MSK/Rheum Flashcards
Brachial plexus: branches (roots), innervation, deficit
Musculocutaneous (C5-C7) - should & forearm flexion; supination - lateral forearm sensation Axillary (C5-C6) - deltoid abduction - shoulder sensation Radial (C5-T1) - forearm & finger extension - posterior arm & posterior 2.5 finger sensation *wrist drop Median (C5-T1) - 1-3 thumb/finger flexion & forearm extension/pronation - palmar 4.5 finger sensation *thumb issues Ulnar (C7-T1) - 4-5 finger flexion - 4-5 finger sensation (palmar & posterior) *Claw hand
Anterior shoulder dislocation presentation, nerve risk, dx
Most common
Arm in abduction & external rotation
Axillary nerve damage
XR: humeral head anterior & inferior to glenoid
Posterior shoulder dislocation hx/pe*
Rare. 2/2 seizure & electrocution
Arm in adduction & internal rotation
Hip dislocation types, etiologies, sequelae, dx
Anterior: obturator nerve risk
Posterior: 90%, flexed/adducted hip pushed back, sciatic nerve & avascular necrosis
Dx: XR not sensitive ==> CT if suspicious
Colles’ fracture path, etiology, tx
Distal radius fx 2/2 FOOSH
Long-arm cast
Scaphoid fracture etiology, dx, tx, risk
FOOSH
Anatomical snuffbox tenderness w/ radial deviation pain
XR may take 2 weeks to become +
Spica thumb cast & repeat XR
AVN
Humerus fracture risk/pe*
Radial nerve: wrist drop
Femoral fx risk/hx/pe
Fat emboli: fever, MS change, hypoxia, petechiae, low platelet
Tibial fx risk
Compartment syndrome
ACL tear pe/dx
+anterior drawer & lachman
MRI
MCL tear pe*/dx/tx
Medial joint tenderness
+valgus stress test (knee forced into abduction)
MRI to confirm
No surgery
LCL tear pe/tx
+varus stress test
No surgery
PCL tear pe
+ posterior drawer
Meniscal tear hx, pe, tx*
**Clicking/popping during distinctly recalled event!
+McMurray: clicking/popping while medially/laterally rotating tibia while knee in flexion OR flexing/extending while palpating lateral/medial aspects
NSAID/rest ==> MRI if progresses to locking ==> surgery
Knee dislocation nerve, PE
Peroneal
Loss of ankle dorsiflexion
Loss of dorsal foot & lateral leg sensation
Compartment syndrome pe, dx, tx
Pain (extreme), parasthesias, pallor, poikilothermia…pulselessness & paralysis occur late!
> 30mmHg pressure
Fasciotomy
Volkmann’s ischemic contracture path* / dx
Supracondylar fracture @ distal humerus ==> brachial artery tear ==> ischemic injury causes permanent wrist flexion
Radial artery pulse test to ensure no brachial artery entrapment
Carpal tunnel path, presentation, dx, tx*
Median nerve entrapment 2/2 MPS matrix deposition*
Parasthesias, pain, atrophy of thenar region and fingers 1-3
Especially at night
Hypothyroidism* (usually more severe & bilateral) & diabetes often
+Phalen’s: full wrist flexion elicits tingling
+Tinnel’s: tapping median nerve elicits tingling
Usually clinical, but EMG can do it ==> MRI if equivocal
Splint ==> NSAIDs (unless pregnant) ==> steroids ==> surgery
Tendinitis pe/dx/tx
Pain with resisted strength test / repetition
Clinical diagnosis
Ice/NSAIDs ==> splint
L4 motor, reflex, sensation
Ankle dorsiflexion
Patellar
Medial leg, medial big toe
L5 motor, reflex, sensation
Great toe extension
None
Lateral leg, dorsal foot
S1 motor, reflex, sensation
Plantar flexion & hip extension
Achilles
Plantar foot
Low back pain red flags*
>50 >6 weeks of pain Cancer hx ==> constant, worse @ night, point tenderness* Constitutional symptoms Neurologic deficit Loss of anal sphincter tone
Cauda equina syndrome path, presentation, dx, tx*
Sacral nerve bundle entrapment @ cord exit
Saddle anesthesia
Bowel/bladder incontinence
Impotence
Glucocorticoids STAT!
Immediate surgery
Low back pain dx/tx
MRI: if warning signs or 12+ weeks of pain
NSAIDs
Heat
PT
Regular physical activity…no bed rest
Spinal stenosis hx/tx
Neck pain radiating to arms / legs
Improves with hip flexion & forward bending
NSAIDs, PT
Corticosteroid injection
Laminectomy
Osteosarcoma path, presentation, dx*, tx
Malignant tumor of bone, often metaphysis distal femur, proximal tibia & proximal humerus ==> metastasizes to lung
Male, 20-30
Night pain, fever, sweat, weight loss
Erythema/enlargement over site
XR: “sunburst” pattern or “Codman’s triangle”
MRI/CT: necessary for staging
Ideally, limb-sparing chemo with pre&post operative chemo
Ewing sarcoma presentation, dx*
Child 10-20
XR: onion skinning [bulbous stringy lines] in diaphysis of femur*
Giant cell tumor hx/dx
Female 20-40
Knee pain & mass
XR: “soap bubble” appearance of metaphysis/diaphysis
Septic arthritis organisms*, presentation, dx, tx
Staph, strep
Prosthetics:
-S. aureus or Pseudomonas if infection occurs 3months post-op
Often prosthetic joints, osteoarthritis, rheumatoid arthritis
Warm, immobile joint
+/- fever, chills
Joint aspiration: +gram stain, >50,000 WBC, culture
Ceftriaxone & vanc
Surgical debridement
Osteoarthritis path, presentation, dx, tx
Non-inflammatory 2/2 cartilage deterioration & osteophyte formation in DIP & PIP (farthest and 2nd farthest joints), hips & knees
Old & obese people *Pain worsens with activity Morning stiffness NSAIDs NSAIDs Steroid injections Joint replacement
Rheumatoid arthritis path, presentation, dx, tx
Systemic, symmetric autoimmune inflammatory @ MCP (metacarpal phalanges), wrists,
SYMMETRIC, swollen joints, especially wrists, MCP, & PIP (not DIP!!)
Morning stiffness > 1hr ==> improves with use
Constitutional symptoms
Ulnar deviation of MCP
Swan-neck: hyperflexed DIP & hyperextended PIP
Boutonniere: hyperextended DIP & hyperflexed PIP
Pleural effusions
Rheumatoid nodules…soft tissue, cervical spine* (risk of subluxation & intubation difficulty) & heart
> 6 weeks*
Anti-CCP / ACPA [specific]
RF [sensitive]
Synovial aspiration: turbid, leukocytosis, >5000PMN
START with DMARDs**: Methotrexate ==> hydroxycholoroquine, sulfasalazine ==> etanercept, infliximab
**must tests for Hep B&C and TB before starting DMARD
NSAIDs & glucocorticoids
Gout path, presentation, dx, tx
Overproduction of uric acid (lesch nyan, hemolysis, malignancy like myeloproliferative*) OR undersecretion (renal disease, NSAIDs) ==> IgG/urate crystals phagocytized by PMN ==> deposition in joints
Excruciating pain, often fat binge-drinkers
Tophi, often first MTP (“podagra”)
Joint aspirate: needle, negatively birefringent; *necessary to rule out septic arthritis
Not helpful: serum uric acid (may be normal)
Attacks: Indomethacin (NSAID) > colchicine (diarrhea) ==> corticosteroids if severe
Chronic: Allopurinol or probenecid
Pseudogout path, hx*/pe, dx
Calcium pyrophosphate crystals 2/2 trauma, hyperparathyroidism* or hemochromatosis (2/2 parathyroid Fe?)
Wrists & knees affected
Acute pain, swelling, redness
Decreased ROM
Leukocytosis, sometimes
Rhomboid, +birefringence
Ankylosing spondylitis path, presentation, complications, dx, tx
HLA-B27 inflammatory condition ==> fusion of hip & spine
Hip/back pain worst in morning& night, worsens with inactivity, improves with exercise
Increased fx risk
Anterior uveitis
Heart block
Restrictive lung disease
Must rule out: Reactive arthritis (uveitis, urethritis, arthritis 2/2 infection) Psoriatic arthritis (sausage digits, often DIP) Enteropathic arthritis (IBD-related sacroilitis)
XR: fused sacroiliac joints, bamboo spine, square vertebrae
Rheumatoid factor: negative
ANA: negative
NSAIDs ==> TNF-inhibitors or sulfasalazine
Polymyositis path, hx/pe, association
Anti-Jo-1 autoimmune muscle inflammation
SYMMETRIC, PROXIMAL muscle weakness & pain ==> breathing difficulty
Malignancy
Dermatomyositis path, hx/pe, association*
Anti-Jo-1 autoimmune muscle & skin inflammation
Heliotrope/butterfly rash: violaceous periorbital rash
Shawl sign: rash in shawl area
V-sign: rash on face, neck, chest
Gottron’s papules: papular, scaly rash on dorsal knuckles
Risk: underlying malignancy (ovarian, breast, lung) ==> needs diagnostic workup
Poly & dermatomyositis dx/tx, ddx*
Two+ = likely myositis: Symmetric, proximal weakness CK: elevated EMG abnormality Muscle biopsy: fibrosis Anti-Jo-1 antibody + Anti-Mi-2(helicase) ==> dermatomyositis?
Steroids or azathioprine/methotrexate
Hypo/hypothyroid also presents with proximal symmetric weakness
ANA antibody
SLE
Anti-CCP antibody
RA
Anticentromere antibody
CREST syndrome
Anti-dsDNA antibody
SLE
Antihistone antibody
Drug-induced SLE
Anti-Jo-1 antibody
Poly & dermatomyositis
Antimitochondrial antibody
Primary biliary cirrhosis
Antinuclear antibody
Scleroderma
Anti-scl-70 antibody
Scleroderm
Anti-Sm
SLE
Antitopoisomerase 1 antibody*
Scleroderma
Anti-TSHR antibody
Graves’
c-ANCA
Vasculities, esp. Wegener’s
p-ANCA
Vasculitis, esp. microscopic polyangiitis
Scleroderma path, presentation, dx, tx
Inflammation ==> fibrosis with type 1&3 collagen
CREST & diffuse forms
Symmetric thickening of skin
- CREST: calcinosis, Raynaud’s, Esophageal (&lower GI) dysmotility, sclerodactyly, telangiectasias
- Diffuse: pulmonary fibrosis* & hypertension, renal failure, GI problems, cardiac problems
CREST: Anticentromere [specific]
Diffuse: *Antitopoisomerase/Anti-Scl-70 [poor prognosis]
+/- RF, ANA, eosinophilia
Corticosteroids
Penacillamine (for skin)
ACE-inhibitors for renal crises
SLE path, presentation, dx*, tx
Antibody attack & deposition of antibody-antigen complexes*
Malar rash + migratory arthritis + fatigue = most common
Basically anything else can occur too…
Suggestive symptoms ==> ANA: sensitive, not specific
Anti-Sm & Anti-dsDNA: specific, not sensitive
Antihistone: drug-induced SLE
4+criteria: Mucucutaneous: malar/butterfly rash, photosensitivity, oropharyngeal ulcers, discoid rash (red, raised, keratotic) Arthritis Pericarditis/pleuritis Hematologic: anemia, -cytopenia *Renal: proteinuria, casts CNS: seizures, psycosis Immunologic: +RPR (false+syphillis) \+ANA
Corticosteroids
Hydroxychloroquine: skin/joint stuff
Cyclophosphamide: renal stuff
Temporal arteritis name, path*, presentation, dx, tx
“Giant cell arteritis”
Granulomatous inflammation of aorta*, external carotid (temporal branch) and vertebral arteries ==> central retinal artery occlusion causes blindness
*Polymyalgia rheumatica patients commonly Bilateral or unilateral headache Jaw claudication Temporal tenderness Monocular vision loss Myalgia
Temporal artery biopsy: giant cells, lymphocytes; thrombosis; necrosis
High dose prednisone (ONCE SUSPICIOUS; before biopsy)
Libmann Sach’s endocarditis path
Noninfectious vegetations of mitral valve 2/2 SLE and antiphospholipid antibody syndrome
Complex regional pain syndrome presentation, dx, tx
Trauma (usually) ==> exquisite pain without clear anatomic correlation ==> loss of function ==> sympathetic dysfunction (skin, hair, soft tissue changes)
Clinical diagnosis
Wide variety of tx…
Fibromyalgia presentation, dx, tx
Women 30-50 with depression, IBS, sleep disorder etc.
Axial & soft tissue pain WITHOUT joint pain*
ESR: normal
Biopsy: normal
>11 tender ponits in all body quadrants ()
*Exercise, sleep hygiene
Antidepressants, gabapentin etc.
PT
Polymyalgia rheumatica presentation, association, dx*, tx
Age >50
Pelvic girdle & shoulder pain/weakness causing difficulty rising from chair or raising hands overhead
Constitutional symptoms
Associated with temporal arteritis
Clinical: hip/shoulder pain + ESR*
ESR: elevated
CBC: anemia
Low-dose prednisone
Nursemaid’s elbow path/hx/tx*
Radial head subluxation 2/2 being pulled
(Child) with non-tender, immobile arm in pronation
Reduction by gentle supination & extension
Salter-harris classifications
I: physis (growth plate) fracture II: physis & metaphysis fx III: physis & epiphysis fx IV: epihysis, physis & metaphysis fx V: crush injury of physics
Duchenne Muscular Dystrophy path, presentation, dx, tx
X-linked recessive causing dystrophin cystoskelton protein ABSENCE
Onset 3-5 years
Often retarded
PROGRESSIVE WEAKNESS: clumsiness, fatigability, difficulty toe walking
Gower’s maneuver: pushing off thighs to stand up
Gastrocnemius pseudohypertrophy
Cardiomyopathy
Western blot: little to no dystrophin
Muscle biopsy: necrotic fibers
GOLD STANDARD*: genetic dystrophin testing
20’s expectancy 2/2 cardiac fibrosis & pulmonary congestion
Becker muscular dystrophy path*, presentation, dx, tx
X-linked recessive causing dystrophin DYSFUNCTION
Onset 5-15 years
MILDER weakness than Duchenne
Not retarded
Cardiomyopathy
Western blot: dystrophin present but abnormal
Life-expectancy: 40’s 2/2 heart failure
Developmental Dysplasia of Hip path, presentation, dx, tx
Subluxed or dislocated femoral heads ==> hip degeneration
First born male in breech
Barlow: thighs abducted ==> posterior pressure ==> adduction ==> “clunk”
Ortolani: thighs adducted ==> anterior pressure from greater trochanter ==> abduction ==> “click”
Allis’/Galeazzi’s: knees @ unequal heights when flexed
PE techniques
Ultrasound & XR work after 10 weeks
< 1 year: Harness or cast
> 1 year: surgery
Legg-Calve-Perth path, presentation, dx, tx
AVN of femoral head
Usually boys 4-10 years old
Limp
Groin or knee pain
Limited abduction & internal rotation
XR: flattened, irregular femoral head
Observation unless ROM decreases ==> surgery
Slipped Capital Femoral Epiphysis path, presentation, dx, tx
Femoral neck displaces from epiphysis & growth plate, often bilateral
Fat 12 year old kid Endocrine disorders KNEE & groin pain Painful limp Unstable SCFE: inability to bear weight Limited abduction & internal rotation
XR: posterior & inferior displacement of femoral head
TSH: send if kid is short
Tx: no weight bearing until SURGICAL PINNING
Scoliosis dx/tx/sequelae
XR
20-50 degrees curvature: brace
50+ degrees: surgery
Restrictive lung disease
Juvenile idiopathic arthritis subtypes, presentation, dx, tx
Acute febrile/Still’s: high fever, rash
Usually girl 5 joints, symmetric
No diagnostic…only nonspecific elevated rheum labs
NSAIDs ==> steroids
Drug-induced lupus hx
No renal or CNS involvement
Drugs: hydralizine, procainamide, isoniazid, chlorpromazine, methyldopa
Sjogren path / risks, dx
Primary: lymphocytic salivary infiltration
Secondary: Above + other rheum conditions
Risk: non-hodgkin’s lymphoma, dental carries*
Sensitive: ANA or RF
*Specific: Ro or La
Neonatal SLE presentation
Heart block
Reactive arthritis path/hx
Infection w/ salmonella, shigella, campylobacter, chlamydia, yersinia ==> asymmetric arthritis, uveitis, urethritis (can’t pee/see/climb tree)
Takayasu’s arteritis path, presentation, dx, tx
Vasculitis of aortic arch and major branches
Younger asian women Constitutional symptoms Pain over involved vessels Absent carotid, radial pulses Aortic regurgitation Stroke
Arteriogram
Steroids and/or surgical recantation
Churg-strauss path, presentation, dx, tx
Vasculitis of multiple organ systems
Constitutional symptoms
Pulmonary: asthma, dyspnea
Skin: nodules, purpura
P-anca
Biopsy necessary
Steroids
Wegener’s alt name, path, presentation, dx, tx
Granulomatosis with polyangiitis
Necrotizing vasculitis of kidneys & respiratory tract
Middle-aged ppl
Pulmonary: epistaxis, rinorrhea, ulcers, sinusitis, airway, cough/hemoptysis
Renal: hematuria 2/2 glomerulonephritis ==> renal failure
Cutaneous: nodules, purpura, ulcers
CXR: nodules*/cavitations/infiltrates \+c-ANCA = sensitive & specific! Light microscope: CRESCENT formation Immunoflouresence: segmental necrotizing (Goodpasture's = linear) Confirmatory: lung biopsy
cyclophosphamide & steroids ==> most die
Polyarteritis nodosa hx/pe/dx
Wegener’s without respiratory involvement… p-anca, renal failure etc.
Buerger’s / Thromboangiitis Obliterans path/hx/pe
Inflammation of small arteries/veins of legs
Young male who smokes ==> claudication, cyanosis of extremities
Smoking cessation
L3 motor
Knee extension
L2 motor
Hip flexion
Cervical myelopathy path / hx
Cervical spinal stenosis
Gait dysfuction, loss of dexterity ==> inability to ambulate & loss of bowel/bladder function
Disc herniation usual level, presentation, dx, tx
L5-S1 & L4-L5
Radiating pain down posterior/lateral leg
Possible loss of reflexes
Worsened with valsalva
Lying relieves pain
Dorsiflexion & leaning forward exacerbates
MRI
NSAIDS & ice!
Surgery: only if loss of bowel/bladder or terrible pain
Bursitis pe*
Pain worsens with palpation (not with arthritis)
Rotator cuff tendonitis (impingement) vs tear hx/pe/dx
Tendonitis:
- repetitive use
- pain with passive motion overhead
- lidocaine injection HELPS
Tear:
- fall/trauma
- pain with passive motion overhead
- drop test: when passively abducted to 90, arm drops when adducting
- lidocaine injection DOESN’T help
Avascular necrosis hx*/pe
> 90% = chronic steroid use & alcohol use
Progressive pain with limited range of motion
Tennis elbow path, hx/pe
Lateral epicondylitis 2/2 repeated wrist extension
Point tenderness @ lateral epicondyle
Pain with wrist extension and supination
Vertebral osteomyelitis path, presentation, dx*, tx
Staph aureus
Pain worsening with activity
*May or may not have fever, constitutional symptoms
Injection drug users, sickle cell, immunosuppressed
*Exquisite tenderness to palpation
*CBC: may or may not have leukocytosis
ESR: elevated
MRI: most sensitive
IV abx
Polyarteritis nodosa presentation
Skin
Kidney
Muscle aches/weakness
ESR elevation
Patellofemoral syndrome hx/pe, dx*, tx
Chronic anterior knee pain
Worse climbing stairs & squatting
Patellofemoral compression test: press patella while extending knee ==> reproduce pain?
Dx: clinical
PT
Osgood-Schlatter disease hx/pe*
Young active children
Anterior knee pain
Pain to palpation @ tibial tubercle
Paget’s disease path, presentation, dx**, tx*
Osteoclast hyper function with excessive compensatory osteoblast bone growth ==> enlarged, weak, inferior woven bone replaces in pelvis, skull, spine, long bones
Bone/joint pain
Hearing loss* (2/2 bone enlargement @ auditory meatus)
XR: thickened cortex, femoral bowing Alk-P elevation (bone formation marker) Urinary N-telopeptide elevation (bone resorption marker) NORMAL Calcium & Phosphorous Mosaic lamellar bone
No cure
Bisphosphonates help symptomatically
Behcet’s syndrome path, dx, tx
Autoimmune multisystem vasculitis
Oral ulcers & 2+
Genital ulcers
Eye lesions (uveitis)
Skin lesions
…sometimes skin lesions, CNS, constitutional symptoms
Steroids
Psoriatic arthritis hx/pe*
*DIP arthritis
Sausages
Red plaques
Morton’s neuroma dx*
Painful clicking upon palpation to plantar 3rd/4th toe space
Stress fx hx, pe, dx*
Classically anorexic female athlete
Tenderness to palpation on any bone
LE innervation & sensation**
Obturator: medial thigh adduction / medial thigh sensation
Femoral: hip flexion & knee extension / anteromedial thigh & anteromedial leg sensation (saphenous)
Sciatic branches:
Tibial: knee flexion & foot-toe flexion / posterior thigh & posterior leg & dorsal foot sensation
Peroneal/fibular nerve: anterolateral leg flexion & sensation
Bicep tenon tear pe
Popeye’s sign: lump in bicep
Weakness supinating
Long thoracic nerve injury pe*
Wing scapula 2/2 serratus anterior paralysis
Trendelenberg sign pe & path*
Contralateral hip drop when standing on one leg
Gluteus weakness 2/2 superior gluteal nerve damage or myopathies
Steinert’s disease path, presentation, dx, tx
Autosomal dominant trinucleotide problem causing skeletal & smooth muscle dysfunction
Onset 12-30 years old Weakness 2/2 impaired relaxation Unable to release grip from handshake Facial weakness w/ temporal wasting Dysphagia Thenar wasting Testicular atrophy
Death 2/2 respiratory or heart failure
Neonatal conjunctivitis path, presentation, dx, tx*
2/2 gonorrhea, chlamydia, or chemical
Chemical: 24hrs post-birth 2/2 silver nitrate ==> mild
Gonorrhea: 2-5 days post-birth ==> severe swelling and discharge ==> IM ceftriaxone or cefotaxime
Chlamydia: 5-14 days post-birth ==> milder swelling and discharge, though bloody discharge often ==> oral erythromycin
Lupus hypercoagulability path, dx, tx
Lupus anticoagulant or antiphospholipid antibody
Miscarriage hx
Prolonged PTT (2/2 Ig against assay chemical...thus artifact) False + VDRL Thrombocytopenia Non-correcting with mixing study Normal bleeding time
Prophylactic aspirin & LMWH
