Musculoskeletal (3%)

Question 1

Osteomyelitis

Answer 1

• Inflammation of bone caused by an infectious organism
• Pathogens – Staph. Aureus, pseudomonas, serratia
• Manifestations – high fever, chills, pain/tenderness of involved bone, localized signs of inflammation
• Diagnostics – increased ESR/CRP, bone biopsy (definitive dx), MRI (most helpful)
• Management – antibiotics (empiric IV – clindamycin, Bactrim, fluoroquinolones), consider ID referral

Question 2

Rhabdomyolysis

Answer 2

 Results from the breakdown of muscle fibers with leakage of muscle contents into circulation
 Etiology – high-intensity exercise, severe dehydration or overheating, trauma, medications, long periods of inactivity
 Manifestations – tea colored urine is usually first clue, cramping, muscle pain, weakness
 Diagnostic – urine myoglobin
 Treatment – prevent hyperkalemia, aggressive fluid resuscitation to preserve renal function

Question 3

Fractures

Answer 3

• Diagnostics – XR
• Be aware of compartment syndrome – 6 Ps – pain, paresthesia, pallor, poikilothermia, pulselessness, paralysis; common areas are the lower leg and forearm; treatment is OR for fasciotomy
• Non-pharm management – immobilization, ice/heat, PT/OT, refer to ortho, +/- surgery depending on nature of fracture
• Pharm management – acetaminophen (mild), opioid (very common), antibiotics (for open or compound fractures – cephazoliln (Ancef) 1-2g)

Question 4

Osteoarthritis

Answer 4

 Key characteristics – non-inflammatory, no systemic symptoms, PAIN RELIEVED BY REST & WORSE WITH ACTIVITY, heberden nodes and bouchard nodes
 X-ray – joint space narrowing, unequal joint spaces, osteophyte formation/lipping of marginal bone
 Pharmacologic management – acetaminophen up to 4g/day (first line for mild), opioids (for those whose pain isn’t controlled with weaker meds/advanced disease, intra-articular injections (methylpred, works well in knees)
 Non-pharm management – education on what to expect, heat and cold, weight loss, exercise, PT/OT
 Refer to ortho when patient is failing conventional treatment

Question 5

Gout

Answer 5

 Caused by urate monohydrate crystals
 Key manifestations – monarticular (MTP joint most susceptible), hyperuricemia (serum uric acid > 6.8), swelling, redness, fever, hot and tender
 Pharm management – NSAIDs (indomethacin 25-50 mg PO TID), xanthine oxidase inhibitors (for maintenance, chronic – allopurinol 300-400 mg/day)
 Non-pharm management – high purine foods should be avoided (organ meats, sardines, mussels, alcohol, bacon)

Question 6

Defining osteoporosis vs. osteopenia

Answer 6

• Osteoporosis – BMD is 2.5 SD or more below that of a “young normal” adult
• Osteopenia – BMD between 1.0 and 2.5 SD below that of a “young normal” adult

Question 7

Who should undergo BMD testing?

Answer 7

• Women age ≥ 65 and men ≥ 70, regardless of risk factors
• Younger post-menopausal women or women in menopausal transition with risk factors for fracture
• Those over 50 who have broken a bone
• Adults with a condition (ex: RA) or taking a medication (ex: long-term glucocorticoid use) associated with low bone mass

Question 8

Osteoporosis

Answer 8

• Risk factors – smoking, low body weight, alcoholism, inadequate physical activity, hx of fracture, advanced age, white, female
• Symptoms – asymptomatic until fracture occurs
• Management – PREVENTION, adequate calcium and vitamin D intake, stop smoking, exercise, PT/OT
• Treatment – bisphosphonates (-onate drugs, first line, alendronate weekly)

Question 9

Polymyalgia rheumatica (PMR)

Answer 9

 Inflammation of unknown origin that affects muscles and joints, generally affects people > 50 years
 Manifestations – aches in the shoulder (often first symptom), neck, upper arms, low back, hips; symptoms tend to come quickly (few days or weeks); symptoms worse in the morning and improve throughout the day
 Diagnostics – no specific test to diagnose; CRP and ESR are elevated; MRI or ultrasound of shoulder and hip can detect inflammation to support the diagnosis
 Treatment – low-dose corticosteroid (10-15 mg/day of prednisone) until symptoms relieve (typically 2-3 weeks) followed by a taper to find the lowest dose necessary to suppress symptoms; treatment can continue up to 2-3 years

Question 10

Lumbar spinal stenosis

Answer 10

 Standing discomfort with symptom improvement with bending over is nearly universal
 Pseudoclaudication (leg pain that worsens with activity and improves with rest)
 Bilateral lower-extremity numbness/weakness in majority
 Diagnostics – none initially; for symptoms > 1 month, consider MRI, EMG, and/or nerve conduction velocity (NVC)
 Treatment – PT, NSAIDs, epidural corticosteroid injection, perhaps surgery

Question 11

Grading of sprains with treatment

Answer 11

 Grade I – mild stretching of ligament, no joint instability, can bear weight with mild pain; does not require immobilization
 Grade II – incomplete tear of ligament, mild-to-moderate joint instability, decreased ROM, weight-bearing is painful; mild-to-moderate pain/swelling/tenderness; immobilization with Aircast or splint for a few weeks
 Grade III – complete tear of ligament, pain/swelling/tenderness; loss of function; unable to bare weight; cast/splint/boot