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PANCE Prep Pearls > Musculoskeletal disorders > Flashcards

Musculoskeletal disorders Flashcards

1
Q

Clinical manifestations of anterior glenohumeral shoulder dislocation

A
  1. Arm abducted, externally rotated** 2. “Squared off shoulder” is usually associated with recurrent dislocations
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2
Q

Anterior glenohumeral diagnosis

A

Axillary & “Y” view (this determines ant. vs. posterior)

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3
Q

Hill-Sachs lesion

A

Groove on humeral head

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4
Q

Bankart Lesion

A

Glenoid inferior rim fracture

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5
Q

Anterior glenohumeral shoulder dislocation management

A
  1. Reduction must r/o axillary nerve injury (pinprick over deltoid)*
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6
Q

Which type of dislocation is associated with seizures and shocks?

A

Posterior glenohumeral shoulder dislocation

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7
Q

Acromialclavicular joint dislocation (shoulder dislocation) most observed injury

A

Direct blow to adducted shoulder

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8
Q

Imaging done in acromioclavicular joint dislocation (shoulder dislocation)

A

X-ray with weights

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9
Q

Type 1 shoulder dislocation

A

normal CXR (ligamental sprain)

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10
Q

Type 2 shoulder dislocation

A

Slight widening AC ligament ruptured. Coraclavivular ligament sprained

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11
Q

Class III shoulder dislocation

A

Significant widening; both ligaments ruptured

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12
Q

Management of acromioclavicular joint dislocation

A

Brief sling immobilization, ice, analgesica, and ortho follow up. Type III may need surgery

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13
Q

SITS

A
  1. Supraspinatus*
  2. Infraspinatus
  3. Teres minor
  4. Subscapularis
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14
Q

What is tendonitis?

A

Inflammation usually associated with subacromial bursitis. Usually in adolescents-<40 years old.

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15
Q

Rotator cuff tear is seen most commonly in what population?

A

>40 years old. Usually results from trauma or chronic overuse.

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16
Q

ROM in rotator cuff injuries

A

There is usually anterior deltoid pain with decreased ROM, especially with overhead activities, internal rotation or abduction

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17
Q

In rotator cuff tears, what clinical manifestastions may be seen?

A

Weakness, atrophy, and continuous pain

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18
Q

Is active or passive ROM greater in rotator cuff injuries?

A

Active ROM

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19
Q

Pain with abduction >90 degrees suggest what?

A

Tendinopathy

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20
Q

“Empty can” test is used to test what?

A

Supraspinatus strength

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21
Q

Impingement tests are used to check what?

A

Subscapular nerve/ supraspinatus

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22
Q

Hawkins test description

A

Elbow/shoulder flexed @90 degrees with sharp anteiror shoulder pain with internal rotation

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23
Q

Neer test description

A

Arm fully pronated (thumb’s down) with pair during forward flexion (while should is held down to prevent shrugging). Supraspinatus test: pain with abduction v. resistance.

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24
Q

Subacromial lidocaine test

A

Distinguishes tendinopathy from tear. Normal strength with pain relief = tendinopathy. Persistent weakness with large tear

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25
Q

Management of tendinitis

A

Shoulder pendulum/wall climbing exercises*, ice, NSAIDs, physical activity

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26
Q

Rotator cuff tear management

A

Conservative: rehab, NSAIDs, intra-articular steroids, ROM preservation

Surgery if conservative doesn’t help

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27
Q

What is a common site for pathologic fx in metastatic breast CA?

A

Proximal humerus fractures

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28
Q

Clinical manifestations of proximal humerus fractures

A

Arm held in adducted position. Check deltoid sensation (to r/o brachial plexus injury)

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29
Q

With a humeral shaft fracture, what must be ruled out on physical exam?

A

Radial nerve injury (wrist drop)

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30
Q

Humeral shaft fracture management

A

“Sugar tong splint”, coaptation splint, sling/swathe. Ortho f/up in 24-48 hours

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31
Q

Complications with clavicle fractures

A

Pneumothorax, hemothorax, cloraclavicular ligament disruption (distal)

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32
Q

Clavicle fracture management

A

Mid 1/3: Arm sling 4-6 weeks in adults; ortho consult if proximal 1/3

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33
Q

What is adhesive capsulitis (frozen shoulder)?

A

Shoulder stiffness due to inflammation (esp. in hypothyroidism and DM)

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34
Q

Adhesive capsulitis (frozen shoulder) management

A

Rehab ROM therapy mainstay of tx. Anti-inflammatories, intraarticular steroid injection, heat

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35
Q

What is thoracic outlet syndrome?

A

Idiopathic compression of brachial plexus (95%), subclavian vein (5%) or subclavian artery (1%) as they exit narrowed space between shoulder girdle and 1st rib

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36
Q

Thoracic outlet syndrome: clinical manifestations (3)

A
  1. Nerve compression: pain/paresthesias to the forearm, arm, ulnar side of hand
  2. Vascular compression: Swelling/discoloration of the arm esp. with abduction of arm
  3. Physical examination: +Adson: loss of radial pulse**​ with head rotated to the affected side
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37
Q

Thoracic outlet syndrome: diagnosis

A

MRI

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38
Q

Thoracic outlet syndrome management

A

Controversial. PT 1st line, avoid strenuous activity. Ortho consult. +/- surgery

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39
Q

Supracondylar fractures are most common in what population?

A

Children aged 5-10

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40
Q

Supracondylar fracture: Diagnosis

A

abn. anterior humeral line on lateral view if displaced. Non-displaced–>ant. fat pad sign*

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41
Q

Anterior fat pad signifies what in children and adults?

A

Children: Supracondylar fracture

Adults: Radial head fracture

(They may also be seen as a normal variant if they are small and almost parallel to the humerus)

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42
Q

What are the complications with supracondylar fractures?

A

Median nerve & brachial artery injury –>Volkmann’s ischemic contracture*

Radial nerve injury

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43
Q

Supracondylar fractures management

A

Non-displaced: Splint

Displaced: ORIF. They should also be admitted and ortho should be consulted

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44
Q

Radial head fracture: Physical examination

A

Lateral (radial) elbow pain, inability to fully extend elbow

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45
Q

Radial head fracture: diagnosis

A

Notoriously difficult to see. Fat pad sign**: posterior or increased anterior

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46
Q

Radial head fractures: Management

A

Non-displaced –>sling, long arm splint 90 degrees

Displaced–>ORIF

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47
Q

Olecranon fracture complication

A

Ulnar nerve dysfunction**

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48
Q

Olecranon fracture: management

A

Nondisplaced–>Splint (90 degree flexion)

Displaced–>ORIF

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49
Q

Olecranon bursitis clinical manifestations (2)

A
  • Abrupt “goose egg” swelling
  • Limited ROM with flexion
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50
Q

What is a Monteggia fracture?

A

Proximal ulnar shaft fracture with anterior radial head dislocation

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51
Q

What nerve can be damaged with a Monteggia fracture?

A

Radial nerve

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52
Q

Monteggia fracture: management

A

ORIF

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53
Q

What is a Galeazzi fracture?

A

Mid-distal radial shaft fracture with dislocation of distal radio-ulnar joint (DRUJ)

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54
Q

Galeazzi fracture management (2)

A
  1. UNSTABLE! Needs ORIF
  2. Long arm splint; sugar tong splint
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55
Q

How to reduce a radial head subluxation (Nursemaid’s elbow)?

A

Pressure on radial hadi with supination and flexion

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56
Q

What is a Hutchinson fracture?

A

Radial styloid fracture (AKA Chauffer’s fracture)

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57
Q

What is the MOI with lateral epicondylitis (Tennis Elbow)?

A

Inflammation of tendon insertion of ECRB (extensor carpi radialis brevis muscle) due to repetitive pronation of forearm and excessive wrist extension.

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58
Q

Lateral epicondylitis clinical manifestations

A

Lateral elbow pain esp. with gripping, forearm pronation and wrist extension against resistance

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59
Q

Medial epicondylitis MOI

A

Inflammation of the pronator teres-flexor carpi radialis due to repetitive stress

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60
Q

How is the pain from medial epicondylitis reproduced?

A

Forcefully extending the elbow vs resistance with forearm supinated and wrist flexion against resistance

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61
Q

What is the most common type of elbow dislocation?

A

Posterior

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62
Q

Elbow dislocation: Management (3)

A
  1. EMERGENT reduction!
  2. Posterior splint @90 degrees x 7-10 d
  3. Unstable –> ORIF
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63
Q

What is Froment’s sign?

A
  1. It is a test that is used for cubital tunnel syndrome
  2. Ulnar nerve via adductor pollicus - pt holds paper and pt compensates with flexion of IP joint - pinching effect
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64
Q

What fracture is associated with pain along the RADIAL surface of the wrist?

A

Scaphoid (navicular) fracture

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65
Q

Scapholunate dissociation clinical manifestations (2)

A
  1. Pain on dorsal radial side of wrist
  2. (+) Terry Thomas sign (>3 mm)
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66
Q

Scapholunate dissocation treatment

A

Radial gutter splint; may need operative repair of scapholunate ligament

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67
Q

What is a Colles fracture?

A

Distal radial fracture with dorsal angulation (posterior)

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68
Q

What is tht most common complication from a Colles fracture?

A

Extensor pollicis longus tendon rupture

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69
Q

Colles fracture management (3)

A
  1. Sugar tong* splint/cast
  2. If stable (<20 degrees angulation –>closed reduction
  3. ORIF if unstable/comminuted
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70
Q

What is a Smith’s fracture?

A

“Reverse Colles fracture” ventral angulation (anterior)

“Garden Spade” deformity

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71
Q

What is a Barton fracture (2)?

A
  1. Intra-articular distal radius fracture with carpal displacement*
  2. “White arrow”
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72
Q

What is a perilunate dislocation?

A

Lunate that doesn’t articulate with capitate (but still articulates with radius)

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73
Q

What is a lunate dislocation?

A

Lunate doesn’t articulate with capitate or radius. EMERGENT CONSULT!

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74
Q

Lunate dislocation: diagnosis (2)

A
  1. AP view: “piece of pie” sign
  2. Lateral view: “spilled teacup sign” with lunate
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75
Q

Lunate dislocation: management

A

unstable needs ORIF

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76
Q

What is the most serious carpal fracture?

A

Lunate fracture since it occupies 2/3 of radial articular surface. X-rays are often negative!

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77
Q

What is Kienbock’s disease?

A

Avascular necrosis of the lunate bone

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78
Q

Lunate fracture management

A

Thumb spica

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79
Q

Complex Regional Pain Syndrome: Stage I

A

Pain out of proportion to injury. ANS sx: swelling, extremity color changes, increased nail and hair growth

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80
Q

Complex Regional Pain Syndrome: Stage II

A

Waxy, pale skin, brittle nails, loss of hair, persistently pale

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81
Q

Complex Regional Pain Syndrome: Stage III

A

Joint atrophy and contractures

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82
Q

What is the prophylactic treatment for complex regional pain syndrome?

A

Vitamin C

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83
Q

MOI of Mallet (baseball) finger

A

Avulsion of extensor tendon

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84
Q

Mallet (baseball) finger: Clinical manifestations

A

Pt unable to straighten distal finger (flexed @ DIP joint)*

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85
Q

What is mallet finger most commonly associated with?

A

Avulsion fracture of distal phalanx

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86
Q

Mallet (baseball) finger: Management

A
  1. Splint DIP uninterrupted extension x 6 weeks vs. surgical pinning
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87
Q

What is gamekeeper’s (skier’s) thumb?

A

Ulnar collateral ligamental injury of thumb–> instability of MCP joint

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88
Q

What is difference between gamekeeper’s thumb and skier’s thumb?

A

Gamekeeper’s thumb: Chronic

Skier’s thumb: acute condition

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89
Q

Gamekeeper’s (skier’s) thumb: management

A
  1. Thumb spica** and referral to hand surgeon (b/c affects pincer function)
  2. Complete rupture: surgical repair
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90
Q

Boxer’s fracture: management

A

Ulnar gutter splint** with joints in @ least 60 degrees flexion

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91
Q

What is Bennett’s fracture?

A

Intraarticular fracture through base of 1st MCP

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92
Q

What is Rolando’s fracture?

A

Comminuted Bennett’s fracture

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93
Q

What is the treatment for Bennett’s fracture/Rolando’s fracture?

A

UNSTABLE!!! Requires ORIF (thumb spica for stabilization)

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94
Q

What is the MC type of all Salter-Harris fractures?

A

Type II

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95
Q

What is Dequiervain’s tenosynovitis?

A

Stenosing tenosynovitis of abductor pollicus longus (APL) and extensor pollicus brevus (EPB)

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96
Q

What distinguishes pronator syndrome from carpal tunnel syndrome?

A

Pronator syndrome is associated with more proximal forearm pain than wrist/hand pain and not associated with pain at night (like seen in carpal tunnel)

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97
Q

Hip dislocations: complications

A

Avascular necrosis*, sciatic nerve injury, DVT, bleeding

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98
Q

What is most common type of hip dislocation?

A

Posterior MC

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99
Q

Hip dislocation clinical manifestations (2)

A
  1. Hip pain with leg shortened, internally rotated and adducted with hip/knee slightly flexed
  2. Anterior may be externally rotated
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100
Q

Hip fractures: clinical manifestations

A
  1. Hip pain with leg shortened, externally rotated**, abducted
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101
Q

Hip fractures: management

A

ORIF

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102
Q

What is Legg-Calve-Perthes disease?

A

Idiopathic avascular osteonecrosis of femoral head in children due to ischemia of capital femoral epiphysis in children

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103
Q

Which patient populatio is at higher risk of having Legg-Calve-Perthes disease? (3)

A
  1. Children 4-10 years old
  2. MC in boys
  3. Low incidence in African-Americans
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104
Q

Legg-Calve-Perthes disease: Clinical manifestations (3)

A
  1. Painless limping* x weeks (worsens with continued activity especially at the end of the day)
  2. Hip pain that may radiate to thigh, knee, or groin
  3. Restricted ROM (loss of abduction and internal rotation)
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105
Q

Early X-rays of Legg-Calve-Perthes disease

A

Increased density of femoral head, widening of cartilage space

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106
Q

Late X-rays of Legg-Calve-Perthes disease

A

Deformity, crescent sign (subchondral fracture)

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107
Q

When is observation indicated for Legg-Calve-Perthes disease?

A

In children <5 years of age or <50% femoral involvement. Usually do NSAIDs, bed rest, PT. Self-limiting with revascularization within 2 years.

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108
Q

When is abduction bracing indicated for Legg-Calve-Perthes disease?

A

Children >5 years of age or significant loss of abduction

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109
Q

What is Slipped Capital Femoral Epiphysis (SCFE)?

A

This is where the femoral head (epiphysis) slips posterior and inferior at growth plate

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110
Q

Which patient population is at higher risk of having SCFE?

A

7-16 year old patients, male children during growth spurt

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111
Q

SCFE: Clinical manifestations

A

Hip, thigh, or knee pain with limp*, external rotation of affected leg. If seen in children before puberty, suspect hormonal/systemic d/o (ex: hypothyroidism)

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112
Q

SCFE: Treatment (2)

A
  1. ORIF (increased risk of AVN)
  2. Non weight bearing with crutches
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113
Q

What is a greenstick fracture?

A

Incomplete fracture with cortical disruption and periosteal tearing on the convex side of the fracture (intact periosteum on the concave side) “bowing”**

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114
Q

What is a torus (buckle) fracture?

A

It is an incomplete fracture with “wrinkling or bump” of the metaphyseal-diaphyseal junction (where the dense bone meets the more porous bone) due to axial loading

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115
Q

Which ligament is tested by the valgus stress test?

A

MCL

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116
Q

Which ligament is tested by the varus stress test?

A

LCL

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117
Q

MCL and LCL collateral ligament injuries: Treatment for Grade I (sprains) and II (incomplete tears)

A

Conservative: pain control, PT to restore ROM and muscle strength, RICE, NSAIDs, knee immobilizer

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118
Q

MCL and LCL collateral ligament injuries: Treatment for Grade III (complete tear)

A

Surgical repair

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119
Q

What is the most commonly injured knee ligament?

A

ACL

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120
Q

In an ACL injury, what is associated with “pop and swelling”?

A

Hemarthrosis

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121
Q

What is the most sensitive specialized exam for ACL injury?

A

Lachman’s test

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122
Q

What is a segond fx?

A

Avulsion of the lateral tibial condyle with varus stress to the knee. If present, ligamental injuries are most likely present. Pathognomonic for ACL tear

123
Q

PCL physical examination

A

Posterior drawer sign and posterior sag sign

124
Q

PCL injury: treatment

A

Almost always treated operatively

125
Q

What is the most common meniscal tear located at?

A

Medial (3x)> lateral

126
Q

Meniscal tear: physical examination

A

(+) McMurray’s sign*, Apley test, joint line tenderness, effusion

127
Q

Meniscal tear: Management

A

NSAIDs, partial weight bearing until ortho f/up. Arthroscopy

128
Q

Patellar fracture: diagnosis

A

Sunrise view X-ray

129
Q

Patellar fracture: Management (2)

A
  1. Non-displaced –> knee immobilizer, 6 week leg cast
  2. Displaced –> surgery
130
Q

Which patient population has a high incidence of patellar and quadriceps tendon rupture? (2)

A
  1. Males >40 years old
  2. History of systemic disease (DM, gout, obesity, renal disease)
131
Q

Clinical manifestations of patellar and quadriceps tendon ruptures (3)

A
  1. Sharp, proximal knee pain with ambulation, inability to extend knee (straight leg raise)
  2. Quadriceps tendon rupture: patella baja - palpable defect above knee
  3. Patellar tendon rupture: patella alta - palpable defect below knee
132
Q

Patellar and quadriceps tendon rupture: management (3)

A
  1. Knee immobilizer
  2. No weight bearing/partial, RICE
  3. Surgical repair within 7-10 days
133
Q

Patellar dislocation: physical exam

A

Apprehension sign. Only done if injury already reduced itself

134
Q

Patellar dislocation: management

A

Closed reduction. Post reduction films. Knee immobilizer x 3-6 weeks (full extension), strengthten quads

135
Q

What is the major complication of knee (tibial-femoral) dislocation?

A

Popliteal artery injury* (this makes it a sever limb threatening injury!!!)

136
Q

Knee (tibial-femoral) dislocation management

A

Immediate ortho consult! Prompt reduction vial longitudinal traction

137
Q

MOI for femoral condyle injury

A

Axial loading (falling from height)

138
Q

Femoral condyle injury: Complications (2)

A
  1. Peroneal nerve injuries (check 1st web space)
  2. Popliteal artery injury
139
Q

Femoral condyle injury: Treatment

A

IMMEDIATE ORHTO CONSULT! Usually heal poorly, ORIF

140
Q

In a tibial plateau fracture, if it is displaced, you should check for what nerve?

A

Peroneal nerve function (foot drop)

141
Q

What is Osgood-Schlatter disease?

A

Osteochondritis of patellar tendon @ tibial tuberosity from overuse

142
Q

What is the most common cause of chronic knee pain in young active adolescents?

A

Osgood-Schlatter disease

143
Q

What population is at high risk of having Osgood-Schlatter disease?

A
  • Males
  • 10-15 years old
  • Athletes with “growth spurts”
144
Q

Osgood-Schlatter disease: clinical manifestations

A
  1. Activity related knee pain/swelling
  2. Painful lump below the knee
  3. Tenderness to the anterior tibial tubercle
145
Q

What is a baker’s cyst?

A

Synovial fuid effusion that is displaced into formation of a cyst

146
Q

What happens if a baker’s cyst ruptures?

A

It causes pseudo thrombophlebitis syndrome which can mimick DVT

147
Q

Baker’s cyst: Treatment

A

Conservative: ice, assisted weight bearing, NSAIDs. Intraarticular steroid injection, surgical excision

148
Q

What is patellofemoral syndrome (chondromalacia)?

A

Idiopathic softening/fissuring of patellar articular cartilage. MC seen in runners*

149
Q

Patellofemoral syndrome (chondromalacia): Diagnosis

A

+ Apprehension sign

150
Q

What is the most common cause of knee pain in runners?

A

Iliotibial band syndrome

151
Q

Iliotibial band syndrome: Clinical manifestations

A

LATERAL knee pain* during onset of running and then resolves. Positive lateral condyle tenderness*

152
Q

Iliotibial band syndrome: Diagnosis

A

(+) OBER TEST*: pain or resistance to adduction of leg parallel to the table in neutral position

153
Q

Which type of ankle dislocation is more common: anterior or posterior?

A

Posterior

154
Q

What ligaments are most commonly involved with ankle sprains?

A

Anterior talofibular* and calcaneofibular (ATFL is the main stabilizer during inversion)

155
Q

Weber A (4)

A
  1. Fibular fracture BELOW Mortise
  2. Tibiofibular syndesmosis intact
  3. Deltoid ligament intact
  4. Usually stable
156
Q

Weber B (4)

A
  1. Fibular fracture AT LEVEL of Mortise
  2. Tibiofibular syndesmosis intact or mild tear (talofibular joint not widened)
  3. Deltoid ligament intact or may be torn
  4. Can be stable or unstable
157
Q

Weber C (4)

A
  1. Fibular fracture ABOVE Mortise
  2. Tibiofibular syndesmosis torn with widening of talofibular joint
  3. Deltoid ligament damage or medial malleolar fracture
  4. Unstable - requires ORIF
158
Q

Anyone with a distal ankle fracture should have a proximal x-ray view to r/o what?

A

Maisonneuve fracture

159
Q

What is Maisonneuve fracture?

A

Spiral proximal fibular fracture due to rupture of the distal talofibular syndesmosis and interosseous membrane as a result of a distal medial malleolar fracture and/or deltoid ligament rupture

160
Q

What is a pilon (tibial plafond) fracture?

A

Fracture of the distal tibia from impact with talus, interrupting the ankle joint space from forceful axial load, high-impact trauma. It extends into the ankle joint.

161
Q

What is the most common location for stress fractures?

A

3rd metatarsal

162
Q

What is tarsal tunnel syndrome?

A

Post tibial nerve compression from overuse, restrictive footwear, edematous states

163
Q

What differentiates tarsal tunnel syndrome from plantar fasciitis?

A

With tarsal tunnel syndrome, the pain increases throughout the day. Pain worsens @ night and with activity

164
Q

What is a hammer toe?

A

Deformity of the PIP joint with flexion of PIP joint and hyperextension of MTP and DIP joint. Seen if the second toe is longer than the first

165
Q

What is Charcot’s joint (diabetic foot)?

A

Joint damage and destruction as a result of peripheral neuropathy

166
Q

What does the X-ray show with charcot’s joint (diabetic foot)?

A

Obliteration of joint space, scattered osteophytes in fibrous tissues

167
Q

What is Morton’s neuroma?

A

Degeneration/proliferation of plantar digital nerve producing painful mass near tarsal heads

168
Q

Which population is at high risk for developing Morton’s neuroma?

A

Women 25-50 yo esp. in those who wear tight shoes/high heels/flat feet

169
Q

What is a Jones fracture?

A

Transverse fracture through diaphysis of 5th metatarsal

170
Q

What is a pseudojones fracture?

A

Transverse avulsion fracture @ base (tuberosity) of 5th metatarsal. More common than true Jones fracture.

171
Q

Pseudojones fracture: Management

A

Walking cast x 2-3 weeks; ORIF if displaced

172
Q

What is the Lisfranc joint?

A

Bases of 1st 3 metatarsal heads and respective cuneiforms

173
Q

What is a Lisfranc injury?

A

Disruption between the articulation of the medial cuneiform and base of 2nd metatarsal

174
Q

What is the Fleck sign?

A

Fracture @ base of 2nd metatarsal and is pathognomonic for disruption of tarsometatarsal ligaments (Lisfranc injury?)

175
Q

Lisfranc injury: management

A

ORIF, followed by NWB cast for 12 weeks

176
Q

L4 sensory (2)

A
  1. Anterior thigh pain
  2. Sensory loss medial ankle
177
Q

L4: weakness

A

Ankle dorsiflexion

178
Q

L4: Reflex diminished (2)

A
  1. Loss of knee jerk
  2. Weak knee extension (quads)
179
Q

L5: sensory (2)

A
  1. Lateral thigh/leg, hip and groin paresthesias and pain
  2. Dorsum of the foot: especially between the 1st and 2nd toes
180
Q

L5: Weakness (2)

A
  1. Big Toe extension (big toe dorsiflexion)
  2. Walking on heels more difficult than on toes
181
Q

L5: Reflex diminished

A

Usually no diminished reflexes (+/- ankle)

182
Q

S1: sensory (2)

A
  1. Posterior leg /calf, gluteus
  2. Plantar surface of the foot
183
Q

S1: Weakness

A
  1. Plantar flexion
  2. Walking on toes more difficult than on heels
184
Q

S1: reflex diminished

A

Loss of ankle jerk

185
Q

Scoliosis: Diagnosis

A

Adams forward bending test most sensitive* Cobb’s angle measured on AP/lateral films

186
Q

What is spondylolysis?

A

Defect in pars interarticularis from either failure of fusion or stress fracture, often from repetitive hyperextension trauma

187
Q

What is spondylolisthesis?

A

Forward slipping of vertebrae on another

188
Q

What is the most common organism of osteomyelitis?

A

S. aureus

189
Q

In sickle cell disease patients, what is the most common organism causing osteomyelitis?

A

Salmonella

190
Q

In chronic (subacute) ostemyelitis, what is the most common organism?

A

S. aureus

191
Q

What is the most common source of getting osteomyelitis?

A

Acute hematogenous spread

192
Q

What is the most sensitive test in early osteomyelitis?

A

MRI

193
Q

What is seen in early osteomyelitis?

A

Soft tissue swelling and periosteal reaction, lucent areas of cortical destruction

194
Q

What is seen in advanced/chronic osteomyelitis?

A

Sequestrum*

195
Q

What is the gold standard in diagnosing osteomyelitis?

A

Bone aspiration

196
Q

Osteomyelitis abx regimen in newborn (<4 months; Group B strep, GNR)

A

Nafcillin or oxacillin + 3rd generation cephalosporin (cefotaxime)

197
Q

Osteomyelitis abx regimen in patients >4 months (S. aureus: Methicillin sensitive [MSSA])

A

Nafcillin or Oxacillin or Cefazolin (Ancef) (Clindamycin or Vanco if PCN allergic)

198
Q

Osteomyelitis abx regimen in patients >4 months (S. aureus: Methicillin resistant [MRSA])

A

Vancomycin or Linezolid

199
Q

Osteomyelitis abx regimen in sickle cell patients (Salmonella, S. aureus)

A

3rd gen. cephalosporin (Cefotaxime) or fluoroquinolone (Ciprofloxacin or Levofloxacin)

200
Q

Osteomyelitis abx regimen in patients with a puncture wound (Pseudomonas)

A

Ciprofloxacin (covers pseudomonas) or Levofloxacin. Ceftazidimine (3rd gen cephalosporin) or Cefipime (4th generation cephalosporin)

201
Q

What is the most common organism in septic arthritis?

A

S. aureus (others include N. gonorrhea in sexaully active young adults and streptococci)

202
Q

What is the most common area where septic arthritis is found?

A

Knee

203
Q

Septic arthritis abx regimen: Gram positive cocci

A

Nafcillin (Vancomycin if suspect MRSA) (Vancomycin or Clindamycin if PCN allergic)

204
Q

Septic arthritis abx regimen: Gram negative cocci, unknown or Gonococcal suspected

A

Ceftriaxone (Gonococcal usu. don’t need arthrotomy) (Ciprofloxacin if PCN allergic)

205
Q

Septic arthritis abx regimen: Gram negative rods

A

Ceftriaxone (3rd gen. ceph.) + Anti-pseudomonal AG (Gentamicin)

206
Q

Septic arthritis abx regimen: No organism seen

A

Nafcillin or Vancomycin + ceftriaxone (+/- anti-pseudomonas)

207
Q

Compartment syndrome: Diagnosis

A

Increased intracompartmental pressure >30-45 mmHg; Increased CK/myoglobin

208
Q

Compartment syndrome: Treatment

A

Fasciotomy

209
Q

What is the most common bone malignancy?

A

Osteosarcoma

210
Q

What patient population is at high risk of having osteosarcoma?

A

Adolescents (80% occur <20 years old). 2nd peak 50-60 years old

211
Q

In osteosarcoma, where is mets most commonly located?

A

Lungs

212
Q

Osteosarcoma: Diagnosis (4)

A
  1. X-ray: “hair on end” or “sun ray/burst”* appearance
  2. Mixed sclerotic/lytic lesions
  3. Periosteal bone reactions
  4. Codman’s triangle*
213
Q

Codman’s triangle

A

Ossification of raised periosteum. This is seen in both osteosarcoma and Paget’s disease

214
Q

Osteosarcoma: treatment

A
  1. Limb-sparing resection (if not neovascular); radical amputation (if neovascular)
  2. Chemotherapy as adjuvant therapy
215
Q

What is Ewing’s sarcoma?

A

Giant cell tumor MC in children and males 5-25 years old

216
Q

Ewing sarcoma: most common location

A

Femur and pelvis

217
Q

Ewing’s sarcoma: Diagnosis

A

Lytic lesion with layered periosteal reaction “onion peel” appearance on x-ray

218
Q

Ewing’s sarcoma: Treatment (2)

A
  1. Chemotherapy
  2. Surgery and radiation therapy
219
Q

What is chondrosarcoma?

A

Cancer of cartilage MC seen in adults (40-75 years old)

220
Q

Chondrosarcoma: Diagnosis

A

Mineralized chondroid matrix punctate or ring and arc appearance pattern of calcification

221
Q

What is the most common benign bone tumor (that is seen at age 10-20 and in males)?

A

Osteochondroma

222
Q

Osteochondroma: Diagnosis

A

Often penduculated, grows away from growth plate* and involves medullary tissue

223
Q

Osteochondroma: Treatment (2)

A
  1. Observation
  2. Resection if it becomes painful, located in the pelvis (MC site of malignant transformation)
224
Q

What is Paget’s disease?

A

Abnormal bone remodeling and disorganized osteoid formation

225
Q

Which population is at high risk for having Paget’s disease? (2)

A
  1. >40 years old
  2. Mainly persons of Western European descent
226
Q

Paget’s disease: Clinical manifestations (4)

A
  1. Asymptomatic (70-90%): usu. found because of high alkaline phosphatase
  2. Bone pain: MC symptom*
  3. Soft bones
  4. Skull involvement: deafness* (due to compression of CN VIII); HA
227
Q

Paget’s Disease: Labs

A
  1. Elevated alkaline phosphatase with normal calcium and phosphate
  2. Increased urinary pyridinolines or N-telopeptide
228
Q

Paget’s disease: X-rays (3)

A
  1. Lytic phase: “blade of grass/flame shaped” lucency
  2. Sclerotic phase: Coarsened trabeculae (Increased trabecular markings, denser/expanded bones)
  3. Skull: Cotton wool appearance
229
Q

Paget’s disease: Treatment (2)

A
  1. Asymptomatic patients in general need no treatment
  2. In symptomatic patients, bisphosphanates and calcitonin. NSAIDs for pain
230
Q

IV forms of bisphosphanates (2)

A
  1. Zoledronic acid
  2. Pamidronate
231
Q

Alendronate (bisphosphanate) is associated with a high incidence of what?

A

Esophagitis (CI if esophageal stricture, dysphagia, or hiatal hernia)

232
Q

Bisphosphanates: Side effects (4)

A
  1. Nephrotoxicity
  2. Thrombocytopenia
  3. Atypical femur fractures*
  4. Jaw osteonecrosis
233
Q

What lab finding is found with drug-induced SLE?

A

+Anti-histone antibodies

234
Q

SLE: Clinical manifestations (4)

A
  1. Triad of joint pain (90%), fever, and malar “butterfly rash”
  2. Serositis: pericarditis, pleuritis
  3. Discoid lupus (annular, erythematous patches on face and scalp heals with scarring)
  4. Systemic: CNS, cardiovascular, glomerulonephritis, retinitis, oral ulcers, alopecia*
235
Q

SLE: Diagnosis (3)

A
  1. ANA (+ RF)
  2. Anti double-stranded DNA and Anti-Smith Ab (100% specific for SLE)
  3. CBC may show thrombocytopenia, hemolytic anemia, leukopenia, lymphopenia
236
Q

Diagnosis of antiphospholipid Ab syndrome (APLS) (3)

A
    • Anticardiolipin Ab (assoc. with false + VDRL/RPR)
  2. Lupus anticoagulant
  3. Beta-2 glycoprotein I Ab
237
Q

Limited cutaneous systemic sclerosis (Scleroderma): Clinical manifestations

A

CREST Syndrome:

  1. Calcinosis cutis
  2. Raynaud’s phenomenon
  3. Esophageal motility disorder
  4. Sclerodactyl (claw hand)
  5. Teleangectasia
238
Q

Diffuse cutaneous systemic sclerosis (Scleroderma): Clinical manifestations

A

Skin thickening: Trunk and proximal extremities

239
Q

Scleroderma: Diagnosis (2)

A
    • Anti-centromere Ab: Associated with limited/CREST disease - more specific. Better prognosis
    • Anti-SCL-70 Ab: Asocciated with diffuse disease and multiple organ involvement. +ANA
240
Q

Scleroderma: Treatment

A

DMARDs, steroids

241
Q

Sjrogen’s syndrome: Diagnosis

A

ANA: esp. antiSS-A (Ro) and antiSS-B (La); +RF, Shirmer test

242
Q

Sjrogen’s syndrome: Treatment (2)

A
  1. Pilocarpine
  2. Cevimeline
243
Q

Fibromyalgia: Diagnosis (2)

A
  1. Diffuse pain in 11 out of 18 trigger points** >3 months + widespread pain
  2. Biopsy: “moth-eaten” appearance type I muscle fibers, injury to muscle
244
Q

What is the only FDA drug that is approved to treat fibromyalgia?

A

Pregabalin

245
Q

What is polymyositis and dermatomyositis?

A

Idiopathic inflammatory muscle disease of proximal limbs, neck, and pharynx

246
Q

Polymyositis and dermatomyositis: Diagnosis (5)

A
  1. Increased muscle enzymes (Inc. Aldolase, CK); Elevated ESR, + muscle biopsy, abnormal EMG
    • Anti-Jo 1 ab: Myositis specific antibody
    • Anti-SRP Ab: Almost exclusively seen with PM
    • Anti-Mi-2-ab: Specific for dermatomyositis
  5. Muscle biopsy
247
Q

With Anti-Jo 1 ab, what is it associated with?

A

Interstitial lung fibrosis, “mechanic hands” (hyperkeratotic “cracked hands” with “dirty appearance”)

248
Q

With a positive anti-SRP ab, what is it associated with?

A

More prominent muscle weakness/atrophy and cardiac manifestations

249
Q

What does the muscle biopsy show with polymyositis?

A

Endomysial involvement

250
Q

What does the muscle biopsy show with dermatomyositis?

A

Perifascicular/perivascular involvement

251
Q

Dermatomysositis: Other findings (5)

A
  1. Heliotrope (Blue-purple) upper eyelid discoloration
  2. Gottron’s papules*: raised violaceous scaly eruptions on the knuckles
  3. Malar rash with erythema (including nasolabial folds)
  4. Photosensitive poikiloderma “shawl or V sign”
  5. Diffuse alopecia
252
Q

Polymyositis and dermatomyositis: Treatment

A

Corticosteroids 1st line treatment (+/- methotrexate, azathioprine, IV immune globulin)

253
Q

Which medications increase uric acid levels?

A

Diuretics (thiazides, loop), ACEI, pyrazinamide, ethambutol, ASA, ARBs (notable exception is Losartan, which actually decreases levels)

254
Q

Acute management of gout (3)

A
  1. NSAIDs (ex: indomethacin, naprosyn. NO ASA!)
  2. Colchicine is second line treatment
  3. Steroids reserved if no response to NSAIDs or Colchicine or severe renal disease
255
Q

What is the only medication that can be used in both the acute and chronic phases of gout?

A

Colchicine

256
Q

Pseudogout: Treatment

A

Steroids are 1st line (intraarticular); NSAIDs, cochicine

257
Q

Felty’s Syndrome

A

Rare disorder triad of: RA + Splenomegaly + decreased WBC/repeated infections

258
Q

Caplan syndrome

A

Pneumoconiosis + RA

259
Q

RA: Stiffness

A
  1. Worse after resting
  2. Morning stiffness @ least >30 minutes
260
Q

OA: Stiffness (3)

A
  1. Worse after effort
  2. Evening stiffness*
  3. If morning stiffness present, it is usually <30 minutes
261
Q

Which is the most common type of juvenile idiopathic arthritis?

A

Pauci-articular

262
Q

Pauci-articular (Oliogarticular) JIA (3)

A
  1. Four or less joint involvement in the 1st 6 months. MC knees, ankle, small joints
  2. Type I associated with anterior uveitis (can lead to blindness)
  3. Type II associated with increased risk of ankylosing spondylitis
263
Q

Systemic (acute febrile) JIA (3)

A
  1. Daily arthritis (often diurnal high fevers) with the first 6 months. Both large and small joints
  2. Salmon-color/pink migratory rash: often accompanies the fever. May Koebner phenomenon
  3. Associated with hepatosplenomegaly, lymphadenopathy, serositis, hepatitis
264
Q

Polyarticular JIA (3)

A
  1. Arthritis ≥5 small joints within the first 6 months. Hip involvement is common.
  2. Increased risk of iridocyclitis (anterior uveitis), may have low-grade fevers
  3. RF negative disease associated with better prognosis than RF positive patients
265
Q

Rhabdomyolysis: Diagnosis (3)

A
  1. Labs: Increased CPK (>20,000), increased LDH, ALT. Hyperkalemia and hypocalcemia
  2. UA: Dark urine that is positive for heme but negative for blood (myoglobinuria*)
  3. ECG: Look for signs of hyperkalemia
266
Q

Rhabdomyolysis: Treatment (4)

A
  1. IV saline hydration
  2. Mannitol
  3. Bicarbonate to alkalinize the urine
  4. Calcium gluconate if hyperkalemia or ECG changes
267
Q

What is Takayasu arteritis?

A

Chronic large-vessel vasculitis that affects the aorta, aortic arch, and pulmonary arteries

268
Q

Takayasu arteritis: Diagnosis

A
  1. Angiography
  2. Increased ESR/CRP
269
Q

Takayasu arteritis: Treatment (2)

A
  1. High dose corticosteroids 60mg/day x 6 weeks with gradual tapering
  2. Cytotoxic drugs (chronic active disease): ex: Methotrexate and azathioprine
270
Q

Kawasaki syndorme (Mucocutaneous Lymph Node Syndrome): Clinical manifestations and diagnosis (6)

A

“Warm + cream” = fever* + 4 of the following 5:

  1. Conjunctivitis: bilateral and nonexudative
  2. Rash: Polymorphous
  3. Extremity (peripheral) changes (including arthritis)
  4. Adenopathy: Cervical lymphadenopathy
  5. Mucous membrane (lip swelling and fissures, strawberry tongue)
271
Q

Kawasaki syndorme (Mucocutaneous Lymph Node Syndrome): complications

A

Coronary vessel arteritis: coronary artery aneurysm*, myocardial infarction, pericarditis myocarditis, peripheral arterial occlusion

272
Q

Polyarteritis nodosa is associated with what conditions?

A

Hepatitis B and C

273
Q

Polyarteritis nodosa: clinical manifestations (4)

A
  1. Renal: HTN, renal failure
  2. Constitutional: fevers, myalgais, arthritis (lungs usu. spared)
  3. CNS: neuropathy, mononeuritis complex
  4. Dermatologic: livedo reticularis
274
Q

Is classic PAN ANCA Positive or Negative?

A

Negative

275
Q

What is shown on renal or mesenteric angiography with polyarteritis nodosa?

A

Microaneurysm with abrupt cut-off of small arteries

276
Q

Polyarteritis nodosa: Treatment (2)

A
  1. Steroids (+/- cyclophosphamide if refractory)
  2. +/- Plasmapharesis in pts with HBV
277
Q

What is eosinophilic granulomatosis with polyangiitis?

A

Systemic small (medium) vasculitis of arteries and veins with:

  1. Asthma (90%)
  2. Hypereosinophilia
  3. Chronic rhinosinusitis
278
Q

Eosinophilic granulomatosis with polyangiitis: Prodromal Phase

A

Atopic disease, allergic rhinitis, asthma

279
Q

Eosinophilic granulomatosis with polyangiitis: Eosinophilic phase

A

Peripheral blood eosinophilia and eosinophilic infiltration of multiple organs (esp. lungs and GI tract)

280
Q

Eosinophilic granulomatosis with polyangiitis: GI manifestations in eosinophilic phase

A

Eosinophilic gastritis: pain, bleeding, colitis

281
Q

Eosinophilic granulomatosis with polyangiitis: Pulmonary manifestations in eosinophilic phase

A

Dyspnea, infiltrates, pulmonary hemorrhage, nodular disease, pleural effusion

282
Q

Eosinophilic granulomatosis with polyangiitis: Vasculitis phase

A

Life-threatening systemic vasculitis

283
Q

Eosinophilic granulomatosis with polyangiitis: Diagnosis

A

Eosinophilia hallmark*; Increased ESR, CRP, BUN/Cr; P-ANCA positive; increased IgE, RF

284
Q

Eosinophilic granulomatosis with polyangiitis: Treatment

A

Corticosteroids (may add cyclophopshamide)

285
Q

What is Granulomatosis with polyangiitis (GPA- Wegener’s)?

A

Small vessel vasculitis with granulomatous inflammation and necrosis of nose, lungs and kidney

286
Q

Granulomatosis with polyangiitis: upper respiratory tract/nose (ENT) symptoms (2)

A
  1. Saddle-nose deformity (cartilage involvement)
  2. Sinusitis often refractory to treatment
287
Q

Granulomatosis with polyangiitis: lower resp. tract (lung) symptoms

A

Parenchymal involvement (cough, dyspnea, hemoptysis, wheezing, pulmonary infiltrates, cavitation)

288
Q

Granulomatosis with polyangiitis: Renal symptoms

A

Glomerulonephritis*, hematuria, proteinuria

289
Q

Granulomatosis with polyangiitis diagnosis

A

+ Increased C-ANA

290
Q

Granulomatosis with polyangiitis treatment

A

Steroids + Cyclophosphamide

291
Q

What is microscopic polyangiitis?

A

Small (medium) vessel vasculitis (NO necrotic nor grannulmatous inflammation); Affects arterioles, venules, and capillaries

292
Q

Microscopic polyangiitis: constitutional symptoms

A

Fevers, arthralgias, weight loss, malaise, palpable (elevated) purpura

293
Q

Microscopic polyangiitis: Lung symptoms

A

Cough, dyspnea, hemoptysis, mononeuritis complex

294
Q

Microscopic polyangiitis: Renal manifestations

A

Glomerulonephritis (rapidly progressing/crescentic)

295
Q

Microscopic polyangiitis: Diagnosis

A

Elevated P-ANCA

296
Q

Microsopic polyangiitis: Management

A

Steroids + Cyclophosphamide

297
Q

What is Henoch Schonlein Purpura (HSP)? (2)

A
  1. IgA deposition in skin –> immune-mediated leukocyotclastic vasculitis
  2. MC systemic small-vessel vasculitis in children
298
Q

Henoch Schonlein Purpura (HSP) clinical manifestations (4)

A
  1. Palpable purpura (MC on lower extremities)
  2. Abdominal pain
  3. Arthritis/arthralgias
  4. Hematuria
299
Q

Henoch Schonlein Purpura (HSP): Diagnosis

A
  1. Kidney biopsy: mesangial IgA deposits
  2. Normal coags (PT/PTT) and normal platelets
300
Q

Henoch Schonlein Purpura (HSP): Management

A

Supportive (self-limiting)

301
Q

Goodpasture’s syndrome: Diagnosis

A

Biopsy: Linear IgG depositis in glomeruli or alveoli on immunofluoresence

302
Q

Psoriatic arthritis: Diagnosis

A

X-ray: “Pencil in cup” deformity; +HLA-B27

303
Q
A

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