Musculoskeletal Disorders Flashcards
Rheumatoid Arthritis - key characteristics
- insidious onset with morning stiffness + joint pain
- SYMMETRIC
- inflammatory polyarthritis
- extraarticular manifestations (nodules, pulmonary fibrosis, serositis)
- serum rheumatoid factor
- suspected RA dx in pts with systemic arthritis in 3+ joints
Rheumatoid Arthritis - symptomatology
- Joints (predominent sympotms): insidious, chronic, progressive, SYMMETRIC, multiple joints, morning stiffness, usually begins in small joints
- Rheumatoid nodules: extensor surfaces and over bony prominences
- Ocular: dry eyes and mucous membranes
- Other: palmar erythema, vasculitis (appears as tiny hemorrhage infarcts in nail folds)
Rheumatoid Arthritis - Deformities
- ulnar deviation
- boutonniere
- swan-neck
- hammertoe
Rheumatoid Arthritis - Diagnostics/workup
Lab - rheumatoid factor, anti-CPP antibodies (most specific for RA), ANA, ESR, CRP, CBC
- XR = most specific for RA!
- XR may look normal for first 6 months. Earliest changes noticed in hands and feet. Later imaging shows UNIFORM joint space narrowing + juxta-articular erosions!
- Arthrocentesis - to rule out other conditions like septic arthritis
Rheumatoid Arthritis - Management (Pharmacologic)
- DMARDS
- Methotrexate start at 75mg PO 1x/week and increase weekly (first-line), see results in 2-6 weeks. Large side effect profile (GI, cytopenia, hepatotoxicity)
- Sulfasalazine (second-line)
Rheumatoid Arthritis - acute vs. subacute vs. chronic
Acute - joint protection, pain relief, proper joint positioning, splinting, heat
Subacute - gradual increase in ROM
Chronic - protection, preserve ability to do ADLs, splits, orthotics, mobility aids, consult PT
Rheumatoid Arthritis - Referrals?
Rheumatologist - early, halt progression and initiate timely interventions
Surgery - advanced, improve function of damaged joints and relieve pain, last resort
Osteoarthritis - Key Characteristics
- deterioration of articular cartilage
- formulation of reactive new bone on articular spaces
- NO systemic symptoms
- Non-inflammatory arthritis
- pain RELIEVED BY REST, any morning stiffness is brief
Osteoarthritis - Risk Factors
- obesity (knee, hand, hip)
- contact competitive sports
- repetitive jobs
Osteoarthritis - Symptomatology
- insidious
- joint pain (exacerbated by activity)
- decreased ROM
- common joints: distal interphalangeal (DIP) joint, proximal interphalangeal (PIP) joint, carpometacarpal of thumb, hip, knee, metatarsal phalangeal (MTP) of big toe, cervical lumbar spine
Osteoarthritis - Exam Findings
- findings mostly limited to affected joint
- most don’t involve erythema or warmth
- may have limited ROM
- may palpate crepitus
- Heberden nodes: palpable osteophyte in DIP joints
- Bouchard nodes: hard outgrowths or gelatinous cysts on PIP joints
- NO SYSTEMIC MANIFESTATIONS!
Osteoarthritis - Diagnostics/workup
XR - joint space narrowing, unequal joint spaces, osteophyte formation/ lipping of marginal bone, thickened/dense subchondral bone
Arthrocentesis - to exclude other diseases
Osteoarthritis - Management (non-pharm)
- prevention! - weight reduction, normal vitamin D levels, focus on bone health
- heat and ice
- routine exercise
Osteoarthritis - Management (pharm)
- Acetaminophen (first line for mild) up to 4mg/day
- NSAIDs (interfere with platelet function and prolong bleeding)
Osteoarthritis - referral
Ortho - when you think pt is failing conventional, non-operative management. Surgery = last resort
Physiatrist (rehab/pain specialists) to help form non-pharm plan
Nutritionist - overweight and struggling to lose weight
Gout vs. pseudogout
gout - caused by monosodium urate monohydrate crystals
pseudogout - caused by calcium pyrophosphate crystals
Gout - phases
Initial - asymptomatic hyperuricemia (uric acid level in blood is high)
Acute gouty arthritis/ gout attack
Chronic arthritis
Gout - Primary vs. Secondary
Primary - hereditary
Secondary - acquired causes (diuretics, low dose ASA, CKD, hypothyroidism, etoh abuse)
Gout - Manifestations
- recurrent acute arthritis
- monarticular
- hyperuricemia (uric acid > 6.8 mg/dL)
Gout - Symptomatology
- acute onset, recurring, often nocturnal
- monarticular
- pedagra - MTP joint, most susceptible
- worsening pain as attack progresses
- fever
- swelling and redness
- tophi (crystal containing nodules)
Gout - Exam findings
- erythematous, edematous, hot, very tender joint
- tophi possible
Gout - Diagnostics/ workup
- Labs: uric acid > 6.8, WBC increased during acute attack
- arthrocentesis - if crystals are seen it is diagnostic for gout
- XR - may show findings consistent with gout but isn’t diagnostic
- Late XR - punched out erosions or lytic areas with overhanging edges
Gout - Management (non-pharm)
- activity, use as able, no bedrest
- dietary modifications (avoid high purine foods) - organ meats
- moderate high purine = seafood, veal, bacon, turkey, alcohol, soda, cheese
Gout - Management (pharm)
- NSAIDs (idomethacin 25-50 mg PO q8h (TID)
- Xanthine oxidase inhibitors (maintenance, chronic) = allopurinol 300-400 mg/day
Septic Joint/Arthritis - Key features
- ACUTE onset (hours)
- inflammatory monarticular arthritis
- commonly large weight-bearing joints
- large joint effusions
Septic Joint/Arthritis - risk factors
- bacteremia (IV drug use, endocarditis, other infection), damaged joints (RA), immunocompromised (DM, CKD, etoh, cirrhosis)
Septic Joint/Arthritis - common causative organism
- staphylococcus aureus
Septic Joint/Arthritis - symptomatology
- acute swelling, heat (hours)
- knee most common, hip, wrist, shoulder, ankle
- fever/chills
- impaired ROM
Septic Joint/Arthritis - Diagnostics/ workup
- arthrocentesis - rule out gout, always gram stain and culture, infected fluid usually yellow/green
- blood cultures x2 to rule out bacteremic origin
- CBC
Septic Joint/Arthritis - Management
- IV ANTIBIOTICS! -
- empiric, IV for 2 weeks
- Non-gonococcal: Vanco 1g q12h + 3rd gen. cephalosporin such as cephtriaxone 1-2g daily
- gonococcal: azithromycin 1g PO once + 3rd gen. cephalosporin such as cephtriaxone 1-2g/day
- MRSA/MSSA at least 4 weeks
- will need opioids early and taper to non-opioids
Septic Joint/Arthritis - Referrals
- PT for early PT and joint immobilization
- Surgery - effective drainage needs to occur
- infectious disease
Ankylosing Spondylitis - key characteristics
- MULTISYSTEM INFLAMMATORY DISORDER INVOLVING SI JOINTS AND AXIAL SKELETON
- progressive limitation of back motion and chest expansion
- young adults < 40
Ankylosing Spondylitis - Symptomatology
- insidious onset of low back pain (months)
- presence of symptoms > 3 months
- pain worse in morning/ with inactivity
- pain better with activity
- stooped posture, kyphosis (advanced)
- extra-articular manifestations (advanced)
Ankylosing Spondylitis - Workup
- Lab: serologic testing negative for rheumatoid factor and anti-ACC
- XR: most helpful in dx
- XR enthesitis - inflammation of enthuses (sites where ligaments and tendons inset into bone)
- XR Bamboo spine - seems to be fused vertically by briding of syndesmophytes
Ankylosing Spondylitis - Management (pharm)
NSAIDS (first line)
Ankylosing Spondylitis - Management (non-pharm)
PT - maintain function, postural training, exercise program
Ankylosing Spondylitis - Referrals
Rheumatology, ophthamology, GI, Cardio, surgery (ortho)
Surgery - tx focuses on fracture stabilization, fusion, joint replacements
Neuropathic Arthropathy - key characteristics
- progressive joint and soft tissue destuction of weight-bearing joints
- characterized by deformities, dislocations, fractures
- ankle and foot are most common
- normal muscle tone and reflexes are lost
Neuropathic Arthropathy - symptomatology
- enlarged, boggy (relatively) painless joint
- if pain, significantly less than one would expect
- instability and decreased ROM
- erythema, hot, joint effusion
Neuropathic Arthropathy - Workup
- ESR and CBC (help differentiate between this and osteomyelitis)
- XR used to stage, determine joint stability, identify osteopenia dislocations, fractures, etc.
Neuropathic Arthropathy - Management
- directed at primary disease (DM)
- acute phase - immobilization, stress reduction
- surgery (mainly for deformity management or amputation (deformity/destruction of tissues and DM)
Osteoporosis - key characteristics
- systemic skeletal disease
- characterized by low bone mass and deterioration of bone + increase in bone fragility
- hallmark = reduction in skeletal mass caused by an imbalance of bone formation and resorption
Osteoporosis - RISK FACTORS
Modifiable - smoking, low body weight, estrogen deficiency, low lifelong calcium intake, alcoholism, recurrent falls, inadequate physical activity, poor health/ frailty
Non-modifiable - personal hx of fracture as adult, white race, advanced age, female, dementia, malignancy
Osteoporosis - Terms (osteomalacia vs. osteoporosis)
Osteoporosis - bone matrix and bone mineral are both decreased
Osteopenia - bone matrix is intact but bone mineral is decreased
Osteoporosis - Symptomatology
- asymptomatic until fracture occurs
- acute pain caused by fall/ minor trauma
Osteoporosis - exam findings (vertebral fx)
- point tenderness
- vertebral muscle spasms
- T-kyphosis, C-lordosis
- height may decreased 2-3 cm with episode of vertebral compression
Osteoporosis - exam findings (hip fx)
- diminished ROM
- external rotation
Osteoporosis - exam findings (colles fx)
- distal radial fx
- pain with ROM of wrist
- dinner fork (bayonet deformity)
Osteoporosis - exam findings (pubic/sacral fx)
- marked tenderness with ambulation
- tenderness to palpation
Osteoporosis - Workup
- Labs: CBC, CMP, thyroid, vitamin D level, biochemical markers (monitoring therapy response)
- XR
- Bone densitometry (DXA) - criterion standard for evaluation
Osteoporosis - DXA Score
T score >/= - 1.0 is normal
T score -1- -2.5 = indicates osteopenia
T score < -2.5 indicates osteoporosis
T score < -2.5 with fragility fx(s) indicates severe osteoporosis
Osteoporosis - Management (non-pharm)
- Prevention!
- dietary modification (adequate calcium 1-2g/day) and vitamin D intake
- smoking cessation
- PT/OT/exercise
Osteoporosis - Management (pharm)
- Biphosphonates (first line): Alendronate (weekly)
- Biphosphonate side effects: acute phase responses = fever, chills, flushing, n/v, diarrhea, and other nonspecific symptoms
Osteoporosis - Referral
Rheumatologist or endocrinolost for anyone who is in therapeutic or diagnostic phase for monitoring and tx
Osteoporosis - DXA Scan recommendations
- FEMALES 65+ YEARS OLD, males 70+ years old
- men 50-69 with clinical risk factors
- comorbid conditions (RA)
- immunosuppressed populations (ex: steroid therapy)
Osteomyelitis - types
- Hematogenous (IV drug users, sickle cell, DM, older adults) - high fever, chills, pain, tenderness
- Contagious (post-trauma, joint replacement, pressure ulcers) - localized signs of inflammation
- Vascular insufficiency (DM, foot and ankle) - bone pain absent/muted, fever commonly absent, wounds > 2 cm or ability to probe bone
Osteomyelitis - Workup
- ESR, CRP (will be high, useful when looking at how tx is going)
- bone biopsy - definitive dx
- XR - periosteal thickening, irregularitis of bone, new bone formation
- CT - helpful for guiding needle biopsies
MRI - most useful
Osteomyelitis - Management
- Antibiotics! Empiric IV (clindamycin, Bactrim, fluoroquinolones)
- ID referral
- surgical debridement and drainage
Low Back Pain/Injuries - red flags
- unexplained weight loss
- failure to improve with tx
- severe pain > 6 weeks
- night/rest pain
- Cauda quina syndrome (bowel or bladder problems, retention, incontinence, saddle parasthesias, decreased anal sphincter tone = emergency!)
- if cauda equina is suspected, a rectal exam needs to happen
Low Back Pain/Injuries - Symptomatology
- good hx is most important
- pain of varying degrees/ descriptions
- paraspinal tenderness
- loss of normal lumbar lordosis
- muscle wasting
- decreased motor strength
- leg raise test (extension of legs)
Low Back Pain/Injuries - Diagnosics
- weak associated between imaging and symptoms
- XR indications: possible fracture (major trauma, minor trauma > 50 years, long-term corticosteroid use, osteoporosis, > 70) or possible tumor or infection (> 50, < 20, hx of cancer, constitutional symptoms, recent bacterial infection, injection drug use, immunosuppression, supine pain
MRI - method of choice for symptoms not responding to conservative tx or who have red flag symptoms
Low Back Pain/Injuries - Management (non-pharm)
Step wise
- pain control
- restoration of ROM
- improve muscle strength
- coordination retraining
- CV conditioning
- maintenance exercises
Low Back Pain/Injuries - Management (pharm)
Acetaminophen!
NSAIDs!
Opioids (short term, acute flares only)
Muscle relaxants such as baclofen (only if you can palpate spasm on exam)
Knee Pain - Varus/Valgus grading
Grade 1: pain with stress test but no instability
Grade 2: pain, instability at 30 degrees flexion
Grade 3: marked instability but not much pain, often unstable at 30 degrees and 0 degrees flexion
Knee Pain - Diagnostics
XR - helpful if you suspect fracture only
MRI - best method, can see soft tissues
MCL injury
- most commonly injured knee ligament
- commonly injured when ACL is injured
- sudden valgus (medial) stress to knee
- may report “pop” sensation
- medial knee pain
- localized swelling over 1-4 hours
- tenderness
LCL injury
- direct blow to medial aspect of knee (varus)
- similar to MCL but lateral)
- tenderness over LCL
- varying degree of joint laxity
Treatment of MCL/LCL injuries
- Early PT
- Grades 1-2: patient can usually bear weight with full ROM
- Grade 3 MCL: requires long leg brace, up to 6-8 weeks
- Always refer LCL injuries! - usually require urgent surgery because they are usually associated with other injuries that don’t heal well without it
ACL injuries
- pain and almost immediate edema following sudden deceleration, jumping
- weight bearing difficult d/t sense of knee instability
- instability when going side to side or down stairs
- effusion
- hemarthrosis
- pain/tenderness
- Drawer and Lachman testing
PCL injuries
- strongest knee ligament
- forced hyperextension of knee
- direct blow to anterior proximal knee
- mild to moderate effusion
- high risk for neurovascular injury!
- Drawer and Lachman testing
- “Sag sign”
What is the “Sag Sign”
- in PCL injuries
- patient supine, both hips and knees flexed 90 degrees
- because of gravity, injured knee will have an obvious “set off” at anterior tibia, sagging posteriorly
Drawer Test
- patient supine with hips and knees flexed, feet flat on exam table
- examiner places hands on both sides of the knee. they will put gentle pressure behind your knee and attempt to move tibia forward
- if tibia moves forward, indicates ACL injury
Lachman test
- patient supine with knees flexed 30 degrees
- examiner places one hand behind tibia and other on patient’s thigh
- examiner attempts to pull tibia forward. If tibia moves forward, it indicates ACL injury
ACL/PCL diagnostics
MRI - most helpful for dx
XR - will be negative but can help rule out fractures
ACL/PCL Treatment
- bracing
- referral to PT and ortho (surg)
- reconstruction: most young and active patients will require surgery within 5 months
- non-op: older adults or sedentary lifestyle patients (bracing and PT only)
Meniscus tear - symptomatology
- pain with twisting of the knee (getting in/out of car) and painful gait
- sense of knee “locking” or “giving away”
- more difficult to go down stairs than up
- edema within first 24 hours (rarely immediate)
- tenderness
- most symptomatic tears cause the most pain with any deep squat or “duck walk”
- McMurrays and Thessaly tests
McMurrays test
- patient supine and examiner holds knee and palpates the joint line with one hand, thumb on one side and fingers on the other
- other hand supports the sole of foot and supports limb through motion
- from point of maximal flexion, extend knee with internal rotation of tibia and varus stress
- then return to maximal flexion and extend knee with external rotation of tibia and valgus stress
- positive test when there is a thud or click that can sometimes be hear but always felt
Thessaly test
- patient stands on one leg while examiner supports patient with out-stretched hand
- patient flexes knee to 5 degrees and rotates femur on the tibia medially and laterally 3x while maintaining flexion
- test uninjured leg first
- test is then repeated at 20 degrees flexion
- test is positive if patient experiences pain or sense of locking/catching in the knee
Meniscus tear - treatment
- conservative
- analgesics
- PT
- referral to ortho/surg for arthroscopic surgery
- arthroscopic surgery - tears in young and active patients with signs of internal derangement (“catching”, swelling) and without signs of arthritis on imaging
Shoulder Pain/ Injuries - acute vs. chronic
Acute = typically young adults Chronic = progression of age, degenerative changes, inflammation
Shoulder Pain/ Injuries - risk factors (chronic)
- repetitive overhead activity
- RA or osteoarthritis
- previous shoulder injury
Shoulder Fracture characteristics
- proximal humerus
- fall directly onto shoulder or outstretch arm
- localized pain, edema
- decreased ROM
Shoulder Fracture Tx
- refer to ortho, follow-up with ortho, serial x-rays
- shoulder immobilization (sling) + early ROM (in 7-10 days)
- PT (3 weeks after surgery)
- surgery - depends on type, location, displacement, and fracture segments (most are non-op)
Shoulder Dislocation characteristics
- relies heavily on rotator cuff muscles
- most occur in anterior direction and usually from fall on outstretched arm
- sensation of shoulder slipping out of joint
- “popping” or clicking of joint
- positive apprehension test
Apprehension Test
- passively externally rotate humerus to end range with shoulder at 90 degrees of abduction
Shoulder dislocation tx
- reduction!
- sling for comfort
- refer for repeated dislocations
Rotator cuff tear characteristics
- > 50 years
- pain may radiate into deltoid area
- “pop” or “something gave”
- night pain
- weakness or inability to externally rotate arm
Rotator cuff imaging
XR + MRI
XR-AP view: look for high-riding humoral head which is indicative of supraspinatus tear
MRI: will show you what you’re looking for as well
Rotator Cuff maneuvers
Empty can test: arms out ahead, rotate arm so thumb points down, examiners places downward force on arms (indicates supraspinatous tear)
Drop arm test: if patient’s can’t fold arm out fully abducted at shoulder level (indicates supraspinatous injury)
Rotator cuff tx
- conservative - PT!
- referral +/- surgery (full thickness tear = ASAP surgery)
- ortho: > 50% tear on MRI, full thickness tear, older/sedentary pts with full thickness who haven’t responded to conservative tx
Separated shoulder (AC joint injury) grading
1 - slight displacement of AC joint, most common
2 - partial dislocation, potential displacement, AC ligament completely torn, separation < 1 cm
3 - complete separation of joint, ligaments and capsule obviously torn, falls under weight of arm, clavicle pushed up causing palpable “bump” on shoulder, > 1 cm on imaging
4-6 = ortho territory
Separated shoulder (AC joint injury) tx
Conservative - sling, MICE, PT/ROM
Grades 1-2 do well with non-op sling support and can return to work in 1-2 weeks (grade 2 may need a longer longer if a complete tear), no heavy lifting
Referral: +/- surgery, refer if > grade 2 to ortho-surg
Adhesive capsulitis (“frozen shoulder”) characteristics
- pain out of proportion to clinical findings during acute phase
- acute phase (4-6 months), then followed by 4-6 months of stiffness/freezing phase, then resolution/thaw phase which can take up to 1 year
- progressive loss of motion
- clinical dx
Adhesive capsulitis (“frozen shoulder”) tx
NSAIDs and PT!
Refer to surgery (rarely indicated) if not improvement after 6 months of conservative tx or no progress/ worsening ROM after first 3 months
Compartment syndrome
- when pressure within a closed muscle compartment exceeds the perfusion pressure and results in muscle and nerve ischemia and eventual death of muscle
- PAIN (especially out of proportion)
- PARESTHESIA
- pallor (very late sign)
- poikilothermia (tissue takes on temp. of environment, very late sign)
- pulselessness - very late sign
- paralysis - very late site
- common areas: LOWER LEG, forearm, wrist, hand
- a strong pulse does NOT rule out compartment syndrome
- Tx = OR for fasciotomy!
Fracture - management (non-pharm)
- immobilization/rest
- PT/OT
- ice/heat
Fracture - management (pharm)
- acetaminophen: good for mild pain
- opioids: common to give these for this type of pain
- muscle relaxants (benzos): ex: femur fracture spasms are common
- antibiotics? - compound or open fx
- if wounds open and contaminated: I&D, washouts, wound vacs, serial debridements
- refer to ortho
- +/- surgery depending on nature of fracture
Ankle sprain - eversion (high ankle sprain) characteristics
- more severe and prolonged pain
- more difficulty with weight-bearing
- involves anterior tibiofibular ligament
- foot usually turned outward/ externally rotated and everted
- make sure to palpate proximal fibia
- associated fracture called Maisonneuve fracture
- document circulation, sensation, and movement before doing any testing!
Ankle sprain - inversion (plantar flexion sprain) characteristics
- common
- injury to anterior talofibular ligament
- localized pain and swelling
- usually results from forced inversion like turning ankle or landing wrong
- document circulation, sensation, and movement before doing any testing!
Ankle strengh testing
- test resisted ankle dorsiflexion, plantar flexion, inversion, and eversion strength
Ankle anterior drawer test
- clinician keeps foot and ankle in neutral position with patient sitting
- one hand to fix tibia and other to hold patient’s heel and draw ankle forward
- normally, there is approximately 3 mm of translation until endpoint is felt
- a positive test includes increased translation
Subtalar tilt test
- foot in neutral position with patient sitting
- clinician uses one hand to fix tibia and other to hold and invert calcaneus
- normal inversion at subtalar joint is approximately 30 degrees
- a positive test consists of increased subtalar joint inversion > 10 degrees on affected side
External rotation test
- clinician fixes tibia with one hand and grasps the foot with the other while ankle is in neutral position and dorsiflexes and externally rotates the ankle, reproducing patient’s pain
Grading of Ankle Sprains
Grade 1: stretching but no tearing. local tenderness, minimal edema, ecchymosis typically insignificant or absent
Grade 2: partial (incomplete) tearing of ligament, some joint instability but definite end-point to laxity. Pain immediately upon injury, localized edema and ecchymosis, significant pain with weight bearing
Grade 3: complete ligamentous tearing, joint unstable with no definitive end-point to ligament stressing, severe pain immediately upon injury, significant edema, profound ecchymosis d/t hemorrhage (worsens over several days)
Ankle Sprain - Diagnostics
- XR: use Ottawa ankle rules, want AP lateral or Mortis view
Ankle sprains - management
- Non-pharm: MICE, may need crutches to modify activities, ROM, +/- PT
- Eversion (more conservative): CAM boot for 4-6 weeks then crutches until patient can walk free from pain
- Pharm: NSAIDs
- Refer - concomitant fracture, chronic ligamentous instability, no response after 3 months of tx, widening of Mortis on Mortis view
