MSK Conditions Flashcards
Multiple Myeloma: MC Symptom
-Persistent skeletal pain (70% of cases) that is usually <6 months in duration
-Pain is usually back and rib pain
What type of fractures are common in multiple myeloma?
Pathological fractures; sudden onset of pain (vertebral collapse)
Multiple Myeloma: Areas of Swelling (7)
Ribs, skull, sternum, vertebrae, clavicle, shoulders, pelvis
Mutiple Myeloma: Other Signs/Symptoms
• Renal failure/insufficiency
• Recurrent bacterial infections
• Anemia
• Bleeding (purpura or epistaxis) – only in thrombocytopenia
• Weight loss, weakness, lethargy
Multiple Myeloma: Lab Findings (Protein)
-Serum total protein (high): High globulin, NL/low albumin*
-Serum protein electrophoresis: Reversed A:G Ratio*
-Bence Jones Proteinuria*
Multiple Myeloma: Lab Findings (CBC/Blood findings)
-N/N anemia
-PBS: Rouleau
-Increased ESR
-Normal: WBC, Platelets
-Lymphocytosis
Multiple Myeloma: Lab Findings (Enzymes)
-Normal ALP*: Marrow issue (osteoclastic), not bone
Multiple Myeloma: Other Lab Abnormalities
-Abnormal KFTs**: BUN, Creatinine, Uric Acid
-Serum Calcium: Elevated in some patients
Mulitple Myeloma: Follow-Up
• Suspicion – order protein electrophoresis
• Definitive diagnosis – bone marrow biopsy
Multiple Myeloma: X-Ray Findings
• Pelvis, spine, ribs and skull are most commonly affected
• Punched-out lytic lesions
• Bone scans are not usually helpful
Osteolytic Metastasis: Lab Findings
-Increased: Urine Calcium, Serum ACP (if prostate cancer)
Osteolytic Metastasis: X-Ray Findings
• Pathological fractures
• No periosteal reaction or sclerosis
• Kidney, lung, breast and thyroid are most common
• Kidney/thyroid - cause blow out lesions
Osteoblastic Metastasis: Lab Findings
-Increases: Serum ALP, Serum ACP (if prostate cancer)
-Decreased: Urine Calcium
-Normal: Serum Calcium
Osteoblastic Metastasis: X-Ray Findings
• Sclerosis
• Normal architecture is lost
• Usually breast or prostate
What is usually affected in multiple myeloma
Pelvis, spine, ribs and skull
Osteolytic Metastasis: Most commonly affected
• Kidney, lung, breast and thyroid are most common
Osteoblastic Metastasis: Most commonly affected
Breast or prostate
Primary Bone Tumors: Lab Abnormalities (“HEAL”)
• Hypercalcemia
• Anemia
• ESR/CRP elevations
• LDH elevation
Osteosarcoma: Signs/Symptoms
*Most significantly night pain
-Pain and swelling are the most consistent symptoms: Onset if gradual, progressive
-Pain is aching and persistent
Osteosarcoma: Lab Findings
Serum ALP increases
Osteoarthritis: Signs/Symptoms
-Pain worsened by exercise: Usually resolves in <30 mins
-Decreased ROM, Crepitis, joint deformity
Osteoarthritis: Lab Findings
Usually Normal Findings: ESR could become increased
Osteoarthritis: X-Ray
• Irregular or asymmetric narrowing of the joint space
Rheumatoid Arthritis: Signs/Symptoms
-Tenderness in nearly all inflammed joints (most sensitive)
-Joint pain on passive ROM
-Stiffness lasting >30 mins (morning/prolonged activity)
-Diffuse swelling of hands and wrists
Rheumatoid Arthritis typically affects:
Small hand joints, feet, wrists, elbows, ankles is typical
Rheumatoid Arthritis: Systemic Symptoms
(“SO FLAMED”)
• fatigue
• malaise
• depression
• anorexia
• lymphadenopathy
• splenomegaly
• ocular disease
• entrapment neuropathies
________ are seen in 30-40% of RA patients
Subcutaneous nodules
What disease is typically found during lab findings w/ RA?
Anemia of chronic disease (80%)
Rheumatoid Arthritis: Lab Findings
• ESR is elevated in 90% of cases; CRP commonly elevated
• Rheumatoid factor positive: Not specific for rheumatoid arthritis (some conditions cause false +)
• Anti-Cyclic Citrullinated Peptide (Anti-CCP) Antibodies
• ANA
Rheumatoid Arthritis: Early X-Ray Findings
• Early: Soft tissue swelling; Increased/decreased joint space; Subarticular osteoporosis; Marginal erosions/cysts
How to differentiate between Osteoarthritis and RA?
-Time: Osteoarthritis (>30 mins)/RA (>30mins)
-Pain: Osteoarthritis (worsened w/ exercise)/RA (Worse in the morning and w/ passive ROM)
-Lab Findings: Osteoarthritis (NL)/RA (Elevated ESR, RF, Anti-CCP, ANA & ACD is common-80%)
Where does Psoriatic Arthritis Most Commonly Occur?
-Psoriasis of the nails (90%) or skin (5%)
• SI Joint & Spine
• The DIPs of the fingers and toes are especially affected.
Psoriatic Arthritis: Signs/Symptoms
• Joint swelling, tenderness, warmth, restricted movement
• Fever, malaise
• Morning stiffness, pain
• Sausage digit
• No subcutaneous nodules
Psoriatic Arthritis: Lab Findings
• Increased serum uric acid in 30% of cases
• HLA-B27 antigen present in patients with spondylitis-type psoriatic arthropathy
• ESR elevated in acute phase
• May have the anemia of chronic disease
Gouty Arthritis: Structures MC Involved
• The metatarsophalangeal joint of the great toe is frequently involved
-Subcutaneous nodules: Ears & extensor surfaces
Gouty Arthritis: Signs/Symptoms
• Acute mono-or polyarticular pain: Described as throbbing, crushing or excruciating
• Inflammatory response: Shiny, tense, hot, dusky red skin, exquisite tenderness
• Subcutaneous or intraosseous nodules (20%) (tophi): Commonly impacts ears & Extensor surfaces
Gouty Arthritis: Precipitating Factors
Precipitating factors:
• Primary pathology->hyperuricemia
• Dietary choices: High purine foods, Fructose & Alcohol
• Insulin resistance
• Hydration
• Certain medications
Does Psoriatic Arthritis contain subcutaneous nodules?
No
Gouty Arthritis: Lab Findings
• Increased serum uric acid levels: Not diagnostic, cardinal biochemical abnormality;
• Leukocytosis with left shift – acute attack
• Increased ESR: Acute attack
What factors can lower uric acid levels?
Aspirin, vitamin C may lower uric acid to below reference values
What factors can lower uric acid levels?
Aspirin, vitamin C may lower uric acid to below reference values
Chondrocalcinosis: Signs & Symptoms
• Acute pain & swelling of 1+ joints: Knee involved in 1/2 of all attacks (ankle, wrist & shoulder also common)
• Inflammation, joint effusion, decreased ROM
• Unexplained attacks of arthritis: acute or subacute
• Fever possible
Chondrocalcinosis (CPPD): Most common areas affected
Knee: Most common, Pubic symphysis pubis 2nd most common; Similar to DJD
Chondrocalcinosis: Lab Findings
Synovial fluid analysis
• Crystals are weakly positively birefringent
• Leukocytosis with predominantly neutrophils (80-90%)
• Elevated ESR
Chondrocalcinosis: X-Ray Findings
• Articular cartilage calcification
• Periarticular calcification
• Pyrophosphate arthropathy
Septic Arthritits is predominantly:
Monoarticular (90%)
Septic Arthritis: Infants
Irritability, fretfulness, fever, fails to move limbs spontaneously, tenderness or pain with passive movement
Septic Arthritis: Older Children & Adults
Acute joint pain, stiffness: Mc = knee (Followed by shoulder, wrist, hip, fingers, elbow)
Septic Arthtritis will have a ______ during the course of an infection?
Fever (90%)
Septic Arthritis: Other Symptoms
• Joint effusion, tenderness
• Joint warmth/redness – present in <50%
• Loss of joint motion
• Tenosynovitis
• Chills, malaise
Septic Arthritis: Lab Findings
• Leukocytosis with neutrophilia
• Increased ESR/CRP
Septic Arthritis: Synovial Fluid Analysis
• Cloudy
• >50,000/ul WBC/hpf
• >90% Neutrophils
• Synovial fluid: blood glucose less than 0.5
• Absence of crystals
Septic Arthritis: X-Ray Findings
• Soft tissue swelling
• Joint displacement
Ankylosing Spondylitis: Signs & Symptoms
• Episodes of insidious onset of aching low back pain: MC
• Subgluteal or LBP and/or stiffness
• Duration >3 months
• Morning stiffness (relieved by activity)
• Often nocturnal recurrent back pain: Get up to “walk off” back pain
• Pleuritic chest pain is often an early feature
Ankylosing Spondylitis: Lab Findings
• Anemia of chronic disease in 30% of cases
• Increased ESR
• Increased CSF protein
• Increased incidence of HLA-B27 antigen
Reactive Arthritis: Urogenital Tract S/Sx
• Urethritis 7-14 days after exposure
• Prostatitis, cervicitis (usually asymptomatic) possible
Reactive Arthritis: Eye Signs & Symptoms
• Conjunctivitis is the most common eye lesion
• 30-50% of patients
• usually bilateral
• mild and non-infectious appearing
• lasts only a few days
• develops over the next few weeks, usually mild
Reactive Arthritis: Other Symptoms
• Joint pain and swelling – knees, ankles, feet
• Enthesitis – Achilles tendon and plantar fascia
• Sacroiliitis: Inflammation of the SI joint
• Skin lesions similar to psoriasis possible
• Enteritis possible
• Fever, fatigue possible
Reactive Arthritis: Lab Findings
• Increased ESR/CRP
• Leukocytosis and mild normo/normo anemia possible
• 60-80% have +HLA-B27
Peripheral Arthritis: Areas Affected
• Affects the large joints of the arms and legs (knees, ankles, elbows, wrists)
• Often migratory and asymmetrical
Axial Arthritis: Areas Affected
• SI joints and spinal involvement
• Chronic lower back pain and stiffness, particularly in the morning or after periods of inactivity
Enteropathic Arthritis: Labs
• ESR/CRP elevations possible (corresponds w/ flare of IBD)
• May have anemia of chronic disease
• HLA-B27 – positive in some patients, more likely in those with spinal involvement
Lyme Disease: Progression
-Stage 1: Skin rash, flu-like symptoms
-Stage 2: 1+ organ systems involved; Neurogenic or Cardiac
-Stage 3: Arthritis (large joints), chronic neurologic symp.
Lyme Disease Lab Findings
-ELISA—>Western Blot (Confirmation)
-IgM and IgG against Borrelia Burgdorferi
-Elevated ESR
-CRP: Monitors treatment
-Leukocytosis possible
Osteoporosis: Signs/Symptoms
• may be asymptomatic
• aching pain in the bones, especially the back
• Acute pain, localized, aggravated by weight bearing
Those with osteoporosis have increased likelihood of:
Atraumatic & Crush Fractures
What areas are commonly affected by osteoporosis:
• Vertebra, upper femur, distal radius, proximal humerus, pubic ramus, ribs
Osteoporosis: Lab Findings
-Usually all normal
• CBC, multi-panel chemistry tests usually normal
• Normal serum calcium, phosphorus, ALP, protein ELP, ESR, urinary calcium
• Following fracture – ALP may be transiently elevated
Paget’s Disease: Signs & Symptoms
• Most often the disorder is asymptomatic
• Picked up on routine blood work
• Increasing skull size: Hat too small & bitemporal skull enlargement with frontal bossing
• Headaches
• Decreasing auditory acuity
Paget’s Disease: Pain symptoms
• Bone pain: Mild to severe, Deep/aching, May be accentuated at night, Constant, unrelated to activity
• Spine pain: LBP common & Can have radiculopathy
• Acute bone pain suggests:Pathologic fracture & malignant degeneration
What enzyme is typically increased in Paget’s disease?
• **Serum alkaline phosphatase usually increased
• Elevations will fluctuate throughout stages of life and disease course
How is serum calcium affected in Paget’s Disease?
• **Serum calcium normal, rarely increased
Paget’s Disease: Other Lab Findings
• Serum phosphorus normal
Osteomalacia & Rickets
• Bowing of long bones – softened bones
• Vertical shortening of the vertebrae – d/t softened bone
• Flattening of the pelvic bones – contracts the pelvic outlet
Osteomalacia & Rickets: Signs/Symptoms
• Bone pain (dull), tenderness, muscle weakness
• Weight loss, anorexia, tetany
• Other symptoms: Malnutrition or chronic renal disease
What is usually affected in osteomalacia & rickets?
Affecting the ribs and upper thighs; muscle weakness is usually proximal
What type of fractures are common in osteomalacia & Rickets?
• Pseudofractures – incomplete ribbon-like demineralizations appear in the cortex
Osteomalacia & Rickets: Lab Findings
• Serum calcium may be normal/decreased (never high)
• Hypophosphatemia (low phosphates)
• ALP is increased
• Decreased serum Vitamin D and its metabolites
• Increased serum PTH
• Urinary calcium is low in all forms of the disease except those associated with acidosis
Which MSK disorders will have HLA-B27 antigens?
-Psoriatic arthritis: spondylitic-type arthropathy
-Enteropathic Arthritis
-Ankylosing Spondylitis
-Reactive Arthritis
“PEAR”
Septic Arthritis: How long before changes are seen on X-Rays?
• 10 days in the extremities
• 21 days in the spine
Most sensitive test of Paget’s Disease
• Urine pyridinoline crosslinks
Rheumatoid Arthritis: Late X-Ray Findings
• Late: Deformities with subluxations; Bony destruction; Bony fusion; Complete destruction of joint space