Natsumi MSK conditions Flashcards
Localized tenderness, pain with movement Decreased ROM Erythema Edema Hx of repetitive movement Alleviated by rest, worsened by exercise
Bursitis
Test:
- fluid aspiration → monosodium urate crystal (DDX: gout) , cell count, gram stain
- MRI
Tx: RICE, NSAID (celecoxib, ibuprofen) , hydrocortisone, bursal aspiration
Men > 40 yo
Diet with seafood and meat
Hx of renal failure
Clinical conditions associated with gout: hypertension, obesity, DM, chemo
Acute Gouty Arthritis
• Most commonly involve the first metatarsophalangeal joint (podagra), ankle and knee
- Joint is hot, red and swollen; limited mobility
- Will subside spontaneously within several days to weeks; may recur
Tophi
- Uric acid crystal accumulate in the joint to produce tophus
© Deposited on cartilage, tendons, bursae, soft tissues, synovial membranes
© Common sites are first MTP joint, ear helix, olecranon bursae, tendons (particularly
the Achilles tendon).
Kidney
• Gouty nephropathy
• Uric acid calculi
Investigations
• Joint aspirate is confirmatory: >90% show monosodium rate crystals
• X-ray may show the tophi as punched out lesions, erosion with “over-hanging”
• Laboratory findings
• Increased serum uric acid (hyperuricemia)
- May have absolute neutrophilic leukocytosis in acute gouty arth
Gout
Investigations
• Joint aspirate is confirmatory: >90% show monosodium rate crystals
• X-ray may show the tophi as punched out lesions, erosion with
“over-hanging”
• Laboratory findings
- Increased serum uric acid (hyperuricemia)
• May have absolute neutrophilic leukocytosis in acute gouty arthritis
allopurinol
Colchicine
Harpagophe
Treatment
Eupatorium pù
• Acute gout: high dose NSAIDs, then taper as symptoms improve; corticosteroids, Colchicine
Smi
• Chronic gout:
- Modify diet to eliminate high purines (organ meats, meat, sardines, shellfish, beans, peas)
- Avoid drugs with hyperuricemic effect (thiazide e.g. Hydrochlorothiazide, alcohol)
LYME DISEASE
Herbs:
Stage 1 (7-14 days) - “bull’s eye” lesion with malaise, fatigue, headache, myalgia
Stage 2 (weeks after infection) - Bilateral Bell’s palsy (CN VIl), peripheral neuritis, Transient heart block or myocarditis
Stage 3 (months to years after infection) - disabling arthritis, encephalopathy, meningitis, neuropathy
Labs:
- ELISA (enzyme-linked immunosorbent assay) testing
Highly sensitive
- Western Blot assay: High specificity (96%)
Prevention and Treatment:
- Preventative measure
- Doxycycline prophylaxis within 72 h of removal of Ixodes scapulars tick in hyperendemic areas (only for ages 8 and up, no preg, no lactation)
Stage 1: Doxycycline/Amoxicillin/Cefuroxime
- HLA-B27
- Sausage-shaped DIP, < 10 yo, nail pitting
- Asymmetric oligoarthritis
- Skin: psoriasis (Scales on EXTENSOR)
CASPAR
evidence psoriatic nail, negative RF, dactylitis, radiological evidence
Psoriatic Arthritis
PSORIATIC ARTHRITIS
• Psoriasis appears before the onset of psoriatic arthritis in 60-80% of patients, usually <10 years
Etiology and Pathophysiology
• Unclear but many genetic associations have been identified like HLA-B27
Investigations: ESR, CRP
DMARDS:Methotrexate, sulfasalazine, cyclosporine
- Most commonly caused by S. aureus and has a history of damaged joints
- Monoarticular joint, warm, swollen joint, erythema; pain on active or passive ROM
- Fever, leukocytosis,
- MC joint: Knee > hip > shoulder > ankle, wrist
Septic Arthritis
nvestigations
• Joint aspirate: cloudy yellow fluid, WBC >50,000 with >90% neutrophils, protein level >4.4 mg/
dL, joint glucose level < 60% blood glucose level, no crystals, positive Gram stain result.
• X-ray may show erosion of cartilage, osteoporosis, and to rule out tumor and fracture
• Listen for heart murmur to reduce suspicion of infective endocarditis
Treatment
• IV antibiotics and adjust dosage and medication based on joint aspirate C&S results
• Therapeutic joint aspiration (if early diagnosis and joint superficial)
• Arthroscopic/open irrigation and drainage ‡ decompression
Investigation and Treatment for tendinitis
Tendinitis
Investigations
• Ultrasonography
• MRI is also accurate in accessing tendon pathology
• MRI can also assess cartilage injuries, bony abnormalities, and ligamentous injury
Treatment
• Rest, decrease activity level
• Ice for the first 24-48 hours
• NSAIDs may reduce pain, but most tendonitis conditions are non-inflammatory in nature
- Unknown if it will work compared to other analgesics
- Male > 50yo
- Mainly pelvis > femur > skull (enlarged) > tibia
- Usually asymptomatic
- Severe bone pain is the most common complaint
- Skeletal deformities: bowed tibias, kyphosis, frequent fractures
- Increased hat size with skull involvement causing headaches, hearing loss
- Increased vascularity creates a complaint of warmth over affected bones
Paget Disease of Bone (Osteitis Deformans) = excessive bone destruction and repair (thick, fragile bone)
**BiG HEAD BENDY, THICC, WEAK BONES*
Labs:
X-ray: lytic lesions
- HIGH ALP, normal calcium and phosphorus
Treatment • Weight bearing exercise • Adequate calcium and vitamin D intake to prevent development of secondary hyperparathyroidism • Treat medically if ALP >3x normal • Bisphosphonates (e.g. Alendronate)
Asetic necrosis of ossification centers in children
“Legg-Calve-Perthes dz”
Osteochondrosis
Investigations
- ESR, CRP, CBC (leukocytosis), aspirate culture/bone biopsy, blood culture
- X-Ray shows soft tissue swelling and lytic bone destruction (seen after 12 days post-infection)
- MRI = high sensitivity
Tx:
- IV antibiotics for 4-6 weeks and adjust based on blood and aspirate cultures
- Send to ER because of the potential of bacterial spread resulting in amputation
- Recent trauma/surgery, immunocompromised patient with S. aureus infection in the vertebra (adults) and tibia and fibula (children)
- EXTREME PAIN, fever, redness, swelling 1-2 weeks after URI
Osteomyelitis
women > 65 yo
primary osteoporosis = post menopausa (low estrogen)
vs secondary osteo
Dowager’s hump
Osteoporosis
T score -2.5 to -1 is?
T score less than -2.5 is?
Osteopoenia
Osteoporosis
- gradual onset of decreased AROM PROM
- pain worse at night, can’t sleep on side of pain
- Inc stiffness 6-12 month after pain gone
Adhesive capsulitis “frozen shoulder”
Test:
- MRI to r/o tear (6 weeks to 3 months)
- X-ray: demineralization or normal
Tx:
- NSAID, strech
- pain and tenderness in the region of biceps tendon
- overuse/too much lifting
which orthos
Biceps tendinopathy
Lippman, speed’s yergason
MRI to r/o
US
inflammation of the extensor tendon or flexor tendon
epicondylitis
extensor = lateral - cozen's & mill's flexor = medial
Tx
RICE, physiotherapy, stretch
NSAID corticosteroids
Surgery
electric shooting pain down forearm to the 4th and 5th digit
weakness of the muscle
Ulnar nerve entrapment
Tinel’s
flexor retinaculum
median nerve entrapment
repetitice trauma wrist flexion
more common in female
numbness an tingling 3rd and half of 4th digit
decreased light touch and 2 point discrimination at fingertip
loss of grip[, dropping things
Carpal tunnel syndrome
clinical diagnosis
nerve condution
electromyography to confirm
phalen’s test and tinel’s
tenosynovitis of the first dorsal compcomprment of the rest abductp pollicis longus
de Quervain tenosynovitis
Finkelstein’s tst
pain localized to 1st extensor comporment
NSAID
mst commonly 4th, sometimes 5th and 3rd
- nodules can be felt in the palmar fascia of the affected finger
Dupuytren
fluid filled synovial lined cyst that protrudes between carpal bones or from tendon sheath of the wrist
more common in women
scapholunate ligamental junction is most common
pea sized
Ganglion cyst
watch and wait, aspirate, excision by arthroscopy
Intervertebral disc herniation at C6-C7 (most commonly), less commonly C5-C6
- Trapezius and shoulder pain that radiates down
- Woese with neck extension, ipsilateral rotation and lateral flexion
- Paralysis, weakness
Cervical discopathy
Test:
- X-ray, CT, MRI
- cervical orthos
Tx:
- PT, analgesic, surgery if no better 3 month
Progerssive degeneratice process of cervical spine leading to canal stenosis C5-C6
- more men 40-50
- gradual neck pain, worse with motion, radiculopathy cervical, hyperredlexia, weakness, lacking motor control
Cervical spondylosis
Test:
- X-ray, CT, MRI**
- cervical orthos
Tx:
- Don’t move! givy
- Surgery
Kyphosis
XX-ray is essential to diagnosis kyphsiss
Scoliosis
Adam;s test
X-ray
TX:
>20 bracing
>45 surgerical correction
Lordosis
inward curvature of a [prtion of the lu,bar and cervai; vertebral colu,m causing anterior pelvic tilt
X-ray
PT
Thoracic outlet syndrome
C8/T1 compression
nubmess, parasthesias
Wright’s test, adson’s test, shoulder depression, east test (Roo’s test)
Tx:
Physiotherapy, massage, rest
sciatica
L4-S3
herniated disk
radiculopathy
Bechtrew’s
SLE
Braggard
foward slip L5-S2, L4-L5 lower back pain radiating to btuttick ti relieve with sitting tight hamsterins pain on hyperextension
sponfylolusthesis
X-ray, MRI
activity restriction, bracing, NSAIDs
This condition is most commonly caused by knee pain in runners. Localized pain is usually the lateral knee, worse with activity, better at rest.
IT Band syndrome
- Varus stress test with knee flexion 30 degrees
Tx: PT & NSAIDs
This condition is often caused by femoral neck fracture. It can also be due to Legg-Calve-Perthes, RA, or SLE. It is Painless in the beginning, then pain is worsened by weight bearing, better with rest. PROM (internal rotation) of hip is limited and painful.
Avascular necrosis of the femoral head
Test: X-ray, MRI***
Tx: Surgery, NSAIDS
Most common mass in the popliteal fossa, located between the tendons of the medial head of the gastrocnemius and the semimembranosus muscles. They are posterior to the medial femoral condyle. Usually due to arthritis of the knee or cartilage tear that causes fluid distention of the gastrocnemio-semimembranosus bursa.
Baker’s Cyst
Test: US, X-ray, MRI
Tx: aspiration, elevate/rest, surgery
Softening, erosion of articular cartilage, mostly along the medial aspect of the patella seen in young females. Knee pain worse with going upstairs and squatting. PE is palpable for crepitus without swelling. Pain with compression of patella with knee ROM or resisted knee extension.
Chondromalacia patella
Tests:
- Patellar-femoral grinding test and bounce home test
- X-ray, MRI
Tx: NSAIDs, PT
This condition has instant pain, swelling and inflammation. Knee feels locked, when shaken it will click and unlock. Pain with squatting and twisting. Tender on palpation of the knee medially or laterally.
Meniscal and ligament disorders (medial tear is more common)
Test:
- MRI, athroscopy, McMurray test - Menisucus
- Lachman, AP drawer test, Apley, medial and lateral collateral ACL/PCL tear
Tx: NSAIDs
Softening, erosion of articular cartilage, mostly along the medial aspect of the patella seen in young females. Knee pain worse with going upstairs and squatting. PE is palpable for crepitus without swelling. Pain with compression of patella with knee ROM or resisted knee extension.
Chondromalacia patella
Tests:
- Patellar-femoral grinding test
- X-ray, MRI
Tx: NSAIDs, PT
Knee pain: Rapid swelling, intense knee pain, and difficulty with any knee flexion. Inability to extend leg without pain is often recurrent, and self-reducing.
Patellofemoral disorders
MRI > CT > X-ray
Patellar apprehension test
Tx: NSAIDS, acetominophen, PT
shin splints
Medial tibial stress syndrome
Painful bursa over medial side of 1st metatarsal, head, pronation of grat tow, valgus displacement of the great to overriding 2nd tow.
Bunion (Halluc valgus)
X-ray
Tx: proper foot wear & surgery
This condition is common in runners and dancers. Stiffness after rest and intense pain in the morning upon walking that subsides with more activities. Worse at the end of the day with prolonged standing. Swelling and tenderness over sole. Greatest at medical calcaneal tubercle and 1-2 cm distal along plnatar fascia.Pain with tow dorsiflection.
Plantar fascitis
X-ray r/o fracture
bone spit detct
RICE
achielles tendon, plantar fascia streitching, us therapy
NSAIDS steroids
“Pain is greater than injury”
Stage 1 (Acute)
- Pain: intense burning or aching pain that is disproportionate to injury
- Sensitive to touch/cold
- Edema and altered temperature
Stage 2 (Dystrophic)
- Hypersensitivity to affected area
- Osteoporosis, hair loss, increasing edema
- Excessive sweating
Stage 3 (atrophic)
- Paroxysmal spread of pain
- Thin, shiny skin, thickened fascia with contractures
- Demineralization of bone
Complex regional pain syndrome
Test: clinical, bone scan, X-rays, MRI
Tx: PT, NSAIDs, topical capsaicin
CT disorder with widespread MSK pain, tender points that is chronic in nature (>3 months). More women.
Signs and Symptoms
• Diffuse, widespread aching, stiffness and reproducible tender points
• Fatigue with unrefreshed sleep, easy fatigability
• Difficulty falling asleep, frequent waking
• Patients say joints are swollen however physical exam shows normal appearance
• Neurologic symptoms of hyperalgesia, paresthesias
• Associated with irritable bowel or bladder syndrome, migraines, tension headaches, restless legs
syndrome, obesity, depression, and anxiety
Fibromyalgia
Test: TSH, ESR, CBC, sleep study
DO not run ANA or RF unless suspicion
Tx:
- exercise, acupunture, massage, stretch good posture
- NSAIDS, amitriptyline, gabapentin
This is an inherited MSK condition.
symptoms occur by 3
weakness and wasting of pelvic muscles causing waddling gait. Child must place hands on knees for help standing up. Hpertrophy of the calf muscles and wasting thigh muscles. Low intellecural skill, cardiac weakness
Muscular dystrophy (Duchenne & Becker’s)
Investigations • Serum creatine kinase (CK) is elevated at birth • Muscle biopsy • DNA testing through Western blot • Electromyography
Becker’s more serious - death in 4th decade due to Resp. failure
Bilateral back and leg pain with neurologic claudication. Normal back flexion, but difficulty with back extension. Positive SLR, no pain with valsalva.
Spinal stenosis
CT/MRI
gold standard = CT myelogram
Tx: PT, decompression surgery
This condition has benign tumors composed of mature hyaline cartilage that affect young people, 10-20 years old. This condition is incidentally discovered by X-ray
Chondromas
X-ray = stippled or popcorn calcifications
This condition has benign tumors composed of mature hyaline cartilage that affect young people, 10-20 years old. This condition is incidentally discovered by X-ray
Chondromas
X-ray = stippled or popcorn calcifications
This is the most common benign bone tumors that occurs in 2nd and 3rd decade Located adjacent to growth plates and are affected by growth factors and hormones. Located on the metaphysics of long bone. Osteochondroma stops growing once the bones ar mature. Usually seen in X-ray incidentally.
osteochondromas
X-ray is sufficient to daignose, biopsy
This condition is benign bone tumor that occur in the shade of long bones. Femur, tibia, and humerus typical. More man. 10-20’s
Deep, aching, intense pain with varying intensity that is typically localized to the are. Pain is worse at night and diminishes in the morning. Pain is alleviated by aspirin
osteoma
X-ray
CT - cicumscrized annuar lesion
Tx: NSAID for night pain, surcail
This condition has pain and abnormal sensation in the forefoot. There’s a painful mass between heads of third and fourth metatarsal bones. Numbness in the toes adjacent to the mass with episodes of pain. Narrow shoes worsen symptoms
Morton’s neuroma
Test
- Morton’s forefoot squeeze test
- MRI (specificity 100%, sensitivity 87%)
- X-ray is normal
Tx: PT & ice
Stippled or popcorn calcifications on x-ray
Chondromas
Highly malignant bone tumor that metastases to the lung
30’s
previous radiation tx
femur > prox tibia > prox humerus
Palpable hard mass with bone pain and inflammation over tumor, more often near joint. destructive lesion of metaphysis
Osteosarcoma
biopdy
x-ray
elevated serum Alkaline posphatase
Tx: complete rescrtion with chemo
prognosis : 75% 5 yr survival rate
Malignant tumor of cartilgr, can arise secondary to wnchondroma
over ag 40,
processing bone pain in arm, leg, spine
hard palpable tumor
Chondrosarcoma
• X-ray, chondrosarcomas are usually large (> 5 cm)
- MRI is the investigation of choice, helps delineate the extent of soft-tissue involvement
• CT may be useful for detecting subtle calcifications in the matrix to help diagnose
cartilaginous tumors.
- Biopsy
Tx: chemo, radiation, surgery
Most common between 5-20 years of age
• Bone tumor thought to be derived from mesenchymal stem cells of the bone marrow
• Metastases frequent without treatment
Clinical Features
- Pain, palpable mass, erythema
• Systemic symptoms of fever and weight loss are indicative of metastatic disease
Ewings sarcoma
Investigations
- Blood tests show anemia, increased WBC, ESR, and lactate dehydrogenase
- X-ray show moth-eaten appearance and ‘onion-like skinning’ of the periosteal bone
- MRI is the gold standard that can help determine extent of disease
• CT scanning is helpful in delineating any extraosseous extent of the tumor
Tx: chemo, radiation, surgery
Prognosis: 70%, worse if there is distant metastases
