Ortho/Rheum Flashcards
Anterior shoulder dislocation at risk for….?
Must rule out axillary nerve injury
Anterior = axillary
Which xray view to order if trying to tell anterior vs posterior?
Y-view
Normal: Y-shape lines up w/ humeral head (superimposed perfectly)
Anterior: Can’t see humeral head, can only see top of Y
Posterior: Y is kind of sideways, humeral head is lateral & not lined up
PE maneuvers to tell rotator cuff injuries
Impingement tests:
Hawkins: + = pain w/ internal rotation
Drop arm: + = cannot lift shoulder above 90
Neer: + = thumb down, pain during forward flexion
Any positive = subscapular nerve or supraspinatous impingement
Supraspinatous strength tests
“empty the can” test
Thumb down (empty can) w/ arm abducted, examiner puts downward pressure on arm - weakness (moreso than pain = positive test
AC joint dislocation - type 1-3 & management
Type 1: AC & CC sprain
Type 2: AC tear, CC sprain
Type 3; AC tear, CC tear
Brief sling immobilization, ice analgesia, ortho follow up
Type III may need surgery
Proximal humeral fractures –> must check for?
Check for brachial plexus injury and axillary nerve injuries
Do this via checking deltoid sensation
Humeral shaft fractures prone to? Type of splint?
Radial nerve injury, manifesting as “wrist drop”
Sugar tong over elbow to shoulder, ortho f/up within 24-48 hours
Complications of clavicular fracture
PTX
CC Ligament disruption
Brachial plexus injury
Mid-distal 1/3 - arm sling 4-6 weeks
Proximal 1/3 - ortho consult
Adhesive capsulitis - MC in? CP? Tx?
MC in 40-60s
CP: Should pain/stiffness that lasts 18-24 mo - dec ROM esp w/ external rotation
PE: Resistance to passive ROM
Tx: Rehab ROM therapy, NSAIDs
Thoracic outlet syndrome - MC in? CP? PE? Dx: Tx?
Idiopathic compression of the brachial plexus - as they exit the narrowed space between shoulder girdle and the 1st rib
MC in women 20-50 YO
CP:
Nerve compression = pain & paresthesias on the ULNAR side of the hand
Vascular compression = erythema, edema, or discoloration of the arm - esp w/ abduction of the arm
PE:
+ ADSON’s = loss of radial pulse with head rotated to the affected side
Dx: MRI
Tx: PT, avoid strenuous activity
Median nerve controls which muscles in hand/forearm?
Anterior compartment
Does all of forearm except FCU, FDP
Only does medium LOAF in hand
Ulnar nerve controls which muscles in hand/forearm?
Anterior compartment
Ulnar is lazy in the forearm - only does FCU, FDP, does ALL hand muscles except LOAF (want a medium-sized LOAF)
Supracondylar fx - MC In? Complications?
MC in KIDS
Adults = radial head fx more common
Anterior/posterior fat pad sign - kids = supracondylar fx, adults = radial head fx or displaced anterior humoral line (should go straight thru capitulum
Complications: Median nerve & brachial artery injury. Can also have radial nerve injury
Suppurative flexor tenosynovitis
Infection of hte flexor tendon synovial sheath of the finger - caused by staph aureus - often 2/2 penetrating trauma
Mnemonic FLEXor:
Flexion - finger held in flexion
Length of tendon sheath is tender
Enlarged finger
Xtension of the finger = pain (passive extension = pain)
Tx: I&D w/ irrigation of the tendon sheath & debridement & IV ABX
Olecranon fracture - MOI, CP, complications, Tx
MOI: Direct blow (fall on flexed elbow)
CP: Pain, swelling, inability to extend elbow - triceps may rupture or pull proximal fragment superiorly, causing distraction
Complications: ULNAR nerve dysfunction
Tx: reduction - non-displaced = splint at 90 deg flexion, displaced = ORIF
**All are considered intra-articular, all need reduction!!!
“Nightstick” fracture - MOI, tx
Ulnar shaft fracture - think if you put your hand up to stop a night stick from hitting you - you’d fracture the unla - normally from perpendicular blow
Nondisplaced distal 1/3 = short arm cast
Nondisplaced mid-proximal = long arm cast
Displaced = ORIF
Monteggia fracture vs galeazzi fracture
MonteggiA vs galeazZi - MUGGER - MUGR
Monteggia = ulnar fracture that’s proximal w/ anterior radial head dislocation - can cause radial nerve injury (wrist drop)
Galleazzi = Mid-distal radial fracture w/ DRUJ (distal radio-ulnar joint dislocation)
BOTH are UNSTABLE - need ORIF
Nursemaid’s elbow tx
Pronation & flexion of forearm at elbow
Lateral epicondylitis
AKA “tennis elbow”
CP: LATERAL elbow pain, especially w/ forearm pronation & wrist extension
Tx: RICE, NSAIDs, PT
Medial epicondylitis
AKA “golfer’s elbow”
Pronator teres & flexor carpi radialis are inflammed due to repetitive stress - pain worse w/ pulling activities - wrist FLEXION against resistance
Tx: RICE, NSAIDs etc
Complications of elbow dislocation
Must rule out brachial artery & median, ulnar, and radial nerve injury (all cross elbow joint obvi)
Cubital tunnel syndrome
AKA ulnar neuropathy - cubital tunnel is tunnel where ulnar nerve crosses elbow
+tinel’s sign at the elbow
Scaphoid fracture - MOI, CP, Dx, Tx
FOOSH on extended wrist
CP: Snuffbox tenderness (schapoid is by thumb)
Dx: Xray, may not bee seen for 2 weeks - if snuffbox tenderness, tx as fracture b/c nonunion of scaphoid = AVN
Tx: Thumb spica
Colles fracture - MOI, CP, Dx, Tx
MOI: Fall on extended wrist, MC in post-menoopausal women
CP: C-D - colles = dorsal angulation
Dx: Dinner fork deformity. Need lateral view to distinguish colles from smith
Tx: Sugar tong splint/cast if stable
Unstable: > 20 deg angulation, intra-articular, > 1 cm shortening or comminuted –> needs ORIF
Smith fracture - MOI, CP, Dx, Tx
MOI: Fall on flexed wrist, MC in post-menoopausal women
CP: S-V - smith = volar angulation
Dx: Need lateral view to distinguish colles from smith
Tx: Sugar tong splint/cast if stable
Lunate dislocation
Lunate doesn’t articulate w/ capitate OR the radius = emergent consult
Dx: AP view - “piece of pie” sign and “spilled teacup” sign - gone loony & had pie & tea for breakfast
Tx: Unstable - needs ORIF
Lunate fracture
Most serious carpal fractures b/c occupies 2/3 of racial articular surface - radiographs are often negative
AVN of lunate - keinbock’s disease
Mallet finger - MOI, CP, TX
MOI: Extensor tendon avulsion after sudden blow to tip of an extended finger = forced flexion
CP: Inability to extend DIP (finger is flexed at DIP)
Comp: commonly a/w avulsion fracture of the distal phalanx
Tx: Splint the DIP in extension x 6 weeks
Boutonniere deformity
MOI: Sharp force against tip of partially extended digit = hyperflexion at the PIP joint with hyperextension at the DIP - disruption of extension tendon at the base of the middle phalanx
CP: Finger flexed at PIP and extended at DIP
Tx: Splint PIP in extension x 4-6 weeks with hand surgeon follow up
Gamekeeper’s thumb
AKA skiier’s thumb (acute) - gamekeeper’s is chronic hyper-abduction injury
Sprain of UCL of the thumb = instability of the MCP joint (UCL usu provides resistance to valgus stress
CP: Thumb far away from other digits esp w/ valgus stress + tenderness on MCP, weak pinch strength
Tx: Thumb spica & referral to hand surgeon
A/w avulsion fractures - complete rupture = surgical repair
Boxer’s fracture
Fx at neck of 5th metacarpal (from punching a wall too)
Tx: Ulnar gutter aplint w/ joints in at least 60 deg flexion. IF > 25-30 deg angulation, must reduce first. Can’t reduce or remains > 40 deg angulation, ORIF
**Note: always check for bite wounds!!
Bennet fracture
Intraarticular fracture thru base of 1st metacarpal bone w/ large distal fragment
Rolando =?
Communited bennett fracture
Salter Harris fx = ? types?
Growth plate (epiphyseal plate) fractures
S = straight across A = above L = lower T = through (or two - above & below) ER = Rammed or cRush- growth plate compression injury = WORST TYPE
Dequervain tx
+ Finklestein’s (fists)
Tx: Thumb spica x 3 weeks, nsaids, steroid injection PT
Dupuytren contracture
Contractures of the palmar fascia due to nodules/cores = fixed flexion deformity at MCP
Tx: PT, steroid injection etc
Hip dislocation
MC after TRAUMA (MVA, fall from height). 90% posterior - TRUE ORTHO EMERGENCY
Comp: AVN, sciatic nerv injury
CP: Hip pain w/ leg shortened & internally rotated, adducted at knee with slight flexion
Hip fx
CP: Hip pain w/ shortened, EXTERNALLY rotated, abducted
Comp: Femoral neck fracture - highest a/w AVN of head. HIGH risk of DVT & PE
FracturE = Externally rotated Dislocat-I-on = Internally rotated
Tx: ORIF
What is legg-calve-perthes disease? Common in? CP? Dx? Tx?
Idiopathic avascular necrosis of hte femoarl head in children due to ischemia of the femoral epiphysis
Pt: 4-10 YO BOY
CP: Painless limping x weeks - worsens w/ activity, esp at end of the day
Dx: Hip radiographs: + Crescent sign - femoral head looks like a crescent moon instead of a half moon
Tx: Observation - self-limiting w/ revascularization within 2 years, activity restriction (NWB) initially w/ ortho follow up then protected WB during early stages until reossification is complete, physical therapy
LCP RARE in AA, whereas SCFE = most common in AA Males during growth spurt - also age range is different. Also LCP = PAINLESS limping. SCFE = PAINFUL
Slipped capital femoral epiphysis
Femoral head slips posteriorly & inferiorly at the growth plate
Common pt - 12 YO AA BOY - in growth spurt it slips off
CP - hip OR KNEE pain w/ limp, EXternal rotation (scfE = EXternal)
Tx: NWB w/ crutches –> ORIF
Segond fracture
+ Avulsion of the lateral tibial condyle with varus stress to the knee - if present, ACL is most likely torn
ACL laxity - LACHMAN’s = most sensitive
ACL tears a/w MCL and medial meniscal tears as well
PCL injury - MOI, CP, PE, tx
MOI: MC a/w “dashboard” injuries - direct anterior blow to proximal tibia w/ knee flexed or direct blow injury or fall on a flexed knee
CP: anterior bruising, large effusion
PE: posterior drawer, pivot shift test
Tx: Surgery (dec degenerative changes)
Meniscal tears - MOI, CP, PE, Tx
MOI: Mc degenerative - squatting, twisting, compression or traume w/ femur rotation on tibia
CP: Locking, popping, giving way, down stairs
PE: Mcmurray’s sign, apley grind
Tx: NSAIDs, partial WB until ortho f/u, arthroscopy
Why is a true knee dislocation a limb-threatening emergency?
in 1/3 of knee dislocations (tivial-femoral) dislocations = POPLITEAL ARTERY INJURY
Tx: immediate ortho consult, prompt reduction w/ longitudinal traction
Femoral condyle fx - MOI, CP, comp, Tx
MOI: Axial loading (fall from heights)
CP: Pain, swelling, inability to bare weight
Comp: Peroneal nerve injuries = dec sensation in first web space & for FOOT DROP, popliteal artery injury
Tibeal plateau fracture - MOI, comp, CP, Tx
MOI: Axial loading or rotation or direct trauma = MC on lateral side in children in MVA
Comp: Post-degenerative arthritis
CP: Check for peroneal nerve injuries = FOOT DROP!!! - may need CT/MRI - can be hard to see on radiograph
Tx: Non-displaced = conservative (NWB, cast 6-8 weeks), displaced - ORIF
Osgood schlatter disease
Osteochronditis of the patellar tendon @ tibial tuberosity from OVERUSE
MCC of chronic knee pain in young, active adults
MC in males 10-15 YO, athletes w/ growth spurts
CP: Pain w/ running jumping (activity-related) knee pain & swelling - tenderness to anterior tibial tubercle
Dx: Xray shows prominence or heterotopic ossification at the tibial tuberosity
Tx: RICE, NSAIDs, quadriceps stretching
CP baker’s cyst
Baker’s = synovial fluid effision
CP: Popliteal mass, knee effusion, clicking, locking of knee - ruptured cyst resembles DVT
Tx: conservative, IC, assisted WB, NSAIDs, intra-articular corticosteroid injection
Patellofemoral syndrome (chondromalacia) = what? MC in? Dx? Tx?
MOI: Idiopathic softening of hte patellar articular cartilage
MC IN RUNNERS
CP: Anterior knee pain behind or around patella, worsened w/ knee hyper-flexion (prolonged sitting)
Dx: + APPREHENSION test
Tx: NSAIDs, rest & rehab
Iliotibial band syndrome
MOI: Inflammation of the iliotibial band bursa 2/2 lack of flexibility ofthe ITB bursa
CP: Lateral knee pain during onset of running then resolves
Dx: + OBER test - pain or resistance to adduction, positive lateral epicondyle tenderness
Tx: NSAIDs, PT corticosteroid injections
Ottawa ankle rules
Ankle films only: Pain along lateral or medial malleolus
Foot films as well: Navicular (midfoot) pain, 5th metatarsal pain (jones fracture)
Which kind of ankle fractures require ORIF?
Unstable ones - disruption of syndesmosis - occurs w/ bimamleolar fractures & Weber C fx (fibular fx above ankle mortisse)
Anyone w/ distal MEDIAL MALLEOLAR ankle fracture needs what?
Proximal view of fibula to rule out a maisonneuve fracture = spiral proximal fibular fracture
Occurs most when have distal talovibular syndesmosis & interosseous membrane rupture as results of distal medial malleolar fracture and or detltoid ligment rupture
Stress fracture in foot
AKA “march” fracture - from overuse - in military personel from “marching”
March = 3rd month = fx of 3rd metatarsal
Dx - 50% of xrays negative
Tx - Rest, splint or post-op shoe
Charcot’s joint (diabetic foot)
AKA Diabetic foot
Joint damage & destruction as a result of peripheral neuropathy from DM
CP: Pain swelling, alteration of the shape of the foot, ulcer or skin changes
The hallmark deformity associated with this condition is midfoot collapse, described as a “rocker-bottom” foot
Dx: Xray = obliteration of joint space, scattered chunks of bone in fibrous tissue +/- inc ESR
Tx: Rest, NWB, surgical
Palpable mass on head of 3rd metatarsal + lancinating pain especially with ambulation =?
Morton’s neuroma
Morton’s & march involve 3rd - March = fx, morton = neuroma ball
Jones fx ?
Transverse fracture through DIAPHYSIS of 5th metatarsal
Tx: NWB . 6-8wk - follow with repeat radiographs as it is often complicated by non-union, malunion
Frequently requires ORIF/pinning!!!
Missing this = serious!
Pseudojones fracture
Transverse AVULSION fx at base of 5th metatarsal - much more common & not as serious as actual jones (tansverse fx thru diaphysis of 5th metatarsal)
Tx: walking cast 2-3 weeks - ORIF if displaced
Lisfranc injury
Disruption between articulation of medial cuneiform bone & 2nd metatarsal, frequently a/w fx at base of 2nd metatarsal (+fleck’s sign)
L4
L5
S1
Sensory, motor fxn
L4, L5, S1 –> ALP = sensory
L4 = Anterior thigh (keeps wrapping around to medial ankle) L5 = Lateral thigh S1 = Plantar surface of foot
Motor function -
L2-L4: Four = door - dorsiflexion (can’t walk on heels)
L5: five = sky - big toe extension
S1 - one = can’t outrun someone quietly (can’t walk on toes)
Spinal stenosis
Narrowing of spinal cord (>60 YO)
CP: Back pain w/ paresthesias in one or both extremities - pain BETTER with flexion - aka with sitting and walking up hill
WORSE w/ extension - prolonged walking & standing
Tx: Steroid injection, decompression laminectomy
Lumbosacral sprain/strain
Acute strain or tear of paraspinal muscles, especially after twisting/lifting injuries
CP: back muscle spasms, loss of lordotic curve, decrease ROM, NO NEUROLOGIC CHANGES
Tx: Brief bed rest - in moderate pain, NSAIDs, analgesics + muscle relaxers
Spinal compression fracture
Occur in hcildren from jumping or falling from hight
LUMBAR from elderly w/ osteoporosis or pathologic fx in malignancy
CP: Point tenderness at the level of compression
Tx: Ortho & neuro consult
Scoliosis
Lateral curvature of spine > 10 deg
MC in girls w/ + family hx, begins at 8-10 years of age
**Note: If a/w cafe au lait spots then 2/2 neurofibromatosis type I
Dx: ADAMs forward bending test = most sensitive
Tx: Observation in most cases - bracing if 20-40 deg, surgery if > 40 deg
Spondylolysis
A pars defect or spondylolysis is a stress fracture of the bones of the lower spine
LYSIS = fracture of bone 2/2 overuse - repetitive hyperextension trauma (football player,
MC cause of back pain in children & adolescents
MC at L5/S1 (b/c that’s junction of mobile & non-mobile spine)
Often the first step to spondylolithesis
Spondylolisthesis
Forward slipping of a vertebrae on another
Sounds like lisp & = a SLIP of vertebrae on one another
MC in adolescents 10-15 YO
**Can cause bowel/bladder dysfunction
Osteomyelitis - MC in ? Etio?
Acute MC in CHILDREN (<20 YO)
Chronic MC in adults 2/2 open injury/bone surrounding soft tissue (trauma/recent surgery
Etio = S. aureus = MC organism for both
MC organism for osteomyelitis in sickle cell disease?
Salmonella
Tx osteomyelitis
4-6 wks antibiotics
At least 2 weeks IV
Earliest indicator of compartment syndrome? When does it happen?
Earliest indicator = Pain on passive stretching - tense extremities - firm/wooden feeling - also pain out of proportion to injury!!!
Occurs MC after long bone fractures
Dx: Inc compartment pressure, inc CK/myoglobin
Tx: Fasciotomy
Osteosarcoma - MC age, MC mets, CP
80% occur < 20 YO, then 2nd peak at 50-60 YO
MC mets to LUNGS
CP - bone pain, joint swelling
Dx - xray shows hair on end, sunray/burst appears of soft tissue masses
Tx: Limb-sparing resection, radical resection and chemotherapy
Ewing sarcoma - MC age, MC sites
MC in MALE CHILDREN
Ewing sounds like Edwin - little boy
MC sites: FEMUR, PEVIS
Dx: Xray - periostal rxn = ONION skin appearance on radiographs
Tx: Chemo, surgery & radiation
MC benign bone tumor? Seen in?
Osteochondroma
MC in YOUNG MALES (like ewing)
Dx: Pedunculated, grows away from growth plate & involves medullary tissue
Tx: Observation
May turn into chondrosarcoma
Resection if pelvis is involved (MC site of malignant transformation)
Involves medullary tissue
- *ends in SARCOMA = CA
- *ends in CHONDROMA = benign
Paget’s disease - patho
Patho:
- Disordered bone remodeling phase-
- Inc osteoclast resorption
- Abnl trabecular bone formation (= larger, weaker, less compact bones, more vascular, more prone to fx)
- Lytic phase - inc osteoclast activity –> sclerotic phase (inc osteoblast act)
CP, dx paget’s
MC = ASX
Bone pain = MC sx (2/2 stress fx or warmth)
Dx:
Labs = INC ALK PHOS, normal Ca/phos
Xray: Skull = cotton wool appearance, Lytic phase = “candle flame” or “blade of grass” appearance on long bone, sclerotic phase = coarsened trabeculae framework
Tx: Bisphosphonates (inhibits osetoclasts), Calcitonin
SLE = what? happens in who?
AI dz - common in YOUNG AFRICAN or CARIBBEAN WOMEN - starts in 20s-30s
Can manifest in any organ system - lots of PE/clinical findings so a CLINICAL dx AND supporting immunologic criteria
SLE = three letters = type III HSN rxn
First presentation of SLE
YOUNG AA WOMAN W/ GASH
Glomerulonephritis…why would young woman have kidney dz?? (hematuria, HTN, edema, nocturia, brown urine, oliguria) –> (Ab against dsDNA)
ANEMIA –> hemolytic anemia, also neutropenia, lymphopenia, leukopenia, thrombocytopenia (ab against blood components)
Arthritis, rash (like most rheum d/o)
Serositis - pericarditis, pleurisy
Hematologic d/o - THROMBOSIS (anti-phospholipid ab)
Also - Neuropsych manifestations = seizures, psychosis etc
Established SLE - common complications / flares
Flares 2/2 stress, infection, medications
Hematologic changes Neuropsychiatric lupus (seizures, psychosis, personality changes etc) Premature CV disease
What antibody to check if suspect lupus?
ANA
If negative, low prob of SLE
Labs to order if someone w/ + ANA suspecting of lupus
If positive - check CBC w/ diff (anemia, thrombocytopenia), UA (GN = hematuria, RBC casts)
Antibodies: Anti-ds DNA, Anti-smith, anti-cardiolipin ab
Smith, double Stranded = SLE –> SSS
Young AA female w/ ARF?
LUPUS until proven otherwise
GET BIOPSY if you suspect lupus - will tell you severity of damage
Tx of lupus flare
CORTICOSTEROIDS
Other tx are tailored based on the organ system involved - mainly steroids but also NSAIDs for serositis & MSKL
NO OPIOIDS!!! ANTI-INFLAM ONLY!!!r
Maintenance SLE
Hydroxychloroquine - reduces frequency of flares & improves survival
CREST syndrome
Local scleroderma
Calcinosis cutis Raynauds*** Esophageal motility d/o Sclerodactyly (claw hand) Telangiectasias
MC type = 80% –> spares the trunk
Ab present in CREST vs diffuse scleroderma?
CREST = Anti-centromere
Systemic/diffuse = Anti-SCL-70 (anti-scleroderma 70)
Sjogren’s syndrome Ab
Anti-ss-A (Ro)
Anti-ss-B (La)
Jo = Ro & La
Sjogren’s = ?
AI d/o that attacks exocrine glands
Can have alone (primary) or with other AI rheum d/o (secondary) –> like SLE,
CP sjogrens
EVERYTHING IS DRY
MOUTH (xerostomia), EYES (–> kearatoconjunctivitis sicca)
Also parotid gland enlargement
Genome abnormality a/w Sjogren’s
HLS-DR52 (DR = DRY)
Dx Sjogren’s
+ AB (Anti-SS-A/B (Ro/La))
+ RF
+ Schrimer test
Tx sjogren’s
Cholinergic drugs - pilocarpine, cevimeline
PMR
Idiopathic inflammatory condition causing pain and stiffness of the proximal joints (shoulder, hip, neck)
Think of POLY-MYALGIA - many muscle aches/pains (NOT WEAKNESS), also P = PROXIMAL = girdles (combing hair, putting on a coat, getting out of chair)
Strong a/w giant cell arteritis
Dx: clinical, inc ESR, anemia
Tx: Low dose corticosteroids (10-20 mg/day), NSAIDs, methotrexate
Polymyositis & dermatomyositis = what? CP? Dx? Tx?
Idiopathic inflammatory muscle disease of proximal limbs, neck & pharynx
Polymyo = PROximal, PROgressive & = WEAKNESS - PMR = proximal as well but = PAIN w/o weakness
CP: Progressive symmetrical PROXIMAL muscle WEAKNESS (usually painless)
Dysphagia, skin rash, polyarthralgias, muscle atrophy
Dermato = D’s = DARK - DARK BLUE/PRUPLE upper eyelid discoloration (pathognomonic), an DARK scaly eruptions on knuckles (Gottron’s papules), poikilo-DERMA - photosensitivie erythematous rash on face, neck, anterior chest “V-sign”
Dx:
Inc muscle enzymes (inc aldolase = inc CK), anti-Jo Ab, anti-SRP ab (PM), anti-Mi-2 Ab (DM)
Muscle biopsy - endomysial involvement (PM) and perifascicular/perivascular involvement (DM)
Tx: HIGH-dose corticosteroids, methotrexate, IVIG
PMR vs polymiositits
BOTH are idiopathic inflammatory conditions involving the PROximal muscles (pelvic girdle, shoulders, neck)
This means the question may mention difficulty getting out of chair, combing hair, putting on a coat for EITHER but…
PMR = PAIN Polymyositis = WEAKNESS
Both have increased ESR (duh) but..
PM also has several specific auto-ab you can order (inc aldolase = inc CK), anti-Jo Ab, anti-SRP ab (PM), anti-Mi-2 Ab (DM)
Rhabdo - labs, dx, tx
Etio - immobility (hip fx), overexertion (marathon), seizures
Labs:
CK>20,000, Hyper-K+ (2/2 intracellular release from damaged tissues –> GET EKG)
UA: DARK urine that is + for heme & NEGATIVE for blood = MYOGLOBINURIA = RHABDO
Tx:
IVF (4-6L/day)
Bicarb (alkalinize the urine)
Comp: AKI –> ATN
Juvenile idiopathic arthritis
Get most of info from the name = autoimmune mono or polyarthritis in children < 16 YO (often resolves by puberty) - 3 types
- Oligoarticular - < 5 joints involved, MC large joints, ASSOCIATED WITH IRIDOCYCLITIS (ANT UVEITIS)
- Systemic - daily arthritis, diurnal HIGH FEVER, salmon-pink migratory rash - no iridocyclitis but other systemic issues - hepatitis, serositis (pericardial & pleural effusions)
- Polyarticular - MC in small joints, > 5, again inc risk of iridocyclitis,
Dx: clinical, will have inc ESR, CRP, + ANA seen in oligo, + RF seen in 15% –> denotes worse prognosis
Tx: NSAIDs, corticosteroids, methotreate, frequent eye exams to detect iridocyclitis
OA - RF, CP, Xray, Tx
RF: OBESITY, mc in weight-baring joints (knees, hips)
CP: Joint stiffness - worsens after effort, worsens throughout the day & with changes in weather
PE: Bony enlargement of joints WITHOUT inflammatory signs = HARD BONY JOINTS
OA exclusively effects DIP - RA effects MCP, PIP- otherwise OA = mostly LARGE joints, RA = SMALL joints
Dx: xray = joint space loss - ASYMMETRIC NARROWING (RA = syemmetric) + osteophytes (RA no osteophytes, has osteopenia)
Tx: APAP»_space; NSAID, steroid injections
RA - who? CP, Dx, Tx
T-cell mediated chronic inflammatory disease = granulation tissue that erodes into cartilage & bone = persistent symmetric polyarthritis
CP:
Prodrome - fever, fatigue, weight loss, anorexia
Small joint stiffness that starts > 60 minutes after morning movement, improves later in the day (OA = worse in day) –> joints feel BOGGY - swollen, tender, erythematous etc - OA = HARD
MC joints = MCP, wrist –> OA spares these & affects DIP most - also OA has NO systemic sx
Dx:
+RF - if negative, then probs not RA (will be positive if have RA) –> But not specific
Most specific for RA = Anti-cyclic citrullinated peptide antibodies (anti-CCP)
Xray = narrowed joint space, subluxation, ulnar deviation
Tx: Prompt initiation of DMARDs - METHOTREXATE = early initiation = dec permanent joint damage
Large vessel vasculitidies
Giant cell arteritis: MC > 50 YO (avg 79 YO) New, localized HA > 50 Jaw claudication Vision loss/disturbances Sx of PMR (present in 50%)
Dx: temporal artery bx (gold)
Tx: STEROIDS - don’t delay steroids for bx - if vision loss/disturbances then admit for IV GC!
ESR VERY HIGH (only vasculitis that causes ESR > 100) - blindnes = MC complication
Takayasu's arteritis = BIG ARTERIES MC < 50 (avg 40 YO) ASIANS, FEMALE Phase 1 - systemically ill Phase 2 = BIG vessel gets blocked: Coronary = MI, carotid = CVA, Renal = HTN, pulmonary artery = hemoptysis, SOB), LE = limb claudication!
Physical exam = arterial bruits, diminished pulses, subclavian steal syndrome (asx bp measurements), cool extremities
Dx: HIGH ESR/CRP, angiography needed to confirm dx
Tx: IV steroids
50 YO scandanavian woman w/
New onset headache
Pain with chewing gum
Diplopia
Giant cell arteritis!!!
OCULAR INVOLVEMENT = ADMIT AND GIVE IV STEROIDS IMMEDIATELY
How can GCA cause permanent blindness?
Anterior ishcemic optic neuritis
Central retinal artery occlusion
Ischemic retinopathy
CVA
Medium vessel vasculitidies
Polyarteritis nodosa
Kawasaki disease
Kawasaki disease - CP
Kawas-A-k-I COMBER
Cervical LAD > 1.5 cm
Oral mm changes (strawberry tongue)
My Heart! = coronary aa. aneurysms (IVIG prevents)
B/l bulbar conjunctival inj
Erythema palm/soles, edema hand/feet, dEsquamination
Rash - polymorphous
I = IVIG
HIGH DOSE aspirin (30-50 mg/kg divided QID until fever gone)
No CV involvement = good prognosis - check EKG baseline the repeat at 2 & 6 weeks to make sure okay!
Three small vessel vasculitidies = ?
Two are associated w/ ANCA (aka are ANCA-positive) = ?
And one = immune-complex mediated vasculitis = ?
ANCA-associated: MPA/GPA
- Microscopic polyangitis (P-ANCA+)
- Granulomatosis with polyangitis (C-ANCA+)
Immune-complex mediated small vessel vasculitis = HSP
Note: “-angitis” = inflam of SMALL vessels! “ AKA microstopic polyANGITIS, granulomatosis with polyAGITIS…
while “-arteritis” = inflammation of BIG vessels AKA giant cell ARTERITIS, Takayasu ARTERITIS - sounds like artery
Microscopic polyangitis
Microscopic polyangitis = PPP-CCC
PPP: P-ANCA positive Pulmonary hemorrhage --> interstitial lung fibrosis Peeing blood - glomerulonephritis Purpura
CCC:
CXR: Fluffy infiltrates, ILD
Corticosteroids
Cyclophosphamide
FOR SIX MONTHS
Note: **NO necrotic or granulomatous inflammation as seen with GPA
Microscopic polyangitis
Microscopic polyangitis = PPP-CCC
PPP: P-ANCA positive Pulmonary hemorrhage --> interstitial lung fibrosis Peeing blood - glomerulonephritis Palpable purpura
CCC:
CXR: Fluffy infiltrates, ILD
Corticosteroids
Cyclophosphamide
FOR SIX MONTHS
Note: **NO necrotic or granulomatous inflammation as seen with GPA
Granulomatosis with polyangitis
GPA -
Grandma, K-LU-NOse (kayla knows) = Granulomatosis = Kidney, lungs nose = classic triad
Nose- ENT/upper respiratory tract sx: nasal congestion, saddle nose deformity, REFRACTORY SINUSITIS
Note: Upper airways not involved in MPA - just think gran always stuffy
Lungs - LRT sx: cough, dyspnea, hemoptysis (pulm hemorrhage), wheezing, pulm infiltrates, CAVITATION (granuloma)
Kidney - glomerulonephritis - rapidly progressing = hematuria
Dx: C-ANCA + (G looks like a C)
Tx: Corticosteroids & Cyclophosphamide
Both MPA & GPA = glomerulonephritis & pulmonary hemorrhage (hemoptysis) –> BUT MPA DOES NOT HAVE GRANULOMAS = NO CAVITATION - both ANCA positive - differentiate w/ P-ANCA (MPA) vs C-ANCA (GPA)
For BOTH the tx = corticosteroids & cyclophosphamide
Which vasculitidies cause glomerulonephritis
GPA
MPA
Goodpasteure’s - AGN & pulm hemorrhage (IgG ab attack alveoli and basement membrane of kidney)
Good = glomerulonephritis Pastures = pulmonary hemorrhage
Tell apart from GPA/MPA b/c it is ANCA negative & kidney Bx = linear IgG deposits
HSP
Mnemonic = HSP-A (affects IgA) & Cardinal sx = HSPA = 4 letters = 4 YEAR OLD MALE , MC AFTER URI!!!
Hematuria
Synovial - arthritis, arthralgias
Palpable purpura (lower ext)
Dx: Clinical
Tx: Supportive - NSAIDs, bed rest, hydration +/- GC
Goodpasteure’s disease
Goodpasteure’s - AGN & pulm hemorrhage (IgG ab attack alveoli and basement membrane of kidney)
Good = glomerulonephritis Pastures = pulmonary hemorrhage
Tell apart from GPA/MPA b/c it is ANCA negative & kidney Bx = linear IgG deposits (G=G)
Management = GP
GC & cyclophosphamide
Plasmapheresis
Seronegative spondyloarthropathies includes?
Psoriatic arthritis
Ankylosing spondylitis
Reactive arthritis
= Group of inflammatory arthritis conditions that are “seronegative” aka they’re RF and ANA negative
**It is more genetics - have HLA-B27 positive & have inc ESR!
**Causes arthritis, uveitis, and sacroiliitis
**MC in MALES < 40 YO!!!
Psoriatic arthritis
Occurs in 15-20% of pt w/ psoriasis. Usually develops YEARS after psoriasis dx. MC around 40-50 YO.
CP:
Asymmetric arthritis - can mimic RA except affects the DIP, causes dactylitis (sausage digits),
UVEITIS, SACROILIITIS
SIGNS OF PSORIASIS - pitting of nails, skin plaques etc
Dx: + PENCIL IN CUP DEFORMITY, narrowed joint space
Tx: NSAIDs, then methotrexate then TNF inhibitors (CAGIE-RAT)
Ankylosing spondylitis
One of the seronegative spondyloarthropathies (RF neg, ANA neg, HLA-B27+)
Causes chronic low back pain - morning stiffness w/ dec ROM - stiffness decreases w/ exercise & activity
+ sacroiliitis, uveitis
Dx: Inc ESR, HLA B27+, x=ray = BAMBOO spine - squaring/ bridging of vertebrae, loss of normal curvature
Tx: NSAIDs, rest, PT = first line. Then TNF-alpha, then steroids
Reactive arthritis
One of the seronegative spondyloarthropathies (RF neg, ANA neg, HLA-B27+)
AI response to an infection in another part of the body –> MC = 2/2 CHLAMYDIA INFECTION = CAN’T SEE (UVEITIS), PEE (URETHRITIS), CLIMB TREE (REACTIVE ARTHRITIS) OR “BE” =HLA B27 POSITIVE
Dx: HLA-B27 + (80%), WBC 10-20k), inc ESR
Arthrocentesis fluid: Inc WBC (1,000-8,000) but fluid is ASEPTIC (no bacteria)
Tx: NSAIDs = first line - if no response, methotrexate
