Musculoskeletal disorders Flashcards
1
Q
Clinical manifestations of anterior glenohumeral shoulder dislocation
A
- Arm abducted, externally rotated** 2. “Squared off shoulder” is usually associated with recurrent dislocations
2
Q
Anterior glenohumeral diagnosis
A
Axillary & “Y” view (this determines ant. vs. posterior)
3
Q
Hill-Sachs lesion
A
Groove on humeral head
4
Q
Bankart Lesion
A
Glenoid inferior rim fracture
5
Q
Anterior glenohumeral shoulder dislocation management
A
- Reduction must r/o axillary nerve injury (pinprick over deltoid)*
6
Q
Which type of dislocation is associated with seizures and shocks?
A
Posterior glenohumeral shoulder dislocation
7
Q
Acromialclavicular joint dislocation (shoulder dislocation) most observed injury
A
Direct blow to adducted shoulder
8
Q
Imaging done in acromioclavicular joint dislocation (shoulder dislocation)
A
X-ray with weights
9
Q
Type 1 shoulder dislocation
A
normal CXR (ligamental sprain)
10
Q
Type 2 shoulder dislocation
A
Slight widening AC ligament ruptured. Coraclavivular ligament sprained
11
Q
Class III shoulder dislocation
A
Significant widening; both ligaments ruptured
12
Q
Management of acromioclavicular joint dislocation
A
Brief sling immobilization, ice, analgesica, and ortho follow up. Type III may need surgery
13
Q
SITS
A
- Supraspinatus*
- Infraspinatus
- Teres minor
- Subscapularis
14
Q
What is tendonitis?
A
Inflammation usually associated with subacromial bursitis. Usually in adolescents-<40 years old.
15
Q
Rotator cuff tear is seen most commonly in what population?
A
>40 years old. Usually results from trauma or chronic overuse.
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
17
Q
In rotator cuff tears, what clinical manifestastions may be seen?
A
Weakness, atrophy, and continuous pain
18
Q
Is active or passive ROM greater in rotator cuff injuries?
A
Active ROM
19
Q
Pain with abduction >90 degrees suggest what?
A
Tendinopathy
20
Q
“Empty can” test is used to test what?
A
Supraspinatus strength
21
Q
Impingement tests are used to check what?
A
Subscapular nerve/ supraspinatus
22
Q
Hawkins test description
A
Elbow/shoulder flexed @90 degrees with sharp anteiror shoulder pain with internal rotation
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.
24
Q
Subacromial lidocaine test
A
Distinguishes tendinopathy from tear. Normal strength with pain relief = tendinopathy. Persistent weakness with large tear
25
Management of tendinitis
**Shoulder pendulum/wall climbing exercises\***, ice, NSAIDs, physical activity
26
Rotator cuff tear management
Conservative: rehab, NSAIDs, intra-articular steroids, ROM preservation
Surgery if conservative doesn't help
27
What is a common site for pathologic fx in metastatic breast CA?
Proximal humerus fractures
28
Clinical manifestations of proximal humerus fractures
Arm held in adducted position. **Check deltoid sensation** (to ***r/o brachial plexus injury***)
29
With a humeral shaft fracture, what must be ruled out on physical exam?
Radial nerve injury (wrist drop)
30
Humeral shaft fracture management
"Sugar tong splint", coaptation splint, sling/swathe. Ortho f/up in 24-48 hours
31
Complications with clavicle fractures
Pneumothorax, hemothorax, cloraclavicular ligament disruption (distal)
32
Clavicle fracture management
Mid 1/3: Arm sling 4-6 weeks in adults; ortho consult if proximal 1/3
33
What is adhesive capsulitis (frozen shoulder)?
Shoulder stiffness due to inflammation (esp. in hypothyroidism and DM)
34
Adhesive capsulitis (frozen shoulder) management
Rehab ROM therapy mainstay of tx. Anti-inflammatories, intraarticular steroid injection, heat
35
What is thoracic outlet syndrome?
Idiopathic compression of brachial plexus (95%), subclavian vein (5%) or subclavian artery (1%) as they exit narrowed space between shoulder girdle and 1st rib
36
Thoracic outlet syndrome: clinical manifestations (3)
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*
37
Thoracic outlet syndrome: diagnosis
MRI
38
Thoracic outlet syndrome management
Controversial. PT 1st line, avoid strenuous activity. Ortho consult. +/- surgery
39
Supracondylar fractures are most common in what population?
Children aged 5-10
40
Supracondylar fracture: Diagnosis
**abn. anterior humeral line** on lateral view if displaced. **Non-displaced**--\>ant. fat pad sign\*
41
Anterior fat pad signifies what in children and adults?
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)
42
What are the complications with supracondylar fractures?
**Median nerve & brachial artery injury --\>Volkmann's ischemic contracture\***
**Radial nerve injury**
43
Supracondylar fractures management
Non-displaced: Splint
Displaced: ORIF. They should also be admitted and ortho should be consulted
44
Radial head fracture: Physical examination
Lateral (radial) elbow pain, inability to fully extend elbow
45
Radial head fracture: diagnosis
Notoriously difficult to see. ***Fat pad sign\*\****: posterior or increased anterior
46
Radial head fractures: Management
Non-displaced --\>sling, long arm splint 90 degrees
Displaced--\>ORIF
47
Olecranon fracture complication
**Ulnar nerve dysfunction\*\***
48
Olecranon fracture: management
Nondisplaced--\>Splint (90 degree flexion)
Displaced--\>ORIF
49
Olecranon bursitis clinical manifestations (2)
* Abrupt "**goose egg**" swelling
* Limited ROM with flexion
50
What is a Monteggia fracture?
Proximal ulnar shaft fracture with anterior radial head dislocation
51
What nerve can be damaged with a Monteggia fracture?
Radial nerve
52
Monteggia fracture: management
ORIF
53
What is a Galeazzi fracture?
Mid-distal radial shaft fracture with dislocation of distal radio-ulnar joint (DRUJ)
54
Galeazzi fracture management (2)
1. UNSTABLE! Needs ORIF
2. Long arm splint; sugar tong splint
55
How to reduce a radial head subluxation (Nursemaid's elbow)?
Pressure on radial hadi with supination and flexion
56
What is a Hutchinson fracture?
Radial styloid fracture (AKA Chauffer's fracture)
57
What is the MOI with lateral epicondylitis (Tennis Elbow)?
Inflammation of tendon insertion of ECRB (extensor carpi radialis brevis muscle) due to repetitive pronation of forearm and excessive wrist extension.
58
Lateral epicondylitis clinical manifestations
Lateral elbow pain esp. with gripping, _forearm pronation_ and _wrist extension_ against resistance
59
Medial epicondylitis MOI
Inflammation of the pronator teres-flexor carpi radialis due to repetitive stress
60
How is the pain from medial epicondylitis reproduced?
Forcefully extending the elbow vs resistance with forearm supinated and ***_wrist flexion_*** ***against resistance***
61
What is the most common type of elbow dislocation?
Posterior
62
Elbow dislocation: Management (3)
1. EMERGENT reduction!
2. Posterior splint @90 degrees x 7-10 d
3. Unstable --\> ORIF
63
What is Froment's sign?
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
64
What fracture is associated with pain along the RADIAL surface of the wrist?
Scaphoid (navicular) fracture
65
Scapholunate dissociation clinical manifestations (2)
1. Pain on dorsal radial side of wrist
2. (+) Terry Thomas sign (\>3 mm)
66
Scapholunate dissocation treatment
Radial gutter splint; may need operative repair of scapholunate ligament
67
What is a Colles fracture?
Distal radial fracture with dorsal angulation (posterior)
68
What is tht most common complication from a Colles fracture?
Extensor pollicis longus tendon rupture
69
Colles fracture management (3)
1. Sugar tong\* splint/cast
2. If stable (\<20 degrees angulation --\>closed reduction
3. ORIF if unstable/comminuted
70
What is a Smith's fracture?
"Reverse Colles fracture" ventral angulation (anterior)
"Garden Spade" deformity
71
What is a Barton fracture (2)?
1. Intra-articular distal radius fracture with **carpal displacement\***
2. "White arrow"
72
What is a perilunate dislocation?
Lunate that doesn't articulate with capitate (but still articulates with radius)
73
What is a lunate dislocation?
Lunate doesn't articulate with capitate or radius. EMERGENT CONSULT!
74
Lunate dislocation: diagnosis (2)
1. AP view: **"piece of pie"** sign
2. Lateral view: **"spilled teacup sign"** with lunate
75
Lunate dislocation: management
unstable needs ORIF
76
What is the most serious carpal fracture?
Lunate fracture since it occupies 2/3 of radial articular surface. X-rays are often negative!
77
What is Kienbock's disease?
Avascular necrosis of the lunate bone
78
Lunate fracture management
Thumb spica
79
Complex Regional Pain Syndrome: Stage I
Pain out of proportion to injury. ANS sx: swelling, extremity color changes, increased nail and hair growth
80
Complex Regional Pain Syndrome: Stage II
Waxy, pale skin, brittle nails, loss of hair, persistently pale
81
Complex Regional Pain Syndrome: Stage III
Joint atrophy and contractures
82
What is the prophylactic treatment for complex regional pain syndrome?
Vitamin C
83
MOI of Mallet (baseball) finger
Avulsion of extensor tendon
84
Mallet (baseball) finger: Clinical manifestations
Pt unable to straighten distal finger (flexed @ DIP joint)\*
85
What is mallet finger most commonly associated with?
Avulsion fracture of distal phalanx
86
Mallet (baseball) finger: Management
1. Splint DIP uninterrupted extension x 6 weeks vs. surgical pinning
87
What is gamekeeper's (skier's) thumb?
Ulnar collateral ligamental injury of thumb--\> instability of MCP joint
88
What is difference between gamekeeper's thumb and skier's thumb?
Gamekeeper's thumb: Chronic
Skier's thumb: acute condition
89
Gamekeeper's (skier's) thumb: management
1. Thumb spica\*\* and referral to hand surgeon (b/c affects pincer function)
2. Complete rupture: surgical repair
90
Boxer's fracture: management
Ulnar gutter splint\*\* with joints in @ least 60 degrees flexion
91
What is Bennett's fracture?
Intraarticular fracture through base of 1st MCP
92
What is Rolando's fracture?
Comminuted Bennett's fracture
93
What is the treatment for Bennett's fracture/Rolando's fracture?
UNSTABLE!!! Requires ORIF (thumb spica for stabilization)
94
What is the MC type of all Salter-Harris fractures?
Type II
95
What is Dequiervain's tenosynovitis?
Stenosing tenosynovitis of abductor pollicus longus (APL) and extensor pollicus brevus (EPB)
96
What distinguishes pronator syndrome from carpal tunnel syndrome?
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)
97
Hip dislocations: complications
***Avascular necrosis***\*, sciatic nerve injury, DVT, bleeding
98
What is most common type of hip dislocation?
Posterior MC
99
Hip dislocation clinical manifestations (2)
1. Hip pain with leg shortened, **internally rotated** and adducted with hip/knee slightly flexed
2. Anterior may be externally rotated
100
Hip fractures: clinical manifestations
1. Hip pain with leg shortened, **externally rotated\*\***, abducted
101
Hip fractures: management
ORIF
102
What is Legg-Calve-Perthes disease?
Idiopathic _avascular osteonecrosis of femoral head in children_ due to ischemia of capital femoral epiphysis in children
103
Which patient populatio is at higher risk of having Legg-Calve-Perthes disease? (3)
1. Children 4-10 years old
2. MC in boys
3. Low incidence in African-Americans
104
Legg-Calve-Perthes disease: Clinical manifestations (3)
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**)
105
Early X-rays of Legg-Calve-Perthes disease
Increased density of femoral head, widening of cartilage space
106
Late X-rays of Legg-Calve-Perthes disease
Deformity, crescent sign (subchondral fracture)
107
When is observation indicated for Legg-Calve-Perthes disease?
In children \<5 years of age or \<50% femoral involvement. Usually do NSAIDs, bed rest, PT. Self-limiting with revascularization within 2 years.
108
When is abduction bracing indicated for Legg-Calve-Perthes disease?
Children \>5 years of age or significant loss of abduction
109
What is Slipped Capital Femoral Epiphysis (SCFE)?
This is where the femoral head (epiphysis) slips posterior and inferior at growth plate
110
Which patient population is at higher risk of having SCFE?
7-16 year old patients, male children during growth spurt
111
SCFE: Clinical manifestations
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)
112
SCFE: Treatment (2)
1. ORIF (increased risk of AVN)
2. Non weight bearing with crutches
113
What is a greenstick fracture?
Incomplete fracture with cortical disruption and periosteal tearing on the convex side of the fracture (intact periosteum on the concave side) "bowing"\*\*
114
What is a torus (buckle) fracture?
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
115
Which ligament is tested by the valgus stress test?
MCL
116
Which ligament is tested by the varus stress test?
LCL
117
MCL and LCL collateral ligament injuries: Treatment for Grade I (sprains) and II (incomplete tears)
**Conservative**: pain control, PT to restore ROM and muscle strength, RICE, NSAIDs, knee immobilizer
118
MCL and LCL collateral ligament injuries: Treatment for Grade III (complete tear)
Surgical repair
119
What is the most commonly injured knee ligament?
ACL
120
In an ACL injury, what is associated with "pop and swelling"?
Hemarthrosis
121
What is the most sensitive specialized exam for ACL injury?
Lachman's test
122
What is a segond fx?
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
PCL physical examination
Posterior drawer sign and posterior sag sign
124
PCL injury: treatment
Almost always treated operatively
125
What is the most common meniscal tear located at?
Medial (3x)\> lateral
126
Meniscal tear: physical examination
**(+) McMurray's sign\***, Apley test, joint line tenderness, effusion
127
Meniscal tear: Management
NSAIDs, partial weight bearing until ortho f/up. Arthroscopy
128
Patellar fracture: diagnosis
Sunrise view X-ray
129
Patellar fracture: Management (2)
1. Non-displaced --\> knee immobilizer, 6 week leg cast
2. Displaced --\> surgery
130
Which patient population has a high incidence of patellar and quadriceps tendon rupture? (2)
1. Males \>40 years old
2. History of systemic disease (DM, gout, obesity, renal disease)
131
Clinical manifestations of patellar and quadriceps tendon ruptures (3)
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
Patellar and quadriceps tendon rupture: management (3)
1. Knee immobilizer
2. No weight bearing/partial, RICE
3. **Surgical repair within 7-10 days**
133
Patellar dislocation: physical exam
Apprehension sign. Only done if injury already reduced itself
134
Patellar dislocation: management
Closed reduction. Post reduction films. Knee immobilizer x 3-6 weeks (full extension), strengthten quads
135
What is the major complication of knee (tibial-femoral) dislocation?
Popliteal artery injury\* (this makes it a sever limb threatening injury!!!)
136
Knee (tibial-femoral) dislocation management
***Immediate ortho consult!*** Prompt reduction vial longitudinal traction
137
MOI for femoral condyle injury
Axial loading (falling from height)
138
Femoral condyle injury: Complications (2)
1. Peroneal nerve injuries (check 1st web space)
2. Popliteal artery injury
139
Femoral condyle injury: Treatment
IMMEDIATE ORHTO CONSULT! Usually heal poorly, ORIF
140
In a tibial plateau fracture, if it is displaced, you should check for what nerve?
Peroneal nerve function (foot drop)
141
What is Osgood-Schlatter disease?
Osteochondritis of patellar tendon @ tibial tuberosity from overuse
142
What is the most common cause of chronic knee pain in young active adolescents?
Osgood-Schlatter disease
143
What population is at high risk of having Osgood-Schlatter disease?
* Males
* 10-15 years old
* Athletes with "growth spurts"
144
Osgood-Schlatter disease: clinical manifestations
1. Activity related knee pain/swelling
2. Painful lump below the knee
3. **Tenderness to the anterior tibial tubercle**
145
What is a baker's cyst?
Synovial fuid effusion that is displaced into formation of a cyst
146
What happens if a baker's cyst ruptures?
It causes pseudo thrombophlebitis syndrome which can mimick DVT
147
Baker's cyst: Treatment
Conservative: ice, assisted weight bearing, NSAIDs. Intraarticular steroid injection, surgical excision
148
What is patellofemoral syndrome (chondromalacia)?
Idiopathic softening/fissuring of patellar articular cartilage. ***MC seen in runners\****
149
Patellofemoral syndrome (chondromalacia): Diagnosis
+ Apprehension sign
150
What is the most common cause of knee pain in runners?
Iliotibial band syndrome
151
Iliotibial band syndrome: Clinical manifestations
***LATERAL knee pain***\* during onset of running and then resolves. **Positive lateral condyle tenderness\***
152
Iliotibial band syndrome: Diagnosis
(+) **_OBER TEST\*_**: pain or resistance to adduction of leg parallel to the table in neutral position
153
Which type of ankle dislocation is more common: anterior or posterior?
Posterior
154
What ligaments are most commonly involved with ankle sprains?
Anterior talofibular\* and calcaneofibular (ATFL is the main stabilizer during inversion)
155
Weber A (4)
1. Fibular fracture BELOW Mortise
2. Tibiofibular syndesmosis intact
3. Deltoid ligament intact
4. Usually stable
156
Weber B (4)
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
Weber C (4)
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
Anyone with a distal ankle fracture should have a proximal x-ray view to r/o what?
Maisonneuve fracture
159
What is Maisonneuve fracture?
***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
What is a pilon (tibial plafond) fracture?
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
What is the most common location for stress fractures?
3rd metatarsal
162
What is tarsal tunnel syndrome?
Post tibial nerve compression from overuse, restrictive footwear, edematous states
163
What differentiates tarsal tunnel syndrome from plantar fasciitis?
With tarsal tunnel syndrome, the pain increases throughout the day. Pain worsens @ night and with activity
164
What is a hammer toe?
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
What is Charcot's joint (diabetic foot)?
Joint damage and destruction as a result of peripheral neuropathy
166
What does the X-ray show with charcot's joint (diabetic foot)?
Obliteration of joint space, scattered osteophytes in fibrous tissues
167
What is Morton's neuroma?
Degeneration/proliferation of plantar digital nerve producing ***painful mass near tarsal heads***
168
Which population is at high risk for developing Morton's neuroma?
Women 25-50 yo esp. in those who wear tight shoes/high heels/flat feet
169
What is a Jones fracture?
Transverse fracture through diaphysis of 5th metatarsal
170
What is a pseudojones fracture?
Transverse _avulsion fracture @ base (tuberosity)_ of 5th metatarsal. More common than true Jones fracture.
171
Pseudojones fracture: Management
**Walking cast** x 2-3 weeks; ORIF if displaced
172
What is the Lisfranc joint?
Bases of 1st 3 metatarsal heads and respective cuneiforms
173
What is a Lisfranc injury?
Disruption between the articulation of the medial cuneiform and base of 2nd metatarsal
174
What is the Fleck sign?
Fracture @ base of 2nd metatarsal and is pathognomonic for disruption of tarsometatarsal ligaments (Lisfranc injury?)
175
Lisfranc injury: management
ORIF, followed by NWB cast for 12 weeks
176
L4 sensory (2)
1. **_Anterior_** thigh pain
2. Sensory loss medial ankle
177
L4: weakness
**_Ankle dorsiflexion_**
178
L4: Reflex diminished (2)
1. **_Loss of knee jerk_**
2. Weak knee extension (quads)
179
L5: sensory (2)
1. **_Lateral_** thigh/leg, hip and groin paresthesias and pain
2. **_Dorsum of the foot:_** especially between the 1st and 2nd toes
180
L5: Weakness (2)
1. **_Big Toe extension_** (big toe dorsiflexion)
2. Walking on heels more difficult than on toes
181
L5: Reflex diminished
Usually no diminished reflexes (+/- ankle)
182
S1: sensory (2)
1. **_Posterior leg /calf_**, gluteus
2. Plantar surface of the foot
183
S1: Weakness
1. **_Plantar flexion_**
2. Walking on toes more difficult than on heels
184
S1: reflex diminished
**_Loss of ankle jerk_**
185
Scoliosis: Diagnosis
**Adams forward bending test most sensitive\*** Cobb's angle measured on AP/lateral films
186
What is spondylolysis?
***Defect in pars interarticularis*** from either failure of fusion or stress fracture, often from repetitive hyperextension trauma
187
What is spondylolisthesis?
Forward slipping of vertebrae on another
188
What is the most common organism of osteomyelitis?
S. aureus
189
In sickle cell disease patients, what is the most common organism causing osteomyelitis?
Salmonella
190
In chronic (subacute) ostemyelitis, what is the most common organism?
S. aureus
191
What is the most common source of getting osteomyelitis?
Acute hematogenous spread
192
What is the most sensitive test in early osteomyelitis?
MRI
193
What is seen in early osteomyelitis?
Soft tissue swelling and _periosteal reaction_, lucent areas of cortical destruction
194
What is seen in advanced/chronic osteomyelitis?
**Sequestrum\***
195
What is the gold standard in diagnosing osteomyelitis?
Bone aspiration
196
Osteomyelitis abx regimen in newborn (\<4 months; **Group B strep**, GNR)
Nafcillin or oxacillin + 3rd generation cephalosporin (cefotaxime)
197
Osteomyelitis abx regimen in patients \>4 months (S. aureus: Methicillin sensitive [MSSA])
Nafcillin or Oxacillin or Cefazolin (Ancef) (Clindamycin or Vanco if PCN allergic)
198
Osteomyelitis abx regimen in patients \>4 months (S. aureus: Methicillin resistant [MRSA])
Vancomycin or Linezolid
199
Osteomyelitis abx regimen in sickle cell patients (**Salmonella**, S. aureus)
3rd gen. cephalosporin (Cefotaxime) or fluoroquinolone (Ciprofloxacin or Levofloxacin)
200
Osteomyelitis abx regimen in patients with a puncture wound (Pseudomonas)
Ciprofloxacin (covers pseudomonas) or Levofloxacin. Ceftazidimine (3rd gen cephalosporin) or Cefipime (4th generation cephalosporin)
201
What is the most common organism in septic arthritis?
S. aureus (others include N. gonorrhea in sexaully active young adults and streptococci)
202
What is the most common area where septic arthritis is found?
Knee
203
Septic arthritis abx regimen: Gram positive cocci
Nafcillin (Vancomycin if suspect MRSA) (Vancomycin or Clindamycin if PCN allergic)
204
Septic arthritis abx regimen: Gram negative cocci, unknown or Gonococcal suspected
Ceftriaxone (Gonococcal usu. don't need arthrotomy) (Ciprofloxacin if PCN allergic)
205
Septic arthritis abx regimen: Gram negative rods
Ceftriaxone (3rd gen. ceph.) + Anti-pseudomonal AG (Gentamicin)
206
Septic arthritis abx regimen: No organism seen
Nafcillin or Vancomycin + ceftriaxone (+/- anti-pseudomonas)
207
Compartment syndrome: Diagnosis
Increased intracompartmental pressure \>30-45 mmHg; Increased CK/myoglobin
208
Compartment syndrome: Treatment
Fasciotomy
209
What is the most common bone malignancy?
Osteosarcoma
210
What patient population is at high risk of having osteosarcoma?
Adolescents (80% occur \<20 years old). 2nd peak 50-60 years old
211
In osteosarcoma, where is mets most commonly located?
Lungs
212
Osteosarcoma: Diagnosis (4)
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
Codman's triangle
Ossification of raised periosteum. This is seen in both osteosarcoma and Paget's disease
214
Osteosarcoma: treatment
1. Limb-sparing resection (if not neovascular); radical amputation (if neovascular)
2. Chemotherapy as adjuvant therapy
215
What is Ewing's sarcoma?
Giant cell tumor MC in children and males 5-25 years old
216
Ewing sarcoma: most common location
Femur and pelvis
217
Ewing's sarcoma: Diagnosis
Lytic lesion with layered periosteal reaction "***onion peel***" appearance on x-ray
218
Ewing's sarcoma: Treatment (2)
1. Chemotherapy
2. Surgery and radiation therapy
219
What is chondrosarcoma?
Cancer of cartilage MC seen in adults (40-75 years old)
220
Chondrosarcoma: Diagnosis
Mineralized chondroid **matrix punctate or ring and arc appearance** pattern of calcification
221
What is the most common benign bone tumor (that is seen at age 10-20 and in males)?
Osteochondroma
222
Osteochondroma: Diagnosis
Often _penduculated, grows away from growth plate_\* and involves medullary tissue
223
Osteochondroma: Treatment (2)
1. Observation
2. Resection if it becomes painful, located in the pelvis (MC site of malignant transformation)
224
What is Paget's disease?
Abnormal bone remodeling and disorganized osteoid formation
225
Which population is at high risk for having Paget's disease? (2)
1. \>40 years old
2. Mainly persons of Western European descent
226
Paget's disease: Clinical manifestations (4)
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
Paget's Disease: Labs
1. Elevated alkaline phosphatase with normal calcium and phosphate
2. Increased urinary pyridinolines or N-telopeptide
228
Paget's disease: X-rays (3)
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
Paget's disease: Treatment (2)
1. Asymptomatic patients in general need no treatment
2. In symptomatic patients, bisphosphanates and calcitonin. NSAIDs for pain
230
IV forms of bisphosphanates (2)
1. Zoledronic acid
2. Pamidronate
231
Alendronate (bisphosphanate) is associated with a high incidence of what?
Esophagitis (CI if esophageal stricture, dysphagia, or hiatal hernia)
232
Bisphosphanates: Side effects (4)
1. Nephrotoxicity
2. Thrombocytopenia
3. **Atypical femur fractures\***
4. **Jaw osteonecrosis**
233
What lab finding is found with drug-induced SLE?
+Anti-histone antibodies
234
SLE: Clinical manifestations (4)
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
SLE: Diagnosis (3)
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
Diagnosis of antiphospholipid Ab syndrome (APLS) (3)
1. + Anticardiolipin Ab (assoc. with false + VDRL/RPR)
2. Lupus anticoagulant
3. Beta-2 glycoprotein I Ab
237
Limited cutaneous systemic sclerosis (Scleroderma): Clinical manifestations
CREST Syndrome:
1. **_C_**alcinosis cutis
2. **_R_**aynaud's phenomenon
3. **_E_**sophageal motility disorder
4. **_S_**clerodactyl (claw hand)
5. **_T_**eleangectasia
238
Diffuse cutaneous systemic sclerosis (Scleroderma): Clinical manifestations
Skin thickening: Trunk and proximal extremities
239
Scleroderma: Diagnosis (2)
1. + Anti-centromere Ab: Associated with limited/CREST disease - more specific. Better prognosis
2. + Anti-SCL-70 Ab: Asocciated with diffuse disease and multiple organ involvement. +ANA
240
Scleroderma: Treatment
DMARDs, steroids
241
Sjrogen's syndrome: Diagnosis
ANA: esp. antiSS-A (Ro) and antiSS-B (La); +RF, Shirmer test
242
Sjrogen's syndrome: Treatment (2)
1. Pilocarpine
2. Cevimeline
243
Fibromyalgia: Diagnosis (2)
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
What is the only FDA drug that is approved to treat fibromyalgia?
Pregabalin
245
What is polymyositis and dermatomyositis?
Idiopathic inflammatory muscle disease of proximal limbs, neck, and pharynx
246
Polymyositis and dermatomyositis: Diagnosis (5)
1. Increased muscle enzymes (Inc. Aldolase, CK); Elevated ESR, + muscle biopsy, **abnormal EMG**
2. + Anti-Jo 1 ab: Myositis specific antibody
3. + Anti-SRP Ab: **Almost exclusively seen with PM**
4. + Anti-Mi-2-ab: Specific for dermatomyositis
5. Muscle biopsy
247
With Anti-Jo 1 ab, what is it associated with?
Interstitial lung fibrosis, "mechanic hands" (hyperkeratotic "cracked hands" with "dirty appearance")
248
With a positive anti-SRP ab, what is it associated with?
More prominent muscle weakness/atrophy and cardiac manifestations
249
What does the muscle biopsy show with polymyositis?
Endomysial involvement
250
What does the muscle biopsy show with dermatomyositis?
Perifascicular/perivascular involvement
251
Dermatomysositis: Other findings (5)
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
Polymyositis and dermatomyositis: Treatment
Corticosteroids 1st line treatment (+/- methotrexate, azathioprine, IV immune globulin)
253
Which medications increase uric acid levels?
Diuretics (thiazides, loop), ACEI, pyrazinamide, ethambutol, ASA, ARBs (notable exception is Losartan, which actually decreases levels)
254
Acute management of gout (3)
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
What is the only medication that can be used in both the acute and chronic phases of gout?
Colchicine
256
Pseudogout: Treatment
Steroids are 1st line (intraarticular); NSAIDs, cochicine
257
Felty's Syndrome
Rare disorder triad of: RA + Splenomegaly + decreased WBC/repeated infections
258
Caplan syndrome
Pneumoconiosis + RA
259
RA: Stiffness
1. Worse after resting
2. Morning stiffness @ least \>30 minutes
260
OA: Stiffness (3)
1. Worse after effort
2. Evening stiffness\*
3. If morning stiffness present, it is usually \<30 minutes
261
Which is the most common type of juvenile idiopathic arthritis?
Pauci-articular
262
Pauci-articular (Oliogarticular) JIA (3)
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
Systemic (acute febrile) JIA (3)
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
Polyarticular JIA (3)
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
Rhabdomyolysis: Diagnosis (3)
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
Rhabdomyolysis: Treatment (4)
1. IV saline hydration
2. Mannitol
3. Bicarbonate to alkalinize the urine
4. Calcium gluconate if hyperkalemia or ECG changes
267
What is Takayasu arteritis?
Chronic large-vessel vasculitis that affects the _aorta, aortic arch, and pulmonary arteries_
268
Takayasu arteritis: Diagnosis
1. _Angiography_
2. Increased ESR/CRP
269
Takayasu arteritis: Treatment (2)
1. **_High dose corticosteroids_** 60mg/day x 6 weeks with gradual tapering
2. Cytotoxic drugs (chronic active disease): ex: Methotrexate and azathioprine
270
Kawasaki syndorme (Mucocutaneous Lymph Node Syndrome): Clinical manifestations and diagnosis (6)
"Warm + cream" = fever\* + 4 of the following 5:
1. **C**onjunctivitis: bilateral and nonexudative
2. **R**ash: Polymorphous
3. **E**xtremity (peripheral) changes (including arthritis)
4. **A**denopathy: Cervical lymphadenopathy
5. **M**ucous membrane (lip swelling and fissures, strawberry tongue)
271
Kawasaki syndorme (Mucocutaneous Lymph Node Syndrome): complications
Coronary vessel arteritis: _coronary artery aneurysm_\*, myocardial infarction, pericarditis myocarditis, peripheral arterial occlusion
272
Polyarteritis nodosa is associated with what conditions?
Hepatitis B and C
273
Polyarteritis nodosa: clinical manifestations (4)
1. Renal: HTN, renal failure
2. Constitutional: fevers, myalgais, arthritis (lungs usu. spared)
3. CNS: neuropathy, mononeuritis complex
4. Dermatologic: livedo reticularis
274
Is classic PAN ANCA Positive or Negative?
Negative
275
What is shown on renal or mesenteric angiography with polyarteritis nodosa?
Microaneurysm with abrupt cut-off of small arteries
276
Polyarteritis nodosa: Treatment (2)
1. Steroids (+/- cyclophosphamide if refractory)
2. +/- Plasmapharesis in pts with HBV
277
What is eosinophilic granulomatosis with polyangiitis?
Systemic small (medium) vasculitis of arteries and veins with:
1. Asthma (90%)
2. Hypereosinophilia
3. Chronic rhinosinusitis
278
Eosinophilic granulomatosis with polyangiitis: Prodromal Phase
Atopic disease, allergic rhinitis, asthma
279
Eosinophilic granulomatosis with polyangiitis: Eosinophilic phase
Peripheral blood eosinophilia and eosinophilic infiltration of multiple organs (esp. lungs and GI tract)
280
Eosinophilic granulomatosis with polyangiitis: GI manifestations in eosinophilic phase
Eosinophilic gastritis: pain, bleeding, colitis
281
Eosinophilic granulomatosis with polyangiitis: Pulmonary manifestations in eosinophilic phase
Dyspnea, infiltrates, pulmonary hemorrhage, nodular disease, pleural effusion
282
Eosinophilic granulomatosis with polyangiitis: Vasculitis phase
Life-threatening systemic vasculitis
283
Eosinophilic granulomatosis with polyangiitis: Diagnosis
Eosinophilia hallmark\*; Increased ESR, CRP, BUN/Cr; P-ANCA positive; increased IgE, RF
284
Eosinophilic granulomatosis with polyangiitis: Treatment
**Corticosteroids** (may add cyclophopshamide)
285
What is Granulomatosis with polyangiitis (GPA- Wegener's)?
Small vessel vasculitis with granulomatous inflammation and necrosis of _nose, lungs and kidney_
286
Granulomatosis with polyangiitis: upper respiratory tract/nose (ENT) symptoms (2)
1. Saddle-nose deformity (cartilage involvement)
2. Sinusitis often refractory to treatment
287
Granulomatosis with polyangiitis: lower resp. tract (lung) symptoms
Parenchymal involvement (cough, dyspnea, hemoptysis, wheezing, pulmonary infiltrates, cavitation)
288
Granulomatosis with polyangiitis: Renal symptoms
**_Glomerulonephritis\*_**, hematuria, proteinuria
289
Granulomatosis with polyangiitis diagnosis
+ Increased C-ANA
290
Granulomatosis with polyangiitis treatment
Steroids + Cyclophosphamide
291
What is microscopic polyangiitis?
Small (medium) vessel vasculitis (NO necrotic nor grannulmatous inflammation); Affects arterioles, venules, and capillaries
292
Microscopic polyangiitis: constitutional symptoms
Fevers, arthralgias, weight loss, malaise, **palpable (elevated) purpura**
293
Microscopic polyangiitis: Lung symptoms
Cough, dyspnea, hemoptysis, **mononeuritis complex**
294
Microscopic polyangiitis: Renal manifestations
Glomerulonephritis (rapidly progressing/crescentic)
295
Microscopic polyangiitis: Diagnosis
Elevated P-ANCA
296
Microsopic polyangiitis: Management
Steroids + Cyclophosphamide
297
What is Henoch Schonlein Purpura (HSP)? (2)
1. IgA deposition in skin --\> immune-mediated _leukocyotclastic vasculitis_
2. MC systemic small-vessel vasculitis in children
298
Henoch Schonlein Purpura (HSP) clinical manifestations (4)
1. Palpable purpura (MC on lower extremities)
2. Abdominal pain
3. Arthritis/arthralgias
4. Hematuria
299
Henoch Schonlein Purpura (HSP): Diagnosis
1. Kidney biopsy: mesangial IgA deposits
2. Normal coags (PT/PTT) and normal platelets
300
Henoch Schonlein Purpura (HSP): Management
Supportive (self-limiting)
301
Goodpasture's syndrome: Diagnosis
Biopsy: Linear IgG depositis in glomeruli or alveoli on immunofluoresence
302
Psoriatic arthritis: Diagnosis
X-ray: "**Pencil in cup**" deformity; +HLA-B27
303
