MSK/Rheum Flashcards
1
Q
Brachial plexus: branches (roots), innervation, deficit
A
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
2
Q
Anterior shoulder dislocation presentation, nerve risk, dx
A
Most common
Arm in abduction & external rotation
Axillary nerve damage
XR: humeral head anterior & inferior to glenoid
3
Q
Posterior shoulder dislocation hx/pe*
A
Rare. 2/2 seizure & electrocution
Arm in adduction & internal rotation
4
Q
Hip dislocation types, etiologies, sequelae, dx
A
Anterior: obturator nerve risk
Posterior: 90%, flexed/adducted hip pushed back, sciatic nerve & avascular necrosis
Dx: XR not sensitive ==> CT if suspicious
5
Q
Colles’ fracture path, etiology, tx
A
Distal radius fx 2/2 FOOSH
Long-arm cast
6
Q
Scaphoid fracture etiology, dx, tx, risk
A
FOOSH
Anatomical snuffbox tenderness w/ radial deviation pain
XR may take 2 weeks to become +
Spica thumb cast & repeat XR
AVN
7
Q
Humerus fracture risk/pe*
A
Radial nerve: wrist drop
8
Q
Femoral fx risk/hx/pe
A
Fat emboli: fever, MS change, hypoxia, petechiae, low platelet
9
Q
Tibial fx risk
A
Compartment syndrome
10
Q
ACL tear pe/dx
A
+anterior drawer & lachman
MRI
11
Q
MCL tear pe*/dx/tx
A
Medial joint tenderness
+valgus stress test (knee forced into abduction)
MRI to confirm
No surgery
12
Q
LCL tear pe/tx
A
+varus stress test
No surgery
13
Q
PCL tear pe
A
+ posterior drawer
14
Q
Meniscal tear hx, pe, tx*
A
**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
15
Q
Knee dislocation nerve, PE
A
Peroneal
Loss of ankle dorsiflexion
Loss of dorsal foot & lateral leg sensation
16
Q
Compartment syndrome pe, dx, tx
A
Pain (extreme), parasthesias, pallor, poikilothermia…pulselessness & paralysis occur late!
> 30mmHg pressure
Fasciotomy
17
Q
Volkmann’s ischemic contracture path* / dx
A
Supracondylar fracture @ distal humerus ==> brachial artery tear ==> ischemic injury causes permanent wrist flexion
Radial artery pulse test to ensure no brachial artery entrapment
18
Q
Carpal tunnel path, presentation, dx, tx*
A
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
19
Q
Tendinitis pe/dx/tx
A
Pain with resisted strength test / repetition
Clinical diagnosis
Ice/NSAIDs ==> splint
20
Q
L4 motor, reflex, sensation
A
Ankle dorsiflexion
Patellar
Medial leg, medial big toe
21
Q
L5 motor, reflex, sensation
A
Great toe extension
None
Lateral leg, dorsal foot
22
Q
S1 motor, reflex, sensation
A
Plantar flexion & hip extension
Achilles
Plantar foot
23
Q
Low back pain red flags*
A
>50 >6 weeks of pain Cancer hx ==> constant, worse @ night, point tenderness* Constitutional symptoms Neurologic deficit Loss of anal sphincter tone
24
Q
Cauda equina syndrome path, presentation, dx, tx*
A
Sacral nerve bundle entrapment @ cord exit
Saddle anesthesia
Bowel/bladder incontinence
Impotence
Glucocorticoids STAT!
Immediate surgery
25
Low back pain dx/tx
MRI: if warning signs or 12+ weeks of pain
NSAIDs
Heat
PT
Regular physical activity...no bed rest
26
Spinal stenosis hx/tx
Neck pain radiating to arms / legs
Improves with hip flexion & forward bending
NSAIDs, PT
Corticosteroid injection
Laminectomy
27
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
28
Ewing sarcoma presentation, dx*
Child 10-20
XR: onion skinning [bulbous stringy lines] in diaphysis of femur*
29
Giant cell tumor hx/dx
Female 20-40
Knee pain & mass
XR: "soap bubble" appearance of metaphysis/diaphysis
30
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
31
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
```
32
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
33
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
34
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
35
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
36
Polymyositis path, hx/pe, association
Anti-Jo-1 autoimmune muscle inflammation
SYMMETRIC, PROXIMAL muscle weakness & pain ==> breathing difficulty
Malignancy
37
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
38
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
39
ANA antibody
SLE
40
Anti-CCP antibody
RA
41
Anticentromere antibody
CREST syndrome
42
Anti-dsDNA antibody
SLE
43
Antihistone antibody
Drug-induced SLE
44
Anti-Jo-1 antibody
Poly & dermatomyositis
45
Antimitochondrial antibody
Primary biliary cirrhosis
46
Antinuclear antibody
Scleroderma
47
Anti-scl-70 antibody
Scleroderm
48
Anti-Sm
SLE
49
Antitopoisomerase 1 antibody*
Scleroderma
50
Anti-TSHR antibody
Graves'
51
c-ANCA
Vasculities, esp. Wegener's
52
p-ANCA
Vasculitis, esp. microscopic polyangiitis
53
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
54
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
55
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)
56
Libmann Sach's endocarditis path
Noninfectious vegetations of mitral valve 2/2 SLE and antiphospholipid antibody syndrome
57
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...
58
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
59
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
60
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
61
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
```
62
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
63
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
64
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
65
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
66
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
67
Scoliosis dx/tx/sequelae
XR
20-50 degrees curvature: brace
50+ degrees: surgery
Restrictive lung disease
68
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
69
Drug-induced lupus hx
No renal or CNS involvement
| Drugs: hydralizine, procainamide, isoniazid, chlorpromazine, methyldopa
70
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
71
Neonatal SLE presentation
Heart block
72
Reactive arthritis path/hx
Infection w/ salmonella, shigella, campylobacter, chlamydia, yersinia ==> asymmetric arthritis, uveitis, urethritis (can't pee/see/climb tree)
73
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
74
Churg-strauss path, presentation, dx, tx
Vasculitis of multiple organ systems
Constitutional symptoms
Pulmonary: asthma, dyspnea
Skin: nodules, purpura
P-anca
Biopsy necessary
Steroids
75
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
76
Polyarteritis nodosa hx/pe/dx
Wegener's without respiratory involvement... p-anca, renal failure etc.
77
Buerger's / Thromboangiitis Obliterans path/hx/pe
Inflammation of small arteries/veins of legs
Young male who smokes ==> claudication, cyanosis of extremities
Smoking cessation
78
L3 motor
Knee extension
79
L2 motor
Hip flexion
80
Cervical myelopathy path / hx
Cervical spinal stenosis
Gait dysfuction, loss of dexterity ==> inability to ambulate & loss of bowel/bladder function
81
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
82
Bursitis pe*
Pain worsens with palpation (not with arthritis)
83
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
84
Avascular necrosis hx*/pe
>90% = chronic steroid use & alcohol use
| Progressive pain with limited range of motion
85
Tennis elbow path, hx/pe
Lateral epicondylitis 2/2 repeated wrist extension
Point tenderness @ lateral epicondyle
Pain with wrist extension and supination
86
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
87
Polyarteritis nodosa presentation
Skin
Kidney
Muscle aches/weakness
ESR elevation
88
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
89
Osgood-Schlatter disease hx/pe*
Young active children
Anterior knee pain
Pain to palpation @ tibial tubercle
90
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
91
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
92
Psoriatic arthritis hx/pe*
*DIP arthritis
Sausages
Red plaques
93
Morton's neuroma dx*
Painful clicking upon palpation to plantar 3rd/4th toe space
94
Stress fx hx, pe, dx*
Classically anorexic female athlete
| Tenderness to palpation on any bone
95
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
96
Bicep tenon tear pe
Popeye's sign: lump in bicep
| Weakness supinating
97
Long thoracic nerve injury pe*
Wing scapula 2/2 serratus anterior paralysis
98
Trendelenberg sign pe & path*
Contralateral hip drop when standing on one leg
Gluteus weakness 2/2 superior gluteal nerve damage or myopathies
99
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
100
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
101
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
