MSK Re-Up #1 Flashcards
What is compartment syndrome?
What is the MC etiology of this?
-Muscle and nerve ischemia (decreased tissue perfusion) when the closed muscle compartment pressure > perfusion pressure.
Trauma (fracture of the long bones) especially involving the LE
-Others: crush injuries, constriction (tight casts, splints, circumferential burns)
Symptoms of compartment syndrome
-Pain out of proportion to injury***
-Pain with passive stretching (earliest exam finding)
-Tense compartment (firm or wood like feeling)
-Pulseless, pallor, paresis.
What is diagnostic for compartment syndrome?
What is the treatment?
-Increased intracompartmental pressure > 30 mmHg
-Increased CK and myoglobin
-Prompt decompression: emergent fasciotomy
–While waiting, place limb at level of heart without elevation. IVF, oxygen, remove tight dressings.
Acute osteomyelitis is infection of the bone. What are the MC bones affected in kids? In adults?
How is this MC spread in kids?
Femur and tibia in kids
Vertebrae in adults
acute hematogenous spread MC route of spread
Notable Organisms for Osteomyelitis:
-MC organism overall:
-Increased incidence after prosthetic joint placement, neonates, kids with indwelling catheters:
-Increased incidence in Sickle Cell Disease:
-Increased incidence in neonates:
-Puncture wounds through tennis shoes:
-MC overall: Staph Aureus
-Prosthetic Joints: Staph Epidermis
-Sickle Cell: Salmonella
-Neonates: Group B Strep
-Puncture Wounds: Pseudomonas
Symptoms of osteomyelitis
What is the initial imaging test that is ordered?
Fever, chills, malaise
-Bone pain, warmth, swelling, tenderness, limitation of function, refusal to bear weight, etc.
Radiographs usually initially ordered: periosteal reaction is seen early, about 2 weeks after symptom onset
However, ________ is the most sensitive test early in disease, but ______ is the gold standard.
MRI sensitive in early disease
Bone aspiration is GOLD
Treatment for the following types of osteomyelitis
-Group B Strep
-Staph Aureus
-MRSA
-Salmonella
-Pseudomonas
-Group B Strep (Neonates): Cefotaxime + Vanco/Ox/Nafcillin
-Staph Aureus: Nafcillin, Oxacillin, Cefazolin (Clinda or Vanco as PCN allergic)
-MRSA: Vancomycin
-Salmonella: 3rd Gen Ceph or Cipro/Levo
-Pseudomonas: Ceftazidime, Ciprofloxacin
Chronic Osteomyelitis, which is chronic infection of the bone (months to years) has a few different, more common sources in adults. Name them.
-Direct inoculation (surgery, trauma, prosthetic joint)
-Contiguous spread with vascular insufficiency (DM, PVD)
MRI is more sensitive than radiographs, and bone biopsy is still gold standard for chronic osteomyelitis, but what is seen on radiographs that you should remember (two words)
-Sequestrum: segment of necrotic bone that become separated from normal bone
-Involucrum: periosteal bone formation that surrounds necrotic bone (sequestrum)
Treatment for chronic osteomyelitis
-Surgical debridement + cultures initially
-Empiric ABX not usually recommended
Septic Arthritis is an infection of the joint cavity. This is a medical emergency as it can rapidly destroy the joint. What joint is MC affected in adults? How about in kids?
What is the MC organism in all age groups?
-How about in sexually active young adults?
-Knee MC involved in adults and older kids
-Hip joint MC involved in younger kids
-S. Aureus MC organism in all age groups
-Neisseria Gonorrhoae in sexual active young adults
-Pseudomonas: in immunocompromised (IVDU, older adults, trauma)
Symptoms of Septic Arthritis
What is the best initial test and what is seen?
-Swollen, warm painful tender joint with decreased ROM
-Fever, chills, malaise, diaphoresis, myalgias
-Arthocentesis: WBC > 50,000 primarily neutrophils
What other labs are shown in septic arthritis?
-Increased ESR and CRP**
-Blood cultures positive in 50%
Prompt IV ABX should be given if septic arthritis is suspected. What ABX is given in…
-No organism seen
-Gram Positive Cocci
-Gram negative Cocci (Gonoccocus)
-Gram Negative Rods
-No organism: Ceftriaxone + Vanco
-Gram Positive Cocci: Vanco for MSSA
-Gram Negative Cocci: Ceftriaxone
-Gram Negative Rods: Ceftazidime + Gentamicin
Polymyalgia Rheumatica is idiopathic inflammation of the joints, bursae, and tendons.
It is highly associated with what other condition?
What are symptoms of this condition?
-Giant Cell (Temporal) Arteritis
-Pain and stiffness in proximal joints and muscles (worse in morning). May have difficulty rising from a chair and combing hair.
-Low grade fever, fatigue, weight loss
On physical exam, patients with PMR have _______ strength of muscles.
What do labs show? Remember, there is something that differentiates PMR from polymyositis.
Normal muscle strength (no muscle inflammation or weakness)
-Increased ESR and CRP
-Normal muscle enzymes (CK and aldolase) distinguishes this from polymyositis
Treatment for PMR
-Low dose corticosteroids initially
On the other hand, polymyositis is an autoimmune condition leading to muscle inflammation.
What are symptoms of this condition?
Progressive symmetric proximal muscle weakness (shoulders, hips). May have problems rising from a chair, combing hair.
-Low grade fever, arthralgia, weight loss, fatigue
-Decreased muscle strength
-NO RASH
Best initial test for polymyositis?
What antibodies are specific to this condition?
What is the definitive diagnostic?
-Increased muscle enzymes (CK and aldolase)
-Anti Jo-1 and Anti-signal recognition protein (most specific)
Muscle biopsy is definitive**
Treatment for polymyositis?
High-dose glucocorticoids
Again, how do you differentiate polymyositis and PMR?
-PMR: normal muscle strength. Normal muscle enzymes.
-Polymyositis: decreased muscle strength. Elevated muscle enzymes.
Dermatomyositis is an autoimmune condition leading to muscle inflammation AND dermatologic manifestations. This is associated with cancer in 25% of cases.
What are symptoms of this condition?
Progressive symmetric proximal muscle weakness (shoulders, hips). May have problems rising from a chair or combing hair.
-Fever, weight loss, fatigue, dysphagia
-Decreased muscle strength
-Gottron’s Papules: raised scaly patches on dorsum of PIP and MCP joints
-Heliotrope Rash: edema and blue color of upper eyelids
-Malar Rash, Photosensitive Rash, SHAWL SIGN (erythema of shoulder, upper chest, and back)
What is the best initial test for dermatomyositis?
What antibodies are associated with this condition?
What is definitive?
-Increased muscle enzymes (CK and aldolase)
-Anti Jo-1 and Anti-Mi-2 (most specific)
Muscle biopsy is definitive
Treatment for dermatomyositis
-How about for skin lesions?
-High dose glucocorticoids
-Hydroxychloroquine for skin lesions
Sjogren Syndrome is an autoimmune disorder primarily affecting the _________.
What are some symptoms of this condition?
What is the best screening test (specific antibodies)
-Exocrine glands
-Dry mouth (xerostomia), dry eyes (keratoconjunctivitis, sicca), vaginal dryness (dyspareunia), bilateral parotid gland enlargement, dental caries (complication of xerostomia)
-ANA, especially antiSS-A (Ro) and antiSS-B (La)
What other study can be done for Sjogren’s?
What is the definitive diagnostic?
-Positive Schirmer’s Test: decreased tear production (<5mm in 5 minutes)
Lip or parotid gland biopsy is definitive
Management for Sjogren’s
What are patients with this condition at increased risk for ?
-Lifestyle: artificial tears, increase fluid intake, sugar-free gum, etc.
-Cholinergic Drugs: Pilocarpine or Cevimeline lead to increased secretions
-At increased risk for Non-Hodgkin Lymphoma
What are some side effects of Pilocarpine, a cholinergic drug that increases lacrimation and salivation?
-Diaphoresis, sweating, flushing, bradycardia, diarrhea, vomiting, nausea, incontinence, blurry vision.
What is scleroderma?
Explain the two types.
-Systemic autoimmune CTD where collagen deposition leads to fibrosis of the skin and internal organs.
-Limited (CREST) Syndrome: (MC). Tight, shiny, thickened skin involving face, neck, and distal to elbows and knees. Spares the trunk. Calcinosis Cutis (calcium deposits in skin), Raynaud’s, Esophageal motility disorder, Scerodactyly, Telangiectasias.
-Diffuse: tight, shiny thickened skin involving trunk and proximal extremities. Greater internal organ involvement (restrictive lung disease, myocardial fibrosis, etc.)
What antibodies are specific to Limited (CREST)?
What antibodies are specific to diffuse disease?
-Anti-centromere antibodies (CREST)
-Anti-SCL-70-antibodies (diffuse)
True or False: Treatment for Scleroderma is organ specific.
True
What is Behcet’s Syndrome characterized by?
Who is it MC in?
-Recurrent, painful oral and genital ulcers, erythema nodosum, uveitis/conjunctivitis, arthritis, and CNS involvement (may mimic MS)
-MC in Asian, Middle Eastern, or Mediterranean
Although Behcet’s Syndrome is a clinical diagnosis, and a biopsy gives a definitive diagnosis, what other thing CAN be diagnostic but is less common?
Pathergy: sterile skin papules or pustules from minor trauma (such as a needle stick)
Treatment for Behcet’s Syndrome
Corticosteroids during flares
Polyarteritis Nodosa (PAN) is systemic vasculitis primarily of medium sized vessels. This MC affects which three types of vessels?
What type is NOT involved (distinguishes PAN from other vasculitides)
-renal, CNS, Gi
Pulmonary vessels (lungs) not involved
PAN has increased incidence with ______ & _______, and has symptoms such as ….
-Chronic Hepatitis B and C
-Hypertension (RAS), Abdominal pain worse with eating
-Mononeuritis Multiplex ()
-Livedo Reticularis ()
Classic PAN is ______ negative
What is seen on renal or mesenteric angiography
ANCA negative
Renal or Mesenteric angiography: micro aneurysms with abrupt cut-off of small arteries (beading)
What is definitive for PAN?
Treatment for PAN?
-Biopsy: definitive
-Glucocorticoids
What is Kawasaki Syndrome?
Who is at risk for this?
-Medium and small vessel necrotizing vasculitis including coronary arteries
-Children < 5, boys, Asians
Explain how “Warm + CREAM” Relates to Kawasaki Syndrome
-Fever > 5 days + 4 of the following 5
–Conjunctivitis
–Rash (erythematous or morbiliform or macular)
–Extremity (edema, erythema, Beau’s lines - transverse nail grooves)
–Adenopathy (cervical)
–Mucositis (strawberry tongue, lip swelling, fissures, pharyngeal erythema)
What is one complication of Kawasaki Syndrome you should keep in mind?
What is the treatment for Kawasaki?
-Coronary vessel arteritis: coronary artery aneurysm
-IV Immunoglobulin + aspirin
On the other hand, Takayasu Arteritis is chronic large-vessel vasculitis that affects the aorta and it’s primary branches (aortic arch and pulmonary arteries). What are some symptoms of this?
-Vessel ischemia: carotid arteries (TIA, stroke), renal artery (HTN crisis), arm claudication, lower extremity claudication.
-Bruits (carotid, subclavian, abdominal)
-Diminished pulses
-Asymmetric blood pressure measurements between arms (>10mmHg)
-Hypertension
-Symptoms of PAD
What is necessary to confirm the diagnosis of Takayasu Arteritis?
-CT or MRA Angiography
Treatment for Takayasu Arteritis
-High dose corticosteroids
