MSK/Rheumatoid Flashcards
Wegner’s
AKA Granulomatosis with polyangitis
- positive C-ANCA
- URI, lower respiratory involvement, progressively worsening glomerulonephritis
Most specific antibodies for SLE
Anti-dsDNA
ANTI-smith
SLE management
Sun protection
Hydroxychloroquine (for leaions)
NSAID for pain
Cytotoxic drugs if severe
Antibodies for anti-phospholipid syndrome
Anticardiolipin AB
*causes clots and miscarriages
CREST Syndrome
C-calcinosis R-Raynaud E-esophageal dysmotility S-sclerodactyly T-telangiectasia
Antibodies associated with limited systemic sclerosis (scleroderma)
Anti-centromere AB
*limited to face, neck, distal to elbows and knees
Antibodies associated with diffuse systemic sclerosis (scleroderma)
Anti-SCL-70 AB
*diffuse dz has multiple organ involvement
Treatment for Raynaud’s
Vasodilators (CCB)
In what dz do you see a “moth eaten” appearance of muscle fibers on bx
Fibromyalgia
Treatment for fibromyalgia
TCA, duloxitine, pregabalin
What does Sjögren’s attack
Experience glands specifically the salivary glands= xerostomia (dry mouth)
Lacrimal glands=dry eyes
Parotid enlargement
Sjögren specific antibodies
Anti-ro
Anti la
(May also see ANA)
What is PMR?
Polymyalgia rheumatica
- synovitis, tenosynovitis, bursitis of large proximal joints such as neck, shoulder, pelvis
- PAIN no weakness
PMR treatment
Low dose steroids
What is poly myositis/ dermatomyositis?
Idiopathic symmetric muscle weakness of the large proximal joints with little pain.
Lab values/antibodies associated with PM or DrM
- high muscle enzymes (aldolase, CK)
- anti-Jo1*also seen with mechanic hands and interstitial fibrosis
- anti-SRP (PM)
- anti-Mi-2 (DRM)
Skin presentations of dermatomyositis
1) heliotrope rash: violet upper eyelid
2) Gottron’s papules: raises violet scales eruptions of the knuckles
3) Malay rash INVOLVING the nasolabial folds (SLE spares them)
4) photosensitivity rash
What is deposited in the joints in gout
Uric acid-byproduct of purine metabolism
What is deposited in pseudogout
Calcium pyrophosphate
Epidemiology of gout vs. pseudogout
Gout: men>30 , Podogra(MTP)
Pseudogout: women >60 (knee)
-associated with OA and hyperthyroid
Medications causing gout
Diuretics ACE ARB (minus losartan) pyrazinamide EthMbutol ASA
Arthrocentesis findings in gout vs. pseudogout
Gout: negatively birefringent needle shaped crystals
Pseudo: positively birefringent rhomboid shaped
Acute and chronic gout management
Acute: NSAID, colchicine
Chronic: ALLOPURINOL*, colchicine, febuxostat, uricosuric drugs
*allopurinol can damage kidneys
Radiographic findings of gout vs pseudogout
Gout: lower extremity ; “mouse bite” punched out lesions
Pseudo: upper extremity knee ; chonedrocalcinosis-calcification of the cartilage
What causes RA?
T cell mediated joint destruction by PANNUS (granulation tissue that eroded into cartilage and bone)
Felty’s syndrome
RA+splenomegaly+ low WBC/recurrent infections
Caplan syndrome
RA+pneumoconiosis
Dx of RA BASED ON
- Rheumatoid factor (initial)
- anti-CCP (most specific)
- multiple joint morning stiffness over 6 weeks
- narrowed joint space on XR
What is polyarteritis nodosa (PAN)
Systemic vasculitis of small arteries causing necrotizing inflammatory lesions
Organ systems involved and spared in PAN
- Renal: HTN, renal failure
- CNS: neuropathy, mononeuritis multiplex
- constitutional: fever, myalgias
- Dermatological: livedo ritucularis, purpura
***LUNGS ARE SPARED
Diagnostic work-up of PAN
- ESR
- classic is ANCA neg. (20% P-ANCA)
- ANGIOGRAPHY
PAN management
Corticosteroids
What dz is PAN associated with ?
Hepatitis B
What is Reiter’s syndrome aka reactive arthritis
1) arthritis
2) conjunctivitis
3) urethritis
*in response to an infection in another part of the body MC chlamydia
Keratoderma blennorrhagicum
Hyperkeratotic lesions on palms and soles found in restive arthritis
Treatment of reactive arthritis
NSAIDS
Tarsal-metatarsal fracture (MC 2nd or 3rd)
Lisfranc fx
Carpel Tunnel Effects what nerve?
median nerve; check using phalen’s test
Risk Factors for carpel tunnel syndrome
Diabetes, pregnancy, and hypothyroidism, excessive wrist strain, RA, obesity
Lateral epicondylitis
Tennis Elbow
Injury to the tendon on extensor carpi radials brevis
Pain on forearm PRONATION and wrist EXTENSION
Medial epicondylitis
Golfers Elbow
Injury to the pronator trees-flexor carpi radialis
Pain with wrist FLEXION
What is MC ligament sprained in the ankle
The Anterior Talofibular ligament (this is the main stabilizer for inversion)
According to the Ottawa Ankle Rules, what are the criteria for getting an X-ray vs treating as just a sprain?
- Pain on lateral malleolus
- Pain on medial malleolus
- navicular (midfoot) pain
- 5th metatarsal pain
What level is MC for a herniated disc?
L5-S1
Herniated disc at the level of L4 would produce what symptoms?
- ANTERIOR thigh pain
- weak ankle DORSIFLEXION
- loss of knee jerk
Herniated disc at the level of L5 would produce what symptoms?
- LATERAL thigh/leg/hip pain
- Loss of sensation to the DORSUM of the foot
- Weak BIG TOE EXTENSION
Herniated disc at the level of S1 would produce what symptoms?
- POSTERIOR leg/calf pain
- sensory loss to the PLANTAR surface of the foot
- weak PLANTARFLEXION
- loss of ankle jerk
Drugs that can cause drug induced Lupus
Procanamide
Hydralazine
INH
Quinidine
**These patients with have anti-histone antibodies
Classic clinical triad of SLE
- Joint pain
- Fever
- Malar rash (SPARING nasolabial folds)
Clinical manifestations of SLE
SOAP BRAIN MD
- Serositis (pleuritis, pericarditis)
- Oral ulcers
- Arthritis
- Photosensitivity
- Blood (anemic, leukopenia, thrombocytopenia)
- Renal (proteinuria)
- ANA
- Immunologic (ds-DNA)
- Neurologic (psych, seizures)
- Malar rash (SPARES FOLDS)
- Discoid rash
What is xerostomia?
Dry mouth
management of Sjogren’s syndrome
Pilocarpine (anti-cholinergic drug)
Antibodies found in Sjogren’s syndrome
Anti-Ro
ANti-La
Management of pseudogout
Corticosteroid injections, NSAIDS, colchicine prophylaxis
X ray findings in gout
Punched out “Rat bite lesions”
What will the synovial fluid be described as in reactive arthritis?
WBC elevated, but culture will be ASEPTIC
Treatment of osteoporosis
- Bisphosphonates
- Vitamin D
- SERM (raloxifen)
- Estrogen
Bisphosphonates MOA
slows down bone loss by inhibiting osteoclast resorption
Bisphosphonate examples
- Alendronate
- Risedronate
IV:
-Zoledronic acid
Special instructions for taking bisphosphonates
- Take on empty stomach
- Take with a lot of water
- Be sure to remain upright for at least 30 minutes
Side effects of bisphosphonates
- Jaw necosis
- pill esophagitis
- pathological femur fracture
What is the MC type of shoulder dislocation?
Anterior
What is a Hill-Sachs lesion
Groove on the head of humerus s/p shoulder dislocation from impact against glenoid
What is a bankart lesion?
Fracture on the rim of the glenoid s/p shoulder dislocation
What could cause a posterior shoulder dislocation?
MC cause are seizures and electric shock
What X ray view is most helpful in determining the type of shoulder dislocation?
Axillary Y view
3 types of shoulder separations
Class 1: simply a sprain of AC and CC ligaments (normal joint space)
Class 2: slight widening of joint space as the acromioclavicular ligament is ruptured but the coracoclaviular ligament is only sprained
Class 3: both are ruptured and severe joint widening
What must be checked when a patient presents with a proximal humerus / humeral head fracture?
Deltoid sensation to rule out brachial plexus or axillary nerve injury
A radial nerve injury would present as what?
Wrist drop
What nerve injury must you rule out in a patient with a humeral shaft fracture?
Radial nerve (would present as a wrist drop)
What is Volkmann ischemic contracture
A complication of a humerus fracture that involves injury to the median nerve and brachial artery.
-Causes a claw like deformity from ischemia with flexion/contracture of the wrist
Clinical manifestation of an olecranon fracture that may distinguish it from another
inability to extend the elbow
Complications of an olecranon fracture
Ulnar nerve dysfunction
Management of an olecranon fracture
REDUCE; all of these are considered intraarticular
What is a monteggia fracture?
Proximal ulnar shaft fx with anterior radial head dislocation
What is a Galeazzi Fx?
Mid-distal radial shaft fracture with dislocation of distal radioulnar joint (DRUJ)
What is a nursemaid’s elbow?
Radial head subluxation, MC in a child under 5 y/o
- Radial head wedges into the stretched annular ligament
- Child will have arm slightly flexed with refusal to use it
- Reduce with pressure on the radial head, arm supination and flexion
What is a hutchinson fracture?
radial styloid fracture; aka Chauffer’s fx
What is the MC direction for an elbow to dislocate?
Posteriorly
Manifestations and management of an elbow dislocation
- Patient with flexed elbow & a marked olecranon prominence
- Emergent reduction is necessary with a posterior splint
- Rule out brachial artery and nerve injuries
What is the MC carpal fx?
Scaphoid
Management of a scaphoid fx
Thumb spica splint, get repeat x-rays even if it does not show fx and there is snuff box tenderness.
*High risk of avascular necrosis or nonunion
What is a Colles fracture?
Distal radius fx with dorsal/posterior angulation, “dinner fork deformity”
-MC result of a FOOSH with wrist extension
What is a Smith fx?
Distal radius fx with ventral/anterior angulation
-MC result of a FOOSH with wrist flexion
What is a Barton fx?
Intra-articular distal radius fx with CARPAL displacement
What is a Boxer’s fx?
Fracture of the 5th metacarpal neck
Boxer’s fx management
Ulnar gutter splint with joints in @ least 60 deg. flexion
-Always check for bite wounds
What is a Bennett Fracture?
Intraarticular fx between the base of the first MCP
***A rolando’s fracture is a comminuted Bennet’s fx
Saltar Harris Classification of fractures
Type 1: Isolated growth plate fracture
Type 2: Growth plate + metaphysis (MC)
Type 3: growth plate + epiphysis
Type 4: growth plate + metaphysics + epiphysis (NEEDS REDUCTION)
Type 5: Growth plate compression
What is the MC direction for a hip to dislocate
Posteriorly
Clinical manifestation of a posterior hip dislocation
Shortened leg
INTERNALLY rotated
Adducted with hip/knee slightly flexed
Clinical manifestation of an anterior hip dislocation
**this is also how a hip fracture would present
Shortened leg
EXTERNALLY rotated
Abducted
Complications of a hip dislocation
- avascular necrosis of the hip in 13%
- Sciatic nerve injury
- This is a true orthopedic emergency
What is a greenstick fracture?
Bowing of the bones in children
What is a buckle fracture?
incomplete fx with wrinkling or a bump
aka torus fx
What is the best radiographic view for a patella fracture?
Sunrise view
What is the MC complication of a knee dislocation
1/3 will have a popliteal artery injury
Weber ankle fracture classifications
Weber A: fibular fx below syndesmosis
Weber B: fibular fx AT level of syndesmosis
Weber C: Fibular fx ABOVE mortise joint, with deltoid ligament damage or medial malleolar fx, this is unstable
What is a maisonneuve fx?
Spiral Proximal fibular fx as a result of a distal medial malleolar fx or deltoid ligament tear
What is a Jones fracture?
transverse fx through the diaphysis of the 5th metatarsal
What is a lisfranc injury?
disruption between the articulation of the medial cuneiform and 2nd metatarsal
Where does the axillary nerve innervate?
deltoid
What part of the rotator cuff is MC injured?
Supraspinatus
Special tests for a rotator cuff injury
1) Hawkins: 90 degree flexion in elbow and shoulder, pain illicited on IR
2) Drop Arm: Hold arm up and keep it there (try with and without lidocaine)
3) Neer test: arm fully pronated with pain during forward flexion
Ligaments of the shoulder
Acromioclavicular ligament (AC)-if ruptured in isolation this is a grade 2 shoulder separation
Coracoclavicular ligament (CC) -If ruptured along with the AC ligament this is a grade 3 shoulder separation
What is the MC fracture in children and adolescents?
Clavicular fracture
*suspect child abuse if under 2 years old
What comorbidities are would increase the risk of adhesive capsulitis ?
DM
Hypothyroid
What arteries and nerves run through the elbow that you must evaluate in the case of a an elbow dislocation?
Radial artery
Median nerve
Ulnar nerve
radial nerve
What is Kienbock’s disease?
Avascular necrosis of the lunate bone
*a lunate fracture is the most serious carpal fx due to the fact that it occupies 2/3 of the radial articular surface
What can be given after fractures to decrease the risk of developing Complex Regional Pain Syndrome?
Vitamin C
What is Mallet finger and how does it present?
Direct blow to an extended finger causes an extensor tendon avulsion, leaving the finger flexed at the DIP
What is a boutoniere deformity?
Flexed PIP joint and hyperextended DIP
What is a swan neck deformity?
Finger hyperextended at the PIP and flexed at the DIP
Gamekeeper’s thumb
sprain or tear of the ulnar collateral ligament of the thumb
- Gamekeeper thumb if chronic condition
- Skier’s thumb if acute injury
What is the pathopneumonic fracture associated with an ACL tear?
Segond fx: this is an avulsion of the lateral tibial condyle
What meniscal tear is most common, medial or lateral?
Medial *it is more fixed to the femoral head
What is the Thompson test?
weak, or absent plantar flexion when gastrocnemius is squeezed.. indicative of chillies tendon injury
Hallmarks of Acute Osteomyelitis
-MC seen in children causes by hematogenous spread of Staph Aureus (group B strep if less than 4 months old)
Hallmarks of Chronic Osteomyelitis
-MC seen in adults 2ry to direct inoculation of an open wound with Staph Aureus
Tests to make the diagnosis of Osteomyelitis
- MRI (most sensitive early test)
- WBC, ESR, CRP (if ESR normal it is most likely NOT osteo)
- XRAY: shows periosteal reaction and sequestrum
-Bone aspiration is GOLD standard
Duration of tx for osteomyelitis
4-6 weeks of abx with at least 2 weeks IV
Tx regimens for osteomyelitis
Under 4 months: (group B strep) Nafcillin
Over 4 months:
(MSSA) Nafcillin or Cefazolin
(MRSA) vancomycin
Sickle Cell dz: (salmonella) 3rd gen. cephalosporin or FQ
Puncture Wound: (pseudomonas) Cipro
What is the MC organism and body part affected by septic arthritis?
Staph Aureus effecting the knee.
Dx of septic arthritis
Arthrocentesis with over 50,000 WBC, predominantly PMNs
TX of septic arthritis
Gram + Nafcillin
Gram - or gonococcus Ceftriaxone + gentamicin if pseudomonas suspected
