Ortho/Rheum 2

Question 1

In treating SLE:

1. How to treat acute flares?
2. What additional medication addresses mainly skin, joint and serositis manifestations?
3. What meds to use if Lupus nephritis?
4. or Cerebritis or other solid organ involvement.

Answer 1

1. Prednisone
2. Hydroxychloroquine (antimalarial)
3. Steroid + Mycophenilate Mofetil
4. Steroids + Cyclophosphamide or MTX.

Question 2

How does steroids effect bones?

What should you supplement all individuals on chronic steroids?

Any surveillance tests required for chronic steroids?

Answer 2

Causes decreased absorption of calcium in gut and increased calcium excretion in urine AND promotes increased bone respiration by osteoclasts.

Vit D and Calcium supplementation (shown to decrease rates of bone loss).

Yearly DEXA.

Question 3

At what age should you screen a woman without risk factors with a DEXA?

Post menopausal woman can be screened earlier if they have one of what 5 Risk factors?

Answer 3

65 years old.

Can get DEXA < 65 yo if 1 or more Osteoreperosis RFs:

• Low weight <127 lbs
• Smoking
• Chronic Steroid use
• Malabsorptive disease (pancreatic insuff)
• Personal or parental history of low impact bone fracture

Question 4

What is the mainstay treatment for Rheumatoid Arthritis?

In severe refractory disease what medications can be added? What test do you need to order before starting treatment?

Answer 4

NSAIDS and MTX

Anti-Cytokine drugs (Etanercept or Infliximab). Can replace MTX or added to it.

Need PPD before starting Anti-Cytokine drugs.

Question 5

What is the pathophysiology of Paget’s Disease?

It is often asymptomatic, and is diagnosed incidentally on imaging, but can present with with what symptoms?

Imaging of bone shows?

DX and TRX?

Answer 5

Increased Bone turnover.

Symptoms:

• Bone pain
• Fractures
• Hearing loss (40%)
• Bow legs

Imaging = osteolytic or mixed lytic and sclerotic lesions.

DX = Alk Phos level (elevated) and Calcium (normal) and Nucleotide bone scan (identify other areas involved). Bone scan better than XR because can localize other areas of involvement.

TRX = Bisphosphonates

Question 6

What is first line treatment for RAYNAUD’S PHENOMENON (vasoconstriction in fingers due to cold)?

Answer 6

Dihydropyridine Calcium channel blockers:

Nifedipine OR Amlodipine.

Question 7

Person falls with outstretched hands and has pain over anatomical snuff box (doral radial wrist) …What bone did they fracture?

Answer 7

Scaphoid bone.

Question 8

You suspect a Scaphoid bone fracture but XR is negative. What is next step?

How do you treat a Scaphoid bone fracture?

Answer 8

(XR often misses Scaphoid fracture)

Either: immediate MRI/CT or Splint and repeat XR in 7-14 days.

TRX = IF non-displaced => thumb spica cast + serial X ray q2 weeks to monitor healing.
IF Displaced =>orthopedic surgeon.

Question 9

untimely treatment of Scaphoid fracture can lead to what two complications?

Answer 9

• nonunion

- Avascular necrosis

Question 10

Tibial stress fractures are commonly seen in what groups doing what?

How do Tibial stress fractures present?

How do you DX?

TRX?

Answer 10

Athletes who suddenly increase their activity level.

Presentation = initially as shin splints (medial lower leg ache), later progressing to tibial tenderness on palpation once fracture occurs.

DX = XR (but 50% will show nothing in the first 2-3 weeks of symptoms). IF negative can empirically treat based on clinical finding/history.

TRX= decreased weight bearing (crutches 1-2 weeks) and gradual return to exercise (2-3 months)

Question 11

How does one typically get a patellar ligament tear?

What are the 3 hallmark physical exam findings?

Answer 11

Sudden strong quadriceps contraction, with the feet firmly planted and knees slightly flexed (landing from a jump).

1. Inability to extend knee
2. Cant raise leg up against gravity
3. Superior displacement of patella

Question 12

Pain in the knee upon Valgus stressing (bending towards medial side) suggests what?

Pain in the knee upon Varus stress (bending knee away from medial side) suggest what?

Answer 12

VAlgus stress = medial collateral ligament damage.

Varus stress = Lateral collateral ligament damage.

Question 13

Gout present with acute onset pain, warmth, erythema, swelling and decreased range of motion of joint. What two joints are mainly affected.

Arthrocentesis shows?

Answer 13

Big toe and knees.

Joint fluid = inflammatory with neutrophils + monosodium urate crystals (diagnostic); negatively birefringent needle shaped crystals.

Question 14

How do you diagnose gout?

Answer 14

Can be clinical, but arthrocentesis with monosodium urate crystals is definitive.

(Uric Acid levels are NOT useful in diagnosing acute gout bc can be suppressed in flare)

Question 15

How do you treat Acute Gouty attack?

What is preventative treatment of Gout?

What is the trx of choice for acute gout in ESRD?

Answer 15

Acute TRX:

1. NSAID (Indomethacin) = first line.
2. Colchicine (IF NSAID C/I)
3. Steroids (systemic (if multiple joints) or intra-articular (1 joint)) if NSAID or Colchicine C/I (renal/hepatic disease).

Preventative TRX:

1. Allopurinol (don’t start during acute attack)
2. Probenecid
3. Weight loss and Etoh avoidance

IF ESRD:
- Steroids