MSK Patho UE Flashcards
DJD/OA are characterized by
- Degeneration of articular cartilage with hypertrophy of subchondral bone & joint capsule of weight bearing joints
- Most common form of arthritis affecting men more than women before age 50 and women more than men after age 50
- Slowly progressive condition
Signs and symptoms of DJD/OA
- Pain
- Swelling
- Loss of ROM
- Bony deformity
Radiographic findings indicating OA
- Diminished joint space
- Decreased height of articular cartilage
- Presence of osteophytes
- Subchondral cysts
Primary medications used for management of DJD/OA
- Oral analgesics
- NSAIDs
- Corticosteroid injections
- Viscosupplementation or intra-articular injections of the knee with a form of hyaluronic acid can be used
Pathology of Ankylosing spondylitis
- Progressive inflammatory disorder of unknown etiology that initially affects axial skeleton
- HLA-B27 biomarker indicating disease
Timeline of symptoms for Ankylosing spondylitis
- Mid to LBP for ≥3 months before the 4th decade of life
- Morning stiffness and sacroiliitis
- Results in kyphotic deformity of cervical/thoracic spine & decreased lumbar lordosis
- Men affected 3x more than women
Medications used for management of Ankylosing spondylitis
- NSAIDs to reduce inflammation & pain
- Corticosteroids to suppress immune system to control various sx
- Cytotoxic drugs (drugs that block cell growth) for those that don’t respond well to other treatments
- Tumor necrosis factor (TNF) inhibitors to improve some sx
Pathology of Gout
- Genetic disorder of purine metabolism
- Characterized by elevated serum uric acid (hyperuricemia)
- Uric acid changes into crystals & deposits into peripheral joints & other tissues
What joints is Gout most frequently observed
- Knee
- Great toe
Medications for management of Gout
- NSAIDs
- COX-2 inhibitors
- Colchicine
- Corticosteroids
- Adrenocorticotropic hormone (ATCH)
- Allopurinol
- Probenecid
- Sulfinpyrazone
Pathology of Psoriatic arthritis
- Chronic, erosive inflammatory disorder of unknown etiology, associated with psoriasis
- Both sexes affected equally
- Erosive degeneration typically of the digits and axial skeleton joints
Medications for management of Psoriatic arthritis
- Acetaminophen for pain
- NSAIDs
- Corticosteroids
- DMARDs (disease modifying anti rheumatic drugs) to slow progression
- Biological response modifiers (BRM) like Enbrel
Pathology of RA
- Chronic systemic autoimmune disorder of unknown etiology thought to have a genetic basis
- Pts produce antibodies to their own immunoglobulins (RF and ACPA)
- Characterized by periods of exacerbation and remission
Who does RA affect
- Women affect 2-4x more than men
- Age of onset ~40-60
- Onset may be gradual or abrupt
How is RA characterized
- Bilateral and symmetrical synovial joint involvement
- Most common joints include hands, feet, and cervical spine
- Systemic features may include weight loss, fever, and extreme fatigue
Diagnostic testing for RA
- Radiographs
- Increased white blood cell count
- Increased erythrocyte sedimentation rate
- Elevated rheumatoid factor
- Hemoglobin and hematocrit will show anemia
Medications for management of RA
- Golds and DMARDs in early stages
- NSAIDs and immunosuppressive agents
- Corticosteroids for acute flare-ups or long term management
Pathology of osteoporosis
- Metabolic disease that depletes bone mineral density/mass, predisposing individual to fracture
- Affects women 10x more than men
Common fracture site for osteoporosis
- Thoracic and lumbar spine
- Femoral neck
- Proximal humerus
- Proximal tibia
- Pelvis
- Distal radius
What is primary/postemenopausal versus senile osteoporosis
- Primary: directly related to a decrease in estrogen production
- Senile: occurs due to a decrease in bone cell activity secondary to genetics or acquired abnormalities
Medications for management of osteoporosis
- Calcium
- Vitamin D
- Estrogen
- Calcitonin
- Biophosphonates
Pathology of osteomalacia
- Decalcification of bones due to vitamin D deficiency
- Sx: severe pain, fractures, weakness, deformities
Medications for management of osteomalacia
- Calcium
- Vitamin D
- Vitamin D injections in the form of calciferol (vitamin D2)
Diagnostic tests for osteomalacia
- Radiographs
- Urinalysis and blood tests
- Bone scan
- Bone biopsy if warranted
Pathology of osteomyelitis
- Inflammatory response within bone caused by an infection
- Usually caused by Staphylococcus aureus
- More common in children and immunosuppressed adults
- More common in men than women
Treatment for osteomyelitis
- Antibiotics
- Proper nutrition
- Surgery if infection spreads to joints
Pathology of myofascial pain syndrome
- Characterized by “trigger point” which is a focal point of irritability found within a muscle
- Trigger point can be identified as a taut, palpable band within the muscle
Difference between an active versus latent trigger point
- Active: tender to palpate & have a characteristic referral pattern of pain when provoked
- Latent: palpable taut bands that are not tender to palpate but can be converted into an active trigger point
Medical intervention for trigger points
- Dry needling
- Analgesic injection
- Can be combined with a corticosteroid
Pathology of tendonosis/tendonopathy
- Dysfunction caused by an imbalance between tendon loading and recovery which leads to tendon failure an a microscopic and eventually macroscopic level
Histological characteristics of tendonosis/tendonopathy
- Hypercellularity
- Hypervascularity
- No indication of inflammatory infiltrates
- Poor organization and loosening of collagen fibrils
Pathology of bursitis
- Inflammation of bursa secondary to overuse, trauma, gout, or infection
Signs and symptoms of bursitis
- Pain with rest
- PROM and AROM are limited due to pain but not in a capsular pattern
Medications for management of bursitis
- Acetaminophen
- NSAIDs
- Steroid injections
Pathology for muscle strains
- Inflammatory response within a muscle following a traumatic event that caused microtearing of the musculotendinous fibers
- Pain and tenderness within that muscle
- Pain with active contraction and passive stretch of the muscle
Pathology of myositis ossificans
- Painful condition of abnormal calcification within a muscle belly
- Usually precipitated by direct trauma that results in hematoma and calcification of the muscle
What are the most frequent locations for myositis ossificans
- Quadriceps
- Brachialis
- Biceps brachii
When is surgery warranted for management of myositis ossificans
- Only in pts with non-hereditary form
- Only after maturation of the lesion (6-24 months)
- Indicated when lesion mechanically interferes with joint movement or impinge on nerves
Pathology of complex regional pain syndrome (CRPS)
- Etiology unknown but thought to be related to trauma or precipitating event
- Results in dysfunction of sympathetic nervous system to include pain, circulation, and vasomotor disturbances
What are the 2 types of CRPS
- CRPS I: frequently triggered by tissue injury; no underlying nerve injury
- CRPS II: experience the same symptoms but their cases are clearly associated with a nerve injury
Medical interventions for CRPS
- Sympathetic nerve block
- Surgical sympathectomy
- Spinal cord stimulation
- Intrathecal drug pumps
Medications for management of CRPS
- Topical analgesics
- Antidepressants
- Corticosteroids
- Opioids
Long term changes associated with CRPS
- Muscle wasting
- Trophic skin changes
- Decreased bone density
- Decreased proprioception
- Loss of muscle strength from disuse
- Joint contractures
Pathology of Paget’s disease (osteitis deformans)
- Etiology unknown but thought to be linked to a type of viral infection along with environmental factors
- Consider a metabolic bone disease involving abnormal osteoclastic and osteoblastic activity
- Results in spinal stenosis, facet arthropathy, & possible spinal fracture
Medications for management of Paget’s disease
- Acetaminophen for pain control
- Calcitonin & etidronate disodium to limit osteoclast activity
Pathology of torticollis
- Spasm and/or tightness of SCM muscle with varied etiology
- Dysfunction observed is sidebending toward & rotation way from the affected SCM
What position do anterior-inferior GHJ dislocations occurs in
- Occurs when abducted upper extremity if forcefully ER causing tearing of inferior glenohumeral ligament, anterior capsule, and possibly the glenoid labrum
What position do posterior GHJ dislocations occur in
- Rare and occur with horizontal adduction and IR of the GHJ
What is a Hills-Sachs lesion
- Compression fracture of the posterior humeral head
- Associated with an anterior-inferior dislocation of the humerus
What is a Bankart lesion
- Avulsion of the anterior-inferior capsule and glenoid labrum
- Associated with an anterior-inferior dislocation of the humerus
Presentation of an axillary nerve injury due to GHJ dislocation
- Exam will demonstrate numbness and tingling in the lateral deltoid and weakness in shoulder abduction
- Inability to abduct arm with neutral rotation
Signs and symptoms of possible spinal accessory nerve involvement in the shoulder
- Inability to abduct arm beyond 90º
- Pain in shoulder on abduction
Signs and symptoms of possible long thoracic nerve involvement in the shoulder
- Pain on flexing fully extended arm
- Inability to flex fully extended arm
- Winging starts at 90º forward flexion
Signs and symptoms of possible suprascapular nerve involvement in the shoulder
- Increased pain on forward shoulder flexion
- Shoulder weakness (partial loss of humeral control)
- Pain increases with scapular abduction
- Pain increases with cervical rotation to opposite side
Characteristics of atraumatic shoulder instability
- Global hypermobility
- Throwing athletes
- Characterized by popping/clicking in the joint
Signs and symptoms of a glenoid labrum tear
- Should pain that cannot be localized to a specific point
- Pain is made worse by overhead activities or when the arm is held behind the back
- Weakness
- Instability in the shoulder
- Pain on resisted flexion of the biceps (bending the elbow against resistance)
- Tenderness over the front of the shoulder
Physical therapy guidelines following a glenoid labrum surgery
- Avoid apprehension position (90/90º abduction/ER) for 12 wks post-op
- Shoulder is usually kept in a sling for 3-4 wks
- After 6 wks more sports specific training can be done although full fitness may take 3-4 months
Common areas of compression for TOS (thoracic outlet syndrome)
- Superior thoracic outlet
- Scalene triangle
- Between clavicle and first rib
- Between pectorals minor and thoracic wall
Special tests useful in making a TOS diagnosis
- Adson’s test (anatomical position of arm with head ipsi turn)
- Roos test (90-90 with pumping fists)
- Wright test (90-90 position no head turn)
- Costoclavicular test (depress/retract shoulder in neutral0
MOI for AC/SC joint disorders
- Fall onto shoulder with upper extremity adducted or a collision with another individual during a sporting event
Tendons of rotator cuff are susceptible to tendonitis and tears due to relatively
- Poor blood supply near insertion of muscles
Common symptoms of rotator cuff disorders
- Pain (night pain is common)
- Weakness
- Loss of shoulder ROM (active > passive)
Common MOIs for rotator cuff disorders
- Compression/impingement: mechanical impingement of distal attachment of rotator cuff on the anterior acromion and/or coracoacromial ligament with repetitive overhead activity
- Tensile overload: repetitive resistance to horizontal adduction, IR, anterior translation, & distraction
- Macrotrauma (RTC tear): forces generated by trauma exceed tendon tensile strength
Characteristics of internal (posterior) shoulder impingement
- Characterized by an irritation between the rotator cuff and greater tuberosity or posterior glenoid and labrum
- Often seen in athletes performing overhead activities
- Pain commonly noted in posterior shoudler
MOI and population typically affected by proximal humeral fractures
- Humeral neck fracture: occur with a FOOSH (fall on outstretched hand) among older osteoporotic women; generally does NOT require immobilization/surgical repair since it is a fairly stable fx
- Greater tuberosity fracture: more common in middle aged and elder adults; usually related to a fall onto the shoulder & does NOT require immobilization for healing
Pathology of adhesive capsulitis (frozen shoulder)
- Characterized by restriction in shoulder motion as a result of inflammation & fibrosis of the shoulder capsule usually due to disuse following injury or repetitive microtrauma
- Commonly seen in association with DM and thyroid disease
Loss of motion in non-capsular pattern (extension > flexion) of the elbow can be the result of
- A loose body in the joint
- Ligamentous sprain
- Complex region pain syndrome (CRPS)
Pathology of lateral epicondylalgia/epicondylitis (tennis elbow)
- Most often a chronic degenerative condition of the the extensor carpi radiialis brevis tendon (ECRB) at its proximal attachment at the lateral epicondyle
- Gradual onset usually the result of sports or occupations requiring repetitive wrist extension or strong grip with wrist extended resulting in overload of the ECRB
Pathology of medial epicondylitis/epicondylalgia (golfer’s elbow)
- Usually a degenerative condition of the pronator teres & flexor carpi radialis tendons at their attachment to the medial epicondyle
- Occurs with overuse sports (pitching, golf swings, swimming) or occupations requiring a strong hand grip & excessive pronation of the forearm
Pathology of osteochondritis dissecans
- Affects central/lateral aspect of capitellum/radial head
- Osteochondral bone fragment becomes detached from articular surface forming a loose body in joint
- Caused by repetitive compressive forces between radial head and humeral capitellum
- Occurs in 12-15 year olds
Pathology of Panner’s disease
- Localized AVN of capitellum leading to loss of subchondral bone with fissuring & softening of articular surfaces of radiocapitellar joint
- Etiology unknown but occurs in children age 10 or younger
Clinical signs of a UCL injury
- Pain along medial elbow at distal insertion of ligament
- Paresthesias in some cases reported in ulnar nerve distribution with positive Tingel’s sign
Possible causes of ulnar nerve entrapment
- Direct trauma at the cubital tunnel
- Traction due to laxity at medial aspect of elbow
- Compression due to thickened retinaculum or hypertrophy of flexor carpi ulnaris muscle
- Recurrent subluxation
- DJD that affects the cubital tunnel
Possible causes of median nerve entrapment
- Occurs within pronator teres muscle and under superficial head of flexor digitorum superficialis with repetitive gripping activities
Clinical signs of median nerve entrapment
- Aching pain with weakness of forearm muscles
- Positive Tinel’s sign with paresthesias in median nerve distribution
Possible causes of radial nerve entrapment
- Entrapment of distal branches (posterior interosseous nerve) occurs within radial tunnel (radial tunnel syndrome) as result of overhead activities & throwing
Clinical signs of radial nerve entrapment
- Lateral elbow pain that can be confused with lateral epicondylitis/epicondylopathy
- Pain over supinator muscle
- Paresthesias in a radial nerve distribution
- Tinel’s sign may be positive
Clinical signs of an elbow dislocation
- Rapid swelling
- Severe pain at the elbow
- Deformity with the olecranon pushed posteriorly
What structures are impacted by a posterior/posterior-lateral dislocation of the elbow
- Occurs as a result of elbow hyperextension from a fall on the outstretched hand
- Can cause avulsion fractures of medial epicondyle secondary to traction pull of medial collateral ligament
Pathology of carpal tunnel syndrome
- Compression of median nerve at the carpal tunnel of the wrist due to inflammation of the flexor tendons and/or median nerve
- Commonly occurs as result of repetitive motions/gripping with pregnancy, DM, & RA
Common clinical findings of carpal tunnel syndrome
- Exacerbation of burning, tingling, pins and needles, and numbness into median nerve distribution at night
- Positive Tinel’s sign and/or Phalen’s test
- long term compression causes atrophy & weakness of thenar muscles & lateral 2 lumbricals
Pathology of de Quervain’s tenosynovitis
- Inflammation/degeneration of extensor pollicis brevis & abductor pollicis longus tendons at 1st dorsal compartment
- Results from repetitive microtrauma or as a complication of swelling during pregnancy
Clinical signs of de Quervain’s tenosynovitis
- Pain at anatomical snuffbox
- Swelling
- Decreased grip & pinch strength
- Positive Finkelstein’s test (which places tendons on a stretch)
MOI of a Colles’ fracture
- FOOSH
- Fracture is immobilized for 5-8 wks
- Complication of median nerve compression can occur with excessive edema
- Characteristic “dinner fork” deformity of wrist/hand results from dorsal/posterior displacement of distal fragment of radius with a radial shift of wrist/hand
Possible complications with a Colles fracture
- Loss of motion
- Decreased grip strength
- CRPS
- Carpal tunnel syndrome
What is a Smith’s fracture
- Similar to Colles fracture except distal fragment of radius dislocates in a volar direction causing characteristic “garden spade” deformity
Possible complications with a scaphoid fracture
- High incidence of AVN of the proximal fragment of the scaphoid secondary to poor vascular supply
- Carpals are immobilized for 4-8 wks
Pathology of Dupuytren’s contracture
- Observed as banding on palm & digit flexion contractures resulting from contracture of palmar fascia that adheres to skin
- Affects men more than women
- Contracture usually affects MCP & PIP joints of 4th/5th digits in nondiabetic individuals & affects 3rd/4th digits most often in individuals with DM
Pathology of Boutonnière deformity
- Results from rupture of central tendinous slip of extensor hood
- Observed deformity is MCP and DIP extension with PIP flexion
- Commonly occurs following trauma or in RA with degeneration of the central extensor tendon
Pathology of Swan neck deformity
- Results from contracture of intrinsic muscles with dorsal subluxation of lateral extensor tendons
- Observed deformity is MCP & DIP flexion with PIP extension
- Commonly occurs following trauma or with RA following degeneration of lateral extensor tendons
Pathology of Ape hand deformity
- Observed as thenar muscle wasting with 1st digit moving dorsally until it is in line with 2nd digit
- Results from median nerve dysfunction
Pathology of Mallet finger
- Rupture or avulsion of extensor tendon at its insertion into distal phalanx of digit
- Observed deformity is DIP flexion
- Usually occurs from trauma forcing distal phalanx into a flexed position
Pathology of Jersey finger (flexor digitorum profundus tendon rupture/avulsion)
- MOI forced hyperextension of DIP with maximal finger flexion contraction
- Ring finger involved in 75% of cases
- May rupture directly from insertion, avulse from bone, or rupture at musculotendinous junction
- Key exam finding of inability to produce isolated DIP flexion
Pathology of Gamekeeper’s thumb
- Sprain/rupture of ulnar collateral ligament of MCP of 1st digit
- Results in medial instability of thumb
- Frequently occurs during a fall while skiing when increasing forces ar replaced on thumb through ski pole
- Immobilized for 6 wks
Pathology of a Boxer’s fracture
- Fracture of neck of 5th metacarpal
- Frequently sustained during a fight or from punching a wall in anger or frustration
- Casted for 2-4 wks
