MSK PANCE Flashcards
Osteoarthritis
Unilateral
Morning stiffness get better within hour
then worsens throughout the day
DIP (Heberden), PIP (Bouchard)
Joint space narrowing, osteophytes
NSAIDS, Tylenol
Rheumatoid arthritis
ANTI CCP, RF, ESR / CRP
Morning stiffness last longer than an hour
Gets better through the day
Boutonniere/ Swan neck deformity
MCP/PIP (DIP is spared)
Boggy, warm, erythematous
Females 30-50
DMARD Methotrexate, Leflunomide, Hydroxychloroquine
TNF, -mab’s
Steroids for symptoms
Lupus
Anti smith
ANti DS DNA
Drug induced - Hydralazine, Isoniazid, Quinidine, Phenytoin, Procainamide, Methyldopa
NSAIDS
Hydroxychloroquine - joints
Steroids for flare ups
Polymyositis
Weak muscles
Pelvic and shoulder issues
CPK Aldolase elevated, biopsy definitive
Anti Jo
Steroids, methotrexate
Polymyalgia rheumatica
Pain stiffness
No weakness
Giant cell arteritis
ESR/CRP
Steroids
Polyarteritis Nodosa
Nodules and necrosis
small medium arteries
Hep B/C
Livedo reticularis (lace like pattern)
Starburst pattern
ESR
ANCA usually negative
Glucocorticoids
cyclophosphamide (immunosuppressant)
Scleroderma
Women 30-50
SCl 70
Anti centromere
ANA
CREST
TIght shiny skin
Lifestyle
Treat symptoms
Sjogrens
Anti Ro
Anti La
High risk of non hodgkins
Schirmer test,
Rose Bengal Stain
Mononuclear cell infiltration on biopsy (salivary gland)
Artificial lubricants, cyclosporine (dry eyes)
Pilocarpine (cholinergic) (systemic)
Osteomyelitis
S. Aureus, Salmonella (Sickle cell)
Children
Femur/Tibia
Bone Marrow biopsy
Surgical debridement
ABX (Vanc)
Osteoporosis
Spine, HIp, Radius Fx
Vertebral Fx MC
Osteoclast increase (decrease in bone density)
Chronic steroids, elderly, menopausal, White
Dexa
Under -2.5 treat
Over 65
under 65 postmenopausal with risk
(-1.0 - -2.5 = osteopenia)
Aerobic weight bearing exercise
Calcium 1000mg, Vit D3 600mg
Bisphosphonate
HRT (estrogen)
PTH if needed
Displaced Humeral Head fracture
Axillary nerve injury
Medial epicondylitis
Golfer
Pronator teres / Flexor Carpi Radialis
Lateral epicondylitis
Tennis
Extensor carpi radialis Brevis
Dequervains
Tenosynovitis
Finkelstein test
Extensor pollicis brevis and abductor pollicis longus
Women, postpartum, DM
Repetitive motion
Pain at radial aspect of wrist
Thumb spica
NSAIDS, PT
Steroid inj
Compartment Syndrome
5 P’s
(MC injury to long bone)
Firm wood like
Compartment pressure over 30
CK / Myoglobin
Fasciotomy, Elevate limb while waiting
Chronic Osteomyelitis
Sprain vs strain
Spain is ligament
Strain has a t - Tendon
Herniated Disk
C4
Shoulder Elevation
Herniated Disk
C5
Weak shoudler abduction
decreased bicep reflex
Herniated Disk
C5-C6
Weak elbow flex
Can’t curl
weak external rotation
Herniated Disk
C6-C7
Decreased Tricep
First 3 digits
Herniated Disk
C7-T1
Weak thumb to pinky
Weak finger grip
ring, pinky
Herniated Disk
Lumbar
L5-S1 MC
Sciatica
Pain, unilateral
radiates down leg from butt
Herniated Disk
Lumbar
L1
Inguinal region
Herniated Disk
Lumbar
L2-L4
Spinal stenosis
anterior aspect of thigh
Diminished reflexes, knee jerk
Herniated Disk
Lumbar
L5
Lateral aspect of thigh
Reduced foot dorsiflexion, toe extension
Normal reflexes (only one with normal)
Herniated Disk
Lumbar
S1
Ankle jerk
Black Swan
Posterior thigh
Loss of sensory of plantar foot
Cauda Equina
Neurosurg emergency
Retention more common
Herniated disc, Tumor, Abscess
L4-L5 Disc Herniation MC
Saddle anesthesia, Sphincter tone
MRI
Surg Emergent
Humeral Shaft Fracture Nerve
Radial Nerve
Humeral Head Fracture Displaced Nerve
Axillary Nerve
Supracondylar fracture Nerve
Anterior interosseous nerve
Radial Nerve
Radial head fracture nerve
Posterior interosseous nerve
Nursemaid elbow reduction
Radial head subluxation
Tx Supination and flexion
or Hyper pronation
Normal xray
Monteggia Fx
Ulna
GRUM
(Radila Dislocation)
Galeazzi Fx
Radial
GRUM
(Ulnar dislocation)
Hip dislocation
Short
Adduction
Internal rotation
Posterior
Hip Fracture
Short
Abduction
External rotation
Femoral Neck
Blood supply (Medial Circumflex femoral artery)
ORIF
Ottawa ankle rules
Pain at
Lateral malleolus
Medial Malleolus
Navicular Pain
pain at 5th meta tarsal
cant walk 4 steps on exam
Gets Xray
Ankle fracture classification
Weber
Normal
A, B, or C
Jones fracture
Fx of diaphysis of 5th metatarsal
pain at Base of 5th meta tarsal
usually with weight bearing
non weight bearing short leg cast 6-8 weeks
Non weight bearing
Gout
Purines, ETOH, HCTZ
Rat bite lesions on imaging
Tx
Acute - NSAIDS, Colchicine
Chronic - Allopurinol (urate lowering)
Contraindicated
Loop, HCTZ, ASA
Cat and dog bite bacteria
Pasteurella
Bartonella henselae
Augmentin
Child with limp and no cause
Rule out septic arthritis
Joint aspiration
Mallett Finger
Avulsion of extensor tenson
Unable to extend DIP joint
DIP Tear, small avulsion fx
Splint for 6 weeks
Boutinere
PIP tear
Splint 4-6 weeks
Jammed finger
Swan shaped
Shoulder dislocation nerve
Axillary nerve
Knee dislocation Nerve
Common peroneal Nerve
(Popliteal Artery)
Open fracture ABX
Small get Ancef
Large gets Ancef and genta
Drug induced lupus antibody
Anti histone
Dermatomyositis Antibody
Anti Jo
scoliosis dx
cobb angle >10 on Xray
Henoch sholein comlication
Intussuseption
flexor synovitis clinical dx
pain on passive extension
ACL Test most sensitive
Lachman
Meniscus tests
McMurray
Apley
Fibromyalgia lab test
All labs are normal
Osteomyletits diagnostic labs
ESR/CRP
Blood cultures 50%
X-ray - Periosteal
Septic Arthritis
Knee MC, Hip MC in peds
S.Aureus - MCC
N. Gonorrhea - Sex
Strep pneumo - Kids
GBS - neonates
WBC >50000, Mostly Neutrophils
ESR/CRP
IV ABX - Ceftriaxone, Vanc, Nafcillian
Drain joint, debridement
Developmental hip dysplasia
Risk factors
Risks
Breech delivery
First born child
Females
Family history
Barlow Maneuver
Dislocates the hip
Adduct fully flexed hip without downward pressure
Ortolani Maneuver
Reduces and puts hip back in
Abduction and elevation
Developmental hip dysplasia
ortolani and barlow
Done at every well check until walking (9months)
Can us US under 4 months
under 6 months - pavlik harness
over 6 months - surgery
Legg Calve Perthes
Idiopathic avascular osteonecrosis of femoral head
Ages 4-10, Males, obesity (rare in AA)
Painless limp for weeks, worsens with activity
Loss of Abduction and internal rotation
Widening cartilage space
Positive crescent sign on x ray
Observation restrict activity
PT
Surgical
SCFE
Displacement of the femoral head from femoral neck
(through growth plate)
age 8-16, obese, AA, commonly seen during puberty
Painful Limp worse with activity
Hip, groin, knee pain
Externally rotated leg
x-ray - posterior displacement of femoral epiphysis
(ice cream slipping off a cone)
Frog leg lateral pelvis view
Non weight bearing crutches then surgery
MCL Test
Valgus
LCL Test
Varus
ACL tear
Lachman - most sensitive
Anterior drawer - less useful
Hemarthrosis
MRI
RICE
Surgery
PCL tear
Commonly associated with hitting the dashboard
Posterior drawer test
MRI
RICE, Surgery
Meniscus tear
Medial 3 times more likely than lateral
Popping, Locking
Mcmurray test
Apley test
MRI
RICE
SURGERY
Patella fx
Direct trauma
limited knee extension
Sunrise view, cross table lateral view
Non displaced = immobilize, cast
displaced = surgery
osgood schlatter
Inflammation of the patellar tendon at the tibial tubercle
due to overuse and repetitive knee extension and quad contraction
Males, ages 10-15, athletes
Pain during activity, knee pain and swelling (swelling at anterior tibial tubercle)
(Jumping)
Imaging not usually helpful
RICE
(surgery rare, but for refractory cases after growth plate is closed)
Quad rupture
Patella is pulled down
Patellar tendon rupture
pulled up by quad tendon
Patellar dislocation
Valgus stress after twisting injury
Females
Apprehension sign (anxiety before quad contracts when pushed laterally)
Reduce while gently extending the leg
Immbolize
Nightstick Fx
Isolated fracture of mid ulnar shaft
Short or long arm cast (depends on location)
Knee dislocation
Emergency
Common peroneal nerve (foot drop)
Popliteal artery
Femoral condyle fx Nerve
Peroneal nerve (foot drop)
Popliteal artery
Ortho, surg
Tibial plateau fx nerve
Peroneal nerve (foot drop)
x-ray may not show
CT is best
patella femoral syndrome
Runners, cyclists
overuse injury
knee pain around and behind patella
worse with hyperflexion, prolonged sitting standing, jumping etc
NSAIDS, RICE
PT
IT Band syndrome
Runners, cyclists
overuse injury
Lateral knee pain
tender over lateral condyle
Worse with stairs, climbing
Positive Noble compression test, or Ober test
RICE
PT
Steroid injections
MC ligament ankle sprain
ATF
Achilles rupture
Fluoroquinolones
Thompson test
MRI
Splint in mid plantar flexion
Surgery
Weber classification
Ankle fractures
Normal, A, B, or C
A is stable
B maybe stable or unstable Surg yes or no
C is unstable ORIF
Maisonneuve fracture
spiral fracture of proximal third of fibula
with distal medial maleolar fracture
Pilon fx
Fracture of distal tibia
Surg
Plantar fasciitis
flat feet or high arches
Pain with dorsiflexion
Worse in morning
RICE
NSAIDS
Tarsal tunnel syndrome
Posterior tibial nerve compression
Pain and numbness in medial malleolus, heel and sole
Worsens throughout the day
does not improve with rest
Positive tinel sign (tapping on nerve at medial malleolus
RICE
Surg
Neuropathic arthropathy (Charcot)
Joint damage and destruction as a result of peripheral neuropathy
decreased sensation, weakness
Joint and foot deformity, ulcer, skin changes
x ray - obliteration of joint space
RICE, special shoes
Surgery rare
Mortons neuroma
Interdigital neuroma
Compression of interdigital nerve
women 25-50
Tight shoes, heels, flat feet
Burning pain between 3rd and 4th digits
Numbness paresthesia
RICE
Steroid injection
SUrgery
Pseudo jones fx
More common than true jones fx
Fx through base of 5th metatarsal
Walking cast 2-3 weeks
If displaced ORIF
Lisfranc Fx
Displaced metatarsal bones
Fleck sign
ORIF
Salter harris fx
Type 1 straight
Type 2 Above
Type 3 Lower
Type 4 Through
Type 5 cRush
Salter harris fx Type 1
Straight
Best
Salter harris fx Type 2
Above
Most common
Salter harris fx Type 3
Lower
Salter harris fx Type 4
Through
Needs reduction
Salter harris fx Type 5
Crush
Worst, can affect growth
Osteosarcoma
Malignant tumor
Most common bone malignancy in children
90% are long bone (distal femur)
MC is METS to lungs (MC cause of Death)
Bone pain, worse at night
X-ray = Sunburst, Hair on end
Biopsy is definitive
Chemo, SUrgery and amputation
Chondrosarcoma
Cancer of cartilage
age 40-75
pain swelling, fx’s
x-ray = punctate or ring/arc appearance
Surg, Chemo
Lumbar Spinal stenosis
Narrowing of spinal canal (nerve impingement)
Pain walking down hill
Relieved with flexion or leaning over
(worse with extension)
No change with valsalva (unlike herniated disc)
Over 60
MRI
Steroid injection
Surgery
Ewing Sarcoma
Males ages 5-25
Lung mets
Femur and pelvis
X ray - Onion skin, Lytic
Chemo, radiation
Osteochondroma
Benign
Cartilage cap on bone cancer
Most common type of benign bone tumor.
Age 10-20, Males
X ray - Pedunculated
Observation
Osteoid Osteoma
Benign
Nidus
Increasing pain worse at night
CT/MRI
NSAIDS relieve pain
Fibromyalgia
Women 20-50
All Labs normal
Must have 11 out of 18 Trigger points
TCA is first line
Duloxetine (SNRI)
Pregabalin
DMARDS
Methotrexate
give folic acid (methotrexate)
Methotrexate affects liver
Test for HIV, Hep, TB (all DMARDS)
What needs to be monitored with Hydroxychloroquie
Eyes
Pex anserine
Gracilis
Sartorius
Semitendinosus
Subacromial buristis
Reduced active ROM
Normal Passive ROM
Pain with Abduction of shoulder
Shoulder
Frozen shoulder
Reduced active and passive ROM
Impingement tests Shoulder
Neer
Hawkins
Transient synovitis
Most common cause of limp in child
ages 3-10
Usually Post URI
Non traumatic
Rule out septic joint, Legg calve, SCFE
Blount Disease
Most common cause of bow legs in children
Is bow legs in children normal
Under 2 children can have bow legs
Bankart lesion location
Inferior Anterior
Under
Hill Sachs lesion
Superior Posterior
On top
ABX for large open fracture
Keflex and Genta
(+/- MRSA)
Kanavel sign
Flexor Tenosynovitis
Pain with passive extension
Tender
Flexed finger posture
Fat finger
Most common rotator cuff injury
Supraspinatus
SITS muscles
Supraspinatus
Infraspinatus
Subscapularis
Teres Minor
Test for sciatica
Straight leg,
Crossed leg test
(L2-L5)
HLA B27
Ankalosing spondylitis
Reiters Syndrome
Colles fracture
Median nerve
(thumb, index, middle fingers)
Fork deformity
Sugar tong splint
Extensor pollicis longus tendon rupture
Carpal tunnel
Median nerve
Diabetics, Women, pregnant
first 3 digits, worse at night
NSAIDS
Steroids
Surgery
Volar Splint
TB of spine
Potts
Sleep on arm (drunk) nerve
C7
Night bone pain
Think Cancer
Multiple Myeloma
Cancer affecting plasma cells of bone
IgG, IgM, IgA are affected
Most common bone cancer in adults over 65
Black males >65
Increased Calcium
Increased Protein
Vertebral Fx
Renal issues
Rouleaux
Punched out lesions
Stem Cell transplant, Chemo
Polymyalgia Rheumatica
Inflammation of Joints, Bursa, Tendons
GIANT CELL ARTERITIS
Pain and stiffness
Shoulder and pelvic girdle
Increased ESR/CRP
Steroids
Rhabdomyolysis
Trauma, Statins Cocaine, seizure etc
Leads to Acute tubular necrosis
Muscle pain, weakness
Dark Urine
ECG - Hyperkalemia
UA, Dipstick
CK > 5 x times limit of normal
Hyperkalemia, Hypocalcemia
IV fluids lots
Sodium bicarb
Mannitol
Calcium gluconate for Hyper K
Polymyositis
Muscle inflammation
WEAKNESS (no pain)
Shoulders and pelvis
CK/Aldolase is best initial test
Anti Jo, Anti SRP
Steroids
Polymyalgia Rheumatica vs Polymyositis
Polymyositis is weakness
Polymyalgia rheumatica is normal strength (pain and stiffness)
Dermatomyositis
Derm issues with muscle inflammation
Associated with cancer 25%
Shoulder and hip weakness
Gottron’s papules (mechanics hands) (violaceous papules on dorsum of hand)
Heliotrope rash - Edema and blue color on upper eyelids
Shawl sign and Malar rash
Ck/Aldolase best initial test
ANTI Jo, Anti MI2
Biopsy is definitive
Steroids first line
Hydroxychloroquine for skin lesions
DMARDS
SLE (Lupus)
Females 20-40, AA
Joints, Malar rash, Antiphospholipid syndrome,
Multiple system issues
ANA Screening
Anti DS DNA and Anti Smith specific for SLE
Pancytopenia
Antiphospholipid syndrome
Avoid UV, Hydroxychloroquine
Steroids, Pulse therapy IV steroids
DMARDS, Immunosuppresants
Drug induced lupus
HIPPS Q - Hydralazine, isoniazid, Procainamide, phenytoin, Sulfas, Quinidine
SLE symptoms
Anti HIstone Antibodies
Anti Phospholipid Syndrome
SLE
Risk of arterial and venous thrombosis (recurrent DVT/PE)
Livedo Reticularis
Anticardiolipin Antibodies
Increased PTT
Warfarin or anticoags if recurrent thrombosis
LMWH if pregnant
Behcets Syndrome
Painful oral and genital ulcers
Erythema Nodosum
Uveitis
Asian/Middle eastern 20-40
Biopsy is definitive
Steroids
Takayasu Arteritis
Aorta and branches (large vessel arteritis)
Women, Asian, 10-40
Lower extremity claudication, vascular issues
Bruits, low pulses, pulse difference in arms
Angiography
Steroids
Dmards
Revascularization
Kawasaki
Small medium vessel arteritis
Boys under 5, asian
CRASH & Burn
Conjunctivitis
Rash
Adenopathy
Strawberry Tongue
Hand and foot edema (swelling)
Burn - Fever for 5 days
ECG,
Coronary artery Aneurysm
IVIG + ASA
Polyarteritis Nodosa
Small medium Vessel vasculitis
This vasculitis does not involve lung vessels
HEP B/C
HTN (renal artery stenosis)
Ulcers, purpura, raynauds
Livedo reticularis (Starburst pattern)
ANCA is negative
Renal/Mesenteric angiography
Biopsy is definitive
Steroids
Cyclophosphamide
Churg strauss
Eosinophilic Granulomatosis with Polyangiitis
Lungs MC affected
Asthma and eosinophilia (chronic Sinusitis)
P-ANCA positive with eosinophils
Steroids, Cyclophosphamide
Wegeners
Granulomatosis with Polyangiitis (no eosinophils)
Triad - Nose, lungs, kidneys
URI, LRI, Glomerulonephritis
C-ANCA positive
biopsy is definitive, (large necrotizing granulomas)
Steroids, Cyclophosphamide
Microscopic polyangitis
Capillary vasculitis
Palpable purpura
Similar to Wegeners but no URI symptoms
Biopsy is definitive, non granulomatous inflammation
Steroids, Cyclophosphamide
Henoch Schonlein
90% ages 3-15
After URI
GABHS, Parvovirus
4 cardinal symptoms
Hematuria, Arthralgia, Palpable purpura, Abdominal pain
Purpura on butt and legs
Normal platelets, PT, PTT
Mesangial IgA
Supportive
Goodpastures
Anti GBM Antibody
(type 2 sensitivity, type 4 collagen))
Lungs and kidneys
Hemoptysis, hematuria
UA
RBC Casts
Anti Glomerular basement membrane antibodies
Steroids + Cyclophosphamide + Plasmapheresis
Psoriatic arthritis
Arthritis with Psoriasis
Looks like RA but includes DIP joint (symmetrical or unilateral)
Pencil in cup deformity (bony erosions)
NSAIDS 1st line
Methotrexate, TNF, Interleukin antagonists
Ankylosing Spondylitis
HLA B27
Men 15-30
Back pain, stiffness
Worse in morning
Uveitis
ESR (neg RF and ANA)
Narrowing sacral joint
Bamboo spine (squaring and fusion of vertebrae)
MRI
NSAIDS, exercise, PT
Anti TNF (infliximab)
Reactive arthritis
Reiter’s syndrome
Cant see, can’t pee, cant climb a tree
Arthritis, Conjunctivitis/uveitis, Urethritis
Lesions on palms and soles
Rule out septic arthritis
ESR, IgG
NSAIDS 1st line
Methotrexate sulfasalazine
Alphafeto protein marker
Liver cancer
testicular cancer
Decreased in down syndrome
Beta HCG Marker
Testicular cancer
Choriocarcinoma
Teratoma
Trophoblastic tumor
Ca-125 Marker
Ovarian cnacer
CA 19-9 Marker
Pancreatic cancer
Calcitonin Marker
Medullary Thyroid cancer
CEA Marker
Colon cancer
Rectal cancer
PSA Marker
Prostate cancer
Losartan in gout
Urate lowering
Pseudogout
calcium deposits in joints
Positive birefringent rhomboid crystals
Large joints - Knee MC, Elbow, wrist, MCP joint
Rule out Septic joint, gout
Steroid injection
NSAIDS
Colchicine
Juvenile rheumatoid arthritis
Children under 16
must last over 6 weeks
Stills disease (fever, Salmon colored rash,
Anterior uveitis
Large joints - Knee, ankle etc
ESR/CRP
NSAIDS
Steroids
Herniated disc
MC L5-S1
Positive straight leg raise, Crossed leg raise
MRI best
NSAIDS, continue normal activity
Steroid injection
Surgery
Spinal abscess
Staph A MC
IV drug use, immunodeficiency
Fever, Spinal pain, Neurodeficits
MRI
Aspirate, drain
ABX - Vanc Plus Cefotaxime or rochepi
Scoliosis
Lateral curve of spine
Girls, family history, age 10
Adams forward bend test
Scoliometer - 7 degree
Xray - cobb angle of >10
Under 25 on Cobb = Observation
Over 25 bracing
Surg if over 40
Thoracic outlet syndrome
compression of brachial plexus
women 20-50
Pain paraesthesia in forearm
Swelling discoloration with raising of arm
Positive adson sign (loss of radial pulse with rotation of head to affected side
Conservative, PT, Ortho consult
Spondylolysis
Scottie dog
Pars interarticularis
failure to fue, stress fx
Low back pain with activity
Spondylolisthesis
Forward slipping of vertebrae
Low back pain
Rotator Cuff
SITS, Supraspinatus MC
Tendonitis MC under 40
Tear MC over 40
Hawkins, Neer, Drop arm,
Adhesive capulitis
Frozen shoulder
DM and hypothyroid
Shoulder pain/stiffness
Decreased ROM (external rotation)
Worse at night
PT
NSAIDS
Supracondylar fx
Anterior or posterior fat pad sign
Hemarthrosis
Median nerve and brachial artery injury can lead to volkmann contracture
Radial nerve injury
Long arm splint then long arm cast
Flexor Tenosynovitis
Infection of finger sheath
Staph A MC
Penetrating trauma
Kanavel Sign
Pain with passive extension
Tender
Flexed finger posture
Fat finger
I & D
ABX
Olecranon Buristis
Trauma
Rule out septic bursitis
Pad area, NSAIDS, Ace wrap
if Septic, drain + ABX
Elbow Dislocation
Posterior MC
Emergent Reduction with posterior splint
Cubital tunnel syndrome
Ulnar nerve compression
Paraesthesia and pain along ulnar nerve
worse with flexion
+tineal elbow sign
Scaphoid fx
Non displaced Thumb spica
Displaced surg
if xray neg - treat as fx splint and reeval or refer
Smith Fx
Distal radius fx
Spoon shovel deformity
Stable - closed reduction
Sugar tong
ORIF
CRPS
Complex regional pain syndrome
30% have no injury
Upper extremities, females, over 30
Pain out of proportion, edema, dysfunction
NSAIDS
PT, Nerve block, steroids, TCA
Vitamin C prophylaxis to reduce fx risk
Gamekeepers thumb (skiers)
Ulnar collateral ligament of thumb sprain
Thumb spread wide
Thumb spica
Boxer fx
5th metacarpal fx
Ulnar gutter splint
Augmentin for bite wound
Bennett Fx
Metacarpal fx at base of thumb
Comminuted = rolando (shattered) (Y sign)
Thumb spica
Dupuytren contracture
Men, over 40, white
Progressive Fibrosis of palmar fascia leading to contracture
Palpable nodule over palmar crease
Deformity of MCP joint
Steroid or collagen injection
Surgery
