitutional
    • 1st metatarsophalangeal joint (Podagra), ankle, midfoot, knee
    • subcutaneous tophus: fingers, wrists, ears, olecranon bursa, achilles tendon
  • tests
    • synovial fluid analysis: crystal negative birefringement
    • rod-shaped crystals
    • +/- serum urate level
    • x-ray (r/o fracture), US to look for crystals
  • Tx
    • lifestyle modifications
    • acute: RICE, NSAIDs, Colchicine, corticosteroids
    • meds
      • xanthine oxidase inhibitor (overproduce/underexcr)
        • Allopurinol 100mg PO daily
        • Febuxostat 40mg po daily
      • increase renal excretion (underexcr)
        • Probenecid 250mg po daily
      • Pegloticase 8mg IV q2w (warn: anaphylaxis, $$$)
130
Q

calcium phyrophosphate dihydrate crystal deposition disease

(CPPD crystal deposition disease)

3 types, s/s, tests, Tx

A
  • types (more common in women, gout in men)
    • pseudogout - acute synovitis
      • knee most common
    • chondrocalcinosis - calcification in hyaline cartilage
      • asymptomatic, incidental finding
    • pyrophosphate arthropathy - OA w/ CPPD
  • tests
    • x-ray
    • synovial fluid analysis
      • postitive bifringement (square crystals)
  • Tx (if symptomatic)
    • RICE, NSAIDs, corticosteroids, +/- Colchicine
131
Q

3 Hydroxyapatite Arthropathy Diseases

  • crystals in joints, tendons, ligaments, bursa
  • identified w/ electron microscopy
  • species of basic calcium phosphate
  • pts tend to be younger
A
  1. calicific tendinitis
    • sudden shoulder pain w/out MOI
    • pain->plateaus->pain when resolving->no pain
    • tx conservative or surgical (usually resolves on own)
  2. Milwaukee shoulder
    • crystals destroy RC and shoulder joint
  3. DISH (diffuse idiopathic skeletal hyperostosis)
    • bridging in cervical spine
132
Q

MSK infection

  • superficial > deep
  • olecranon, prepatellar, infrapatellar, 1st MTP
  • redness, warmth, swelling
  • typically no ROM restriction (if joint infection, pt will not move)

PE, tests, Tx

A

septic bursitis

  • PE
    • aspirate to r/o infection
      • acute: S. aureus, B hemolytic strep, psuedomonas
      • chronic (think systemic): B abortus, M. tuberculosis
  • tests
    • x-ray to r/o other, look for foreign body
  • Tx
    • outpatient
      • PCN or 1st gen cephalosporin
      • tri/sulfa (Bactrim) if MRSA
      • Clindamycin or Linezolid if PCN allergy
    • inpatient
      • Nafcillin, oxacillin, cefazolin IV
      • Vanco, daptomycin, linezolid if MRSA
133
Q

MSK infection

  • very painful, red, swollen, hot joint (knee typical)
  • decreased ROM
  • +/- fever
  • IV drug use (SC or SI joint), diabetes, alcohol, immuno
  • UTIs / indwelling catheters
  • injury

PE, tests, Tx

A

septic arthiritis (infection to joint)

  • PE
  • tests
    • x-rays: ususally normal, soft tissue swelling
      • radiolucent lines if prosthetic infection
    • MRIs
      • identify osteomyelitis
    • bone scan for associated osteomyelitis
    • labs
      • synovial fluid analysis
        • WBC > 50,000, low glucose, high protein
      • ESR & CRP
    • cervical/urethral cultures if +gonococcal
  • Tx
    • surgery
    • IV antibiotics (4-6w)
134
Q

infection of the bone

PE, tests, Tx

A

osteomyelitis

  • PE
    • trauma, surgery, immuno, systemic disease
    • localized bone pain
    • +/- sinus tract, swelling, abscess, constitutional
  • tests
    • biopsy/culture of affected area (GOLD standard)
    • CBC - leukocytosis
    • elevated CRP/Sed rate
    • plain films
    • MRI - marrow changes
    • CT - early cortical erosions
    • bone scan (highly sensitive, low specificity)
  • Tx
    • debridement and excision of infected bone
      • abx spacer
    • IV abx
    • Abx impregnated methylmethacrylate beads
135
Q
  • loss of articular cartilage (trauma, obesity)
  • extra-articular organs not affected
  • pain affecting sleeping
  • stiffness lasting <30 min (worse w/ inactivity)
  • swelling
  • joint instability
  • locking and grinding

PE, tests, Tx

A

osteoarthritis

  • PE
    • joint effusion, crepitus, antalgic gait, decreased ROM, muscle atrophy
    • +/- deformity
      • knees: genu varum (bow) vs. valgum (knock)
      • hands:
        • Bourchard nodes (PIP)
        • Heberden nodes (DIP)
  • tests
    • x-ray: joint space narrowing, osteophytes, sclerosis
    • MRI: r/o other sources of pain (not routinely used in OA)
    • no US
    • no specific labs
  • Tx
    • conservative as long as possible
      • RICE, bracing, corticosteroid injections
      • meds
        • NSAIDs, tramadol, glucosamine/chondroitin
        • NO opiates
      • PT
      • patient education- activity, occupation, weight loss
      • CAM: accupuncture, Tai Chi, supplements
    • surgical
      • NO arthroscopy
      • joint replacement
136
Q

autoimmune attack of synovial tissue/joints

  • genetics (+ family history)
  • female
  • age, smoking, coffee 3+/day

PE, tests, Tx

A

rheumatoid arthritis

  • PE
    • symmetric polyarthritis, deformities
    • morning stiffness
    • isidious onset w/ distal joints first - MCP, PIP (spares DIPs, toe IPs)
    • swelling, tenderness, fever, malaise, weakness
    • nodules anywhere
    • improves with pregnancy then flares after
    • C1-C2 articulation can affect surgery
    • swan-neck; boutonniere deformity; hammer toes
    • Felty’s syndrome: RA, splenomegaly, neutropenia
  • tests
    • Rheumatoid factor
    • anti-CCP (anti-cyclic citrulinated peptide antibody)
  • Tx
    • lifelong - no cure, just management/remission
    • NSAIDs, low-dose prednisone, steroid injections
    • disease modifying antirheumatic drugs (target inflammation/antibodies)
      • Sulfasalazine, hydryoxychloroquine
      • Methotrexate/Leflunamide
      • Cyclophosphamide
    • anti-TNF drugs
      • inflixamab, entanercept
      • adalimumab, golimamab
    • surgery - joint replacement
137
Q

RA scoring system

A
138
Q

4 phases of fracture healing

A
  1. cellular callus
    • mesenchymoid cell proliferation
  2. mineralized callus
    • collagen to cartilage
  3. bony callus
    • lamellar bone replaces mineralized callus
  4. remodeling
140
Q

fracture complications

A
  • acute respiratory distress syndrome (ARDS)
    • fat embolism to lungs
  • atelectasis (partial or complete collapse of lung)
  • DVT, PE
  • compartment syndrome (5 P’s)
  • nerve/blood vessel injury
  • failure of normal healing
141
Q

5 P’s of compartment syndrome

A
  1. pain out of proportion
  2. paresthesia
  3. pallor
  4. paralysis
  5. pulselessness
142
Q

fracture description

A
  • bone side and name, position
    • proximal, mid, distal
    • line: transverse, spiral, oblique
  • type of fracture
    • open (no skin break) / closed (bone protruding)
    • complete / incomplete
      • greenstick, buckle (Torus) - “squished can”
    • simple / comminuted (w/ or w/out butterfly fragment)
  • angulation (bent- change in anatomical position)
    • direction apex is pointing, location of distal fragment
    • ex.: angulated 45 deg apex dorsal
  • displacement (distance apart)
    • anterior, posterior, lateral, medial
    • 100% = no contact at fracture site
  • other:
    • distraction- amount of separation
    • shortening- overriding, impacted
    • # of pieces
    • fragments
    • joint disruption- intra-articular
    • % subluxation- dislocation laterally, medially…
143
Q

Mechanism, Presentation, Dx, Tx

A

clavical fracture

  • mechanism
    • direct blow, fall on outstretched arm
  • presentation
    • pain, deformity, grinding at fx site, sagging shoulder
    • CHECK SKIN for necrosis
  • tx
    • based on displacement
    • conservative
      • immobilize: sling, brace 4-6w
    • surgery
      • ORIF: open reduction w/ internal fixation
      • IM nail (intermedulary)
144
Q

Mechanism, Presentation, Dx, Tx

*what nerve affected

A

proximal humerus fracture

(axillary nerve)

  • high energy injury: fall, MVA
  • Neer classification: 2, 3, 4-part (head, shaft, greater/lesser tuberosity)
  • tx
    • conservative: sling 6w, passive ROM after 3w
    • surgery
      • ORIF
        • hemiarthroplasty
145
Q

Mechanism, Presentation, Dx, Tx

*what nerve affected

A

humeral shaft fracture

(radial nerve)

  • mechanism: trauma, fall
  • tx
    • varies by severity
    • malunion common
146
Q

Mechanism, Presentation, Dx, Tx

*artery injury to watch

A

supracondylar fracture

(brachial artery)

  • mechanism: fall w/ elbow extended
  • tx
    • surgery
147
Q

Mechanism, Presentation, Dx, Tx

A

epicondyle/condylar fractures

(medial/lateral condyle)

  • mechanism
    • fall on outstreatched arm (valgus/varus force)
  • tx
    • conservative
      • rest, splint, delayed, ROM
    • surgical
      • percutaneous pinning
      • ORIF
148
Q

Mechanism, Presentation, Dx, Tx

A

radial head/neck fracture

  • mechanism
    • fall w/ elbow extended
    • most common elbow fx in adults
  • tx
    • long arm splint 2-3w (must go beyond wrist)
    • rarely surgery
    • DO NOT immobilize too long
    • PT
149
Q

Mechanism, Presentation, Dx, Tx

A

olecranon fracture

  • mechanism
    • fall onto posterior elbow
    • active tricep avulsion
  • tx
    • displacement & triceps guide treatment
150
Q

Mechanism, Presentation, Dx, Tx

A

MUGR “gruesome murder”

  • Galeazzi
    • radial fracture w/ distal radioulnar joint dislocation
    • fall on outstreatched arm w/ elbow flexed
    • surgical fixation
  • Monteggia
    • ulnar fracture w/ radial head dislocation
    • fall on outstretched arm
    • surgery
151
Q

Mechanism, Presentation, Dx, Tx

A

radial shaft fracture

  • mechanism
    • high energy injury, MVA
    • usually w/ ulnar fracture/dislocation
  • tx
    • surgery
152
Q

Mechanism, Presentation, Dx, Tx

A

ulnar shaft fracture

  • mechanism
    • usually direct blow
  • tx
    • spint
    • rarely surgery
153
Q

Mechanism, Presentation, Dx, Tx

A

distal radius fracture

  • mechanism
    • Colles: low energy FOOSH
    • Smith: fall on flexed wristh (reverse Colles)
    • most common fx of upper extremity
  • presentation
    • deformity, swelling, ecchymosis
    • tenderness over fracture site
  • tx
    • buckle/minimal displacement - immobilize
    • colles/smith/angulation/displacement - reduction or surgery (6w: 2 splint, 4 cast)
154
Q

Mechanism, Presentation, Dx, Tx

A

chauffeur fracture (radial styloid fracture)

  • mechanism
    • direct blow to back of wrist
    • forced ulnar deviation and supination
  • tx
    • surgery
155
Q

Mechanism, Presentation, Dx, Tx

A

scaphoid fracture

  • mechanism
    • FOOSH
    • often misdiagnosed as sprain
    • “snuff box pain”
    • most common carpal fx
  • tx
    • when in doubt- tx as fx: thumb SPICA splint
    • splint 12w
    • surgery rarely
156
Q

Mechanism, Presentation, Dx, Tx

A

metacarpal fracture - boxer’s fracture

  • mechanism
    • hitting object with closed fist
    • neck, shaft, or base fx
    • 5th metacarpal neck most common
  • presentation
    • pain, swelling, rotational deformity, depressed knuckle
    • CHECK for open wounds
  • tx
    • acceptable angulation: 10-20-30-40 rule from 1st digit
    • rotational deformity NOT acceptable
    • conservative
      • ulnar gutter splint/cast
      • 4-6w immobilization
    • referral
      • unstable fractures/rotational deformity
      • closed reduction vs. surgeryd
157
Q

1st metacarpal fractures

A

fracture at base of 1st metacarpal

  • ​types:
    • Bennett fracture: intra-articular avulsion fx - CMC joint
      • sublux/dislocation
    • Rolando fracture: “Y” or “T” shaped comminuted, intra-articular fx
      • same mechanism, less commom
158
Q

failures of healing

A
  • malunion
    • incomplete or faulty healing that affects function
  • delayed union
    • slower than normal healing
  • non-union
    • lack of bony reconstituion - bone remains at callus stage
159
Q

Mechanism, Presentation, Dx, Tx

A

phalange fractures

  • mechanism
    • most common MSK injury
  • presentation
    • pain, swelling, deformity
    • CHECK open wounds, nail bed injury - ortho referral
  • tx
    • budding taping
    • surgery: angulation, displacement, open fracture
    • complications:
      • loss of motion, malunion, nonunion
160
Q

Mechanism, Presentation, Dx, Tx

A

pelvic fracture

  • mechanism
    • high energy, MVAs
  • presentation
    • check for GU injuries: bladder, prostate
    • fall - unable to bear weight
    • leg shortened and externally rotated
  • tx
    • stabilize
    • most need surgery
161
Q

3 hip fracture types

A
  1. femoral neck
    • types:
      • subcapital, transcervical, basicervical
      • intracapsular
        • blood flow to femoral head disrupted
    • tx
      • femoral neck w/ no/minimal displacement - pinning
      • w/ displacement - arthroplasty (replacement)
  2. intertrochanteric
    • tx
      • intramedullary nail/gamma nail
      • dynamic hip screw (DHS)
  3. subtrochanteric
    • tx: screws
162
Q

Mechanism, Presentation, Dx, Tx

A

femur shaft fracture

  • mechanism
    • high energy, MVA
  • tx
    • nonsurgical
      • non-displaced or multiple comorbidities
    • surgical
      • displaced/unstable
163
Q

Mechanism, Presentation, Dx, Tx

A

supracondylar fracture

  • mechanism
    • load to flexed knee
  • presentation
    • assess popliteal artery, ACL
    • pain, swelling, inability to flex/extend knee, +/- deformity
  • tx
    • conservative vs. surgical
164
Q

Mechanism, Presentation, Dx, Tx

A

tibial plateau fracture

  • mechanism
    • extreme load or fall
    • 60% lateral
  • tx
    • non-operative
      • nwb w/ close follow-up
    • surgery
      • cannulated screw fixation or plate/screw, NWB
165
Q

Mechanism, Presentation, Dx, Tx

A

patella fracture

  • mechanism
    • direct trauma
    • forceful quadriceps contraction
  • presentation
    • deformity, swelling, can’t SLR
  • tx
    • non-operative:
      • nwb 6w, gradually increase PROM
    • surgery if displacement >3mm
166
Q

Mechanism, Presentation, Dx, Tx

A

tibial shaft fracture

  • mechanism
    • high energy, often open, twisting mechanism
    • most common long bone fracture
  • presentation
    • pain, deformity, wounds, fracture blisters
    • compartment syndrome - 5 P’s, fasciotomy
    • assess n/v status
  • tx
    • conservative - LLC w/ progressive weight bearing
    • surgical
      • unstable, open fracture
      • presentation after reduction
      • IM nail
168
Q

Mechanism, Presentation, Dx, Tx

A

Maisonneuve fracture

  • mechanism
    • eversion injury - Mortise widening
    • proximal 1/3 fibula fracture
    • w/ fibular neck - think peroneal nerve palsy
  • tx
    • surgery
      • ORIF
169
Q

Mechanism, Presentation, Dx, Tx

A

ankle fracture

  • mechanism
    • twisting (inversion/eversion), MVA
    • most common bone + joint injury
    • smoking and habitus
  • presentation
    • pain, swelling, deformity, inability to ambulate
  • tx
    • conservative
      • avulsion: treat like ankle sprain
      • posterior splint vs. walking cast vs. walking boot
    • surgical
      • if any mortise widening/suspicion
170
Q

Mechanism, Presentation, Dx, Tx

A

medial malleolus fracture

  • mechanism
    • usually high impact: MVA, fall, tackled
  • considerations:
    • displacement (<2mm in joint acceptable)
    • joint involvement (<25% joint surface acceptable)
    • tenderness elsewhere
  • tx
    • referral
    • non-operative
      • nwb short leg splint vs. wbat short leg cast
171
Q

Dx, Tx

A

bi/tri-malleolar frature

  • unstable, refer for surgery
172
Q

3 types 5th metatarsal fractures

A

Stress, Jones, Avulsion

  • mechanism
    • IMPORTANT: sudden vs. aching over time
    • inversion - Jones
    • eversion - other fracture
  • tx
    • stress - nwb cast 6-8w
    • Jones - surgery vs. short-leg walking cast vs nwb cast 6-8
    • avulsion - most common, short-leg walking cast/boot 4-6
173
Q

Mechanism, Presentation, Dx, Tx

A

stress fractures

  • mechanism
    • overuse
  • presentation
    • insidious pain that progressively gets worse
    • MRI for inflammatory stress
  • tx
    • eliminate the stress - REST
    • nwb 6-12w, immobilize, PT, pain control
174
Q

Physeal Fractures Typing

(pediatric/growth plate)

A

SALTER

  • Type I: S- straight across
  • Type II: A- above
  • Type III: L- lower
  • Type IV: T- through/transverse
  • Type V: R- ruined (cRushed)
190
Q

metacarpal fracture complications

A
  • loss of grip strength
  • residual dorsal deformity
  • loss of knuckle prominence
199
Q

Mechanism, Presentation, Dx, Tx

(fibula fracture - no pic)

A

fibula fracture

  • mechanism
    • direct blow, inversion/eversion injury
  • presentation
    • limping or uable to bear weight due to pain, edema, ecchymosis
  • tx
    • non-weightbearing
    • dependent on location, ankle stability
200
Q

4 Spondyloarthopathies

share predisposing factors and clinical features

A
  • ankylosing spondylitis
  • reactive athritis
  • psoriatric arthritis
  • enteropathic arthritis
201
Q

Spondylarthropathies Common Features and Tx

A
  • spine/joint pain
  • chronic inflammation -> new bone formation (joint ankyloses)
  • asymetrical peripheral arthritis
  • ocular inflammation (acute anterior uveitis
  • HLA-B27 gene
  • sacroiliitis in imaging
  • Tx
    • pt education
    • exercise
    • NSAIDs, corticosteroids, sulfasalazine, methotrexate, anti-TNF therapy
202
Q
  • most common axial skeleton inflammatory disease
  • white males 15-40
  • LBP >3m: SI joint +/- buttocks
  • early morning stiffness, fatigue
  • asymmetrical polyarthritis
  • entesitis: achilles tendinitis and/or heel pain
  • ocular involvement

PE, tests, Tx

A

Ankylosing Spondylitis

  • PE
    • stooped posture (advanced)
    • chest expansion
  • tests
    • Schober test - measure points on back (lumbar mobility)
    • +/- FABER test (for SI joint)
    • RF/ANA negative
    • HLA-B27
    • x-rays: “bamboo spine”
    • MRI: inflammatory changes
203
Q
  • develops 1-3w after systemic infection (but aseptic)
  • GI (salmonella, ersinia, shigella), GU (chlamydia)
  • LE asymmetrical polyarthritis
  • malaise, fever, fatigue
  • enthesitis: achilles tendon or plantar fasciitis
  • dactylitis: suasage fingers
  • Reiter’s syndrome
    • conjuntivitis, urethritis/cervicitis, arthiritis (“can’t see, can’t pee, can’t climb a tree”)

PE, tests, Tx

A

Reactive Arthritis

  • PE
    • mucocutaneous lesions
    • papulosquamous eruptions on palms and soles
    • diarrhea
  • tests
    • x-rays, MRI
    • HLA-B27
    • synovial fluid analysis to dx septic vs. aseptic
  • Tx
    • NO CURE - self limited
    • NSAIDs
    • +/- intra-articular injection
207
Q
  • papulosquamous disease w/ kertinocyte proliferation
  • asymmetric polyarthritis in large and small joints w/ dactylitis
  • DIP joints w/ nail dystrophy (pitting, oil drop stains)

PE, tests, Tx

A

Psoriatric Arthritis

  • PE
    • spondylitis - inflammation of vertabrae
    • mimics RA but no nodules or RF
  • tests
    • x-rays
  • Tx
    • pain control
    • anti-TNF
208
Q
  • nonerosive, assymtrical polyarthritis - large joints
  • pt has Crohn’s or ulcerative colitis
  • inflammation of joints follow GI inflammation

PE, tests, Tx

A

Enteropathic Arthritis

  • PE
    • lower extremeties- peripheral arthritis not assoc. w/ HLA-B27
    • spondylitis/sacroiliitis- assoc. w/ HLA-B27
  • tests
    • HLA-B27
  • Tx
    • control GI -> controlled joint inflammation
209
Q

autoimmune connective disease - thickening of skin/connetive tissue

3 cardinal processes

A

Scleroderma (systemic sclerosis)

  1. autoimmunity and inflammation
  2. vascular injury and obliteration
    • capillary loss
  3. fibrosis and matrix deposition
    • deposition of connective tissue matrix
210
Q

3 Classifications of Scleroderma

A
  • Systemic
    • Diffuse
      • all over, rapid progression
      • swelling, erythema, pruritis, fatigue, stiffnesss, malaise, Raynaud later
      • early pulmonary fibrosis and acute renal failure
    • Limited
      • peripheral (spares trunk)
      • CREST
        • Calcinosis cutis
        • Raynaud’s:
          • primary cause: cold/stress = episodic vasoconstriction
          • secondary: disease, B-blockers, chemotherapy
        • Esophageal dysmotility (thickening)
        • Sclerdactyly
        • Telangiectasia
  • Mixed Connective Tissue Disorder
    • overlap of SLE, scleroderma, myositis
    • Raynaud w/ hand edema, renal crisis later
    • autoantibody against U1-RNP
  • Localized
    • more common in children
    • Morphea - reddish/purple lesion of skin
    • skin induration (hardening) spares digits, common on LE
    • NO Raynaud, NO systemic involvement
211
Q

Scleroderma Organ Involvement

A
  • skin
    • thickening, symmetrical/bilateral, starts @ fingers and works proximal, masklike facies, hyperpigmentation/vitiligo in dark skinned, calcium deposits
  • GI tract
    • periodontal disease; GERD; stomach-gastroparesis; small intestine-impaired mobility, malabsorption; colon-constipation, rectal prolapse
  • lungs
    • honeycomb x-ray; RF: AA, male, difuse skin, severe GERD, topoisomerase-I antibodies
    • pulmonary HTN; RF: limited cutaneous, late disease onset, many telangiectasias, anticentromere autoantibodies
  • kidneys
    • life threatening; CKD; RF: AA, tendon rubs, RNA plymerase I & II autoantibodies
  • cardiac
    • diffuse disease; tachychardia; conduction abnormalities; regurgitation; diastolic HF; pericardial effusion
  • MSK
    • CTS; decreased joint mobility; tendon friction rubs (rupture)
  • other
    • dry eyes/mouth; hypothyroid; CNS spared
212
Q

Scleroderma Tests, Dx, Tx

A
  • tests
    • labs
      • CBC /w diff - anemia
      • Sed rate/CRP/RA normal
      • Vit deficiencies: folate, B12, D
    • nailfold capillaroscopy
  • Dx
    • skin induration, Raynaud’s, organ manifestations
  • Tx
    • No known regime to alter course
    • immunosuppressants
      • corticosteroids (sparingly in low doses)
      • cyclophosphamide (slow lung disease)
      • methotrexate (for skin manifestations)
    • antifibrotic therapy
      • D-penicillamine (prev. new organ involvement, improved survival)
    • ACE inhibitors (for renal crisis)
    • treat specific organ complications
213
Q

Cells of Bone Remodeling

A
  • osteoblasts - build
  • osteoclasts - break down
  • ostecytes - mature cells
    • secrete and calcifies bone matrix material
    • regulate bone reabsorption and formation
    • release cytokines
      • osteoprotogerin (OPG)
      • receptor activator of nuclear factor kB ligand (RNAKL)
      • regulate osteoclast production and rate of bone reabsorption
214
Q

amount of bone acquired by modeling and remodeling / peak times

A

bone mineral density (BMD)

  • peak bone mass
    • 18-20 - proximal femur
    • 25-30 - spine
    • more loss than formation after this
215
Q

bone physiology vs. pathology

A
217
Q

primary / secondary causes of osteoporosis

A
  • primary (idiopathic)
    • juvenile (8-14 y/o)
    • Stage I
      • post-menopausal women (51-75)
      • trabecular bone loss
      • common fx: vertebral body, distal forearm
    • Stage II (senile)
      • men and women 70+
      • trabecular and cortical bone loss
      • common fx: wrist, vertebra, hip
  • secondary
    • men > women
    • environmental factors
      • nutrition, Ca/Vit D deficiency, inactivity, meds (PPI, chemo), tobacco, alcohol, caffeine, trauma
    • disease
      • RA, cushings, DM, hyperthyroid
218
Q

Who to DEXA Scan

A

DEXA - bone density scan

  • 70+ y/o
  • 50-70 postmenopausal
  • 50-59 w/ wrist fracture
  • 70’s w/ vertebral fracture
  • 50+ w/ hip fracture
219
Q

Osteoporosis S/s, PE, tests, workup

A
  • S/s
    • NO s/s - must screen at risk
  • PE
    • measure height loss: >4cm since young adult max suggests vertebral fx
    • BMI
    • kyphosis: Dowager hump (wedge shaped compression fx)
    • +/- spinal TTP and percussion
  • tests
    • FRAX - fracture risk assessment tool: demographics, prev fx, parent fx, smoking, glucocorticoids, RA, alcohol, DEXA BMD #
  • workup
    • labs to assess secondary causes
    • x-rays to check for fractures
    • duel energy x-ray absorptiometry (DEXA) for bone mineral density
      • T-score: value of control peak BMD
        • within 1 SD = normal
        • -1.0 to -2.5 SD = osteopenia
        • -2.5 SD and below = osteoporosis
        • -2.5 and below + fragility fx = severe/established osteoporosis
      • Z-score: value of age/sex match
        • -2.0 and above = normal
        • -2.0 and below = below expected
      • Repeat testing
        • normal - mild osteopenia: 10-15y
        • moderate osteopenia: 3-5y
        • advanced osteopenia: annually
        • undergoing tx: annual to monitor response
      • Not recommended
        • premenopausal, men < 70, women < 65 w/out risk factors
220
Q

Other Osteoporosis Screening Tests

A
  • QCT-quantitiative CT (spine)
  • pQCT (wrist and tibia)
  • Finger DXA
  • US of calcaneous or wrist
  • 3D CT of bone biopsy microarchitecture
221
Q
  • softening of bone - decreased mineralization between calcified bone and osteoid
  • rickets - defective mineralization of cartilage in epiphyseal growth plate

PE, tests, Tx

A

osteomalacia

  • PE
    • asymtomatic
    • deformity over time
    • muscle weakness
    • fracture
    • antalgic gait/difficulty ambulating
  • tests
    • Chvostek’s sign: tap on facial nerve elicits twitch
    • labs for underlying disorders: CMP, LFT, calcium, Vit D
    • x-rays
    • bone biopsy
  • Tx
    • Vit D replacement (>18 6,000 IU qd or 50,000 qw x 8w, 1500-2000 qd maint.)
    • patient education: dietary changes, fall risk
222
Q
  • localized bone remodeling disorder:
    • lytic phase: excessive reabsorption (osteoclasts)
    • mixed phase: then increased bone formation of weaker, disorganized bony structure (osteoclast and osteoblast)
    • sclerotic phase: disorganized bone becomes vascular, fibrous connective tissue

PE, tests, Tx

A

Paget Disease

  • PE
    • asymptomatic or specific bone pain
    • increased hat size, hearing loss, tinitis (if skull)
    • deformities: bowing, kyphosis, abnormal gait
  • tests
    • x-rays, +/- bone scan, No MRI/CT
    • labs
      • alkaline phosphatase (bone specific) - high sensitivity for diagnosis
      • NOT a calcium/Vit D issue (osteoclast problem)
      • urine: hydroxyproline, dexypyridinoline, C-telopeptide
  • Tx
    • goal: control activity, treat complications
    • Bisphosphonates
      • Zoledronate acid (Reclast) 5mg IV
      • Alendronate (Fosamax) 40mg x 6m
      • Risedronate (Actonel) 30mg qd x 2m
    • neoplasm - refer for amputation, chemo
    • joint disease (OA or fracture) - replacement/ORIF
223
Q

Osteoporosis Treatment

A
  • supplemental calcium (1000/1200 W>50 & M>70) and vitamin D (600/800 W/M>70)
  • Bisphosphonates
    • inhibit osteoclasts to decrease turnover and bone loss
    • oral
      • Alendronate (Fosamax)
      • Alendronate/cholecalciferol (Fosamax + D)
      • Risedronate (Actonel)
      • Iandronate (Boniva)
    • Parenteral
      • Zoledronic acid (Reclast)
      • Ibandronate (Boniva)
  • Expensive:
    • Selective Estrogen REceptor Modulators (SERMs)
      • decrease cytokines that activate osteopblasts - vertebral fx only
      • Raloxifene (Evista) 60mg po qd
    • Recombinant human parathyroid hormone
      • Teriparatide (Forteo) 20mcg SQ qd (thigh or abdominal wall)
      • high risk vertebral fractures, stimulates bone formation, no more than 2y, black box: osteosarcoma
    • Human monoclonal antibody
      • Denosumab (Prolia) 60mg SQ q6m
      • Abx to RANKLE - inhibits osteoclast formation/activity
  • Calcitrol
    • nasal spray, inhibits osteoclasts
  • Estrogen/progestin
    • decreases bone turnover/loss
  • Fracture treatment (total hip, hemiarthroplasty, vertebroplasty, kyphoplasty)
224
Q

Bone Lesion Abbreviations

ABC, CMF, EG, GCT, FD, NOF, SBC

A
  • ABC - aneurysmal bone cyst
  • CMF - chondromyxoid fibroma
  • EG - eosinophilic granuloma
  • GCT - giant cell tumor
  • FD - fibrous dysplasia
  • NOF - non ossifying fibroma
  • SBC - simple bone cyst
225
Q

Benign vs. Malignant Lesions

benign types

A

benign typically have well defined borders

  • bone forming (osteo-)
    • osteoid osteoma, osteoblastoma, osteoma
  • cartilage forming (chondro-)
    • chondroma, osteochondroma, chondroblastoma
  • fibrous bone lesions (fibro-)
    • fibrous dysplasia, nonossifying fibroma
  • radiolucent bone lesions
    • giant cell tumor, unicameral bone cyst, aneurysmal bone cyst
227
Q
  • most common benign osteoid tumor
  • most common in long bones - proximal femur
  • most common in 2nd decade of life (10-30 y/o)
  • night pain
  • pain relieved w/ NSAIDs

tests, Tx

A

osteoid osteoma

  • tests
    • <1cm lytic nidus w/ surrounding sclerosis
    • HOT on bone scan, use CT to localize
    • “cherry red” nidus histology
  • Tx
    • NSAIDs for pain
    • curettage/burring
    • radiofrequency ablation
228
Q
  • dnew bone depositied on skull, tibia, femur
  • 2nd to 4th decade
  • associated w/ Gardner’s syndrome
    • colonic polyps, desmoid tumors

PE, tests, Tx

A

osteoma

  • PE
    • firm mass w/ little to no pain
  • tests
    • xray: dense cortical bone, not contiguous w/ intramedullary canal
  • Tx
    • observation vs. marginal resection
229
Q
  • larger osteoid tumor (>2cm and more aggressive)
  • 1st to 3rd decades
  • posterior spine, long bones (femur, tibia)
  • night pain
  • pain w/ activity NOT responsive to NSAIDs

tests, Tx

A

osteoblastoma

  • tests
    • x-ray: no sclerotic rim, NO nidus
  • Tx
    • biopsy
    • surgical
      • curettage and bone grafting
      • tumor excision w/ bone reconstruction vs internal fixation
231
Q
  • exostosis - bony projection on surface of bone covered with cartilage
  • most common benign bone tumor
  • solitary or multiple (Multiple Hereditary Exostoses)
  • femur (at knee), tibia, humerus

PE, tests, Tx

A

osteochondroma

  • PE
    • often asymptomatic
    • pain or painful mass
    • away from growth plate
  • tests
    • xrays
  • Tx
    • asymptomatic
      • monitor
    • symptomatic
      • surgical excision
232
Q
  • tumor of hyaline cartilage within medullary canal
  • <5cm
  • associated w/
    • Ollier’s disease
    • Maffucci’s syndrome

PE, tests, Tx

A

enchondroma

  • PE
    • asymptomatic - usually incidental finding
    • pain w/ pathologic fracture
  • tests
    • plain films: stippled calcification
  • Tx
    • no tx if asymptomatic
    • symptoms
      • biopsy
      • currettage w/ bone grafting
233
Q
  • tumor of hyaline cartilage on surface of bone
  • usually metaphyseal (near tendon/ligament attachment)

PE, tests, Tx

A

periosteal chondroma

  • PE
    • painful, sometimes palpable mass
  • tests
    • xray: saucerization w/ sclerosis
  • Tx
    • excision
    • need to r/o chondrosarcoma
234
Q
  • abnormal tissue formation in place of lamellar bone
  • more common in femur

PE, tests, Tx

A

fibrous dysplasia

  • PE
    • pain
  • tests
    • xray: ground glass appearance
  • Tx
    • Bisphosphonates
    • surgical management
      • rigid fixation
236
Q
  • fluid filled cystic tumor w/ fibrous lining
  • near physis and grows distally
  • age 5-15 y/o

PE, tests, Tx

A

unicameral bone cyst

  • PE
    • incidental finding -or-
    • mild pain, swelling, stiffness in joint
    • sudding pain d/t pathologic fracture
  • tests
    • xray
  • Tx
    • r/o sarcoma!
    • intralesional aspiration and corticosteroid injection
    • surgery
      • curettage w/ bone grafting
237
Q
  • aggressive vascular lesion w/ cystic blood filled cavities
  • less frequent than GCT
  • locally destructive
  • d/t secondary lesion

tests, Tx

A

aneurysmal bone cyst

  • tests
    • MRI (instead of CT) to image fluid levels
  • Tx
    • surgery
      • curettage and bone grafting
238
Q
  • most common malignant bone tumor
  • common w/ other carcinomas:
    • breast/prostate, lung, kidney, GI tract, thyroid
A

metastatic disease

239
Q
  • proliferation of interosseus plasma cells
  • found in bone marrow
  • more common in AA, men, 50+

PE, tests, Tx

A

multiple myeloma

  • PE
    • bone pain, pathologic fractures, weakness/malaise
    • neuro complaints - spinal cord compression
  • tests
    • plain films
  • Tx
    • surgical fixation of pathologic fractures
    • chemotherapy
    • radiation
240
Q
  • most common malignant bone tumor
  • primitive mesenchymal bone forming cells produce malignant osteoid
  • femur, tibia, humerus
  • more common in 12-25 y/o

PE, tests, Tx

A

osteosarcoma

  • PE
    • variable: pain, swelling, night pain, no hx trauma
    • palpable mass
    • decreased ROM
    • lymphandenopathy
    • +/- respiratory mets
    • primary (surface) vs. secondary (intramedulary) - variants
  • tests
    • labs: LDH, ALP, CBC w/ diff, CMP, urinalysis
    • open biopsy
    • plain xrays
      • CXR to check for mets to lungs
    • bone scan (evaluate metastatic disease)
    • CT (location and staging)
    • MRI (eval soft tissue involvement)
  • Tx
    • wide resection - limb sparing
    • rotationplasty
    • amputation
    • chemo
241
Q
  • cartilage malignancy
  • low grade/low mets - high grade/aggressive

PE, tests, Tx

A

chondrosarcoma

  • PE
    • pain over time
    • night pain
    • +/- mass
    • symptoms near location of tumor
242
Q
  • arises from benign cartilage lesion (enchondroma, osteochondroma)
  • pelvis, femur, humerus, ribs

tests

A

secondary chondrosarcoma

  • tests
    • plain films: scattered, irregular calcification
243
Q
  • endothelioma (internal surface) of bone
  • associated w/ chromosomal translocation
  • birth - 20’s

PE, tests, Tx

A

Ewing sarcoma

(boards question - know osteo vs. ewing sarcomas)

  • PE
    • progressively worse pain
    • night pain
    • localized swelling/mass
    • increased warmth over area, fever, incr sed rate/WBCs, anemia, malaise (mimics infection)
  • tests
    • plain films: destructive lesion w/ poor border, periosteal bone formation
    • MRI for soft tissue involvement
    • CT scan for staging
  • Tx
    • dependent on location and size
      • chemo/radiation
      • surgery
        • limb sparing vs. amputation (rare)
244
Q
  • cartilage forming in epiphysis (d/t immature cartilage cell proliferation)
  • ususally 2nd decade when growth plates open

PE, tests, Tx

A

chondroblasoma

  • PE
    • pain, tenderness, swelling, limp (if in LE)
  • tests
    • xray: well circumscribed/defined lytic lesion w/ surrounding sclerosis; +/- stippled calcification
    • histology: “chickenwire calcification”
  • Tx
    • curettage (scrapping) and bone graft
    • increased risk of osteoarthritis when joint involved
245
Q
  • proliferation of fibrous tissue
  • fibrous cortical defect <1 cm affecting cortex only
  • children/adolescents
  • Jaffe-Campanacci syndrome - multiple NOFs and cafe au lait spots

PE, tests, Tx

A

nonossifying fibroma

  • PE
    • asymptomatic to painful
  • test
    • xray: geographic, thick sclerotic rim, well circumscribed
  • Tx
    • usually heals spontaneously by 20’s
    • oberservation vs. surgical
      • curettage and bone graft
247
Q
  • aggressive proliferation of benign multinucleated cells
  • ages 20-50
  • femur, tibia, radius

PE, tests, Tx

A

giant cell tumor

  • PE
    • pain, swelling, deformity w/ increasing size
    • pathologic fractures
    • can metastasize to lung
  • tests
    • xray: lucent, sometimes see bony destruction, can enter soft tissue
  • Tx
    • surgery
      • curettage, ablation, bone grafting, fixation
248
Q
  • chronic multisymptom inflammatory autoimmune disease - autoantibodies
  • frequent relapses, permanent organ damage, women of childbearing age

epidemiology, hx, systems, tests, Tx

A

systemic lupus erythematosus (SLE)

  • epidemiology
    • unknown: genetics, environment (UV, drugs: procainamide, hydralazine, quinidine, isoniazid), viruses, diet (a.a.), hormonal
  • Hx
    • sunlight, hair loss, Raynaud’s, FH
  • systems
    • fever, malaise, wt loss; skin; MSK: pain, stiffness out of proportion, non-erosive; kidneys; CNS: seizures, psychosis; cardio; GI; hematologic: anemia, thrombocytopenia; ocular
  • tests
    • CBC w/ diff, CMP, ESR, CRP, PT, PTT, ANA, urinalysis
    • anti-dsDNA
    • anti-Smith
    • anithistone (drug induced SLE)
    • plain films to r/o other
    • CXR, ECG, echocardiogram to eval other systems
  • Tx
    • conservative vs. medicinal based on severity
    • counseling/lifestyle - smoking cessation, sun, fatigue, sleep
    • PT/OT
    • meds
      • antimalarials: hydroxycholoroquine (Plaquenil)
      • NSAIDs
      • corticosteroids: Prednisone (not w/ NSAIDs)
        • supplement CA+Vit D if long-term
      • DMARDs (immunosuppressants)
        • Methotrexate (Trexall)
        • Azathioprine (Imuran)
        • Cyclophosphamide
        • Mycophenolate
249
Q
  • autoimmune disorder affecting exocrine glands
    • salivary and lacrimal glands
    • bilateral parotid gland swelling
    • women 40-60
  • primary
    • SICCA symptoms
      • keratoconjunctivitis
    • ​xerostomia
      • mouth infections: dental carries, difficulty swallowing, pain, hoarseness, parotitis
  • secondary
    • associated w/ SLE, RA, scleroderma

etiology, systems, tests, Tx

A

Sjorgren’s Syndrome

  • etiology
    • unknown: genetics, environment: viruses, hormones
  • systems
    • fatigue, fever; skin; pulmonary; MSK; renal; neuro: neuropathy, myelopathy; neoplasia: lymphandenopathy
  • tests
    • ocular/oral exams
    • Schirmer test (strip from eye)
    • Rose Bengal staining
    • labs: CBC w/ diff, CMP, +RF, +ANA, +ESR
    • anti-Ro/SSA
    • anti-La/SSB
  • Tx
    • no cure - treat symptoms/systems
    • fluid replacement, skin lotion, humidifiers, eye & dental exams
    • rheumatology referral
250
Q
  • non-erosive inflammatory affecting shoulders and pelvic girdle
  • typically 50+
  • sudden onset muscle pain and stiffness
  • morning stiffness >45min
  • associated w/ giant cell arteritis (temporal arteritis)*
    • extracranial blood vessels, can cause blindness

tests, Tx

A

Polymyalgia Rheumatica

  • tests
    • HLA-DR4
    • ESR >40, CRP, CBC w/ dif, -RF, -antiCCP, CPK
    • GCA (temporal artery biopsy) - gold standard
  • ​Tx
    • Prednisone 12.5-25mg/d
    • PPI to protect GI
    • Ca+/Vit d
    • giant cell arteritis
      • Prednisone 40-60mg 4w then decrease 10mg q2w until at 20mg, then reduce by 2.5mg q2-4w to 10mg then decrease 1mg q1-2m as long as no relapse
251
Q
  • systemic vascular syndrome that obliterates small/medium vessels
  • necrotizing inflammation occuring at bifurcations that weakens vessels (aneurysms, thrombi, hemorrhage, ischemia, infarction)
  • men ages 40-60

etiology, systems, tests, Tx

A

Polyarteritis Nodosa

  • etiology
    • unknown: HBV/HCV, CECR1 gene mutation
  • systems
    • fever, fatigue, anorexia/weight loss, myalgia
    • nervous system, cutaneous: Raynaud’s, rash, purpura, livido reticularis; GI, renal failure, testicular tenderness
  • tests
    • CBC w/ diff, CRP, ESR, liver function, HBV/HCV, -RF, -ANA
    • biopsy skin
    • abdominal CT for ischemic/affected organs
  • Tx
    • refer to rheumatologist
    • meds:
      • Prednisone 1-2mg/kg/d
      • antivirals for HBV
      • tx HTN
252
Q
  • humoral attack to muscle capillaries and small arterioles - capillary infarctions/destruction
  • abnormal T-cell activity, genetic HLA types DR3/5/7, infections, drugs (statins, interferon, quinidine)

S/s, tests, Tx

A

Dermatomyositis

  • S/s
    • Gottron’s papules: raised scaly lesions on MCP, PIP, elbows, eyelids
    • rash in V neck distribution
    • arthralgias in knees, wrists, hands; fatigue, weight loss, fever; Raynaud’s; GI; pulmonary; cardiac
    • proximal muscle weakness - standing climbing, walking, lifting
  • tests
    • CBC, ESR, CK, AST/LDH
    • +ANA (non specific)
    • anti-Mi2 & anti-MDA5 (specific)
    • MRI, EMG
    • muscle biopsy - definitive
  • Tx
    • non-med: high protein, exercise, consult system specialists
    • skin: avoid UV, topical corticosteroids, hydroxychloroquine
    • oral meds:
      • corticosteroids - Prednisone 1mg/kg/d 4-8w; d/c when CK level normal
      • Methotrexate 7.5mg po weekly, increase as needed; take w/ folic acid
254
Q
  • T-cell mediated cytotoxic process against muscle antigens

S/s, tests, Tx

A

Polymyositis

  • S/s
    • arthralgias in knees, wrists, hands; fatigue, weight loss, fever; Raynaud’s; GI; pulmonary; cardiac
    • proximal muscle weakness - standing climbing, walking, lifting
  • tests
    • CBC, ESR, elevated CK, AST/LDH
    • +ANA (non specific)
    • anti-Jo-1 (specific)
    • MRI, EMG
    • muscle biopsy - definitive
  • Tx
    • non-med: high protein, exercise, consult system specialists
    • skin: avoid UV, topical corticosteroids, hydroxychloroquine
    • oral meds:
    • corticosteroids - Prednisone 1mg/kg/d 4-8w; d/c when CK level normal
    • Methotrexate 7.5mg po weekly, increase as needed; take w/ folic acid
255
Q
  • central sensitization - chronic widespread pain and tenderness

S/s, tests, Tx

A

Fibromyalgia

  • S/s
    • widespread pain and stiffness (neck, shoulder, low back, hips)
    • fatigue, disordered sleep, cognitive function, depression, HA, IBS, TMJ, overactive bladder
  • tests
    • labs to r/o other diseases: CBC w/ diff, BMP, TSH, ESR, CRP, ANA, RF, CPK
    • imaging for underlying pathology
  • Tx
    • focus on non-pharm: education, counseling, eliminate stressors, PT/OT
    • meds (low dose, short term)
      • acetaminophen, Tramadol 50mg q6-8h PRN
      • muscle relaxers: Cyclobenzaprine (Flexeril) 5mg po q8h
      • NO OPIOIDS
    • anxiety and insomnia
      • Alprazolam (Xanax)
      • Zolpidem (Ambien)
    • antidepressants
      • Amitriptyline, Duloxetine (Cymbalta), Venlafaxine (Effexor)
    • anticonvulsants for neuropathic pain
    • Gabapentin (Neurontin), Pregabalin (Lyrica)
256
Q
  • pain, swelling, vasomotor dysfunction in extremeties following trauma or surgery
  • soft tissue disorder, immobilization when pt should be getting better

S/s, tests, Tx

A

Complex Regional Pain Syndrome

  • S/s
    • pain out of proportion to event
    • color changes
    • skin dry, shiny, wrinkles w/ temp changes
    • joint fibrosis: flexion contractures, frozen shoulder
    • muscle weakness/tremors
    • 3 stages: acute (3m), subacute (9m), chronic (1+y)
  • tests
    • no specific labs
    • plain films for bone demineralization (DEXA scan)
    • triple phase bone scan - increased uptake in articular structures
  • Tx
    • conservative
      • education - screen for depression and suicide
      • NSAIDs, corticosteroids
      • sympathetic nerve block
      • PT/OT
    • surgical
      • upper thoracic/lumbar sympathectomy
      • chemical sympathectomy
      • spinal cord stimulator implant
257
Q
  • cognitive difficulties and skeletal muscle fatigue
  • myalgic encephalomyelitis

S/s, tests, Tx

A

Chronic Fatigue Syndrome

  • S/s
    • sudden onset of abrupt, debilitating fatigue - impacts ADLs
    • +/- flulike prodrome
    • similar to fibromyalgia
  • test
    • r/o heart disease, thyroid, anemia, liver and renal disease, psych
  • Tx
    • supportive and symptomatic
258
Q
  • autosomal dominant connective tissue disorder
  • multi-system: eye, skeleton, heart, aorta, lung, integument

S/s, tests, Tx

A

Marfan Syndrome

  • S/s
    • eye: lens displacement, retinal detachment; msk: ligament laxity, increased limb and finger length; mouth: arched palate, crowded detention; spontaneous pneumothorax; striae atrophy; cystic organs
  • tests
    • genetic testing
    • opthalmic exam
    • skeletal testing
  • Tx
    • education, tx of pathology
259
Q
  • heterogeneous disorder of connective tissue - affects structure, production or processing of collagen
  • fragile tissues, joint hypermobility, skin hyperextensibility

S/s, tests, Tx

A

Ehlers-Danlos Syndrome

  • S/s
    • velvety skin/atrophy
    • medium and large vessel rupture
    • easily bruises
    • organ rupture, premature rupture of fetal membranes
  • Tx
    • treat manifestations
    • care w/ suturing
    • B-blocker to protect vessels
260
Q
  • defects in bony matrix causes hereditary osteopenia
  • blue sclera

S/s, tests, Tx

A

Osteogenesis Imperfecta

  • S/s
    • recurrent fx w/ bony deformity, impaired mobility
    • short stature
    • restrictive lung disease, compression of brain stem
    • abnormal teeth
    • blue sclera
  • Tx
    • fracture management
    • Risedronate - increase bone mineral density

Clinical Medicine I (8 decks)

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