Ortho/Rheum Flashcards
Pediatric Septic Arthritis
Pathogenesis
- Age less than 3 months is staph aureus, GBS, gram neg bacilli
- Age 3 months and up is staph aureus, group A strep
Clinical
- Acute onset joint pain, swelling, limited motion
- refusal to bear weight
- fever over 38.5C (101.3)
Dx
- elevated WBC, ESR, CRP
- BCx
- Joint aspiration (synovial WBC above 50,000)
- Effusion on US/MR
Tx
- joint drainage and debridement
- IV Antibiotics
Large joints (think knee and hip most)
Signs of septic arthritis in neonate or infant
Can be more subtle. Look for irritability and poor feeding. Aversion to being held. Fever may be absent.
On exam, hip may be flexed, abducted and externally rotated to relieve pressure on inflamed joint capsule.
Pseudoparalysis (lack of movement) and swelling of affected joint may be present.
Developmental dysplasia of the hip
Abnormally developed, mechanically unstable hip joint.
Breech presentation and female (plus family history and excessive tight swaddling) are risk factors.
Exam shows positive barlow and ortolani tests with hip dislocation, limited hip abduction and asymmetric gluteal/inguinal folds. US would not show effusion.
From abnormal acetabular development. Shallow hip socket. May feel clicking.
Children with DDH may initially be asymmetric until they are weight bearing. Due to posterior positioning of the femoral head, adolescents and young adults may have a leg-length discrepancy and gait abnormalities such as toe walking on the affected side or a Trendelenburg gait. Premature joint damage and may see activity related pain in front hip and groin
Leg-Calve-Perthes Disease
Idiopathic avascular necrosis of the hip. Children 3-12 years. Insidious onset hip pain and limp. Deformity of femoral head on XR and MR. Inflammatory markers not elevated.
Transient synovitis
Can present with hip effusion usually in kids age 3-8 following viral illness. Patients typically appear well with normal or mildly elevated inflammatory markers
Approach to patient with low back pain
Acute, uncomplicated low back pain (no apparent neuro deficit). Nonspecific exam (paraspinal tenderness, reduced lumbar lordosis, aching pain on SLR - NOT shooting, burning, radiating pain on SLR). These all suggest benign lumbosacral strain.
Can manage most patients under 50 without diagnostic testing. Maintain normal, moderate activity. Avoid bedrest. Heat, massage may be used. If meds, use NSAIDs. If pain persists, muscle relaxants can be added (cyclobenzaprine, tizanidine). Opioids are not more effective than NSAIDs.
MRI is reserved for patients with significant neuro compromise (cauda equina, severe/progressive radiculopathy) or suspected epidural abscess (fever, IVDU)
XR of L spine for suspicion of mets or compression fracture (midline tenderness, postmenopausal woman)
Hereditary hemochromatosis
Skin - hyperpigmentation
MSK - arthralgia, arthropathy, chondrocalcinosis
GI - Elevated hepatic enzymes with hepatomegaly (early), cirrhosis (later), and higher risk of HCC
Endo - DM, secondary hypogonadism, hypothyroidism
Cardiac - restrictive or dilated cardiomyopathy and conduction abnormalities
Infection - increased susceptibiltity to listeria, vibrio and yersinia
Look for polyarticular arthopathy associated with hepatomegaly and family history of diabetes
Women present later due to menstrual iron loss
Joint aspiration can identify CPPD crystals in half of cases (rhomboid, positive birefringence)
Treatment is serial phlebotomy to reduce iron stores. Joints do not improve.
initial eval of HH
Iron studies. Increased Fe, ferritin, and transferrin saturation
Can confirm dx with genetic testing for hemochromatosis associated mutations
Kawasaki Disease
You need more than 3 of the 5 diagnosic criteria to officially diagnose it. This is usually in a child 5 or younger with fever for 5 days.
- rash (inguinal folds, perineum, trunk)
- nonexudative conjunctivitis (often bilateral)
- mucositis (red lips, tongue, oral mucosa)
- cervical LAD. More than 1 LN, at least 1.5cm
- extremity erythema/edema
KD symptoms often do not manifest at the same time so if you see a child with at least 5 days of fever and only 3 or fewer criteria met, get CRP and ESR with daily follow up. Do not wait to order shit even though a million viruses can do this.
It’s a febrile vasculitis of unknown etiology
Failure to treat early can lead to coronary artery aneurysms, esp after day 10.
Tx is aspirin plus IVIG
increased incidence in east asians
All kids diagnosed should get a baseline echo with follow up studies at 2 and 6 weeks after treatment as well, even if initial study is normal.
Note that IVIG contains pooled antibodies that interfere with body’s normal immune response to live vaccines. Therefore, patients should defer live vaccines for 11 months after receiving IVIG
Age 4 vaccines typically have live vaccines (second dose of MMR)
Postmenopausal osteoporosis
Diagnosis
- Osteopenia is Tscore between -1 and -2.5
- Osteoporosis is below -2.5 or confirmed osteoporotic fracture
Initial eval - serum chem, CBC, serum 25-hydroxyD
Lifestyle
- avoid smoking and excessive alcohol
- regular weight bearing exercise
- total intake (diet and supplement) of at least 1200mg Ca and 800 IU of D per day
Pharm tx
- indicated for osteoporosis or high risk osteopenai (10 year hip fracture risk of 3% or combined major fracture of 20%)
- first line is oral bisphosphonates (risks are jaw osteonecrosis and pill esophagitis)
FRAX is for calculaitng
Criteria for diagnosis of giant cell arteritis
- Age at least 50 (greatest risk factor)
- new onset localized headache with fever and visual disturbances
- ESR above 50
- tenderness or decreased pulse of the temporal artery
- tempory artery biopsy showing necrotizing arteritis with mainly mononuclear cells
Need 3 out of 5. That is 94% sensitive and 91% specific.
If suspected, send for expedited biopsy and start on high dose glucocorticoids while evaluation is in progress
Note that GCA often accompanies PMR
Aldolase and creatine kinase
markers of myocyte injury and are use to rule out myopathies such as polymyositis
bone density screening
Begin at age 65 in women without risk factors. Postmenopausal women with risk factors (body weight less than 58kg, chronic steroid use, smoking, pancreatic insufficiency in cystif fibrosis, malabsorptive issues and parental history of hip fracutre or personal history of low impact fracture) start earlier.
Whenever a woman is placed on chronic steroid therapy (even if they’re 40), supplement with calcium and vitamin D
Indications for imaging in low back pain
XR
- osteoprosis/compression fracture
- suspected malignancy (get XR and ESR then follow with MR)
- ankylosing spondylitis (insidious onset, nocturnal pain, better with movement)
MR
- sensory/motor deficits
- cauda equina syndrome (urine retention, saddle anesthesia)
- suspected epidural abscess/infection (fever, IVDU, concurrent infection, hemodialysis)
- lumbosacral radiculopathy over a month
- known malignancy
Radionuclide bone scan or CT
- indications for, but patient not able to have MRI
Red flags of back pain
- Constiutional symptoms (fever, weight loss)
- Age over 50
- IVDU, immune suppression, or recent bacterial infection
- Nocturnal pain
- history of malignancy
Ankylosing Spondylitis
Diagnosis relies on these criteria
- presence of low back pain and stiffness for more than a 3 month duration that improves with exercise or activity
- limitation of the range of motion of the lumbar spine
- limitation of the chest expansion relative to the normal values
Reduced forward flexion on Schober testing. A diagnosis cannot be made unless there is evidence of sacroiliitis which is the earliest change that is seen on XR.
So when a patient has features of AS, a plain XR is next step. Can also see erosion of ischial tuberosity and iliac crest. Squaring of vertebral bodies.
If strongly suspected clinically but XR is negative, further imaging like MR or CT can be used to find a diagnosis.
HLA-B27 is not specific. If it’s negative though you can rule it out.
Monitor disease progression with XR and ESR (acute phase reactants)
Aerobic exercise helps.
Normal lifespan.
Extra-articular manifestations of AS
Acute anterior uveitis (acute unilateral eye pain, blurry vision, photophobia - sometimes initial presentation of AS), aortic regurgitation, apical pulmonary fibrosis, IGA nephropathy, restrictive lung disease are most important
Atlanto-axial subluxation causing spinal cord compression, secondary amyloid presenting as nephrotic syndrome, cauda equina, ilea/colonic mucosal ulcerations, increased risk of varicocele, mitral prolapse, cataracts
Scoliosis
Thoracic or lumbar prominence is seen on forward bend test. Exclude limb length discrepancy by placing block under the shorter leg. If the prominence corrects then it was limb length issue. If not, scoliosis. XR confirms the diagnosis.
Management is determined by risk of progression. This depends on skeletal maturity and degree of curvature.
Once skeletal maturity is reached, treatment is generally not needed for mild/moderate (Cobb less than 40) scoliosis.
Monitor for disease progression in mild scoliosis with XR in skeletally immature patient.
Refer to surgery for severe scoliosis (over 40 degrees) at high risk for progression and complications (chronic back pain, neuro symptoms, pulmonary compromise)
Paget Disease of Bone (indications for treatment)
It’s a osteoclast abnormality leading to increased bone turnover and abnormal remodeling.
Bony pain with thickened cortex/sclerotic lesions on XR with bone scan showing increased uptake due to increased remodeling.
Treatment is indicated when patients have sympomatic disease (intolerable pain, involvement of weight bearing bones, neuro involvement, hypercalcemia, hypercalciuria, CHF)
Treatment is with bisphosphonates or calcitonin if cannot tolerate.
Clinical features of Paget
Signs/symptoms
- Most asymptomatic
- Skull - deformity with enlargement, hearing loss, dizziness
- Spine/pelvis - bone pain, spinal stenosis, nerve compression
- Long bones - bowing deformities with increased fracture risk
- bone tumors - osteosarcoma, giant cell tumors
Labs/imaging
- elevated serum and bone specific ALP
- bone markers may or may not be elevated with active disease (PINP - procollagen 1 N terminal propeptide, CTx C terminal peptide of type 1 collagen , NTx N terminal peptide of type 1 collogen, and urinary hydroxyproline)
- calcium and phosphorus are usually normal, may be elevated with fracture or immobilization
- plain XR shows osteolytic or mixed lytic/sclerotic lesions
Diagnosis
- combination of radiologic and elevated ALP
- No additional bone turnover tests or imaging is needed
- bone scan is more sensitive than XR and is helpful to document the extent and locations of skeletal invovlement
Treatment is bisphosphonates
Dermatomyositis
Muscle weakness
- proximal, symmetric
- weakness in upper extremity is same as lower
Skin
- Gottron sign/papules
- heliotrope rash
Extramuscular findings
- ILD
- Dysphagia
- myocarditis
diagnosis
- increased CPK, aldolase, LDH
- Anti M2, anti Jo1
- diagnostic uncertainty - EMG/MRI, biopsy of skin/muscle
Management
- high dose steroids plus glucocorticoid sparing agent
- screening for malignancy
Initial test of choice is ANA (positive in 80%)
CXR to screen for ILD if asymptomatic. If symptomatic or abnormal XR, chest CT
malaise, weight loss and low grade fever in patient with DM is highly suggestive of malignancy. Screen.
scaphoid fracture
FOOSH with tenderness at snuff box. It’s the most common carpal fracture. If suspected, next step is XR preferrably in full pronation and ulnar deviation to better expose the scaphoid. Initial XRs can be negative. If negative but suspected, further imaging such as MR should be performed or place in splint and repeat XR in 7-14 days.
- surgery if fracture displaced by at least 1mm, tilt of lunate, osteonecrosis, or scapholunate dissocation.
- most common complications from mismanagement are avascular necrosis and non-union (higher risk at proximal or waist)
Colles fracture - also FOOSH. It’s a dorsally angulated or displaced distal radial fracture
Hamate fracture - FOOSH with pain/swelling of hypothenar eminence and ulnar aspect of wrist. Hook contains ulnar artery and nerve.
Reactive arthritis
Preceding infection
- GI - salmonella, Shigella, yersinia, campy, cdif
- GU - chlamydia
MSK
- asymmetric, peripheral oligoarthritis
- enthesitis
- dactylitis
extra-articular
- ocular - uveitis, conjunctivitis
- genital - urethritis, cervicitis, prostatitis
- derm - keratoderma blennorrhagicum, circinate balantitis
- oral ulcers
management
- ABx (chlamydia, non self limiting GI infection)
- NSAIDs (even if also giving antibiotics)
- NSAID failure/contraindication
- intra-articular steroids, then
- systemic steroids, then
- disease modifying antirheum agents
Look for inflammatory (elevated synovial WBC) yet sterile (culture neg) arthritis in a patient with recent history of infection. Usually develops 1-4 weeks after infection so repeat chlamydia testing even if no symptoms of actual chlamydia (NAAT).
How do you handle amputated body parts?
wrap in gauze, moisten with saline and place it in a sealed sterile plastic bag. Then place bag in ice mixed with saline/water. Don’t cool below 1-10C.
Acute gout and HTN
Acute gout is usually treated with oral NSAID (indomethacin) but colchicine is a good alternative in patients with contraindications to NSAIDs (PUD). Serum uric acid levels can be normal in acute gout so don’t use to guide acute management.
HTN must be managed cautiously in gout. Most diuretics (HCTZ, loops) decrease fractional excretion of urate and should be avoided when possible
ARBs (losartan) has mild uricosuric effect and is effective as first line treatment for HTN in patients with gout. ACE/ARB are also preferred in patients with CKD (regardless of baseline Cr) as they improve proteinuria and slow progression
Aspirin should be avoided in patients with gout if possible (lowers urate excretion)
Nursemaid’s elbow
Radial head subluxation
Mechanism - axial traction on forearm with elbow extended (child pulled, lifted, or swung by arm)
Physical findings - arm held extended and pronated. no swelling, deformity or focal tenderness
Tx - hyperpronation of forearm OR supination of forearm and flexion of elbow
you don’t need XRs
Meniscus and knee ligament injuries
Menisucs
- acute or subacute symptoms
- small effusion
- locking sensation with extension
- inability to fully extend
- joint line tenderness
- positive mcmurray test
Cruciates
- acute pop with rapid onset large effusion/hemarthrosis
- ACL - anterior drawer and lachman tests
- PCL - posterior drawer
Collaterals
- effusion uncommon
- MCL - instability with lateral movement, valgus laxity (blow to lateral knee/valgus stress). Most patients managed nonoperatively
- LCL - instability with medial movement, varius laxity
shoulder pain
Rotator cuff impingement or tendinopathy
- pain with abduction, external rotation
- subacromial tenderness
- normal ROM with positive impingemnet tests (Neer, Hawkins)
Rotator cuff tear
- similar to tendinopathy
- weakness with abduction and external rotation
- age over 40
Adhesive capsulitis (joint capsule contracture)
- decreased passive and active ROM (manage with ROM exercises)
- stiffness with/witout pain
Biceps tendinopathy or rupture
- anterior shoulder pain
- pain with lifting, carrying or overhead reaching
- weakness (less common)
Glenohumeral OA
- uncommon and usually caused by trauma
- gradual onset of anterior or deep shoulder pain
- decreased active and passive abduction and external rotation
Fibromyalgia vs polymyositis vs PMR
Fibro
- young to middle age women
- chronic widespread pain
- fatigue, impaired concentration
- tenderness at trigger points
- Diagnosis after 3 months of symptoms with widespread pain index or symptom severity score
- Normal labs
Poly
- prox muscle weakness (trouble climbing up stairs)
- Pain mild/absent
- elevated muscle enzymes (CK, aldolase, AST)
- Autoantibodies (ANA, Jo1)
- Biopsy with endomysial infiltrate and patchy necrosis
- pulm complications like ILD, interstitial pneumonia, drug induced pneumonitis, etc. Get PFTs to separate ILD from respiratory muscle weakness
PMR
- age over 50
- systemic signs and symptoms
- stiffness more than pain in shoulders, hip girdle, neck
- associated with giant cell arteritis
- elevated ESR, CRP
- rapid improvement with steroids
Common features of sarcoid
Epi - young adults, african americans
clinical
- constitutional symptoms
- cough, SOB, CP
- extrapulmonary
- skin
- anterior/posterior uveitis
- lofgren syndrome(fever, erythema nodosum and bilateral hilar LAD)
- parotid gland swelling
imaging
- bilateral hilar LAD
- pulm reticular infiltrates
labs
- hypercalcemia/hypercalciuria
- elevated serum ACE
path
- biopsy with noncasseating granulomas that stain negative for fungi and acid fast bacili
Most cases resolve over time and do not recur. Symptoms may be treatd with 12-24months of steroids
