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AANPCB Board Exam > Musculoskeletal Conditions > Flashcards

Musculoskeletal Conditions Flashcards

1
Q

Osteoarthritis: Predisposing Factors

A
  • genetics
  • bone density & vitamin D intake
  • biomechanical factors: joint laxity, prior injury, obesity, muscle weakness
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2
Q

Osteoarthritis: Presenting Signs and Symptoms

A
  • 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
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3
Q

Osteoarthritis: How to Diagnose

A
  • consider other differential diagnoses of mono and polyarticular arthritis
  1. 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
  2. determine if inflammation is present, or is the arthritis degenerative?
  3. monoarticular arthritis: determine if infection is present (typically, fever is high)
  4. is problem local or systemic?
  5. how sick is the patient?
  • if trauma or focal bone pain, x-ray
  • if effusion or inflammation, joint aspiration with fluid cell count
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4
Q

Osteoarthritis: Red Flags

A
  • 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
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5
Q

Osteoarthritis: Treatment

A

**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)
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6
Q

define OSTEOPHYTE

A

palpable bony enlargement from calcium deposition
can further wear down cartilage

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7
Q

Rheumatoid Arthritis: Predisposing Factors

A
  • 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
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8
Q

Rheumatoid Arthritis: Presenting Signs and Symptoms

A

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

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9
Q

Rheumatoid Arthritis: Poor Prognostic Indicators

A
  • rheumatoid nodules: firm, contender subcutaneous nodules
  • high RF titers
  • onset prior to age 20
  • acute disease presence > 1 year
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10
Q

Rheumatoid Arthritis: How to Diagnose

A
  • 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
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11
Q

Rheumatoid Arthritis: 4 Domains of the 2010 ACR*/EULAR** Classification Criteria for RA

A

6/10 points:

  1. 3+ joints
  2. serologic abnormality: RF or anti-CPP (anticitrullinated peptide/protein AB)
  3. Elevated ESR or CRP
  4. sx for 6+ weeks
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12
Q

Rheumatoid Arthritis: Lab Work & why

A

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
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13
Q

Rheumatoid Arthritis: Treatment by the PCP

A

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
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14
Q

Rheumatoid Arthritis: Red Flags

A
  • 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
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15
Q

Fibromyalgia: Predisposing Factors

A
  • more common in females
  • more typical between ages 30-50
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16
Q

Fibromyalgia: Presenting Signs and Symptoms

A
  • 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
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17
Q

Fibromyalgia: How to Diagnose

A
  • 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
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18
Q

Fibromyalgia: Treatment

A
  • 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
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19
Q

Fibromyalgia: Red Flags

A
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20
Q

SPRAIN: Predisposing Factors

A
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21
Q

SPRAIN: Presenting Signs and Symptoms

A
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22
Q

SPRAIN: Red Flags

A
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23
Q

SPRAIN: How to Diagnose

24
Q

SPRAIN: Treatment

25
STRAIN: Predisposing Factors
26
STRAIN: Presenting Signs and Symptoms
27
STRAIN: Red Flags
28
STRAIN: How to Diagnose
29
STRAIN: Treatment
30
BURSITIS: Predisposing Factors
31
BURSITIS: Presenting Signs and Symptoms
32
BURSITIS: Red Flags
33
BURSITIS: How to Diagnose
34
BURSITIS: Treatment
35
TENDONITIS: Predisposing Factors
36
TENDONITIS: Presenting Signs and Symptoms
37
TENDONITIS: Red Flags
38
TENDONITIS: How to Diagnose
39
TENDONITIS: Treatment
40
SHOULDER JOINT ISSUES
* rotator cuff tear * rotator cuff tendinopathy (impingement syndrome) * adhesive capsulitis (Frozen Shoulder) * Acromioclavicular osteoarthritis
41
Shoulder: Rotator Cuff Tendonitis – Presenting Signs
* anterolateral shoulder pain worsened by reaching overhead * pain with supraspinatus testing -→ what test? * subacromial bursa tenderness * normal passive ROM * normal strength * pain with testing * pain with impingement test -→ what test?
42
How to test the supraspinatus?
Empty Can Test
43
How to test for impingement of the shoulder?
Hawkins-Kennedy Test
44
Shoulder: Osteoarthritis
* typically of the acromioclavicular joint * AC joint tenderness * joint space narrowing on X-Ray
45
Shoulder: Adhesive Capsulitis – Predisposing Factors
* DM * h/o immobilizing condition of shoulder * diminished shoulder ROM
46
Shoulder: Rotator Cuff Tendonitis – Presenting Signs
* anterolateral shoulder pain worsened by reaching overhead * pain with supraspinatus testing -→ what test? * subacromial bursa tenderness * normal passive ROM * normal strength * pain with testing * pain with impingement test -→ what test?
47
Important Factors for the Differential Diagnoses for Shoulder Pain
extrinsic pain is a possibility and includes: * MI * ectopic pregnancy * splenic injury * cervical root compression
48
Orthopedic Principle #1 ...and it's impact on the differential diagnosis
**Orthopedic pain/pathology should be reproducible!** If not, the differential diagnosis needs to be reconsidered.
49
ELBOW JOINT ISSUES
* lateral epicondylitis * medial epicondylitis
50
Common term for lateral epicondylitis
Tennis Elbow
51
Common term for medial epicondylitis
Golfer's Elbow
52
Lateral Epicondylitis: How to Test
* Cozen's Test * Mill's Test * Maudley's Test
53
Cozen's Test
* PURPOSE: test for lateral epicondylitis * POSITION: * patient seated, forearm comfortable on table * examiner palpates lateral epicondyle with one hand * patient instructed to make a fist and radially deviate wrist * patient instructed to lift/extend wrist while examiner opposes * POSITIVE: sudden lateral elbow pain reproduced
54
Mill's Test
* PURPOSE: test for lateral epicondylitis * POSITION: * patient seated * examiner stabilizes humerus and palpates lateral epicondyle with one hand * ask patient to pronate forearm * ask patient to extend 3rd digit of hand while examiner opposes extension * POSITIVE: sudden lateral elbow pain reproduced
55
Mill's Test
* PURPOSE: test for lateral epicondylitis * POSITION: * patient standing, elbow in flexion * examiner palpates lateral epicondyle with one hand * examiner passively pronate's patient's forearm * examiner flexes the patient's wrist and extends elbow maximally * POSITIVE: sudden lateral elbow pain reproduced
56
Medial Epicondylitis: How to Test
* POSITION: * patient standing * examiner palpates medial epicondyle with one hand * examiner passively supinates patient's forearm * examiner extends patient's wrist and fully extends elbow * POSITIVE: sudden pain at medial epicondyle

AANPCB Board Exam (4 decks)

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