MSK/Rheum #3 Flashcards
What are the most common bones affected in children in osteomyelitis?
Femur and tibia
What is the MC bone affected in adults in osteomyelitis?
Vertebrae
Risk factors for Osteomyelitis
Sickle cells disease, DM, immunocompromised, pre-existing joint disease
MC route of osteomyelitis spread in children?
Acute hematogenous spread
MC organism overall of osteomyelitis
Staph Aureus
What organism has an increased incidence after recent prosthetic joint placement, indwelling catheters, neonates
Staph Epidermidis
What organism is most common in osteomyelitis in those with Sickle Cell Disease
Salmonella
What organism has an increased incidence in neonates in osteomyelitis?
Group B Strep
What organism for osteomyelitis occurs in puncture wounds through tennis shoes?
Pseudomonas Aeruginosa
What is the MC JOINT affected in children in osteomyelitis?
Hip joint
Diagnostics for osteomyelitis
- Labs: ESR and CRP increased
- Xrays (initially)
- MRI: (most sensitive)
What is the definitive diagnostic for osteomyeltitis
Bone aspiration
Treatment for Group B Strep Osteomyelitis (Birth - 3 months)
Cefotaxime + Vanco, Nafcillin, or Oxacillin
Treatment for S. Aureus Osteomyelitis (3 months - adults)
Nafcillin, Oxacillin, Cefazolin (Clinda or Vanco if PCN allergy)
If the patient has sickle cell and the organism is Salmonella for Osteomyelitis, what is the treatment?
3rd Gen Cephalosporin Or Fluoroquinolone
If the organism is Pseudomonas for osteomyelitis, what is the treatment?
Ceftazidime or Ciprofloxacin
Risk factors/Causes of Primary Osteoporosis
- Postmenopausal
- Senile
- Caucasian
- Low BMI (Thin body habitus)
- Corticosteroid use
- Smoking
- CKD
- Alcohol
- Inactivity
What other drugs cause Secondary Osteoporosis?
- Heparin
- Glucocorticoids
- Phenytoin
- Lithium
- Levothyroxine
Symptoms of Osteoporosis
- Bone fractures: pathologic fractures, vertebrae most common
- Spine compression: loss of vertebral height, kyphosis (hunchback), back pain
What is the best diagnostic test for osteoporosis
- DEXA scan (bone densitometry)
- -T score of -2.5 or less is osteoporosis
What are the treatment options for osteoporosis
- Adequate Vitamin D and Calcium supplementation
- exercise (weight lifting, high impact)
- Periodic height and bone mass measurements
- Smoking cessation
- Fall prevention
What is the first line pharm treatment for osteoporosis?
Bisphosphonates (-dronate)
What is the mechanism of action of Bisphosphonates?
-Inhibit osteoclast activity (decreasing bone resorption and turnover)
What are some considerations to remember when taking Bisphosphonates?
- Taken with 8 ounces of water 1-2 hours before meals, aspirin, Ca, and antacids
- Poor oral absorption
- Calcium and Vitamin D supplementation recommended
- Adverse effects include esophagitis: must stay upright for 30 minutes
What is the screening recommendation for Osteoporosis?
DEXA scan in patients 65 years or older
Symptoms of Pes Anserine Bursitis
- Inflammation of the bursa located between the tibia and 3 tendons of the hamstring muscles at the inside of the knee, 2-3 inches below the joint
- Pain when arising from a chair, at night, or with using stairs
Describe the most common history and PE findings for patients with plantar fasciitis
-Gradual onset of heel pain with first few steps in AM and at night
- Local point tenderness to underside of the heel
- Pain increases with dorsiflexion of toes
Polymyalgia Rheumatica is ______ and is closely associated with _____
- Idiopathic inflammation of the joints, bursae, and tendons
- Giant Cell Arteritis
Symptoms of Polymyalgia Rheumatica
- Pain and stiffness in the proximal joints and muscles
- May have difficulty combing hair and rising from a chair
- Normal muscle strength
- May have decreased active and passive ROM
Diagnostics for PMR
- Increased ESR and CRP
- Normal muscle enzymes
- Increased platelets
Treatment for PMR
-Low dose corticosteroids, NSAIDs, Methotrexate
Symptoms of Polymyositis
- Progressive symmetric proximal muscle weakness (shoulders, hips)
- Decreased muscle strength
- NO RASH
Diagnostics/Antibodies for Polymyositis
- Increased muscle enzymes (CK and aldolase): best initial test
- Anti Jo-1 and Anti-signal recognition protein
However, what is the definitive diagnostic for polymyositis
-Muscle biopsy (shows enodmysial inflammation)
Treatment for Polymyositis
-High-dose glucocorticoids
Symptoms of Posterior Tibial Tendon Dysfunction
- Player of high-impact sports
- Pain and swelling to medial foot and ankle
- Flattened arch
- “Too many toes sign”
In a proximal humerus fracture, what is the treatment and what should you check for?
- Sling/Swathe and ortho follow up in 24-48 hours
- Check deltoid sensation to rule out axillary nerve or brachial plexus injuries
Reactive Arthritis/Reiter Syndrome is
Inflammatory arthritis in response to infection of inflammation in another part of the body.
-1-4 weeks after Chlamydia or GI infection
What is associated with increased incidence of reactive arthritis?
HLA-B27
Symptoms of Reactive Arthritis
- Triad: arthritis + conjunctivitis + urethritis (can’t see, can’t pee, can’t climb a tree)
- Keratoderma Blennorrhagicum: lesions on palms and soles
What diagnostic should be done in reactive arthritis and why?
arthrocentesis to rule out septic arthritis
Treatment for Reactive Arthritis
- NSAIDs (1st line)
- Methotrexate (if no response)
Etiologies of Rhabdomyolysis
- Crush Injuries
- Immobility
- Seizures, Burns
- Statins, Niacin, Fibrates
Pathophysiology of rhabdomyolysis
-Myoglobin from muscle breakdown is extremely toxic to renal tubular cells, leading to acute tubular necrosis (acute kidney injury)
Symptoms of rhabdomyolysis
Muscle pain + muscle weakness + dark (tea-colored urine)
Diagnostics for Rhabdomyolysis
- ECG: initial (most important) to look for hyperkalemia
- Urine Dipstick and UA: positive for heme but negative for RBCs
- Muscle enzymes: increased creatinine phosphokinase
- Electrolytes: hyperkalemia, hyperuricemia, hypocalcemia
Treatment of of Rhabdomyolysis
- IVF saline hydration
- Mannitol or Sodium Bicarbonate (alkalinization of the urine)
- Calcium Gluconate: stabilize cardiac membranes
Symptoms of Rheumatoid Arthritis
- Systemic (fever, weiht loss, anorexia)
- Joint pain: Morning stiffness > 1 hour, improves later in day
- Affects small joints: wrist, MCP, PIP, MTP (spares DIP)
- Symmetric, warm, boggy joints
- Ulnar deviation of hand
- Swan neck and boutonniere deformities
Diagnostics and antibodies for RA
- RF (best initial)
- Anti-CCP (most specific)
- Radiographs: symmetric joint narrowing, osteopenia, bone and joint erosions
- -C1-C2 subluxation common
treatment for RA
- Methotrexate, Leflunomide (DMARDs) + NSAIDs (for pain control)
- Glucocorticoids second-line for symptom control
Methotrexate is a _______ and adverse effects include
Folic antagonist
-Liver, lung marrow. Hepatitis, interstitial pneumonitis, and bone marrow suppression
What four muscles make up the rotator cuff muscles?
- Supraspinatus
- Infraspinatus
- Teres Minor
- Subscapularis
What is the MC injured rotator cuff muscle?
Supraspinatus
Symptoms of a rotator cuff muscle injury
- Anterolateral shoulder pain with decreased ROM
- Decreased ROM with overhead activities, ER, or abduction
- Passive ROM > Active ROM
What test has a 90% specificity for assessing supraspinatus involvement?
Empty Can Test
What are three tests for impingement?
- Hawkins Test: elbow flexed and pain with IR
- Drop Arm Test: slowly lowering arm
- Neer Test: arm pronated (thumbs down) forward flexion
Treatment for a rotator cuff tear
- Conservative: PT, NSAIDs, Injections
- Surgery: if failed conservative
Regarding Scleroderma, what is Limited (CREST) Syndrome?
- Tight, shiny thickened skin involving the face, neck, and distal to elbows and knees. Spares the trunk.
- Calcinosis Cutis
- Raynaud’s Phenomenon
- Esophageal Motility Disorder
- Sclerodactyly
- Telangiectasias
Diagnostics and Antibodies for Scleroderma
- Anti-centromere antibodies (CREST specific)
- Anti-SCL-70 antibodies/anti-topoisomerase (diffuse)
- ANA positive but non-specific
Symptoms of Diffuse Scleroderma
- Tight, shiny, thickened skin involving the trunk and proximal extremities
- Greater organ involvement
