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*PANCE by subspecialty > Ortho/Rheum > Flashcards

Ortho/Rheum Flashcards

1
Q

Anterior shoulder dislocation at risk for….?

A

Must rule out axillary nerve injury

Anterior = axillary

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2
Q

Which xray view to order if trying to tell anterior vs posterior?

A

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

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3
Q

PE maneuvers to tell rotator cuff injuries

A

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

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4
Q

Supraspinatous strength tests

A

“empty the can” test

Thumb down (empty can) w/ arm abducted, examiner puts downward pressure on arm - weakness (moreso than pain = positive test

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5
Q

AC joint dislocation - type 1-3 & management

A

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

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6
Q

Proximal humeral fractures –> must check for?

A

Check for brachial plexus injury and axillary nerve injuries

Do this via checking deltoid sensation

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7
Q

Humeral shaft fractures prone to? Type of splint?

A

Radial nerve injury, manifesting as “wrist drop”

Sugar tong over elbow to shoulder, ortho f/up within 24-48 hours

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8
Q

Complications of clavicular fracture

A

PTX
CC Ligament disruption
Brachial plexus injury

Mid-distal 1/3 - arm sling 4-6 weeks
Proximal 1/3 - ortho consult

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9
Q

Adhesive capsulitis - MC in? CP? Tx?

A

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

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10
Q

Thoracic outlet syndrome - MC in? CP? PE? Dx: Tx?

A

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

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11
Q

Median nerve controls which muscles in hand/forearm?

A

Anterior compartment

Does all of forearm except FCU, FDP
Only does medium LOAF in hand

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12
Q

Ulnar nerve controls which muscles in hand/forearm?

A

Anterior compartment

Ulnar is lazy in the forearm - only does FCU, FDP, does ALL hand muscles except LOAF (want a medium-sized LOAF)

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13
Q

Supracondylar fx - MC In? Complications?

A

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

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14
Q

Suppurative flexor tenosynovitis

A

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

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15
Q

Olecranon fracture - MOI, CP, complications, Tx

A

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!!!

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16
Q

“Nightstick” fracture - MOI, tx

A

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

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17
Q

Monteggia fracture vs galeazzi fracture

A

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

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18
Q

Nursemaid’s elbow tx

A

Pronation & flexion of forearm at elbow

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19
Q

Lateral epicondylitis

A

AKA “tennis elbow”

CP: LATERAL elbow pain, especially w/ forearm pronation & wrist extension

Tx: RICE, NSAIDs, PT

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20
Q

Medial epicondylitis

A

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

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21
Q

Complications of elbow dislocation

A

Must rule out brachial artery & median, ulnar, and radial nerve injury (all cross elbow joint obvi)

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22
Q

Cubital tunnel syndrome

A

AKA ulnar neuropathy - cubital tunnel is tunnel where ulnar nerve crosses elbow

+tinel’s sign at the elbow

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23
Q

Scaphoid fracture - MOI, CP, Dx, Tx

A

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

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24
Q

Colles fracture - MOI, CP, Dx, Tx

A

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

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25
Q

Smith fracture - MOI, CP, Dx, Tx

A

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

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26
Q

Lunate dislocation

A

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

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27
Q

Lunate fracture

A

Most serious carpal fractures b/c occupies 2/3 of racial articular surface - radiographs are often negative

AVN of lunate - keinbock’s disease

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28
Q

Mallet finger - MOI, CP, TX

A

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

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29
Q

Boutonniere deformity

A

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

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30
Q

Gamekeeper’s thumb

A

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

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31
Q

Boxer’s fracture

A

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!!

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32
Q

Bennet fracture

A

Intraarticular fracture thru base of 1st metacarpal bone w/ large distal fragment

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33
Q

Rolando =?

A

Communited bennett fracture

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34
Q

Salter Harris fx = ? types?

A

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
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35
Q

Dequervain tx

A

+ Finklestein’s (fists)

Tx: Thumb spica x 3 weeks, nsaids, steroid injection PT

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36
Q

Dupuytren contracture

A

Contractures of the palmar fascia due to nodules/cores = fixed flexion deformity at MCP

Tx: PT, steroid injection etc

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37
Q

Hip dislocation

A

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

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38
Q

Hip fx

A

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

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39
Q

What is legg-calve-perthes disease? Common in? CP? Dx? Tx?

A

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

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40
Q

Slipped capital femoral epiphysis

A

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

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41
Q

Segond fracture

A

+ 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

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42
Q

PCL injury - MOI, CP, PE, tx

A

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)

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43
Q

Meniscal tears - MOI, CP, PE, Tx

A

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

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44
Q

Why is a true knee dislocation a limb-threatening emergency?

A

in 1/3 of knee dislocations (tivial-femoral) dislocations = POPLITEAL ARTERY INJURY

Tx: immediate ortho consult, prompt reduction w/ longitudinal traction

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45
Q

Femoral condyle fx - MOI, CP, comp, Tx

A

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

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46
Q

Tibeal plateau fracture - MOI, comp, CP, Tx

A

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

47
Q

Osgood schlatter disease

A

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

48
Q

CP baker’s cyst

A

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

49
Q

Patellofemoral syndrome (chondromalacia) = what? MC in? Dx? Tx?

A

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

50
Q

Iliotibial band syndrome

A

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

51
Q

Ottawa ankle rules

A

Ankle films only: Pain along lateral or medial malleolus

Foot films as well: Navicular (midfoot) pain, 5th metatarsal pain (jones fracture)

52
Q

Which kind of ankle fractures require ORIF?

A

Unstable ones - disruption of syndesmosis - occurs w/ bimamleolar fractures & Weber C fx (fibular fx above ankle mortisse)

53
Q

Anyone w/ distal MEDIAL MALLEOLAR ankle fracture needs what?

A

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

54
Q

Stress fracture in foot

A

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

55
Q

Charcot’s joint (diabetic foot)

A

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

56
Q

Palpable mass on head of 3rd metatarsal + lancinating pain especially with ambulation =?

A

Morton’s neuroma

Morton’s & march involve 3rd - March = fx, morton = neuroma ball

57
Q

Jones fx ?

A

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!

58
Q

Pseudojones fracture

A

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

59
Q

Lisfranc injury

A

Disruption between articulation of medial cuneiform bone & 2nd metatarsal, frequently a/w fx at base of 2nd metatarsal (+fleck’s sign)

60
Q

L4
L5
S1

Sensory, motor fxn

A

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)

61
Q

Spinal stenosis

A

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

62
Q

Lumbosacral sprain/strain

A

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

63
Q

Spinal compression fracture

A

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

64
Q

Scoliosis

A

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

65
Q

Spondylolysis

A

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

66
Q

Spondylolisthesis

A

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

67
Q

Osteomyelitis - MC in ? Etio?

A

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

68
Q

MC organism for osteomyelitis in sickle cell disease?

A

Salmonella

69
Q

Tx osteomyelitis

A

4-6 wks antibiotics

At least 2 weeks IV

70
Q

Earliest indicator of compartment syndrome? When does it happen?

A

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

71
Q

Osteosarcoma - MC age, MC mets, CP

A

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

72
Q

Ewing sarcoma - MC age, MC sites

A

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

73
Q

MC benign bone tumor? Seen in?

A

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
74
Q

Paget’s disease - patho

A

Patho:

  1. Disordered bone remodeling phase-
    • Inc osteoclast resorption
    • Abnl trabecular bone formation (= larger, weaker, less compact bones, more vascular, more prone to fx)
  2. Lytic phase - inc osteoclast activity –> sclerotic phase (inc osteoblast act)
75
Q

CP, dx paget’s

A

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

76
Q

SLE = what? happens in who?

A

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

77
Q

First presentation of SLE

A

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

78
Q

Established SLE - common complications / flares

A

Flares 2/2 stress, infection, medications

Hematologic changes
Neuropsychiatric lupus (seizures, psychosis, personality changes etc) 
Premature CV disease
79
Q

What antibody to check if suspect lupus?

A

ANA

If negative, low prob of SLE

80
Q

Labs to order if someone w/ + ANA suspecting of lupus

A

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

81
Q

Young AA female w/ ARF?

A

LUPUS until proven otherwise

GET BIOPSY if you suspect lupus - will tell you severity of damage

82
Q

Tx of lupus flare

A

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

83
Q

Maintenance SLE

A

Hydroxychloroquine - reduces frequency of flares & improves survival

84
Q

CREST syndrome

A

Local scleroderma

Calcinosis cutis
Raynauds***
Esophageal motility d/o
Sclerodactyly (claw hand) 
Telangiectasias

MC type = 80% –> spares the trunk

85
Q

Ab present in CREST vs diffuse scleroderma?

A

CREST = Anti-centromere

Systemic/diffuse = Anti-SCL-70 (anti-scleroderma 70)

86
Q

Sjogren’s syndrome Ab

A

Anti-ss-A (Ro)
Anti-ss-B (La)

Jo = Ro & La

87
Q

Sjogren’s = ?

A

AI d/o that attacks exocrine glands

Can have alone (primary) or with other AI rheum d/o (secondary) –> like SLE,

88
Q

CP sjogrens

A

EVERYTHING IS DRY

MOUTH (xerostomia), EYES (–> kearatoconjunctivitis sicca)

Also parotid gland enlargement

89
Q

Genome abnormality a/w Sjogren’s

A

HLS-DR52 (DR = DRY)

90
Q

Dx Sjogren’s

A

+ AB (Anti-SS-A/B (Ro/La))

+ RF

+ Schrimer test

91
Q

Tx sjogren’s

A

Cholinergic drugs - pilocarpine, cevimeline

92
Q

PMR

A

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

93
Q

Polymyositis & dermatomyositis = what? CP? Dx? Tx?

A

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

94
Q

PMR vs polymiositits

A

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)

95
Q

Rhabdo - labs, dx, tx

A

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

96
Q

Juvenile idiopathic arthritis

A

Get most of info from the name = autoimmune mono or polyarthritis in children < 16 YO (often resolves by puberty) - 3 types

  1. Oligoarticular - < 5 joints involved, MC large joints, ASSOCIATED WITH IRIDOCYCLITIS (ANT UVEITIS)
  2. Systemic - daily arthritis, diurnal HIGH FEVER, salmon-pink migratory rash - no iridocyclitis but other systemic issues - hepatitis, serositis (pericardial & pleural effusions)
  3. 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

97
Q

OA - RF, CP, Xray, Tx

A

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&raquo_space; NSAID, steroid injections

98
Q

RA - who? CP, Dx, Tx

A

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

99
Q

Large vessel vasculitidies

A 
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

100
Q

50 YO scandanavian woman w/

New onset headache
Pain with chewing gum
Diplopia

A

Giant cell arteritis!!!

OCULAR INVOLVEMENT = ADMIT AND GIVE IV STEROIDS IMMEDIATELY

101
Q

How can GCA cause permanent blindness?

A

Anterior ishcemic optic neuritis

Central retinal artery occlusion

Ischemic retinopathy

CVA

102
Q

Medium vessel vasculitidies

A

Polyarteritis nodosa

Kawasaki disease

103
Q

Kawasaki disease - CP

A

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!

104
Q

Three small vessel vasculitidies = ?

Two are associated w/ ANCA (aka are ANCA-positive) = ?

And one = immune-complex mediated vasculitis = ?

A

ANCA-associated: MPA/GPA

  1. Microscopic polyangitis (P-ANCA+)
  2. 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

105
Q

Microscopic polyangitis

A

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

106
Q

Microscopic polyangitis

A

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

107
Q

Granulomatosis with polyangitis

A

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

108
Q

Which vasculitidies cause glomerulonephritis

A

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

109
Q

HSP

A

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

110
Q

Goodpasteure’s disease

A

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

111
Q

Seronegative spondyloarthropathies includes?

A

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!!!

112
Q

Psoriatic arthritis

A

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)

113
Q

Ankylosing spondylitis

A

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

114
Q

Reactive arthritis

A

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

*PANCE by subspecialty (22 decks)

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