Musculoskeletal + Integumentary Flashcards
Valgus stress test
Tests MCL
Varus stress test
Tests LCL
McMurry’s
Medial and Lateral Meniscus tests
Steinman’s
Medial and Lateral Meniscus tests
Lachman’s tests
ACL
Apley’s grind
Medial and Lateral Meniscus tests
Patella apprehension
Test patella dislocation
Patellar ballotment
Test for joint effusion
Patella grind
Patellar chondral surface test
Lateral injury to knee - what test is highest yield?
Valgus stress test
Lachman’s
Drawer tests
Back pain causes
Infection Neoplasm MS stain Osteoarthritis Vertebral compression fx Spondylothesis - forward slip fo cephalad vertebra on caudal - usually L4-L5, L5-S1
Lumbar disk herniation
- radicular leg pain/sciatica
- Tx w/ NSAIDs, steroids
Spinal stenosis
- narrow of spinal canal
- can get neurogenic claudication
- Tx: steroid injection
Drugs accelerating bone loss
Phenytoin glucocorticoids, cyclosporine, phenobarbital, heparin
Hormone replacement therapy reduces risk of…
Osteoporosis
CRC after 5 yrs
Developmental dysplasia of hip
- charac
- tx
Developmental dysplasia of the hip encompasses both subluxation and dislocation of the newborn hip, as well as anatomic abnormalities.
It is more common in firstborns, females, breech presentations, oligohydramnios, and patients with a family history of developmental dysplasia.
1st step:
- refer to ortho
Tx: Closed reduction and immobilization in a Pavlik harness, with ultrasonography of the hip to ensure proper positioning, is the treatment of choice until 6 months of age
Myopathy
- w/ elevated CPK
- no elevated CPK
Elevated CPK
- Polymyositis
- Dermatomyositis
- Drug-induced myopathy
- Hypothyroid endocrinopathy
No elevated CPK
- polymyalgia rheumatica
- hyperthyroidism
Risk factors for osteoarthritis of the hip include
obesity, high bone mass, old age, participation in weight-bearing sports, and hypothyroidism
patients who are beginning long-term treatment with prednisone (≥3 months at a dosage ≥5 mg/day), or an equivalent, receive what supplements
Bisphosphanates
Calcium
Vit D
in cases where a joint effusion is accompanied by fever, what should be performed to help guide therapy
diagnostic arthrocentesis
Sx: minimally tender lesions with central ulceration and crust formation
Refractory to abx tx
Recently overseas in Iraq
What is it?
cutaneous leishmaniasis
Melasma or chloasma
is common in pregnancy
an acquired hypermelanosis of the face, with symmetric distribution usually on the cheeks, nose, eyebrows, chin, and/or upper lip.
UV sunscreen is important, as sun exposure worsens the condition.
Tx:
often resolves or improves post partum.
Persistent melasma can be treated with hydroquinone cream, retinoic acid, and/or chemical peels performed post partum by a dermatologist.
Cellulitis in patients after breast lumpectomy is thought to be related to
lymphedema.
Axillary dissection and radiation predispose to these infections.
Non–group A hemolytic Streptococcus is the most common organism associated with this infection.
Tx actinic keratosis
5-fluorouracil
Tx persistent leukoplakia
1st observe
Then bx
lesion is dome shaped and has a central plug
grows rapidly, heals spontaneously
What is it?
Keratoacanthoma
Lichen simplex chronicus,
the end result of habitual scratching or rubbing, usually presents as isolated hyperpigmented, edematous lesions, which become scaly and thickened in the center.
The pain from infiltration of local anesthetics can be decreased by
using a warm solution,
using small needles,
performing the infiltration slowly
adding sodium bicarbonate to neutralize the anesthetic since they are shipped at an acidic pH to prolong shelf life.
—An exception to this tip is bupivicaine (Marciane, Sensorcaine) as it will precipitate in the presence of sodium bicarbonate.
lesion is located dorsally between the web of his right third and fourth toes, and extends toward the ankle.
It is erythematous, and has a serpiginous track.
What is it?
cutaneous larva migrans, a common condition caused by dog and cat hookworms
Ancylostoma species
Sudden monoarticular non-traumatic joint pain after drinking lots of EtOH and being on thiazides
Afebrile
Edema
Erythema
Warmth
What is next dx step?
Most likely dx?
Next step tx?
Next dx step = Joint aspiration
- -> blood uric acid levels can be nl b/c it all deposited in joints!
- use uric acid levels to monitor tx effects b/n attacks
Most likely gout
Next step:
- NSAID
- Colchicine
Pseudogout
Joint pain 2/2 Calcium pyrophosphate dehydrate crystals in joints
Rhomboid, weakly + birefringence
Slipped capital femoral epiphysis
Pain with activity is the most common presenting symptom, as opposed to the nighttime pain that is typical of malignancy.
Usually in obese males
Pain mostly in anterior thigh
Limited internal rotation of hip
Meralgia paresthetica
is pain in the thigh related to entrapment of the lateral femoral cutaneous nerve, often attributed to excessively tight clothing
Legg-Calvé-Perthes disease
(avascular or aseptic necrosis of the femoral head)
is more likely to occur between the ages of 4 and 8 years.
Tx polymyositis/dermatomyositis
corticosteroids
What drug for RA can delay progression of disease?
Hydroxychloroquine
Joints involved in osteoarthritis vs. RA
Osteo -
PIP
DIP
RA -
MCP
PIP
What will reduce both pain and disability in patients with osteoarthritis of the knee
A therapeutic exercise program
Gout
High uric acid –> gouty attack/arthritis
highly negative birefringent, needle-shaped urate crystals
Tx midshaft tibial stress fractures
rest
A pneumatic stirrup leg brace has been found to be helpful during treatment
Wt bearing ok
DO NOT cast
NO US pulse tx
Common cause of heel pain
Plantar fascitis
- burning pain in the heel
- there is tenderness of the plantar fascia where it inserts onto the medial tubercle of the calcaneus.
- The patient experiences heel or arch pain,
- often is worse upon arising and taking the first few steps of the MORNING.
Examination reveals tenderness at the site and pain with dorsiflexion of the toes
Tx septic joint
Surgery to drain
IV abx
Tx rheumatoid arthritis
PT NSAIDs Steroids Dmards like sulfasalazine, MTX Infliximab Etanercept
Tx osteoarthritis
Mobility exercises Wt loss Maintain ROM Steroid injection q4-6 mo Surgery if severe
Dx infectious arthritis
Joint aspiration
Sprained ankle. Next step?
No imaging
PRICE therapy
In acute ankle sprains, functional treatment with a semi-rigid brace that allows flexion and extension, or a soft lace-up brace is recommended over immobilization.
Ankle ligament most commonly injured
Anterior talofibular ligament
When do an X-ray for an ankle injury?
If there is bony tenderness of medial or lateral malleolus at tip
Or pt can’t bear weight for 4 steps immediately or while being examined
ankle radiograph series is required only if there is pain in the malleolar zone and bone tenderness of either the distal 6 cm of the posterior edge or the tip of either the lateral malleolus or the medial malleolus. Inability to bear weight for four steps, both immediately after the injury and in the emergency department, is also an indication for ankle radiographs.
Foot radiographs are required only if there is pain in the midfoot zone and bone tenderness at the base of the 5th metatarsal or the navicular, or if the patient is unable to bear weight both immediately after the injury and in the emergency department.
Sprain
Stretch or tear of ligament
Strain
Stretch or tear of muscle or tendon (muscle to bone)
When do a knee X-ray?
Any of the 5 criteria
> =55
Isolated patella tenderness
Tenderness of head of fibula
Can’t flex knee to 90 deg
Inability to bear wt for 4 steps
Types of melanoma
Superficial spreading
-most common
Lentigo maligna
- usually in elderly.
- superficial spreading
Acral lentiginous
- most common in AA and Asians
Nodular
- most aggressive
4 main stabilizers of shoulder
Supraspinatus = abduction
Infraspinatus = external rotation
Teres Minor = external rotation
Subscapularis = internal rotation
Knee sx - what do these suggest:
- locking
- popping
- giving way
locking = a meniscal tear or loose body trapped
popping = ligamentous injury, probably complete rupture of a ligament (third-degree tear).
giving way = knee instability and may indicate patellar subluxation or ligamentous rupture.
Meniscal vs ligamentous presentation
Rupture of ligament = Rapid onset of effusion
Meniscal injury / ligament sprain = slower onset (24 to 36 hours) of a mild to moderate effusion
Meniscal injury = Recurrent knee effusion after activity
Global range of motion deficit in shoulder (both passive and active)….what do you suspect?
Adhesive capsulitis
Inflammation and thickening of shoulder capsule
Global ROM deficit - active AND passive (vs only active in impingement)
Insidious onset
Usually in non-dominant arm
Can be predisposed by endocrine dz, clinical depression, recent MI
Dx via hx and physical exam. No imaging.
Tx: PT, NSAIDs. Surgery if no improvement in 4-6 months
Tests for ACL or PCL injury
ACL - anterior drawer, lachmanns (best), pivot shift
PCL - posterior drawer
Tests for MCL or LCL injury
Valgus (MCL) and varus stress tests
Tests for meniscal injury
McMurray’s
Steinmans
Anterior dislocation of shoulder
- no sign of neurovascular compromise
- in ED already
What do you do next?
Xray for documentation
Reduction only if neurovascular compromise or on the court
Anterior knee pain ddx
Patellar subluxation or dislocation
Tibial apophysitis (Osgood-Schlatter lesion)
Patellar tendonitis
Chondromalacia patellae
Medial knee pain ddx
MCL sprain
Medial meniscal tear
Pes anserine bursitis
Medial plica syndrome
Lateral knee pain ddx
LCL sprain
Lateral meniscal tear
Iliotibial band tendonitis
Posterior knee pain ddx
Baker’s cyst
PCL injury
Giving-way episodes of knee
Mild effusion w/ patellar apprehension
What is going on?
Patellar subluxation
Anterior knee pain localized to tibial tuberosity
Young kid who recent went through growth spurt
Osgood-Schlatter lesion
- stress on patellar tendon –> microavulsions of growth plate on tibial tubercle where patellar tendon inserts
Pain reproduced by extending knee against resistance
Can see on xray lifting of tubercle from shaft of tibia
Tx w/ activity restrict, stretching, NSAIDs
Overweight pt
Knee pain, no recent injury
hip flexed and externally rotated
Pain in hip w/ passive internal rotation or extension….what do you suspect?
Slipped capital femoral epiphysis
Vague, poorly localized knee pain
Morning stiffness
Recurrent effusion
Xray: osteochondral lesion or loose body in knee joint
What do you suspect?
Osteochondritis dissecans
Pain at medial aspect of knee
worsened w/ repetitive flexion and extension
TTP on medial aspect
no joint effusion
small swelling at insertion of medial hamstring muscles
Pes anserine bursitis
pes anserine bursa is associated with the tendinous insertion of the sartorius, gracilis, and semitendinosus muscles into the medial aspect of the proximal tibia
Valgus stress test fails to reproduce pain
Radiographs normal
Pain can be present overnight
Tender to palpation at area
Tx: RICE, steroid injections
Runner
Lateral knee pain
aggravated by activity, downhill running, climbing stairs
No joint effusion
+Noble’s test (flex and extend knee repeatedly)
Iliotibial band tendonitis
Popliteus tendonitis also possible but rarer
When is it best to do surgery on degenerative or torn meniscus?
If no arthritic changes present
1 cause of shoulder pain
supraspinatus tendinitis = impingement syndrome
Tx lateral epicondylitis
Splint forearm
PT
Rarely: injections
Lateral epicondylitis = tennis elbow = degeneration of extensor tendons of forearm
+ Finklestein test: pt clenches thumb under fingers when making fist, ulnar deviation of wrist
pain in radial aspect of wrist
What is it?
DeQuervain’s disease
Tx: thumb spica splint + NSAIDs
local cortisone injections OK
Numbness, pain or tingling in 1st 3 fingers
worse at night
can have pain along entire arm
What is likely?
Carpal tunnel
Tinel’s sign
Tap over medial nerve @ wrist –> paresthesias in median N distribution
Phalen’s test
Palmar flexion of wrist for 1 min –> paresthesias in median N distribution
How definitively dx carpal tunnel?
EMG and nerve conduction velocity study
radiographic findings in osteoarthritis
Joint space narrowing
osteophytes
subchondral sclerosis
subchondral cysts
Type 1 vs 2 osteoporosis
1 - loss of trabeuclar bone; vertebral compression and colles fractures more common
2 - equal loss of cortical and trabecular bone. older, both fem and male; fx femoral neck, humerus, pelvis common
Endocrine causes of osteoporosis
Hypogonadism in men
hyperthyroidisum
vit D deficiency
Hx trauma
Pt tenderness at spine level
Pain worse w/ flexion and while pulling up from supine to sitting position and from sitting to standing position
Compression fx
Leg pain greater than back pain
Worse w/ sitting
Can radiate to hip/thigh or below knee
Herniated nucleus pulposus
Diffuse back pain w/ or w/o butt pain
worse w/ mvmt
better with rest
lumbar strain/sprain
Leg pain more than back pain
pain worse with standing and walking
better with rest or spine flexed
Spinal stenosis
Back pain in adolescents
Worse with spine extension and acitivty
Spondylolysis
Constant back pain spinous process tenderness No fever normal CBC elevated ESR or CRP
Vertebral diskitis/osteo
1st line tx for low back pain
NSAIDs
When does anterior fontanelle close? What if it closes early?
13.5 months on average
Serial head measurement circumference
The patient needs to be monitored for craniosynostosis (premature closure of one or more sutures) and for abnormal brain development
When craniosynostosis is suspected, a skull radiograph is useful for initial evaluation. If craniosynostosis is seen on the film, a CT scan should be obtained
A positive flexion abduction external rotation (FABER) test that elicits posterior pain indicates involvement of which joint?
sacroiliac joint
anterior pain indicates hip involvement
The three most common knee conditions in children and adolescents are
patellar subluxation, tibial apophysitis, and patellar tendinitis.
Seizure d/o and chronic pain…which pain med do you have to be careful not to give?
Tramadol - causes seizures!
The only approved treatments for male osteoporosis are
alendronate and recombinant parathyroid hormone.
Meds causing increased falls in elderly
SSRIs, tricyclic antidepressants, benzodiazepines, and anticonvulsants have the strongest association with falls in the elderly
Reducing the number of medications a patient takes reduces the risk of falling
Polymyalgia rheumatica
The clinical hallmarks of polymyalgia rheumatica are pain and stiffness in the shoulder and pelvic girdle.
Fever is common, with temperatures as high as 39°C (102°F) along with night sweats. Additional symptoms include depression, fatigue, malaise, anorexia, and weight loss.
Tx polymyalgia rheumatica
Corticosteroids
helps a lot!
treatment of severe osteoporosis, for patients with multiple osteoporosis risk factors, or for patients with failure of bisphosphonate therapy
Teriparatide
erythema toxicum neonatorum
Lots of macule, papules, and pustules on baby
Normal to have
Eosinophils seen in scrapings of skin
1 cause of erythema multiforme
HSV
pyogenic tenosynovitis.
When early tenosynovitis (within 48 hours of onset) is suspected, treatment with antibiotics and splinting may prevent the spread of the infection. However, this patient’s infection is no longer in the early stages and is more severe, so it requires surgical drainage and antibiotics.
Which one of the following tinea infections in children always requires systemic antifungal therapy?
Tinea capitis
Most effective tx for plaque psoriasis
topical vitamin D analogues and topical corticosteroids.
Intertrigo
is inflammation of skinfolds caused by skin-on-skin friction and is common on opposing cutaneous or mucocutaneous surfaces. Secondary cutaneous bacterial and fungal infections are common complications
Erythrasma
is caused by Corynebacterium minutissimum and presents as small reddish-brown macules that may coalesce into larger patches with sharp borders.
Intertrigo complicated by erythrasma is treated with topical or oral erythromycin.
Tx chronic paronychia.
This condition is often associated with chronic immersion in water, contact with soaps or detergents, use of certain systemic drugs (antiretrovirals, retinoids) and, as is most likely in a 6-year-old child, finger sucking.
Topical corticosteroids
Patellofemoral pain syndrome
is a common overuse injury observed in adolescent girls.
The condition is characterized by anterior knee pain associated with activity.
The pain is exacerbated by going up or down stairs or running in hilly terrain. Can also c/o pain w/ sitting due to sustained flexion
It is associated with inadequate hip abductor and core strength;
Patients complain of popping, catching, stiffness, and giving way.
- EXAM: + J sign = patella moving from a medial to a lateral location when the knee is fully extended from the 90° position.
therefore, a prescription for a rehabilitation program is recommended
BP med which decreases uric acid levels?
Losartan
Spinal stenosis vs. herniated disk - how do you tell the difference?
Pain from spinal stenosis is relieved by sitting and aggravated by standing, whereas the opposite is true for pain from a herniated disk.
Tx MRSA
clindamycin and doxycycline
minocycline and trimethoprim/sulfamethoxazole.
Best initial therapy for rheumatoid arthritis
Methotrexate
“sprained wrist” + tenderness in anatomic snuffbox.
What do you suspect?
Tx?
Fx of scaphoid
Radiographs can be negative initially
The scaphoid circulation enters the bone for the most part through the DISTAL half.
Fractures through the PROXIMAL 1/3 tend to cause loss of circulation and are slower to heal, and should be referred to an orthopedist because of the risk of nonunion and avascular necrosis.
Fractures through the middle or DISTAL one-third can be handled by the family physician in consultation with an orthopedist. The fracture is treated with a thumb spica cast for 10–12 weeks.
Which bisphosphanates are best for preventing hip fx? vertebral fx?
Only zoledronic acid, risedronate, and alendronate have been confirmed in sufficiently powered studies to prevent hip fracture
Ibandronate, raloxifene, denosumab, and etidronate have been shown to reduce new vertebral fractures, but are not proven to prevent hip fracture.
The antalgic gait occurs when
the stance phase of gait is shortened, usually because of pain during weight bearing
Why in slipped capital femoral epiphysis hurt with the internal rotation?
Internal rotation of the hip increases the intracapsular pressure within the acetabulum.
How can you find pathology in the sacroiliac joint?
The FABER test (Flexion, Abduction, External Rotation—the ipsilateral ankle placed on the contralateral knee and mild downward pressure placed on the ipsilateral knee) can find pathology located in the sacroiliac joint, often seen in rheuma- tologic disorders.
Children with a septic hip joint will often lay with their hip
flexed, abducted, and externally rotated,
Any suspected septic joint must be aspirated.
Congenital hip dysplasia tx
If the problem is found in the first few weeks of life, the child can be treated with splinting of the hip and normal development usually follows.
If diagnosed late, the treatment is often surgical.
Transient synovitis is a
self-limited inflammatory response that is a common cause of hip pain in children.
It occurs typically in children ages 3 to 10 years, is more common in boys than in girls, and often follows a viral infection.
It is frequently seen as gradually increasing hip pain that results in a limp or refusal to walk.
low-grade or no fever, a normal white blood cell (WBC) count, and a normal ESR.
On examination, there is pain with internal rotation of the hip and the overall range of motion is limited by pain.
X-rays are either normal or show some nonspecific swelling
Septic joint vs transient synovitis
A septic joint will have a purulent aspirate with a WBC count greater than 50,000/μL, elevated ESR, fever
transient synovitis will have a yellow/clear aspirate with a lower WBC count (<10,000/μL)
Legg-Calvé-Perthes (LCP) disease
avascular necrosis of the femoral head that typically occurs in children ages 4 to 8 years.
Boys > girls
etiology of the disruption of blood flow is unknown.
gradual onset of hip, thigh, or knee pain, and limping over a few months.
Early in the course, x-rays of the hip may appear normal. Later radiographic findings include collapse, flattening, and widening of the femoral head.
Bone scans or magnetic resonance imaging (MRI) may be necessary to confirm the diagnosis.
TX- conservative, with protection of the joint and efforts to maintain range of motion.
Tx slipped capital femoral epiphysis
surgical pinning of the femoral head.
These patients must be closely followed, as approximately 33% will develop avascular necrosis and 33% will develop SCFE in the contralateral hip.
Tx surgical site infections
Incision and drainage is the most important therapy for SSI.
Antibiotics are used solely in cases of significant systemic involvement.
What is the correct study in a patient of any age with chronic neck pain and no history of trauma, malignancy, or surgery?
a complete cervical spine series that includes five views
If the radiographs are normal and the patient has neurologic signs or symptoms, the next step would be MRI
Rosella rash
erythematous maculopapular eruption that starts on the trunk and spreads rapidly to the extremities, with sparing of the face
The rash of scarlet fever looks like…
usually starts about 2 days after the onset of sore throat.
The rash consists of punctate, raised, erythematous eruptions that can become confluent and feel like sandpaper.
The rash tends to start on the upper trunk and spreads to the rest of the trunk and the extremities.
Do you do MRI for sciatica?
MRI is not recommended for patients with sciatica unless the symptoms last for greater than 1 month or if the patient is not a candidate for surgery or epidural injection.
Conservative treatment involves NSAIDs, possibly short-course steroids, and avoidance of sitting.
Spinal stenosis
congenital or acquired spinal canal narrowing that puts pressure on the spinal cord.
Sx:
- lower back & leg pain
- leg weakness
- pseudoclaudication that occurs after walking different distances while the vascularity of the legs remains intact.
- Pain is relieved by bending over or sitting.
Tx:
NSAIDs
physical therapy
epidural corticosteroids
Vertebral compression fractures
more common in older people and those with osteoporosis or chronic steroid use.
This may happen after low-impact trauma or no trauma history at all.
pain is generally well localized to the spine and may be brought on by certain sudden movements.
Dx: X-ray
Tx:
- pain control
- calcitonin or alendronate.
- conservative decreased mvmt until pain is tolerable
- 2 weeks of pain - surgery; Surgical management includes vertebroplasty or kyphoplasty.
Tx and Dx herniated disk
A herniated disc can be treated conservatively for 4 weeks before imaging has any proven benefit.
If symptoms persist after 1 month, then the MRI would be the correct choice.
X-rays do not show disks or nerve roots
Lumbar strain
common,
generally resolves within a few weeks,
is treated with NSAIDs, muscle relaxants, and no more than 2 days of bed rest
About a month after returning from the Middle East, an American soldier develops a papule on his forearm that subsequently ulcerates to form a shallow annular lesion with a raised margin. The lesion shows no signs of healing 3 months after it first appeared. He has no systemic symptoms.
The most likely diagnosis is: (check one) A. leishmaniasis B. schistosomiasis C. malaria D. trypanosomiasis E. syphilis
Cutaneous leishmaniasis
pityriasis rosea.
mild prodrome
then development of an ovoid salmon-colored, slightly raised herald patch, most commonly seen on the trunk.
then outbreak of multiple smaller, similar lesions that trend along Langer’s lines.
Frozen shoulder is
an idiopathic condition that most commonly affects patients between the ages of 40 and 60.
Diabetes mellitus is the most common risk factor
Symptoms include shoulder stiffness, loss of active and passive shoulder rotation, and severe pain, including night pain.
Laboratory tests and plain films are normal;
diagnosis is clinical
Sx: Pain occurs around the ankle, and there is decreased range of motion of the hindfoot and pain on foot inversion on examination.
Bilateral
Tarsal coalition
- is the fusion of two or more tarsal bones.
- It occurs in mid-to late adolescence and is bilateral in 50% of those affected.
Os trigonum
results from non-ossification of cartilage.
Sx: unilateral and causes palpable tenderness of the heel.
Sever’s apophysitis
is inflammation of the calcaneal apophysis,
causes pain in the heel.
Tx Plantar fasciitis
Treatment strategies include relative rest, ice, NSAIDs, and prefabricated shoe inserts that provide arch support, as well as heel cord and plantar fascia stretching.
If conservative therapy fails, a corticosteroid injection may be useful.
Surgery is reserved for patients refractory to 6-12 months of uninterrupted conservative therapy.
Spinal flexion vs extension increases spinal stenosis pain?
Extension
Rosacea
Central facial erythema and telangiectasias are prominent early features that may progress to a chronic infiltrate with papules and sometimes sterile pustules.
The usual presenting symptoms are central facial erythema and flushing that many patients find socially embarrassing.
Ocular problems occur in half of patients with rosacea, often in the form of an intermittent inflammatory conjunctivitis with or without blepharitis.
Management:
- avoidance of precipitating factors
- use of sunscreen.
- Oral metronidazole, doxycycline, or tetracycline also can be used, especially if there are ocular symptoms.
- These are often ineffective for the flushing, so low-dose clonidine or a nonselective β-blocker may be added.
In person w/ renal failure, what is first line tx for osteoarthritis of joint?
NOT NSAIDS!
Acetaminophen
A 45-year-old female presents to your office with a 1-month history of pain and swelling posterior to the medial malleolus. She does not recall any injury, but reports that the pain is worse with weight bearing and with inversion of the foot. Plantar flexion against resistance elicits pain, and the patient is unable to perform a single-leg heel raise.
Which one of the following is true regarding this problem?
(check one)
A. The patient most likely has a medial ankle sprain
B. NSAIDs will improve the long-term outcome
C. Injecting a corticosteroid into the tendon sheath of the involved tendon is recommended
D. A lateral heel wedge should be prescribed
E. Immobilization in a cast boot for 3 weeks is indicated
The diagnosis of tendinopathy of the posterior tibial tendon is important, in that the tendon’s function is to perform plantar flexion of the foot, invert the foot, and stabilize the medial longitudinal arch. An injury can, over time, elongate the midfoot and hindfoot ligaments, causing a painful flatfoot deformity.
The patient usually recalls no trauma, although the injury may occur from twisting the foot by stepping in a hole. This is most commonly seen in women over the age of 40. Without proper treatment, progressive degeneration of the tendon can occur, ultimately leading to tendon rupture.
Pain and swelling of the tendon is often noted, and is misdiagnosed as a medial ankle sprain. With the patient standing on tiptoe, the heel should deviate in a varus alignment, but this does not occur on the involved side. A single-leg toe raise should reproduce the pain, and if the process has progressed, this maneuver indicates progression of the problem.
While treatment with acetaminophen or NSAIDs provides short-term pain relief, neither affects long-term outcome. Corticosteroid injection into the synovial sheath of the posterior tibial tendon is associated with a high rate of tendon rupture and is not recommended. The best initial treatment is immobilization in a cast boot or short leg cast for 2–3 weeks.
Tx restless leg syndrome
lower-body resistance training
avoiding or changing medications that may exacerbate symptoms (e.g., antihistamines, caffeine, SSRIs, tricyclic antidepressants, etc.).
patients with a serum ferritin level < 50 ng/mL take an iron supplement
Ropinirole may be used if nonpharmacologic therapies are ineffective.
Gradually worsening anterolateral hip joint pain that is sharply accentuated when pivoting laterally on the affected hip or moving from a seated to a standing position is consistent with
femoroacetabular impingement.
Reproduction of the pain on range-of-motion examination by manipulating the hip into a position of flexion, adduction, and internal rotation (FADIR test) is the most sensitive physical finding.
What do you need to dx poly myalgia rheumatica?
There must be bilateral shoulder or hip stiffness and aching for at least one month in order to make the diagnosis of polymyalgia rheumatica.
erythrocyte sedimentation rate should be ≥40 mm/hr.
Best to dx septic arthritis
Ultrasound
It is highly sensitive for detecting effusion of the hip joint.
If an effusion is present, urgent ultrasound-guided aspiration should be performed.
CT is indicated for what MS path?
when cortical bone must be visualized.
MRI is indicated for what MS path?
excellent visualization of joints, soft tissues, cartilage, and medullary bone.
Great for: osteomyelitis, delineating the extent of malignancies, identifying stress fractures, diagnosing early Legg-Calvé-Perthes disease.
Tx fibromyalgia
Exercise 1st
Then meds if fail tx:
amitriptyline
duloxetine
Paget’s disease of bone
is a focal disorder of skeletal metabolism in which all elements of skeletal remodeling (resorption, formation, and mineralization) are increased.
Tx: bisphosphonates.
What do you do for suspected melanoma?
The diagnosis of melanoma should be made by simple excision with clear margins.
Wide excision with or without node dissection is indicated for CONFIRMED melanoma, depending on the findings from the initial excisional biopsy.
What should be obtained in any patient with suspected vitamin D deficiency?
Serum 25-hydroxyvitamin D = major circulating form of vit D
- this tells you if they are low on vit D
1,25-Dihydroxyvitamin D is the most active metabolite, but levels can be increased by secondary hyperparathyroidism.
In persons with vitamin D deficiency, what can be used to replenish stores ?
ergocalciferol (vitamin D ) or cholecalciferol (vitamin D )
The combination of arthritis with a typical palpable purpuric rash is consistent with a diagnosis of
Henoch-Schönlein purpura.
It is now recommended that all infants and children, including adolescents, have a minimum daily intake of X of vitamin D, beginning soon after birth
400 IU
A 40-year-old runner complains of gradually worsening pain on the lateral aspect of his foot. He runs on asphalt, and has increased his mileage from 2 miles/day to 5 miles/day over the last 2 weeks. Palpation causes pain over the lateral 5th metatarsal. The pain is also reproduced when he jumps on the affected leg. When you ask about his shoes he tells you he bought them several years ago.
Which one of the following is the most likely diagnosis?
(check one)
A. Ligamentous sprain of the arch
B. Stress fracture
C. Plantar fasciitis
D. Osteoarthritis of the metatarsal joint
A stress fracture causes localized tenderness and swelling in superficial bones, and the pain can be reproduced by having the patient jump on the affected leg.
An otherwise healthy 37-year-old male presents to your office with a 2-week history of redness and slight irritation in his groin. On examination a tender erythematous plaque with mild scaling is seen in his right crural fold. The area fluoresces coral-red under a Wood’s light. Which one of the following would be the most appropriate treatment at this time? (check one) A. Amoxicillin B. Erythromycin C. Ketoconazole D. Nystatin (Mycostatin) E. Triamcinolone (Kenalog)
The characteristics of this lesion, including coral-red fluorescence under a Wood’s light, suggests Corynebacterium infection, which is associated with erythrasma. Tinea cruris caused by Microsporum infection fluoresces green, while intertrigo and tinea cruris caused by Epidermophyton or Trichophyton infections do not fluoresce. Erythromycin, either systemic or topical, is the treatment of choice.
Tx impetigo
Limited area: mupirocin
Oral antibiotics are widely used, based on expert opinion and traditional practice, but are usually reserved for patients with more extensive impetigo or with systemic symptoms or signs.
typical fibromyalgia trigger points lie along
the medial scapula borders,
posterior neck,
upper outer quadrants of the gluteal muscles,
medial fat pads of the knees
Tx alopecia areata
> 10 yo or < 50% of the scalp = intralesional corticosteroid injections
< 10 yo or >50% scalp = Minoxidil
Dupuytren’s disease is characterized by
shortening and thickening of the palmar fascia.
Early asymptomatic disease does not require treatment.
- A series of cortisone injections over a period of months may lead to disease regression
- Surgery is indicated if a metacarpal joint contracture reaches 30°, or with a proximal interphalangeal joint contracture of any degree.
There is a strong association between diabetes mellitus and Dupuytren’s disease
A 39-year-old female presents with lower abdominal/pelvic pain. On examination, with the patient in a supine position, you palpate the tender area of her abdomen. When you have her raise both legs off the table while you palpate the abdomen, her pain intensifies.
Which one of the following is the most likely diagnosis?
(check one)
A. Appendicitis
B. A hematoma within the abdominal wall musculature
C. Diverticulitis
D. Pelvic inflammatory disease
E. An ovarian cyst
Carnett’s sign is the easing of the pain of abdominal palpation with tightening of the abdominal muscles. If the cause is visceral, the taut abdominal muscles could guard the source of pain from the examining hand. In contrast, intensification of pain with this maneuver points to a source of pain within the abdominal wall itself.
Skin tags, or acrochordons, are associated with
diabetes mellitus and obesity.
The onset often occurs in early adulthood, and the most common locations are the neck and axillae.
These skin lesions are not associated with any significant cancer risk
What has been used to tx external genital and perianal warts in patients 12 years of age and over?
imiquimod
Dx Rheumatoid arthritis
clinical diagnosis
Anti-cyclic citrullinated peptide (anti-CCP) antibody most specific
What provides pain relief within a few days in many patients with osteoporotic vertebral compression fractures?
Calcitonin, either intranasal or subcutaneous,
What is + straight leg raise test?
Sciatica reproduced w/ elevations of leg < 60 deg
What is the suggested etiology in:
Monoarticular joint pain
Multiple joint involvement
Symmetric polyarthritis
Monoarticular joint pain
- infection,
- gout,
- pseudogout,
- trauma,
- toxic synovitis
Multiple joint involvement
- connective tissue disease,
- osteoarthritis,
- RA.
Symmetric polyarthritis = RA
RA xray findings
periarticular soft tissue swelling,
periarticular osteopenia,
uniform loss of joint space (nonuniform loss is more consistent with osteoarthritis),
bony erosions
1st line tx osteoarthritis
Acetaminophen
NSAIDs have more side effects
Tx RA symptoms
NSAIDs
MTX early on can help modify disease course
Tx Gout
1st line = NSAIDs
Colchicine in attack
Allopurino not during attack but yes for ppx
Probenecid for ppx
Shoulder pain w/ active ROM vs passive ROM - what defines a dx?
Pain with both active range of motion (AROM) and passive range of motion (PROM) suggests joint or ligament involvement,
pain with AROM but not PROM suggests muscular and/or tendon injury.
woman taking steroids p/w hip pain - what happened?
Avascular necrosis of femoral head
Use MRI to dx
Pagets disease lab values
high alp and urinary hydroxyproline
Nl all else
Causes of Reactive arthritis
Chlamydia
GI pathogens
NOT gonorrhea
Common sites of ankylosing spondylitis pain
2/2 Enthesitis
Heel
Tibial tuberosities
Iliac crests
Temporal arteritis dx - what arteries involved? What do you follow pts with?
Ophthalmic
Branches of aorta
Follow with serial CXR to monitor for aortic aneurysm
What puts you at increased risk for pseudogout?
Hyper PTH
Previous trauma
+ anti topoisomerase I antibodies
Systemic sclerosis
Antimitochondrial antibodies
primary biliary cirrhosis
C-ANCA antibodies
Wegner’s granuloma
Anti-smooth muscle antibodies
autoimmune hepatitis
SLE manifestations
Fatigue Fever Wt loss non-deforming arthritis (usually in MCP and PIP) oral ulcers serositis heme abnormalities proteinuria rash
Osteoarthritis dx
age > 50 minimal or no AM stiffness bony tenderness bony enlargement crepitus on active motion no warmth of joint
1 cause of vertebral osteo in IVDU
Staph aureus
How long does arthritis have to be present to dx RA?
6 weeks
Charcot’s joint
Due to diabetic neuropathy, B12 def, etc
It is a neurogenic arthropathy
Nl neuro input lost –> pts unknowingly traumatize their wt bearing joints –> degenerative joint disease, joint deformation, functional limitation
Xray:
loss of cartilage
osteophytes
loose bodies
Tx:
tx underlying dz
providing mech support to assist wt bearing
S/E hydroxychloroquine
good drug for SLE skin and joint involvement
Can cause retinopathy and corneal damage though
Suspect new onset lupus nephritis - what do you do next?
Renal bx first!
- for baseline and tx options
Morton neuroma
Mech-induced neuropathic degeneration
Sx
numbness + burning of toes
aching
burning in distal forefoot radiating forward from metatarsal heads to 3rd and 4th toes
Tx:
support w/ padded shoe inserts
surgery if conservative tx fails
Punched out erosions w/ rim of cortical bone on xray - what is this?
Gout
Xray shows periarticular osteopenia + joint margin erosions
rheumatoid arthritis
Xray shows normal joint space w/ soft tissue swelling
infectious arthritis
xray shows calcificatino of cartilaginous structures
pseudogout
Tx symptomatic sarcoidosis
Steroids
Dx secondary amyloidosis
Ab fat pad aspiration bx
Facial swelling
b/l LE edema
Massive proteinuria
Hepatomegaly
Palpable kidneys
Ventricular hypertrophy
Chronic inflammatory dz pmh
What could this be
Secondary amyloidosis
- tx underlying inflammatory dz (eg RA, bronchiectasis, TB, osteo, Crohns, Malignancy, vasculitits)
Tx and ppx secondary amyloidosis
Colchicine
Behçet’s syndrome
genital and oral ulcerations and relapsing uveitis.
Patients may develop arthritis, vasculitis, intestinal manifestations, or neurologic manifestations. This disease is also associated with cutaneous hypersensitivity; 60%–70% of patients will develop a sterile pustule with an erythematous margin within 48 hours of an aseptic needle prick.
