MSK Flashcards
List the order of tests in an MSK physical exam
Gait assessment Inspection Palpation Range of Motion Power Assessment Neuro & Vascular (esp back & wrists/hands) Special tests
Acronym for MSK Inspection
SEADS = swelling, erythema, atrophy, deformities, scars/skin
Acronym for MSK Palpation
TESTCA = tenderness, effusions, swelling, temperature, crepitus, atrophy
4 muscles of the quadriceps
Rectus femoris
Vastus lateralis
Vastus medialis
Vastus intermedius
3 muscles of the hamstrings
Semimembranosus (medial)
Semitendinosus
Biceps femoris (short & long)
Innervation of the quadriceps
Femoral nerve
Innervation of the hamstrings
Sciatic nerve
Innervation of the gluteus
Superior/inferior gluteal nerves
Innervation of the adductors
Obturator nerve (except tibial for adductor magnus, femoral for pectineus)
Hip adductors
Adductor brevis, longus, magnus, minimus
Pectineus
Gracilis
Obturator externus
What is the only intracapsular ligament of the hip?
Ligamentum teres
There is less stability ___ to the hip, so hip is most likely to dislocate ____
Posteriorly (just the ischiofemoral, anterior has ileofemoral + pubofemoral + ligamentum teres)
2 phases of gait
Swing phase (40%) (toe off --> heel strike) Stance phase (60%) (heel strike --> toe off)
If pelvis drops on the swinging side, this indicates….
Weakness of hip abductors on opposite side
Antalgic gait
Stance phase shortened on affected side (pain on weight-bearing)
Bilateral hip abductor weakness –>
Waddling/Trendelenburg Gait
Exaggerated lumbar lordosis could indicate
Flexion contractor of the hip joint
Bony prominence on lateral aspect of him =
Greater trochanter
True leg length is measured from…
From ASIS to medial malleolus (crosses leg) (<1cm = normal)
Apparent leg length is measured from
Umbilicus to medial malleolus
Diff between true and apparent leg lengths?
Apparent = issues at level of hip True = issue below hip
To check internal hip rotation you move the foot which way?
Laterally!! and vv
Expected internal hip rotation, external hip rotation, abduction, adduction, extension
Internal = 30o External = 45 Abduction = 45 Adduction = 30 Extension = 20
Name 3 special tests in the hip exam and what they are looking for (not including leg length discrepancy)
Thomas test (hip contracture) FABER/Patrick's test (SI joint pathology (pain in lower back/gluts) or hip joint path (anterior/lateral pain)) Ober test (tight iliotibial band)
Fibularis longus/brevis AKA? Insertions?
Peroneus
Longus –> under foot to 1st metatarsal
Brevis = 5th metatarsal
4 arches of the foot
1) Medial longitudinal
2) Lateral longitudinal
3) Anterior/transverse metatarsal
4) Transverse mid-tarsal arch
Muscle compartments in thigh
Anterior: Rectus femoris, vastus muscles, sartorius
Medial: Adductor longus/brevis/magnus, gracilis
Posterior: biceps femoris, semitendinosus, semimembranosus
Muscle compartments in leg
Anterior: tib ant, EDL, EHL, fibularis tertius
Lateral: fibularis longus/brevis
Poterior superficial: triceps surae (gastroc/soleus), plantaris
Deep: Tib post, FDL, FHL
Define gonarthrosis & coxarthrosis
OA of knee (most common) and hip (2nd most)
OA leads to ___ formation of knee in early stage. Why?
Varus, medial cartilage lost first
What nodes are caused by osteophyte formation in the hands in OA?
Heberdens (DIPs)
Bouchards (PIPs)
4 possible radiograph findings in OA? Important note for diagnosis?
Subchondral cysts/sclerosis
Joint space narrowing
Osteophytes
OFTEN DON’T CORRELATE TO CLINICAL SYMPTOMS?FINDINGS, clinical features more important
Acetaminophen toxic dose
7.5-10 g in adults (boxes now say max 3 grams, docs can recommend up to 4)
150 mg/kg in children
Most common nontraumatic causes of osteonecrosis (2)
Chronic corticosteroid use (>20 mg prednisone, >2000 mg cumulative)
Alcohol consumption
What is SPONK?
Spontaneous osteonecrosis of the knee (femoral condyle or tibial plateau, usually in older women)
Tendon sheath
Synovial membrane layer surrounding tendons
Arthritides
Inflammatory joint diseases (does NOT include osteoarthritis which is degenerative)
Synovitis
Inflammation of synovial membrane
Septic arthritis
Bacterial infection of joint
Inflammation of tendon sheath = ?
Common in what disease?
Tenosynovitis
RA
What is enthesitis
inflammation where tendon inserts into bone
Palliation and provocation of pain in OA vs inflammatory arthritis
OA: exertion, evening; heat/rest help
A: rest, morning; movement/cold help
4 categories of inflammatory arthritis & demographics
RA (young/mid-age women)
SLE (young women)
Spondyloarthropathies (young men)
Gout (mid-age men, post-menopausal women)
2 most acute types of arthritis
Gout (hyperacute) Septic arthritis (acute)
Can joint distribution of arthritis be symmetrical if DIPs/PIPs are differentially affected?
Yes, as long as symmetrical DIGITS are affected
Classification of arthritis based on # of joints affected
1 = monoarthritis 2-4 = oligoarthritis 5+ = polyarthritis
3 common differentials for acute monoarthritis
Gout (usually 1st MTP)
Pseudogout (CPPD deposition, usually knee)
Septic arthritis
Oligoarthritis presentation is common in _____
Spondyloarthropathies
Common axial spondyloarthritis
Ankylosing spondylitis
Common peripheral spondyloarthrites (3)
Enteropathic (IBD! usualy lower extremities)
Reactive (after bact infection GI/urethra, usually lower extrem)
Psoriatic (small joints esp hands)
Name 3 common features of spondyloarthritises (since peripheral ones don’t actually all impact the spine)
Enthesitis
Extra-articular manifestations (skin, eyes)
Seronegative (e.g. no rheumatoid factor)
2 patters of presentation in psoriatic arthritis
Ray pattern (asymmetric polyarthritis) Transverse involvement (across DIPs)
RA usually impacts what body part first?
Feet (symmetric)
Which small joints tend to be spared by RA?
CMC
DIPs
(more likely to be OA)
SLE arthritis presentation
Symmetric polyarthritis in small joints of hands (DIP mayyy be affected in addition to others)
Crystals that form in gout are what?
Monosodium urate
Repeated gout attacks cause aggregation of urate crystals & giant cells =
Tophi (bone or soft tissue)
What is inflammation caused by in gout?
crystals precip coated by IgG –> phagocytosis, cytokine release
Things that decrease UA excretion
Meds (aspirin, loop/thiazide diuretics, etc) CKD Ketoacidosis Post-menopause Alcohol
Things that increase UA production
High-fructose corn syrup (pop)
Cell turnover (TLS, chemo, hemolytic anemia, psoriasis, cancers)
Enzyme defects
Obesity, hypercholetersol/TAGs, hypertension
Alcohol
Most common type of gout =
Podagra (1st MTP)
Knee (gonacra), fingers, ankle, wrist also possible
Gold standard diagnostic tool for gout
Arthrocentesis + synovial fluid analysis (if diagnosis uncertain or septic likely)
3 patient characteristics in gout diagnosis tool
Male
CV risk factors
History of prev attacks
4 features of attack in gout diagnostic tool
Onset within 24 hours
Joint erythema
1st MTP
Elevated serum UA (higher range of normal?)
Renal manifestations of chronic gout
Uric acid nephrolithiasis
Nephropathy
Gold standard for gout diagnosis (if unsure)
Arthrocentesis + synovial fluid analysis
Name 3 meds for acute gout flare
1) NSAIDS
2) Glucocorticoids (avoid giving w/ NSAIDs w/out PPI)
3) Colchicine (inhibits phagocytosis of crystals + neutrophil activation/degranulation)
NSAIDs from strongest to weakest
Indomethacin > naproxen (Aleve) > diclofenac (Voltaren) > ibuprofen (motrin/advil)
What MUST be done when initiating urate-lowering therapy for gout?
Give anti-inflamm prophylaxis for 1 week first (mobilizing urates increases acute flares) –> GCs, NSAIDs, or colchicine
Indications for urate-lowering therapy
Absolute: >2 attacks/year, tophi
Relative: CKD, high serum uric acid, urolithiasis
Name top 3 urate-lowering therapies and mechanisms
1) Xanthine oxidase inhibitors (Allopurinol/Febuxostat) - prevent UA formation from purines
2) Uricosurics (probenecid) - prevent UA reabsorption in PCT
3) Recombinant uricase (pegloticase) - breaks UA down to allantoin
Difference between rasburicase and pegloticase?
Pegloticase is conjugated to PEG to increase half-life and immunogenicity
Rasburicase used in TLS/pre-chemo
Tendinitis vs tendinosis
Tendinitis = inflammation due to micro-tears Tendinosis = collagen restructuring (immature/disorganized) due to chronic overuse & improper healing
Treatment goals/strategies in tendinitis vs tendinosis
Itis –> reduce inflamm (ice, NSAIDs, steroids)
Osis –> facilitate proper healing (heat unless inflamm episode, long-term physio)
What is adhesive capsulitis and what is a key indicator that this is the issue?
Frozen shoulder = reversible contraction of joint capsule
Won’t move actively OR passively
Most common cause of shoulder pain
Rotator cuff tendinopathy (usually supraspinatus tendon)
Distal tibiofibular syndesmosis = what type of joint?
Fibrous
Synchondroses are ___ joints. Examples?
Cartilagenous Epiphyseal plates (temp hyaline cartilage), b/w first 7 ribs & sternum
6 types of synovial joints
1) Plane (e.g. intercarpals)
2) Hinge (e.g. elbow, interphalangeal)
3) Pivot (proximal radioulner)
4) Condyloid (MCP joints)
5) Saddle (CMC of thumb)
6) Ball & socket (shoulder, hip)
The knee consists of one __ joint and 2 ___ joints
1 plane (femoropatellar) 2 hinge (med/lat tibiofemoral) (these are also the 3 compartments)
Define juvenile idiopathic arthritis
Rheumatic disease diagnosed <16yo with inflamm lasting >6 weeks
What part of the eye is often inflamed in JIA?
Anterior uvea (uvea = iris + ciliary body + choroid; anterior = iris + ciliary body) **often asymptomatic
Main diagnostic imaging technology in JIA?
Ultrasound (can see synovial hypertrophy, intraarticular fluid collection, bone erosions)
Define acute, subacute, and chronic back pain
Acute <6 weeks
Subacute = 6-12 weeks
Chronic > 12 weeks
Anterolisthesis
Anterior displacement of vertebral body relative to the one below
Anterolisthesis secondary to spondylolysis
Spondylolisthesis
Displacement of vertebral body posterior relative to the one below
Retrolisthesis
Define spondylosis
Degenerative arthritis of the spine (disc space narrowing, arthritic changes of facet joint)
Radiculopathy
Impairment of nerve root –> radiating pain, numbness, tingling, muscle weakness in corresponding area
Sciatica
Pain/numbness/tingling in distribution of sciatic nerve (posterior/lateral aspects of leg –> foot)
Loss of bowel/bladder control and numbness in groin + weakness of lower extremities = ___ syndrome. Caused by what?
Cauda equina syndrome
Pressure on bottom of spinal canal and spinal nerve roots (bony stenosis, herniated disk)
> 90% of radiculopathies involve what nerve roots?
L5 & S1 (–>sciatica)
*L5 goes from glut across front of leg to top of big toe
S1 stays down the back
3 main categories of differentials for NONmechanical spine disease
Neoplasia
Infection
Inflammatory (usually HLA-B27 associated) - not usually RA!! (RA rarely affects spine except cervical)
The vast majority of low back pain is ____ (97%) and 70% are specifically…
Mechanical
70% lumbar strain/sprain
Pt presents with low back pain that is better when spine is flex or when seated, aggravated by walking downhill more than uphill, bilateral symptoms. Most likely diagnosis?
Spinal stenosis
Pt presents with low back pain but WORSE leg pain, radiating below knee. Most likely diagnosis?
Herniated disk?
Viral illness that can cause unilateral dermatomal back pain + rash?
Shingles
In a herniation, the affected nerve root is above or below the level of disc herniation?
BELOW (e.g. L4-L5 disc herniation–> L5 radiculopathy)
Leading causes of morality in SLE (4)
Heart disease
Malignancy
Infection
(also kidney disease)
5 lab markers for SLE?
ANA >1:80 (v sensitive!)
Sm & dsDNA (both v specific!)
Low complement
Anti-phospholipid Ab
2 types of rashes with SLE? (nonscarring & scarring)
Malar = nonscarring, usually over bridge of nose Scaring = discoid
SLE nephritis is characterized by…(3)
Renal insufficiency
RBC casts
Proteinuria
(Full house glomerular deposits = IgG/M/A + complement)
3 types of inflammatory myopathy
Polymyositis
Dermatomyositis
Inclusion body myositis
Polymyositis & dermatomyositis affect ___ muscles
Proximal
Name 4 cutaneous manifestations of DM
Gottron papules (dorsum of hands) Heliotrope rash (upper eyelids) Mechanics hands (dirty-appearing fingers) Photosensitive poikiloderma
Name 5 muscle enzymes that can be elevated in myositis
Creatine kinase, aldolase
LDH, AST, ALT, myoglobin
4 roles of electrophysiological studies (nerve conduction + electromyography) in diagnosis of myopathy
1) Exclude neuromuscular issue
2) Provide EMG evidence of myopathy
3) Characterize it (location, severity)
4) Identify target muscles for biopsy (contralateral!)
MRI advantage over EMG for determining biopsy site?
You can biopsy the actual muscle you image not just contralateral
Treatment for lupus
Induction = oral GCs Maintenance = hydroxychloroquine (+methotrexate or azathioprine if needed)
Treatment for giant cell arteritis
Steroids (high dose at first then low)
Treatment for inflammatory myositis
Physical therapy
UV light protection in DM
Corticosteroids
3 organ complications in inflammatory myopathy
Pneumonia (related to resp muscle failure) –> ILD/resp failure
Myocarditis –> arrhythmia
Esophageal muscle weakness –> aspiration pneumonia
4 steps in approach to muscle weakness
1) Determine if true muscle weakness vs lassitude
2) Determine site of lesion
3) Determine cause of lesion
4) Evaluate for resp muscle weakness
Objective muscle weakness can be broken down by general localization into…
Generalized (e.g. cachexia)
Localized asymmetric
Localized symmetric (proximal e.g. myopathy, distal, specific pattern)
5 possible sites of lesion causing true muscle weakness
Upper motor neuron Anterior horn cell Peripheral nerve NMJ Muscle
Muscle strength testing scale
0 = no contraction 1 = flicker 2 = can move w/out gravity 3 = move against gravity 4 = move against limited resistance 5 = normal
6 differential diagnostic categories for MSK lesions causing muscle weakness
Inflammation Infection Toxins/drugs Metabolic/endocrine Genetic Neoplastic
5 common features of spondyloarthropathies
Family history HLA-B27 association Enthesitis!! Extra-articular manifestations (uveitis, psoriasis) Seronegative (no RF)
Major extra-articular manifestation of ankylosing spondylitis
Acute, unilateral anterior uveitis
Anky Spon affects the spine &
SI joint!!
Physical exam tests for ankyspon (5)
Bilateral chest expansino Modified Schober test FABER test Gaenslen test Occiput-wall distance
What might labs in an akyspon patient show (3)
High CRP/ESR
No auto-antibodies
High HLA-B27
Best imaging for EARLY detection of ankyspon?
Pelvic MRI (very sensitive for sacroiliitis)
Difference between syndesmophyte and osteophyte?
Syndesmophytes originate from annulus fibrosis & spinal ligaments in AnkySpon (inflammatory). Grow vertically –> bamboo spine
Osteophytes originate from vertebral bodies, usually in OA (degenerative). Grow horizontally
Both are ossifications
Most important treatment for ankyspon
Physical therapy
Respiratory complications of ankyspon
Breathing difficulties
Apical fibrosis of lungs (due to aspiration, defective ventilation, etc)
Medications for ankyspon (4)
NSAIDs = first line
TNF-a inhibitors to reduce axial progression
DMARDs for associate peripheral arthritis
Temporary intra-articular GCs if severe
Diagnostic approach to ankyspon:
Physical exam + history + pelvic x-ray
If inconslusive –> HLA B27 testing –> pelvic MRI
Cardinal symptom of ankyspon
Nocturnal back pain (sacroiliitis) that improves w/ NSAIDs/movement (morning stiffness)
+ pain/stiffness along spine
Scoliosis is characterized by ___ curvature (___ > ___) and __ of vertebral bodies
Most common curve?
Lateral curvature (Cobb angle >10)
Rotation
(most commonly R convex thoracic)
Most idiopathic scoliosis is what class (by age)? Gender distribution?
80% adolescent (10+ years old)
Mostly females
(*for juveniles 4-9yo mostly males, equal below that)
Do kids with scoliosis have pain?
Not usually (though adults may due to degeneration/compression of spinal nerves) - assess all kids as often discovered incidentally
4 important things to note on spinal X-ray in scoliosis patient
Major curvature Minor curvatures (compensatory) Cobb angle (>10) Risser sign (skeletal maturity on iliac crest, rated 1-5)
Based on Cobb angle, treatment for scoliosis progresses how?
Monitoring –> bracing (slows/halts progression but doesn’t fix underlying) –> surgery
Which brace most common for scoliosis
Boston (fits under clothes)
Congenital spine issues cause by failures of ___ or ___
Segmentation
Formation (e.g. hemivertebrae)
Discs usually herniate in what direction?
Posterolaterally (posterior longitudinal ligament is thinner)
Up to 80% of all disc herniations are ___
self-limiting (usually resolve within 4 weeks)
When is imaging indicated for uncomplicated herniated disc or spinal stenosis?
After 6-wk trial conservative management & symptoms severe enough to consider surgery
Trick to differentiate muscle/joint vs bone pain?
Give anti inflamm
If helps –> probably muscle/joint; won’t help bone
Red flags indicating imaging required (6)
Suspected epidural abscess or hematoma, cancer, infection
Cauda equina syndrome
Severe/progressive neuro deficit
Suspected compression fracture
Define cauda equina syndrome
A clinical syndrome caused by compression of nerves in the cauda equina (involving ≥ 2 of the L2–S5 nerve roots).
4 symptoms of cauda equina syndrome
Back pain
Variable lower extremity neurological defects
Perianal/saddle anesthesia
Bowel/bladder dysfunction (retention or incontinence)
Neurological claudication caused by ___ - when you do things your limbs feel “heavy”. Progresses into ____ (compression).
Spinal stenosis
Cauda equina syndrome
Bloodwork in rickets (5)
Low: Vit D, Ca, Phosphate
High: PTH, ALP
What are looser zones? In what disease are these seen
Pseudofractures = bands of low bone density on bone surfaces, look like fractures (e.g. in osteomalacia)
name 3 features of rickets (bone deformities)
Craniotabes (soft skull) & delayed closure of fontanelles Knee deformities (genu varum) Rachitic rosary
Cupping, stippling, and fraying of growth plates are seen in what disease?
Rickets
In case of spontaneous fractures, what neoplasm shoudl be tested for? How?
multiple myeloma (plasma cells infiltrate BM) Serum protein electrophoresis --> monoclonal peak (M spike) = abnormal M protein produced by monoclonal plasma cells
___ is the primary mediator of bone resorption
___ is the endogenous inhibitor of the action of above
Ratio determines BMB
RANKL
OPG (decoy receptor)
Define fragility fracture
Spontaneously or after minor trauma
- Fall form standing hight or sitting or supine <1m high
Fall missing 1-3 stairs
Coughing, twisting, etc.
DIfference between Z-score and T-score in DEXA scan
Z = diff from average person your age/sex T = diff from 30yo same sex (more important!)
T score cutoffs for osteoporosis & osteopenia
Calcium, phosphate, and PTH levels in osteoporosis?
Normal (unless other pathology going on)
What blood parameter may be elevated in osteoporosis
ALP
Recommended biochemical tests for osteoporosis workup (7)
Calcium (corrected for albumin) CBC Creatinine ALP TSH Vit D Serum protein electrophoresis (if vertebral fractures)
Recommended dietary intake of Ca
1000 mg/d
1200 mg/d for women >50 and men>70
(avoid >2500 or >2000 if >50)
Daily recommended Vit D
400-800 IU if <50
800-2000 IU if >50
Name 6 treatment categories for osteoporosis + examples
- Exercise (balance + strength)
- Diet (Ca + vit D)
- HT (estrogen)
- SERMs (Raloxifene)
- PTH (teriparatide)
- mAbs (denosumab)
- Bisphosphonates (aldendronate)
Why does PTH work as an osteoporosis treatment if it’s responsible for bone break down? Drug name example?
Teriparatide
Opposite affect if given INTERMITTENTLY vs continuously
How does denosumab work?
Binds RANKL so it can’t bind RANK on osteoclasts
What are the rare but serious side effects of bisphosphnoates?
Atypical femoral fracture (subtrochanteric insufficiency fracture)
Avascular necrosis of jaw
Advantage of denosumab > bisphosphonates re bone?
Not incorporated iNTO the bone!
Bisphosphonates mechanism of action
Bind bone surface –> taken up by osteoclasts –> impair their cellular function –> osteoclast apoptosis
Name 2 oral bisphosphonates + 1 IV bisphosphonates
Oral: alendronate, risedronate
IV: zoledronate, pamidronate
3 most important tests of synovial fluid
1) Culture + Gram stain
2) Cell count + differential
3) Crystal examination
Synovial fluid analysis: %PMN in non-inflammatory, inflammatory, and infectious arthritis
Non-inflamm: <25%
Inflamm: >25%
Infectious: >75%
How does infectious arthritis beget destruction of joint?
Inflamm –> effusion –> compress BVs –> necrosis of bones & cartilage
Bacterial proteases digest collagen
Septic arthritis key triad
Joint pain + impaired ROM + fever
Name 3 pathogens that can commonly cause septic arthritis?
Staphylococcus aureus
Mycobacterium tuberculosis
Borrelia (lyme)
What are you looking for on arthrocentesis for septic arthritis?
High WBCs
Positive culture
R/O crystals
What is the utility of ultrasound/X-ray/MRI in septic arthritis workup?
Hip/SI joints can’t be easily aspirated
R/O differentials (osteomyelitis, other joint diseases)
U/S —> effusions, soft tissue around
X-ray –> see osteolysis after a few weeks
MRI –> early detection of soft tissue infection
What is Reiter syndrome?
Reactive arthritis with the whole triad (arthritis + urethritis + uveitis)
Reactive arthritis is a sero___ ___arthritis
Seronegative spondyloarthritis (HLA-B27 associated) AUTOIMMUNE not infectious
Name 4 common pathogens causing reactive arthritis
Shigella
Chlamydia
Salmonella
Campylobacter
Arthrocentesis in reactive arthritis
High WBCs (not as high as infectious) Negative gram stain/culture
Treatment for reactive arthritis (4 main groups)
Self-limiting! NSAIDs Intraarticular/oral GCs if refractory If >6mo (chronic) --> DMARDs, biologics (anti-TNF) Local cryotherapy, physiotherapy
4 specific MSK manifestations of reactive arthritis
Asymmetric olifoarthritis
Dactylitis
Enthesitis
Sacroiliitis
ANA is a defining features of ____ autoimmune disorders, including (4):
Connective tissue
1) SLE
2) Scleroderma
3) Polymyositis/dermatomyositis
4) Sjogren’s syndrome
Signs/features of MAS in JIA?
Pancytopenia
Liver insufficiency: high AST/ALT/PT/ferritin, low fibrinogen
UNREMITTING fever
Interesting bloodwork sign in MAS
High CRP but LOW ESR because of lack of fibrinogen
Steroids important in the case of what 2 JIA complications
Anterior uveitis (topical) Macrophage activation syndrome (parenteral)
MAS is widespread ____ & ____ caused by activation & overproliferation of what cells?
Hemophagocytosis & cytokine release (macrophages + T cells)
Most common JIA subtype = ?
Complication risk? Which joints most commonly involved? ANA?
Oligoarthritis
Anterior uveitis
Large joints (knee/ankle, wrist/elbow)
ANA+ (70%); RF-
What pathogen/infection is associated with RA development? Why?
Porphyromonas gingivalis (gingivitis) PPAD enzyme (like endogenous PAD but not regulated) --> citrullination
How does RA lead to anemia of chronic disease?
Inflamm cytokines (IL-6) –> hepcidin production in liver –> prevents iron absorption/release (so treating the RA can treat the anemia!)
Clue that the diagnosis is RA and probably not reactive arthritis?
> 6 week duration
4 important things of RA pathogenesis
1) Cirtrullination
2) Synovitis
3) Angiogenesis + pannus formation
4) Osteoclast activation + bone breakdown
What are 2 important Abs in RF diagnosis?
RF (IgM against IgG)
anti-CCP (against citrullinated proteins)
Useful imaging modality to monitor RA progression/response to treatment
Doppler U/S
MRI is good but need to be selective, x-ray can be good for bone dislocations, deformities, erosions
4 steps of treatment of RA
- Non-pharmacological therapy
- Pain control
- Conventional synthetic DMARDS
- Biological and targeted synthetic DMARDS
Non-pharm therapy for RA
Stop smoking
Physio, OT
Orthotics/splints
name 3 csDMARDS for RA
Hydroxychloroquine
Methotrexate
Sulfasalazine
What are tsDMARDS? Advantages?
Jak inhibitors
Small molecule, work better/safer (less infection) than biologics
e.g. Olumiant
In OA the joint capsule is…
Thickened
6 Ps of compartment syndrome
1) Pain
2) Pallor
3) Paresthesias
(later)
4) Poikilothermia (cold)
5) Pulselessness
6) Paralysis
6 components of describing a fracture
1) Location on bone
2) Pattern
3) Displacement
4) Angulation
5) Articular involvement
6) Open or closed
Describing fracture location
Epiphysis
Metaphysis
Diaphysis (proximal, mid, distal)
Fracture pattern
Transverse Oblique (>30o) Spiral Segmented Comminuted
Fracture displacement
Describe distal relative to proximal
Shortened (impacted) vs distracted
Lateral/medial, palmar/dorsal, radial/ulnar
Fracture angulation
Opposite of apex or say ___ apex
Dorsal vs palmar, varus vs vaLgus (L = lateral)
Radial vs ulnar
Fracture articular involvement
Intra- or extra-articular
Open fracture AKA
Requires what intervention?
Compound fracture
30 min of surgical lavash
AB used for type I-III open fractures? What do you also add for type III?
Cefazolin (gram + coverage) for all
Gentamicin for type III (severe contamination)
What is a salter-harris fracture? 5 types?
Fracture through physis I = transverse through entire physis II = through physis + metaphysis III = through physis + epiphysis IV = through all 3 layers V = crush fracture of physis
Primary method for treating clubfoot
Ponseti method (serial casting)
Name the 5 deformities associated with clubfoot
Hindfoot: equinus (short achilles), varus
Midfoot: cavus
Forefoot: adductus, supination/inversion
Clubfoot detectable prenatally at ___ weeks via ___
12-13 weeks (after physiological shift away from equinovarus adductus position)
Transvaginal U/S
Clubfoot AKA
Talipes equinovarus
Common shoulder tendinopathy must be distinguished from ___ (reduced ROM), ____ (persistent weakness), and ____ (painful flexion)
Adhesive capsulitis
Rotator cuff tendon tear
Biceps tendinopathy
Trick to differentiate tendinopathy from tear (shoulder)
Give lidocaine , if ROM improves it’s tendinopathy & vv
Empty can test for ___ function
Supraspinatus
___ = gold standard imaging for tendon disorders
Ultrasound (dynamic)
____ and __ useful for evaluating & treating frozen shoulder respectively
Arthrography Arthroscopy (if conservative measures dont' work)
