MSK

Question 1

Bone Cell Types

Answer 1

• 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

Question 2

Medical History

Answer 2

• 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

Question 3

Physical Exam Components

Answer 3

• 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

Question 4

9 Categories of MSK Disorders

Answer 4

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

Question 5

Local and Regional Conditions

Answer 5

• 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

Question 6

• loss of articular cartilage
• formation of osteophytes

Answer 6

cartilage degeneration

• primary
  
  • biomechanical abnormalities leading to micro-fisures in the articluar cartilage
• secondary
  
  • infection, autoimmune
  • trauma or hypermobility of joint

Question 7

• pigmented vilonodular synovitis (PVNS)
  
  • thickening vascular swelling and infiltration of synovia
• autoimmune disease

Answer 7

inflammatory synovitis

Question 8

• monosodium urate
• calcium pyrophosphate
• hydroxyapatite

Answer 8

crystal-induced synovitis

• gout
• pseudogout

Question 9

• disorder of transition zone where tendons, ligaments and joint capsule attach

Answer 9

enthesopathy

• hallmark: spondyloarthropathies
• enthesis affected

Question 10

• microorganisms in the joint
• extremely painful

Answer 10

joint space disease

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

Question 11

Osteoarticular Disease

Answer 11

• osteopenia
• osteoperosis
• osteonecrosis (typically w/ joint separation)
• periostitis

Question 12

• painless inflammation and weakness of proximal skeletal muscles

Answer 12

inflammatory myopathy

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

Question 13

General Conditions

Answer 13

• polymyalgia rheumatic
• fibromyalgia
• complex regional pain syndrome

Question 14

Initial Imaging Technique

Answer 14

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

Question 15

X-ray Requirements

Answer 15

• Pt identification
  
  • name, age, sex, birth date, medical record number
• location to image
• technical quality
  
  • positioning of body part
  • quality
  • contrast

Question 16

• continuous x-ray imaging
• used w/ procedures
• assess joint motion

Answer 16

flouroscopy

Question 17

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

Answer 17

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

Question 18

MRI with contrast

Answer 18

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)

Question 19

• 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

Answer 19

CT scan

• contrast used to determine if mass is solid or cystic

Question 20

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

Answer 20

• DEXA scan
• electromyography test
• nerve conduction study test
• myelogram
• nuclear medicine (Bone/PET scan)

Question 21

• imaging using sound waves
• typically for prodedures- injections

Answer 21

Ultrasound

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

Question 22

Common Ortho Labs

• inflammation markers
• autoantibody test
• antinuclear antibodies (ANA)
• cryoglobulins
• metabolic markers

Answer 22

• 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

Question 23

Synovial Fluid Analysis

Answer 23

• 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

Question 24

Joint Injection for Inflammation Reduction Drugs

Answer 24

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

Question 25

Steroid Injection Contraindications

Answer 25

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

Question 26

Joint Injection for OA Pain

Answer 26

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

Question 27

Complications of Corticosteroid Injections

Answer 27

• 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

Question 28

MSK Treatment Approaches

Answer 28

• 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

Question 29

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

Answer 29

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

Question 30

inflammation of long head of biceps

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

Answer 30

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

Question 31

impingement signs

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

Answer 31

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

Question 32

shoulder pain, unable to move arm, deformity

• s/s, tests, dx

Answer 32

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

Question 33

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

• s/s, tests, dx

Answer 33

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

Question 34

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

• s/s, tests, dx

Answer 34

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

Question 35

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

• s/s, tests, dx

Answer 35

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

Question 36

Shoulder Joint Injections

Answer 36

• 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

Question 37

compression of brachial plexus +/- subclavian vessels

• s/s, tests, dx

Answer 37

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

Question 38

Elbow Physical Exam

Answer 38

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

Question 39

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

• s/s, tests, dx

Answer 39

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

Question 40

pain in medial joint line

• types, s/s, tests, dx

Answer 40

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

Question 41

tender mass at tip of elbow

• s/s, tests, dx

Answer 41

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)

Question 42

aching over medial elbow, numbness/tingling, claw hand

• s/s, tests, dx

Answer 42

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

Question 43

pain and ecchymosis in antecubital fossa, “pop”,

“reverse Popeye” deformity

• s/s, tests, dx

Answer 43

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

Question 44

extreme swelling, pain, and inability to move elbow

• s/s, tests, dx

Answer 44

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

Question 45

Elbow Injections

Answer 45

• 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

Question 46

Wrist and Hand Exam

Answer 46

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

Question 47

compression of median nerve

• s/s, tests, dx

Answer 47

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

Question 48

swelling/stenosis in tendon sheath of snuff box

(abductor pollicis longis/extensor pollicis brevis)

-s/s, tests, dx

Answer 48

DeQuervain’s Tenosynovitis

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

Question 49

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

• s/s, tests, dx

Answer 49

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

Question 50

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

• s/s, tests, dx

Answer 50

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

Question 51

forced abduction of thumb

• s/s, tests, dx

Answer 51

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

Question 52

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

• s/s, tests, dx

Answer 52

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

Question 53

finger flexion weakness following injury

• s/s, tests, dx

Answer 53

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 ***

Question 54

flexed PIP and hyperextended DIP

• s/s, tests, dx

Answer 54

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

Question 55

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

• s/s, tests, dx

Answer 55

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

Question 56

hyperextension of PID/flexion of DIP

• s/s, tests, dx

Answer 56

swan neck deformity

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

Question 57

infection of soft tissue around fingernail

• s/s, tests, dx

Answer 57

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

Question 58

finger pulp infection

• s/s, tests, dx

Answer 58

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

Question 59

fight bite in index, middle, ring finger

• s/s, tests, dx

Answer 59

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

Question 60

clear fluid filled vesicles on finger

• s/s, tests, dx

Answer 60

herpetic whitlow

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

Question 61

Lower Extremity Physical Exam

Answer 61

• 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

Question 62

Hip Anatomy Terminology

Answer 62

• 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

Question 63

Hip Exam Special Tests

Answer 63

• 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

Question 64

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

• s/s, tests, dx

Answer 64

hip strain

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

Question 65

lateral hip/thigh pain

• s/s, tests, dx

Answer 65

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

Question 66

buttock, labial/scrotal pain

• s/s, tests, dx

Answer 66

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?

Question 67

clicking, popping, locking hip with lateral pain

“C sign”

• s/s, tests, dx

Answer 67

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

Question 68

high trama impact to leg in seated position

• s/s, tests, dx

Answer 68

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

Question 69

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

• s/s, tests, dx

Answer 69

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)

Question 70

loss of articular cartilage in hip

• s/s, tests, dx

Answer 70

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

Question 71

ASIS compression

• s/s, tests, dx

Answer 71

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

Question 72

Knee Physical Exam Technique

Answer 72

• 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

Question 73

Knee Special Tests

Answer 73

• 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

Question 74

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

• s/s, tests, dx

Answer 74

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)

Question 75

anterior knee pain w/ running, jumping, kicking

Answer 75

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

Question 76

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

Answer 76

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

Question 77

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

• s/s, tests, dx

Answer 77

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

Question 78

severe knee pain, inability to ambulate, patella lateral

• s/s, tests, dx

Answer 78

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

Question 79

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

• s/s, tests, dx

Answer 79

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

Question 80

excessive joint fluid tracts to popliteal bursa

• s/s, tests, dx

Answer 80

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

Question 81

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

• s/s, tests, dx

Answer 81

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)

Question 82

force to anterior tibia w/ flexed knee

• s/s, tests, dx

Answer 82

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

Question 83

valgus or varus grade I / II / III

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

• s/s, tests, dx

Answer 83

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

Question 84

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

• s/s, tests, dx

Answer 84

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

Question 85

Foot and Ankle Exam

Answer 85

• 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

Question 86

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

• s/s, tests, dx

Answer 86

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

Question 87

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

• s/s, tests, dx

Answer 87

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

Question 88

vague paresthesis of plantar foot, compression of tibial nerve

• s/s, tests, dx

Answer 88

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

Question 89

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

• s/s, tests, dx

Answer 89

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

Question 90

posterior tibial tendon dysfunction

• s/s, tests, dx

Answer 90

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

Question 91

forefoot pain

• s/s, tests, dx

Answer 91

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

Question 92

perineural fibrosis of common digital nerve

• s/s, tests, dx

Answer 92

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

Question 93

lateral deviation of great toe at MTP joint

• s/s, tests, dx

Answer 93

hallux valgus (“bunion”)

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

Question 94

1st MTP joint sprain

• s/s, tests, dx

Answer 94

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

Question 95

Toe Deformities

Answer 95

• 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

Question 96

brachial plexus innervations

Answer 96

Question 97

lumbar plexus innervations

Answer 97

Question 100

cervical spine test

Answer 100

spurling test

• narrows neural foramen
• increases/reproduces redicular symptoms

Question 101

• pain
  
  • base of skull to thoracic region
  • SCM / trapezious muscles
  • < ROM
• headache
• sleep disturbances
• fatigue
• difficulty concentrating
• +/- radicular symptoms
  
  • pain, numbness, tingling

Answer 101

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)

Question 102

lumbar spine tests

Answer 102

• 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

Question 103

tests for “non-organic” pain

Answer 103

Waddell signs

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

Question 104

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

Answer 104

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

Question 105

• 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

Answer 105

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

Question 107

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

Answer 107

cervical rediculopathy

• can be caused by disc herniation or degenerative changes

Question 108

• 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

Answer 108

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

Question 109

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

Answer 109

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)

Question 112

general low back or SI joint tenderness

• doesn’t radiate past the knee

PE, tests, Tx

Answer 112

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

Question 113

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

Answer 113

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

Question 115

4 cervical vetabrae fractures

PE, tests, Tx

Answer 115

• 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

Question 116

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

Answer 116

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

Question 117

lumbar fracture

Answer 117

Question 118

• 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

Answer 118

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

Question 119

tailbone pain

• pain w/ sitting, BM, sexual intercourse

PE, tests, Tx

Answer 119

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

Question 120

pars interarticularis defect / forward translation of vertebrae

• repetetive hyperextension
• back pain w/ movement
• radiculopathy

PE, tests, Tx

Answer 120

spondylolysis / spondylolisthesis

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

Question 121

lateral curvature in spine

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

PE, tests, Tx

Answer 121

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

Question 122

• 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

Answer 122

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

Question 124

these spinal fracture uccur mostly d/t osteoporosis/weakening

Answer 124

thoracic vertebral fractures

Question 126

vertebral fracture goal, type, tx

Answer 126

• 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

Question 127

crystal deposition disease characteristics & 2 types

Answer 127

• 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

Question 128

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

Answer 128

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)

Question 129

gout

s/s, test, tx

Answer 129

• 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, $$$)

Question 130

calcium phyrophosphate dihydrate crystal deposition disease

(CPPD crystal deposition disease)

3 types, s/s, tests, Tx

Answer 130

• 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

Question 131

3 Hydroxyapatite Arthropathy Diseases

• crystals in joints, tendons, ligaments, bursa
• identified w/ electron microscopy
• species of basic calcium phosphate
• pts tend to be younger

Answer 131

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

Question 132

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

Answer 132

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

Question 133

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

Answer 133

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)

Question 134

infection of the bone

PE, tests, Tx

Answer 134

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

Question 135

• 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

Answer 135

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

Question 136

autoimmune attack of synovial tissue/joints

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

PE, tests, Tx

Answer 136

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

Question 137

RA scoring system

Answer 137

Question 138

4 phases of fracture healing

Answer 138

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

Question 140

fracture complications

Answer 140

• 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

Question 141

5 P’s of compartment syndrome

Answer 141

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

Question 142

fracture description

Answer 142

• 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…

Question 143

Mechanism, Presentation, Dx, Tx

Answer 143

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)

Question 144

Mechanism, Presentation, Dx, Tx

*what nerve affected

Answer 144

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

Question 145

Mechanism, Presentation, Dx, Tx

*what nerve affected

Answer 145

humeral shaft fracture

(radial nerve)

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

Question 146

Mechanism, Presentation, Dx, Tx

*artery injury to watch

Answer 146

supracondylar fracture

(brachial artery)

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

Question 147

Mechanism, Presentation, Dx, Tx

Answer 147

epicondyle/condylar fractures

(medial/lateral condyle)

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

Question 148

Mechanism, Presentation, Dx, Tx

Answer 148

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

Question 149

Mechanism, Presentation, Dx, Tx

Answer 149

olecranon fracture

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

Question 150

Mechanism, Presentation, Dx, Tx

Answer 150

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

Question 151

Mechanism, Presentation, Dx, Tx

Answer 151

radial shaft fracture

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

Question 152

Mechanism, Presentation, Dx, Tx

Answer 152

ulnar shaft fracture

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

Question 153

Mechanism, Presentation, Dx, Tx

Answer 153

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)

Question 154

Mechanism, Presentation, Dx, Tx

Answer 154

chauffeur fracture (radial styloid fracture)

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

Question 155

Mechanism, Presentation, Dx, Tx

Answer 155

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

Question 156

Mechanism, Presentation, Dx, Tx

Answer 156

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

Question 157

1st metacarpal fractures

Answer 157

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

Question 158

failures of healing

Answer 158

• 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

Question 159

Mechanism, Presentation, Dx, Tx

Answer 159

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

Question 160

Mechanism, Presentation, Dx, Tx

Answer 160

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

Question 161

3 hip fracture types

Answer 161

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

Question 162

Mechanism, Presentation, Dx, Tx

Answer 162

femur shaft fracture

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

Question 163

Mechanism, Presentation, Dx, Tx

Answer 163

supracondylar fracture

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

Question 164

Mechanism, Presentation, Dx, Tx

Answer 164

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

Question 165

Mechanism, Presentation, Dx, Tx

Answer 165

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

Question 166

Mechanism, Presentation, Dx, Tx

Answer 166

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

Question 168

Mechanism, Presentation, Dx, Tx

Answer 168

Maisonneuve fracture

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

Question 169

Mechanism, Presentation, Dx, Tx

Answer 169

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

Question 170

Mechanism, Presentation, Dx, Tx

Answer 170

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

Question 171

Dx, Tx

Answer 171

bi/tri-malleolar frature

• unstable, refer for surgery

Question 172

3 types 5th metatarsal fractures

Answer 172

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

Question 173

Mechanism, Presentation, Dx, Tx

Answer 173

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

Question 174

Physeal Fractures Typing

(pediatric/growth plate)

Answer 174

SALTER

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

Question 190

metacarpal fracture complications

Answer 190

• loss of grip strength
• residual dorsal deformity
• loss of knuckle prominence

Question 199

Mechanism, Presentation, Dx, Tx

(fibula fracture - no pic)

Answer 199

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

Question 200

4 Spondyloarthopathies

share predisposing factors and clinical features

Answer 200

• ankylosing spondylitis
• reactive athritis
• psoriatric arthritis
• enteropathic arthritis

Question 201

Spondylarthropathies Common Features and Tx

Answer 201

• 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

Question 202

• 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

Answer 202

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

Question 203

• 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

Answer 203

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

Question 207

• 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

Answer 207

Psoriatric Arthritis

• PE
  
  • spondylitis - inflammation of vertabrae
  • mimics RA but no nodules or RF
• tests
  
  • x-rays
• Tx
  
  • pain control
  • anti-TNF

Question 208

• nonerosive, assymtrical polyarthritis - large joints
• pt has Crohn’s or ulcerative colitis
• inflammation of joints follow GI inflammation

PE, tests, Tx

Answer 208

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

Question 209

autoimmune connective disease - thickening of skin/connetive tissue

3 cardinal processes

Answer 209

Scleroderma (systemic sclerosis)

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

Question 210

3 Classifications of Scleroderma

Answer 210

• 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

Question 211

Scleroderma Organ Involvement

Answer 211

• 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

Question 212

Scleroderma Tests, Dx, Tx

Answer 212

• 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

Question 213

Cells of Bone Remodeling

Answer 213

• 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

Question 214

amount of bone acquired by modeling and remodeling / peak times

Answer 214

bone mineral density (BMD)

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

Question 215

bone physiology vs. pathology

Answer 215

Question 217

primary / secondary causes of osteoporosis

Answer 217

• 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

Question 218

Who to DEXA Scan

Answer 218

DEXA - bone density scan

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

Question 219

Osteoporosis S/s, PE, tests, workup

Answer 219

• 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

Question 220

Other Osteoporosis Screening Tests

Answer 220

• QCT-quantitiative CT (spine)
• pQCT (wrist and tibia)
• Finger DXA
• US of calcaneous or wrist
• 3D CT of bone biopsy microarchitecture

Question 221

• softening of bone - decreased mineralization between calcified bone and osteoid
• rickets - defective mineralization of cartilage in epiphyseal growth plate

PE, tests, Tx

Answer 221

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

Question 222

• 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

Answer 222

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

Question 223

Osteoporosis Treatment

Answer 223

• 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)

Question 224

Bone Lesion Abbreviations

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

Answer 224

• 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

Question 225

Benign vs. Malignant Lesions

benign types

Answer 225

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

Question 227

• 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

Answer 227

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

Question 228

• dnew bone depositied on skull, tibia, femur
• 2nd to 4th decade
• associated w/ Gardner’s syndrome
  
  • colonic polyps, desmoid tumors

PE, tests, Tx

Answer 228

osteoma

• PE
  
  • firm mass w/ little to no pain
• tests
  
  • xray: dense cortical bone, not contiguous w/ intramedullary canal
• Tx
  
  • observation vs. marginal resection

Question 229

• 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

Answer 229

osteoblastoma

• tests
  
  • x-ray: no sclerotic rim, NO nidus
• Tx
  
  • biopsy
  • surgical
    
    • curettage and bone grafting
    • tumor excision w/ bone reconstruction vs internal fixation

Question 231

• 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

Answer 231

osteochondroma

• PE
  
  • often asymptomatic
  • pain or painful mass
  • away from growth plate
• tests
  
  • xrays
• Tx
  
  • asymptomatic
    
    • monitor
  • symptomatic
    
    • surgical excision

Question 232

• tumor of hyaline cartilage within medullary canal
• <5cm
• associated w/
  
  • Ollier’s disease
  • Maffucci’s syndrome

PE, tests, Tx

Answer 232

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

Question 233

• tumor of hyaline cartilage on surface of bone
• usually metaphyseal (near tendon/ligament attachment)

PE, tests, Tx

Answer 233

periosteal chondroma

• PE
  
  • painful, sometimes palpable mass
• tests
  
  • xray: saucerization w/ sclerosis
• Tx
  
  • excision
  • need to r/o chondrosarcoma

Question 234

• abnormal tissue formation in place of lamellar bone
• more common in femur

PE, tests, Tx

Answer 234

fibrous dysplasia

• PE
  
  • pain
• tests
  
  • xray: ground glass appearance
• Tx
  
  • Bisphosphonates
  • surgical management
    
    • rigid fixation

Question 236

• fluid filled cystic tumor w/ fibrous lining
• near physis and grows distally
• age 5-15 y/o

PE, tests, Tx

Answer 236

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

Question 237

• aggressive vascular lesion w/ cystic blood filled cavities
• less frequent than GCT
• locally destructive
• d/t secondary lesion

tests, Tx

Answer 237

aneurysmal bone cyst

• tests
  
  • MRI (instead of CT) to image fluid levels
• Tx
  
  • surgery
    
    • curettage and bone grafting

Question 238

• most common malignant bone tumor
• common w/ other carcinomas:
  
  • breast/prostate, lung, kidney, GI tract, thyroid

Answer 238

metastatic disease

Question 239

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

PE, tests, Tx

Answer 239

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

Question 240

• 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

Answer 240

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

Question 241

• cartilage malignancy
• low grade/low mets - high grade/aggressive

PE, tests, Tx

Answer 241

chondrosarcoma

• PE
  
  • pain over time
  • night pain
  • +/- mass
  • symptoms near location of tumor

Question 242

• arises from benign cartilage lesion (enchondroma, osteochondroma)
• pelvis, femur, humerus, ribs

tests

Answer 242

secondary chondrosarcoma

• tests
  
  • plain films: scattered, irregular calcification

Question 243

• endothelioma (internal surface) of bone
• associated w/ chromosomal translocation
• birth - 20’s

PE, tests, Tx

Answer 243

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)

Question 244

• cartilage forming in epiphysis (d/t immature cartilage cell proliferation)
• ususally 2nd decade when growth plates open

PE, tests, Tx

Answer 244

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

Question 245

• 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

Answer 245

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

Question 247

• aggressive proliferation of benign multinucleated cells
• ages 20-50
• femur, tibia, radius

PE, tests, Tx

Answer 247

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

Question 248

• chronic multisymptom inflammatory autoimmune disease - autoantibodies
• frequent relapses, permanent organ damage, women of childbearing age

epidemiology, hx, systems, tests, Tx

Answer 248

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

Question 249

• 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

Answer 249

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

Question 250

• 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

Answer 250

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

Question 251

• 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

Answer 251

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

Question 252

• 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

Answer 252

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

Question 254

• T-cell mediated cytotoxic process against muscle antigens

S/s, tests, Tx

Answer 254

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

Question 255

• central sensitization - chronic widespread pain and tenderness

S/s, tests, Tx

Answer 255

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)

Question 256

• pain, swelling, vasomotor dysfunction in extremeties following trauma or surgery
• soft tissue disorder, immobilization when pt should be getting better

S/s, tests, Tx

Answer 256

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

Question 257

• cognitive difficulties and skeletal muscle fatigue
• myalgic encephalomyelitis

S/s, tests, Tx

Answer 257

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

Question 258

• autosomal dominant connective tissue disorder
• multi-system: eye, skeleton, heart, aorta, lung, integument

S/s, tests, Tx

Answer 258

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

Question 259

• heterogeneous disorder of connective tissue - affects structure, production or processing of collagen
• fragile tissues, joint hypermobility, skin hyperextensibility

S/s, tests, Tx

Answer 259

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

Question 260

• defects in bony matrix causes hereditary osteopenia
• blue sclera

S/s, tests, Tx

Answer 260

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