muskuloskeletal Flashcards
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Musculoskeletal –ROS and PE
- Patient complaints: hand, shoulder, knee, hip
- PE: look for crepitus, subluxation, dislocation, range of motion, contracture, deformity, inflammation, assess for gait and mobility disturbance
- Diagnostics: X-ray of area of complaint, CT scan, US for soft tissue injury, MRI, synovial fluid aspiration, CBC, ESR, CRP, uric acid level, rheumatoid factor, antibody levels, ANA, ANCA, ASO titers
ANA- diffuse
nonspecific, drug induced lupus
ANA - peripheral
50% of SLE
ANA Speckled
SLE, Sjogrens, lupus, scleroderma, polymyositis,
dermatomyositis, pneumonitis (all based on identified antigen)
ANA Nucleolar
progressive systemic sclerosis
ANA - centromere
Centromere – limited scleroderma
Synovial Fluid Aspiration
- Appearance, viscosity
- WBC count
- Gram Stain
- Crystal identification
Musculoskeletal –Evaluation and Management
- Is it articular?
- Is it acute or chronic? - > 6 weeks is chronic
- Is there inflammation?
- How many joints involved?
- How old is the patient? • Is it drug induced?
Non-articular Conditions
- Trauma
- Fibromyalgia
- Polymyalgia rheumatic
- Bursitis
- Tendinitis
Fibromyalgia
• Defined as chronic widespread musculoskeletal pain and tenderness.
• Complaints of pain, neuro-psychological symptoms (anxiety, insomnia etc), overlaps with chronic conditions, exacerbated by
stress
• Assess trigger points
• DX – routine labs are normal
• TX – PT, exercise, treat underlying cause
Polymyalgia Rheumatica
- Patient complains of stiffness, aching, pain in the muscles of the neck, shoulders, lower back, hips and thighs.
- Occurs with giant cell arteritis
- DX - ESR, CBC for anemia, temp for fever, alk phos will be elevated, IgG is elevated
- TX – Prednisone 10 – 20 mg/day
Bursitis
- Inflammation of the bursa
- Patient will be tender over joint
- DX – by H and P, sometimes US
- TX – decrease aggravating factors, NSAID, glucocorticoid steroid injection
Tendonitis
- Inflammation of the tendon
- DX – based on exam, x-ray, US
- TX – Rest, Ice, NSAIDs, PT, surgical repair if function is loss
Acute Articular Conditions
- Acute arthritis
- Infectious arthritis
- Gout
- Pseudogout
- Reactive arthritis
Infectious Arthritis (Septic Arthritis)
• Most common organisms are Staph. Aureus and Neisseria gonorrhea
• Can be a single or multiple joints
• Bacteria enters bloodstream then enters bone/soft tissue or direct inoculation during a procedure (eg surgery or CLABSI)
• DX – CBC with diff, blood cultures, synovial fluid cultures
• TX – IV antibiotic for specific organisms
(2-6 weeks depending on org.),drain joint of pus
Gout
• Metabolic disease in middle-aged to elderly men and postmenopausal women
• Heberden’s or Bouchard’s nodes on exam
• DX – needle aspiration of fluid, serum uric acid level
• TX – NSAIDs, colchicine, glucocorticoids,
allopurinol long term
Pseudogout
(Acute Calcium Pyrophosphate Deposition Disease – CPPD)
• CPP crystals found in the joint of the elderly mostly over age of 85
• Have underlying disorder as cause
• Can be asymptomatic, acute, subacute, chronic
• Looks like gout but it’s not
• Triggered by trauma, illness, or surgery
• Presents with fever, pain
• DX – synovial aspiration
• TX – rest, aspiration, NSAIDs, glucocorticoid injections, low dose
colchicine, eventually may need joint replacement.
Reactive Arthritis
- Develops several weeks after urethritis or enteric infections
- DX – genetic testing for HLA-B27, x-ray of joint
- TX – anti-inflammatories
Chronic Non-inflammatory Conditions
- Osteoarthritis
- Osteonecrosis
- Charcot Arthritis
Osteoarthritis
Defined as joint failure, commonly in first carpometacarpal, distal and proximal interphalangeal, cervical vertebrae, hip, lower lumbar, knee, first metatarsophalangeal (aka degenerative joint disease)
• Found in elderly, highly prevalent, high rate of disability
• Risk factors: age, women, hereditary , joint vulnerability, injury, ligament and cartilage tear, obesity, repeated use/exercise
• DX – made based on exam and x-ray
• TX – avoid aggravating activities, exercise, braces, NSAIDs,
acetaminophen, COX 2 inhibitors, steroid injections, surgery
Osteonecrosis
• Death of osteocytes and adipocytes and eventually bone loss by decreased blood flow to the bone
• Risk factors include chemo, radiation treatment, steroids, transplants, cancer, lupus, HIV, gout, vasculitis, OA, osteoporosis, blood disorders, decompression sickness
• DX: bone scan, MRI
• TX: pain control, cord decompression, osteotomy or joint
Replacement
Charcot Arthritis (Charcot joint)
- Progressive destructive arthritis, loss of pain sensation, proprioception, or both. Muscular reflexes are lost.
- Most commonly caused by DM, tabes dorsalis, amyloidosis, leprosy
- PE: starts with a single joint, joint becomes enlarged with bony overgrowth and synovial effusion
- DX: clinical features and x-ray (joint space narrowing, subchondral bone sclerosis, osteophytes, joint effusion; late stage shows destructive and hypertrophic changes)
- TX: stabilize joint (braces and splints), treat underlying disorder, NWB for 8 weeks.
Chronic Inflammatory Arthritis
- Indolent Infection
- Psoriatic Arthritis
- Reactive Arthritis
- SLE
- Scleroderma
- Polymyositis
- Rheumatoid Arthritis
Psoriatic Arthritis
- Inflammatory disease with both autoimmune and autoinflammatory features
- Starts with psoriasis and within a year arthritis, men and women affected equally
- PE: nail changes (pitting, horizontal ridging, onycholysis, yellow discoloration, dystrophic hyperkeratosis, or a combination), shortening of digits, rapid ankyloses of proximal interphalangeal joints
- DX: ESR, CRP, x-ray, CASPAR criteria
- TX: anti-TNF-a agents (eg infliximab, adalimumab, and certolizumab pegol), methotrexate
CASPAR Criteria
- Evidence of psoriasis or family history
- Typical psoriatic nail dystrophy
- Negative rheumatoid factor
- Dactylitis (current or history of)
- Juxtaarticular new bone formation in hand or foot on xray
Systemic Lupus Erythematous
- Autoimmune disease, organs and cells undergo damage mediated by tissue binding autoantibodies and immune complexes
- PE: lupus dermatitis, oral ulcers, alopecia, synovitis, prot/cr >0.5, seizures, psychosis, mononeuritis, myelitis, neuropathies, polyarthritis
- DX: clinical features, ANA, Anti-dsDNA, Anti-Sm, antiphospholipids, low serum complement, positive direct Coombs, hemolytic anemia,leukopenia, lymphopenia, thrombocytopenia, x-rays (joint erosions), MRI, muscle biopsy
- TX: no cure, goal is to reduce remissions, NSAIDs, supportive care
Scleroderma
Connective tissue disorder, multisystem involvement, heterogenous, chronic and progressive with significant disability and mortality.
• Starts with inflammatory leading to functional and structural
alterations in vascular beds and visceral organ dysfunction due to fibrosis
• Risk factors: genetics, EBV and CMV exposure, occupational exposure such as epoxy, miners, drug induced bleomycin, cocaine
• DX: anemia, ANA, skin biopsy,
• TX: goal is to alleviate symptoms, immunosuppressants
Scleroderma
Physical Exam
• Raynauds Phenomenon
• Skin: sclerodactyly
• Pulm: ILD, PAH
• GI: dental caries, periodontal disease, xerostomia, GERD, gastroparesis, GAVE (gastric antral vascular ectasia), B12
deficiency, malabsorption, SBO, GIB
• Renal: narrowing causing decreased renalblood flow
• Cardiac: secondary to pulm complications (pericardial tamponade, pericardial effusion)
• MSK: carpal tunnel syndrome, arthralgia,stiffness
• Malignancy: increased risk of lung CA andesophageal adenocarcinoma
Treatment
• Skin: antihistamines, low dose steroids
• PAH: bosentan or phosphodiesterase type 5 inhibitor
• GI: regular dental care, GERD precautions, PPI, domperidone
• Renal crisis: poor prognosis, renal transplant, avoid nephrotoxins
• MSK: NSAIDs, weekly methotrexate, low dose steroids,
PT, OT
Polymositis
- Subacute inflammatory myopathy affecting adults
- Inflammation of the muscles as a result of cell damage
- Caused by virus, drugs, parasites/bacteria, systemic autoimmune diseases, connective tissue disordres
- DX: EMG, MRI, muscle biopsy, CPK, aldolase
- TX: zathioprine (Azasan, Imuran) and methotrexate (Trexall) with glucocorticoid steroids
Rheumatoid Arthritis
Rheumatoid Arthritis
• Chronic inflammatory disease with symmetric, peripheral polyarthritis leading to joint damage and physical
disability
• DX: RF, CRP, ESR, x-ray (joint erosions or SQ nodules), immunoglobulins, synovial fluid analysis (inc WBC, used for
exclusion), MRI, US
• TX: glucocorticoid steroids, DMARDS, anti-TNF agents, small-molecule inhibitor, PT, OT, surgery (replacements),
Osteomyelitis
• Infection of the bone derived from other locations ( ie. Stepped on a nail)
• SX – fever, pain, SIRS, neuro deficits (neuropathy, weakness etc)
• DX – identify organism, CBC with diff, CRP, blood cultures before abx, bone biopsy,
• TX – abx x 6 weeks (review table 158-1 in Harrisons), surgical
debridement, ID consult
Rhabdomyolysis
• Death of muscle fibers as a result of direct or indirect muscle injury.
• Many causes from snake bite to crush injury, medications, athletes, heat stroke
• PE: Triad - Muscle pain, muscle weakness, and red/brown urine
• DX: inc creatine kinase, + myoglobin in urine, CBC, BMP for renal injury
• Complications: acute kidney injury, hyperkalemia, cardiac
arrhythmias, elevated liver function tests, compartment syndrome.
• TX: IVF, treat electrolyte abnormality, fasciotomy, supportive
treatment, treat underlying causes
