MSK/rheumatologic Flashcards

1
Q

What is polymyalgia rheumatica?

A

Polymyalgia rheumatica (PMR) is an inflammatory rheumatic condition characterized clinically by aching and morning stiffness in the shoulders, hip girdle, and neck. It can be associated with giant cell (temporal) arteritis (GCA), and the two disorders may represent different manifestations of a shared disease process. Usually responds well to steroids.

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2
Q

What treatment is best for a midshaft tibial stress fracture (e.g. from running)?

A

A pneumatic stirrup leg brace

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3
Q

What is the typical presentation and treatment of plantar faciitis?

A

Pain usually around medial calcaneal tuberosity. Pain is worse first thing in the morning or after sitting for long periods of time. No need for x-ray usually.

Treatment may not be needed as most cases resolve on their own. NSAIDs, icing, and over-the-counter shoe inserts may be beneficial. Expensive custom inserts should not be considered unless first line therapies fail.

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4
Q

What is the first-line treatment for Achilles tendinopathy?

A

Eccentric exercise should be the first-line treatment for chronic midsubstance Achilles tendinopathy.

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5
Q

What drugs are indicated for prevention of osteoporotic hip fractures?

A

Only zoledronic acid, risedronate, and alendronate have been confirmed in sufficiently powered studies to prevent hip fracture. Ibandronate, raloxifene, denosumab, and etidronate have been shown to reduce new vertebral fractures, but are not proven to prevent hip fracture.

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6
Q

What are the screening recommendations for osteoporosis in men and women?

A

All women ≥65 (SOR A) and all men ≥70 (SOR C) should be screened for osteoporosis. For men and women age 50–69, the presence of factors associated with low bone density would merit screening. Risk factors include low body weight, previous fracture, a family history of osteoporosis with fracture, a history of falls, physical inactivity, low vitamin D or calcium intake, and the use of certain medications or the presence of certain medical conditions.

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7
Q

What does pain and swelling posterior to the medial malleolus, that is worse with weight bearing and inversion of the foot, with pain elicited with plantar flexion against resistance in a woman over 40 who is unable to perform a single-leg heel raise suggest?

A

Tendinopathy of the posterior tibial tendon (patients often cannot recall an injury)

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8
Q

What is the treatment for tendinopathy of the posterior tibial tendon?

A

Immobilization in a cast boot for 2-3 weeks. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity.

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9
Q

What is the FADIR test and what does it test for?

A

Flexion, ADduction and internal rotation. Test for hip impingement.

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10
Q

What is the FABER test?

A

Flexion, ABduction, and external rotation. Used to differentiate between hip and lumbar pain - positive test suggests hip pain (e.g. OA).

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11
Q

How is the diagnosis of polymyalgia rheumatica made?

A

Bilateral hip or shoulder pain for at least a month, with an ESR of > or =40

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12
Q

What therapies have the best evidence for being effective in the treatment of chronic back pain?

A

Treatment options that have the best evidence for effectiveness include analgesics (acetaminophen, tramadol, NSAIDs), multidisciplinary rehabilitation, and acupuncture (all SOR A). Other treatments likely to be beneficial include herbal medications, tricyclics, antidepressants, exercise therapy, behavior therapy, massage, spinal therapy, opioids, and short-term muscle relaxants (all SOR B). There is conflicting data regarding the effectiveness of back school, low-level laser therapy, lumbar supports, viniyoga, antiepileptic medications, prolotherapy, short-wave diathermy, traction, transcutaneous electrical nerve stimulation, ultrasound, and epidural corticosteroid injections (all SOR C).

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13
Q

How soon should surgery for rotator cuff tears be done after the initial injury?

A

Within 6 weeks, before muscle atrophy occurs

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14
Q

What imaging study is best for assessing early osteomyelitis?

A

MRI

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15
Q

What is the best medical management for fibromyalgia?

A

An antidepressant such as amitriptyline or duloxetine. Tramadol may be used for pain management.

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16
Q

What are the Ottawa ankle and foot rules?

A

According to these guidelines, an ankle radiograph series is required only if there is pain in the malleolar zone and bone tenderness of either the distal 6 cm of the posterior edge or the tip of either the lateral malleolus or the medial malleolus. Inability to bear weight for four steps, both immediately after the injury and in the emergency department, is also an indication for ankle radiographs. Foot radiographs are required only if there is pain in the midfoot zone and bone tenderness at the base of the 5th metatarsal or the navicular, or if the patient is unable to bear weight both immediately after the injury and in the emergency department.

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17
Q

Patients with what rheumatologic condition have the highest risk for cancer?

A

In one study, 32% of patients with dermatomyositis had cancer. The risk of cancer was highest at the time of diagnosis, but remained high into the third year after diagnosis. The cancer types most commonly found were ovarian, pulmonary, pancreatic, gastric, and colorectal, as well as non-Hodgkin’s lymphoma. Among patients with polymyositis, 15% developed cancer.

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18
Q

Where are the fibromyalgia trigger points?

A

The typical fibromyalgia trigger points lie along the medial scapula borders, as well as the posterior neck, upper outer quadrants of the gluteal muscles, and medial fat pads of the knees.

19
Q

What is the best treatment for lateral epicondylitis?

A

None - it is a self-limited condition that will resolve on its own without treatment the vast majority of the time. Neither physical therapy, bracing, nor splinting is
proven to provide long-term pain relief.

20
Q

What is the best initial treatment for patellofemoral stress syndrome?

A

Physical therapy

21
Q

What is Dupuytren’s disease?

A

It is characterized by shortening and thickening of the palmar fascia. It is initially asymptomatic, but may progress and cause difficulty with function of the hand, and may eventually lead to contracture.

22
Q

How is Dupuytren’s disease treated?

A

Early asymptomatic disease does not require treatment. A series of cortisone injections over a period of months may lead to disease regression, and is useful in patients with mild to moderate symptoms. Surgery is indicated if a metacarpal joint contracture reaches 30°, or with a proximal interphalangeal joint contracture of any degree. If surgery is delayed, irreversible joint contracture may occur.

23
Q

What disease is Dupuyten’s disease associated with?

A

Diabetes - up to a third of diabetic patients having evidence of the disease. There is also an increased risk of dying from cancer, probably related to smoking, alcohol use, or diabetes mellitus, but a search for cancer at the time of diagnosis is not indicated.

24
Q

Treatment of a boxer’s fracture of the 5th metacarpal with a volar angulation of <40 degrees is what?

A

An ulnar gutter splint (greater than 40 degrees requires more intensive treatment)

25
Q

What is the treatment for acute ankle sprains?

A

A semi-rigid brace that allows flexion and extension (e.g. stirrup brace), or a soft lace-up brace is recommended over immobilization.

26
Q

Subcutaneous or intranasal calcitonin may be helpful for relieving acute pain from what condition?

A

Acute osteoporotic vertebral compression fractures.

27
Q

Fat pad atrophy is a common cause of heel pain in what patient population?

A

Geriatric. Classically the pain gets worse as the day progresses.

28
Q

What is the most common lower extremity stress fracture?

A

Tibial fractures are the most common lower extremity stress fractures in both children and adults, accounting for about half of all stress fractures.

29
Q

What are contraindications to zoledronic acid use?

A

Hypocalcemia and a creatinine clearance <35 mL/min or other evidence of acute renal impairment. An eGFR should be calculated before starting.

30
Q

What is the recommended thromboprophylaxis following major orthopedic surgery?

A

Up to 35 days

31
Q

What medication has been shown to be beneficial in the setting of acute back pain other than pain medication?

A

Cyclobenzaprine (Flexeril)/ non-benzo muscle relaxers

32
Q

What is the treatment for a mallet fracture?

A

Splinting for 8 weeks in full extension

33
Q

What is the primary indication for joint replacement surgery in patients with OA?

A

Intractable pain, which is almost always relieved by the surgery.

34
Q

When is static stretching recommended in athletes?

A

Based on current understanding of sports performance, static stretching is of most benefit when performed during the cool-down period following exercise, which has been found to increase flexibility, and is best avoided immediately before athletic endeavors.

35
Q

To prevent joint damage from gout, uric acid levels should be lowered by medication to what level?

A

<6.0 mg/dL

36
Q

What is the first-line treatment for midsubstance Achilles tendinopathy (symptoms lasting longer than 6 weeks)?

A

The preferred first-line treatment is an intense eccentric strengthening program of the gastrocnemius/soleus complex.

37
Q

What is the initial management of an ankle sprain?

A

RICE: rest, ice, compression, elevation plus NSAIDs

38
Q

How are grade 1 and 2 ankle sprains managed?

A

Early mobilization after aggressive control of inflammation (e.g. icing, compression, elevation). After initial control of inflammation, should use gel or air splints. PT should be started in the first 48 hrs - early mobilization (otherwise risk slower recovery - avoid crutches).

39
Q

What is the grading of ankle sprains?

A

Grade 1: stretching or small tears of ligament
Grade 2: large tear
Grade 3: complete tear

40
Q

How does the pain of Paget’s disease present?

A

Constant, increases with rest. Worsens with application of heat and at night.

41
Q

What is the leading cause of death in patients with RA?

A

CAD - RA patients have accelerated atherosclerosis related to a chronic inflammatory state. It is thus particularly important to address modifiable risk factors for coronary disease in these patients, including tobacco use, hypertension, and dyslipidemia

42
Q

What diseases are patient with RA at increased risk for?

A

CAD, lymphoma, lung cancer, and thromboembolic disease

43
Q

What are the return to play guidelines for stress fractures in athletes?

A

Most stress fractures heal in 6–10 weeks with conservative management such as non–weight bearing and activity limitation. Athletes can return to play once they are pain free and have a normal physical examination, even if the time since diagnosis is less than 6 weeks. However, they should refrain from all high-impact activities such as running and jumping until they can walk without pain