Musculoskeletal Disorders Flashcards
Osteoarthritis is…
- Osteoarthritis is often referred to as a dysfunctional ‘wear and tear’ process within the joint.
- An initial imbalance in cartilage homeostasis leads to cartilage degradation, remodeling of bone and associated inflammation of the joint.
- Rather than simply causing joint tissue damage by wear and tear, excessive or abnormal joint loading stimulates joint tissue cells to produce proinflammatory factors and proteases that mediate joint tissue destruction.
- Over time, the cartilage thins, leading to exposure of the underlying subchondral bone. This causes subchondral sclerosis and the continuous remodeling of subchondral bone, which then leads to bone hypertrophy and formation of subchondral cysts and osteophytes. And eventual loss of joint space.
Common sites of Osteoarthritis are…
Common sites: Knees, Hand (DIP, 1st CMC [carpometocarpal]), hip, feet (1st metatarsophalangeal joint-MPJ), spine
However, can occur in any joint
The 1st CMC joint is…
Carpal (wrist) bone + a Metacarpal (or long bone of the thumb)
Incidence of OA
25% of population
More common in women than in men
Risk factors for OA
- Increasing age: 50+
- Women
- Genetic predisposition; distal interphalangeal (DIP) joint involvement
- Trauma (previous fractures, ligamentous injuries, or occupational related repetitive stress)
- Altered joint anatomy or instability
- Obesity
- Secondary inflammation such as infections, inflammatory arthropathies and metabolic disorders
- Metabolic (gout)
- Endocrine (hyperparathyroidism can cause bone thinning)
Common complaints of OA include:
- Unilateral joint pain frequently involving the joints of the hands, neck, lower back, knees and hips
- Morning stiffness lasting less than 1 hour.
- Tenderness, bony prominence, and crepitus of affected joints.
Where are Bouchard’s nodes located?
PIP: Proximal Interphalangeal joints
Where are Herberden’s nodes located?
DIP: Distal Interphalangeal joints
Diagnostics for OA include…
- Radiographs (x-rays) of the joint affected
- ESR (OA does not cause increased ESR)
- Chem panel
- CBC
- Rheumatoid Factor
- CT scan or MRI: considered with nerve impingement syndrome (spine) or spinal stenosis
What is Reiter’s disease?
Reiter’s: reaction to an infection by certain bacteria. Most often, these bacteria are in the genitals (Chlamydia trachomatis) or the bowel (Campylobacter, Salmonella, Shigella and Yersinia).
Why should you ask about rashes when someone comes in complaining about joint pain?
Because it could be due to Lyme’s disease (one differential diagnosis for arthritis).
Additional differentials diagnoses for OA and RA include:
- Psoriatic arthritis
- Ankylosing Spondylitis
- CPPD: Calcium Pyrophosphate Dihydrate Crystal Deposition Disease (pseudo gout)
- Gout
- Septic arthritis
- Inflammatory Bowel Disease
- Reiter’s disease (Reactive Arthritis)
- Lupus
- Fibromyalgia
- Tendinitis, soft tissue injury
- Osteoporosis
- Multiple myeloma
First line pharmaceutical therapies for OA include:
- Topical NSAIDs, in patients with one or a few joints affected, especially knee and/or hand. Similar efficacy compared with oral NSAIDs and better safety profile
- Oral NSAIDs in patients with inadequate symptom relief from topical NSAIDs, symptomatic OA in multiple joints, and/or patients with hip OA.
- The use of NSAIDs in most patients is limited by the increased risk of serious gastrointestinal, cardiovascular, and renal complications.
- Caution in patient w/comorbidities such as DM, HTN, and advanced age. Consider using COX-2 selective NSAID (e.g., Celebrex) or a nonselective NSAID associated with a proton-pump inhibitor.
- High caution with high comorbidity risk (eg, previous gastrointestinal bleeding or chronic renal failure, cardiovascular disease).
Additional pharmaceutical treatment for OA:
- Duloxetine for patients with OA in multiple joints and concomitant comorbidities that may contraindicate oral NSAIDs and for patients with knee OA who have not responded satisfactorily to other interventions.
- Topical capsaicin is a treatment option when one or a few joints are involved and other interventions are ineffective or contraindicated
- Intraarticular glucocorticoid injection (though are due to the short duration of its effects (ie, approximately four weeks) and evidence that it may have deleterious effects on the hyaline cartilage may accelerate OA progression
- Narcotic analgesics – rarely due to side effect
- Acetaminophen - not first line
- Hyaluronic acid injections -hyaluronic acid in synovial fluid breaks down. Loss of hyaluronic acid appears to contribute to joint pain and stiffness
- Platelet-rich plasma (PRP) -lack of solid evidence for the recommendation. Pain relief up to 12 months post-injection
- Nutraceauticals (glucosamine, chondroitin, MSM) -May take 6 to 8 weeks for improvement
Rheumatoid Arthritis is…(Choose all of the appropriate answers).
A. More common than Osteoarthritis
B. Is a systemic disease and not limited to the joints
C. Is unilateral in symtomatology
D. Involves joint stiffness that does not resolve in less than 1 hour for greater than 6 weeks
E. Is more common in Women than Men
F. All of the above.
Answers:
B, D, E
Not A because OA is more common than RA (25% incidence compared to 1%)
Not C because RA typically involves bilateral inflammation of joints
Not F…because see above.
True or False: The pathogenesis of RA is unknown.
True: The cause of RA is unknown. Articular inflammation results in joint destruction. Antibody formation in the joint area results in inflammation and pain.
True or False: Common sites of bursitis are the shoulder, elbow, hip, knee, and heel.
True: Bursitis is Inflammation or infection of synovial membrane of the bursal sac overlying a bony prominence
Common sites include:
- Shoulder (subacromial or subdeltoid)
- Elbow (olecranon)
- Hip (trochanteric)
- Knee (prepatellar, pes anserine, suprapetellar)
- Heel (retrocalcaneal)
Causes: Trauma, overuse, irritation, infection
If someone has range of motion losses with the affected extremity, would a differential diagnosis likely be bursitis?
Answer: No.
Reason: Typically, during the assessment of bursitis a person would have full ROM despite the pain or discomfort.
- *Physical Exam**
- Localized fluctuant swelling
- Sometimes warm and painful
- -No loss of ROM*
- If painful and warm consider infection
Diagnostics: If warm and painful, CBC or aspiration
What does the RICE protocol stand for?
Answer:
- *R**est
- *I**ce
- *C**ompression
- *E**levation
True or False: Strains and Sprains are injuries to the bones, ligaments, and tendons.
Answer: False
Strains – Injury to muscle and/or tendon
- *Sprain –** Stretching or tearing of ligament
- *—Grade I:** Stretching but no tearing of ligament, no joint instability
- *—Grade II:** Partial (incomplete) tearing of ligament; some joint instability but definite end-point to laxicity
- *—Grade III:** Complete ligamentous tearing, joint instability
Questions to gather a history for potential sprain/strain include:
- Trauma – valgus (→←) or varus (←→) stress
- Direct blow?
- Forced hyperextention?
- ‘Pop’ (felt or heard)?
- Pain onset – immediate or gradual
- Swelling – immediate or gradual
- Pain with weight bearing
- Worse going up or down stairs
- Locking catching or giving way?
Which two provocative tests check the ACL?
A) Valgus stress and Posterior drawer
B) Anterior drawer and Posterior drawer
C) Varus stress and Lachman’s test
D) Anterior drawer and Lachman’s test
E) None of the above
Answer: D (Anterior drawer and Lachman’s test)
- Valgus stress – tests MCL
- Varus stress – tests LCL
- Anterior drawer – tests ACL
- Posterior drawer – tests PCL
- Lachman’s test – tests ACL
- Knee Exam - YouTube McMurray’s test / Thessaly test– tests meniscus injury
- Knee Exam (18 of 27): McMurray’s test – YouTube
- Thessaly test
Which provocative test is used to assess the MCL?
A) Varus stress
B) Anterior drawer
C) Posterior drawer
D) All of the above
E) None of the above
Answer: E (none of the above)
Valgus stress – tests MCL
Which provocative test assesses the LCL?
A) Valgus stress
B) Lachman’s test
C) Posterior drawer
D) Varus stress
Answer: D (Varus stress)
Why?
Valgus stress-tests MCL
Varus stress – tests LCL
Anterior drawer – tests ACL
Posterior drawer – tests PCL
Lachman’s test – tests ACL
The posterior drawer technique assesses which ligament?
A) MCL
B) ACL
C) PCL
D) LCL
Answer: C
Posterior drawer- tests PCL
Valgus stress – tests MCL
Varus stress – tests LCL
Anterior drawer – tests ACL
Lachman’s test – tests ACL
