Musculoskeletal Conditions Flashcards
Osteoarthritis: Predisposing Factors
- genetics
- bone density & vitamin D intake
- biomechanical factors: joint laxity, prior injury, obesity, muscle weakness
Osteoarthritis: Presenting Signs and Symptoms
- deep, aching PAIN that is exacerbated by activity and relieved with rest
- early morning stiffness, usually < 30 minutes
- tenderness on palpation of affected joints
- audible crepitus
- erythema and marked warmth absent
- possible joint effusion
- joint instability in advanced disease
- common joints: DIP joints (Heberden nodes due to osteophytes), MCP joint @ BASE OF THUMB, hips, knees
- cervical and lumbosacral vertebral joints
- occasionally: PIP joints (Bouchard’s nodes from osteophytes)
- X-Ray: presence of osteophytes or joint space narrowing
Osteoarthritis: How to Diagnose
- consider other differential diagnoses of mono and polyarticular arthritis
- determine if pain is articular or periarticular
- articular disease usually limits motion
- articular disease usually encompasses entire joint space
- preservation of ROM usually argues against articular involvement
- determine if inflammation is present, or is the arthritis degenerative?
- monoarticular arthritis: determine if infection is present (typically, fever is high)
- is problem local or systemic?
- how sick is the patient?
- if trauma or focal bone pain, x-ray
- if effusion or inflammation, joint aspiration with fluid cell count
Osteoarthritis: Red Flags
- septic arthritis requires hospital admission
- undiagnosed monoarticular arthritis with a high white count and possibility of infection requires consultation with ID for possible IV abx
Osteoarthritis: Treatment
**symptomatic treatment to address pain
exercise: ROM and strengthening
weight loss if appropriate, especially in obese patients; even 11# weight loss can be beneficial
patient education
heat, ultrasound
NSAIDs: use cautiously, only when pain present (topical 1st, then oral if no relief)
APAP –> not 1st line d/t no clinically significant effect on pain; but some patients do experience benefit
- DO NOT USE:
- -OPIOIDS (risks too high)
- -INJECTABLE STEROIDS (very short benefit, lifetime limit on # of injections)
define OSTEOPHYTE
palpable bony enlargement from calcium deposition
can further wear down cartilage
Rheumatoid Arthritis: Predisposing Factors
- women more commonly than men
- any age, but onset more common with advancing age
- peak incidence in 4th decade
- Raynaud phenomenon is common
- smoking increases risk
Rheumatoid Arthritis: Presenting Signs and Symptoms
typically subacute, can be more intense
**SYMMETRICAL, PERIPHERAL POLYARTHRITIS
inflammatory
**COMMON JOINTS: wrists, PIP joints, MCP joints, MTP joints
also: elbows, neck, hips, knees, ankles, feet may be involved
fatigue may precede onset of joint sx
fever and weight loss in severe cases
**CHARACTERISTIC CHANGES: subluxation, swan neck deformities of the fingers, ulnar deviation of the wrists
Rheumatoid Arthritis: Poor Prognostic Indicators
- rheumatoid nodules: firm, contender subcutaneous nodules
- high RF titers
- onset prior to age 20
- acute disease presence > 1 year
Rheumatoid Arthritis: How to Diagnose
- no single clinical feature or test is definitive; dx requires constellation of findings
- >= 6/10 from the 2010 ACR*/EULAR** Classification Criteria for RA
- no imaging studies: radiographic evidence does not typically appear prior to 2 years
\*ACR = American College of Rheumatology \*\*EULAR = European League against Rheumatism
Rheumatoid Arthritis: 4 Domains of the 2010 ACR*/EULAR** Classification Criteria for RA
6/10 points:
- 3+ joints
- serologic abnormality: RF or anti-CPP (anticitrullinated peptide/protein AB)
- Elevated ESR or CRP
- sx for 6+ weeks
Rheumatoid Arthritis: Lab Work & why
WHY: lab testing is not definitive for RA, but the following labs are part of the initial workup for rheumatology
- ESR: nonspecific
- CRP: nonspecific
- RF
- Anti-CPP antibodies (ACPAs): very uncommon in other autoimmune conditions; present in 60% of RA patients
- ANA (to exclude SLE)
- CBC, LFTs, BUN, Cr, Uric Acid, UA
Rheumatoid Arthritis: Treatment by the PCP
PCP:
- early dx as RA can decrease life expectancy by 10 years
- prompt implementation for 1st line DMARDs: as few as 3 months of active disease can be destructive to joints
- timely referral to rheumatologist for further management, esp for refractory cases
Rheumatoid Arthritis: Red Flags
- RARE: atlantoaxial subluxation (causes lack of blood supply to the brainstem)
- fever
- other signs of severe extra-articular disease require hospital admission for work up and admission of IV corticosteroids
Fibromyalgia: Predisposing Factors
- more common in females
- more typical between ages 30-50
Fibromyalgia: Presenting Signs and Symptoms
- disturbance in central pain processing
- chronic, diffuse pain > 3 months
- fatigue
- sleep disturbances
- somatic complaints (headaches, bowel irritability, cognitive disturbances)
- NO evidence INFLAMMATION
- PE normal (except for trigger point tenderness)
- lab, radiology WNL
Fibromyalgia: How to Diagnose
- clinical diagnosis (similar to chronic fatigue syndrome)
- use the 2011 criteria, supplemented with a physical exam
- consider and rule out other conditions
- myofascial syndromes
- rheumatoid disease (e.g. PMR w/ elevated ESR)
- ankylosing spondylitis (Psoriasis, family history, inflammatory bowel disease, risk factors for Reiter syndrome, relief of pain with exercise, sacroiliitis, pain/tenderness at site of tendon insertion)
- Lyme disease, Babesiosis, anaplasmosis
- hypothyroidism
- depression
- somatization disorder
- physical exam: look for rashes, changes in nails, goiter, joint deformity, swelling, redness, proximal muscle weakness, delayed relaxation of DTRs, mental status (depression/anxiety)
- labs to rule out suspected treatable conditions
Fibromyalgia: Treatment
- goal: maintenance and enhancement of functional capacity
- formation of strong patient-provider relationship
- exercise! Tai Chi is hugely beneficial
- sleep hygiene
- Pharmacologic Therapy: anticonvulsants (pregabalin, gabapentin); SNRIs (duloxetine, milnacipran – full antidepressant doses needed); TCAs (amitriptyline, cyclobenzaprine – lower doses needed than those for depression)
- may need referral to rheumatology
Fibromyalgia: Red Flags
SPRAIN: Predisposing Factors
SPRAIN: Presenting Signs and Symptoms
SPRAIN: Red Flags
