Ortho/Rheumatology

Question 1

Chostochondritis

Answer 1

• >40yo, mostly F
  
  • Tietze syndrome = <40, M=F, much less common than costochondritis, 1 + joints are swollen, red, and tender
• sxs: ant chest pain (sudden or gradual, localized, may radiate to arms or shoulders, worse with cough, sneeze, etc., brief and darting, persistent dull ache), reproduced with palp.
• dx: radiograph, bone scan, vitD level, bx
• tx: analgesics, antiinflamm, local steroid injections

Question 2

reactive arthritis

Answer 2

• reiter syndrome: most patients dont have classic findings, so term reactive arthritis is used
• classic triad: arthritis, urethritis, ocular inflamm (conjunctivitis or anterior uveitis) - cant see, cant pee, cant climb a tree
• pt can develop reactive arthritis after nongonococcal urethritis or after enterif infxn with SECSY bugs
• HLA-B27 + pts, asymmetric inflamm oligoarth of the lower extremitis preceded by infxous process remote from the site, sterile inflamm process
• sxs: mucocutaneous lesions, constitutional sxs
• dx: synovial fluid analysis
• tx: NSAIDs (first line), if no response sulfasalazine or azathioprine

Question 3

onset, commonl locations, presence of inflamm, radiographic changes, lab findings, and other features of osteoarthritis vs rheumatoid arthritis vs gouty arthritis

Answer 3

• Onset:
  
  • O: insidious
  • R: insidious
  • G: sudden
• locations:
  
  • O: wt bearing jnts (knees, hips, lum/cerv spine)
  • R: hands (PIP, MCP), wrists, ankles, knees
  • G: great toe, ankles, knees, elbows
• inflamm?:
  
  • O: no
  • R: yes
  • G: yes
• radio changes:
  
  • O: narrowed jnt space, osteophytes, subchond sclerosis and cysts
  • R: narrowed jnt space, bony erosion
  • G: punched-out erosions w/ overhanging rim of cortical bone
• lab findings:
  
  • O: none
  • R: high ESR, RF, anemia
  • G: crystals
• other features:
  
  • O: no systemic sxs, bouchard nodes, Heberden nodes
  • R: systemic = extra articular manifestations, ulnar deviation, swan neck and boutonniere
  • G: tophi, nephrolithiasis

Question 4

gout etiology and dx

Answer 4

• inflamm monoarticular arthritis caused by crystalization of monosodium urate in jnts
• precipitants: cold, dehydration, stress, excessive ETOH, starvation
  
  • 90% are men >30yo
• dx: joint aspiration and synovial fluid analysis (needle shaped and neg birefringent urate crystals), gram stain and cx, serum uric acid is NOT helpful, XR (punched out erosions

Question 5

Four stages of gout

Answer 5

• 1. asx hyperuricemia
• 2. acute gouty attacks (peak onset 40-60yo) - initial attack = one jnt of lower extremity, sudden onset exquisite pain, most often first MT joint, pain and redness, swelling, warmth, +/- fever
• 3. intercritical gout - sxatic period after initial attack, attacks become polyarticular and increase in severity
• 4. chronic tophaceous gout (ppl with poorly controlled gout for >10-30ys), tophi (urate crystals surrounded by giant cells in inflammatory rxn, cause deformity and destruction of hard and soft tissue, common locations = extensor surfaces of forearms, elbows, knees, achilles tendon, pinna of external ear

Question 6

tx of gout

Answer 6

• do not tx asx hyperuricemia
• avoid secondary causes of hyperuricemia (meds that increase uric acid, obesity, ETOH, dietary purines
• acute gout: bed rest, NSAIDs (indomethacin), colchicine, steroids if not responding or intolerant to NSAID/colchicine
• prophylaxis: must have 2-3 attacks before initiating prophylactic tx → NSAIDs x 3-6mos, uricosuric drugs (probenecid, sulfinpyrazone), allopurinol (not for acute exacerbations, watch for SJS)

Question 7

rheumatoid arthritis sxs

Answer 7

• F>M 3:1, etiology uncertain (maybe viral, genetic)
• inflammatory polyarthritis (PIP, MCP), and wrists, knees, ankles, elbows, hips
• ulnar deviation of MCP jnts, boutionniere, swan neck
• morning stiffness with improvement later in the day, low grade fever, wt loss, fatigue
• cervical spine involvement at C1-C2
• Skin: thing, bruises easy, subcut rheum nodules
• Lungs: pleural effusions - fluid has low glucose and complement, pulm fibrosis, rheum nodules in lungs
• Heart: rheum nodules, pericarditis, pericard effus.
• Eyes: scleritis, scleromalacia, dry eyes and mucous membranes
• Nervous system: mononeuritic multiplex (infarct of nerve trunk), pt cant move arm or leg
• Felty syndrome: RA, neutropenia, splenomeg; happens late in RA dz process
• Blood: anemia of chronic dz (mild, normocytic, normochromic)
• Vasculitis
• Juvenile RA: begins before 18yo, Still dz

Question 8

Rheumatoid arthritis labs

Answer 8

• Rheumatoid factor
• anticitrullinated peptide/peptide antibodies (ACPA)
• ESR/CRP elevated
• normolytic normochromic anemia
• XR: loss of juxtaarticular bone mass (periarticular osteoporosis) near fingers, narrowing of jnt space, bony erosions, synovial joint fluid analysis

Question 9

rheumatoid arthritis tx

Answer 9

• preventative: exercise, NSAIDs, steroids (low dose)
• primary: DMARDs (initiate early, slow onset 6+ wk)
  
  • first line: methotrexate (best initial DMARD - can cause hepatocellular injury, pulm fibrosis, oral ulcers, bone marrow suppression; monitor LFTs and renal fn, supplement w/ folate)
  • alternatives: leflunomide, hydroxychloroquine (requires biannual eye exam), sulfasalazine, anti-TNF inhib agents (etanercept, infliximab)
• severe: surgery (synovectomy decreased jnt pain, swelling; jnt replacement for severe cases)

Question 10

synovial jnt fluid analysis: normal, noninflammatory, inflammatory, and septic arthritis

Answer 10

Question 11

Systemic lupus erythematosus presentation and dx

Answer 11

• sxs: fatigue, malaise, fever, wt loss, butterfly rash over cheeks and bridge of nose, photosensitivity, discoid lesions, oral and nasopharyngeal ulcers, Raynaud, alopecia
  
  • jnt pain, arthritis (symmetric), peri/endo/myocarditis, hemolytic anemia or reticulocytosis of chronic dz, leukopenia, lymphopenia, thrombocytopenia, proteinuria, azotemia, pyuria, N/V, seizures, psychosis, depression, HA, TIA, CVA, Sjogren syndrome
• dx: +ANA screening, anti-ds DNA (100% specific), anti-Sm Ab, Antiphospholipid ab, anti-ss DNA, antihistone Abs (drug induced lupus), false + w/ syphillis, complement decreased

Question 12

lupus tx

Answer 12

• avoid sun, NSAIDs if less severe, local or systemic corticosteroids, systemic steroids for severe manifestations
• Long-term tx: best = antimalarials (hydroxychloroquine) w/ annual eye exam, cytotoxic agents (cyclophosphamide) for active GN
• monitoring: BUN/Cr (renal dz), blood pressure (HTN)
• Prevalence: women of childbearing age (90%), AA
• prognosis: more severe in children, appears in late childhood or adolescence

Question 13

Osteoporosis etiology and sxs

Answer 13

• systemic skeletal disorder characterized by low bone mass, deterioration of bone tissue, increased fragility, susceptibility to fx
• more women than men
• RF: lifestyle (caffeine, smoking, ETOH, no exercise, low Ca), dec E, eating disorder, genetic (FH, cystic fibrosis, Ehlers-Danlos), endo (hyperPT, hyperT), SLE, lymphoma)
  
  • meds (steroids, chemo, thyroid hormone), vitD def, advanced age (50+, white, F)
• sxs: usually asx; 1+ fx (MC = vertebral body, proximal femur, distal forearm/wrist)

Question 14

osteoporosis dx and tx

Answer 14

• DEXA scan (measures BMD) - dual energy radiograph, Tscore >/= 2.5, dec 1 pnt increases fx risk by 2-3x
• tx indicated for pts with 10y prob of hip fx (3% or higher) or major osteoporosis related fx (>20%)
• tx if BMD = -2.5 with no RF, hx of spine/hip fx, FRAX over 3% or T-score <-1
• tx: bisphosphonates (alendronate, BMD prior and repeated biennially), calcitonin, E, PTH, raloxifene, denusomab
• prophylaxis: ovarian E and postmen E, Ca 1200mg/d, vitD 800-1200u
  
  • counsel: balanced diet, no ETOH, no smoking, exercise, Ca and vitD, reduce risk of falls,
• Health maintenance: recheck BMD 1-2y after starting bisphosphonates

Question 15

Fibromyalgia

Answer 15

• adult women, unkown etiology, somatization not a proven cause
• sxs:stiffness, body aches, fatigue, pain is constant and aching, aggravated b weather, stress, sleep dep, cold temp (worse in morning); better with rest, warmth, mild exercise; sleep disrupted, anxiety and depression = common
• Dx: multiple trigger points (TTP - symmetrical, 18 characteristic locations including occiput, neck shoulder, ribs, elbows, buttocks, knees), widespread pain including axial pain for at least 3 mo, pain in at least 11 of the 18 possible tender pnt sites
• Tx: advise pt to stay active and productive, meds not very effective (SSRI and TCAs, avoid narcotics), CBT, exercise, psychiatric eval

Question 16

ganglion cysts

Answer 16

• benign soft tissue mass
• sxs: soft, nontender, transilluminating mass, usually on dorsum of hand or wrist
• tx: surgical excision (definitive), recommended if cyst causes pain, disruption of fn, or cosmetic distress

Question 17

plantar fasciitis

Answer 17

• common in runnders and overweight pts, caused by microscopic tears in plantar fascia at calcaneal origin
• sxs: pts will complain of pain w/ first few steps in AM and heel pain at night
• signs: pain at calcaneal origin, inflexible achilles tendon
• dx: plain XR normal, but may reveal calcaneal fracture or bone spur, MRI (calcifications of plantar fascia)
• tx: conservative x 6-12mo (physical tx for stretching, heel pads, arch supports, massage area w/ tennis ball), steroid injections used with caution owing to risk of rupture of plantar fascia, surgery for extreme cases

Question 18

overuse syndrome

Answer 18

• result of repetitive stresses and microtrauma outpacing the body’s ability to heal
• ex: Tendonitis, Bursitis, Carpal Tunnel Syndrome, Patellofemoral Pain, IT Band Syndrome, Plantar Fasciitis
• patellofemoral syndrome: major cause of ant knee pain (runners knee), caused by trauma, overuse, or weak quadriceps; gradual onset, worse with prolonged knee flexion; crepitus to palpation, patellar grind test
  
  • dx: XR; tx: PT and strengthening, brace support of knee
• IT band syndrome: MC in distance runners (bursa underlying band becomes irritated); localised TTP over lateral epicondyles
  
  • tx: rest, dec distance running, change shoes, stretching, steroid inxns

Question 19

sprain vs strain

Answer 19

• strain = inj to bone-tendon unit at myotendinous jn or the muscle itself
• sprain = involves collagenous tissue, such as ligaments or tendons (90% ankle injuries result from inversion and plantar flexion

Question 20

• acute low back pain

Answer 20

• minor, self-limiting, usually associated w/ heavy lifting, fall, prolonged uncomfortable postures
• signs: paraspinous muscle spasms
• tx: short duration bed rest, apply ice, heat and massage, NSAIDs during first few days, muscle relaxants (cyclobenzaprine, carisoprodol, metaxalone, and diazepams), wt bearing resumed

Question 21

ankle sprain/strain

Answer 21

• one of the MC sports-related injuries; 85% from inversion inj., mostly involves lateral ligaments (anterior talofibular ligament)
• sxs: hear a “pop”, ecchymosis and tenderness of lateral ankle
• dx: XR to r/o fx, especially if unable to bear wt or TTP over bone (often not required to guide mngmt)
• tx: if able to bear weight (RICE) - compressive wrapping, icing, early mobilization, supervised PT (isometric exercises), once 90% strength, active isotonic as well as isokinetic exercise
  
  • if unable to bear weight - crutches 48-72hrs, brace for support, posterior splint
  • refer to PT

Question 22

Ottawa ankle rules

Answer 22

• X-rays needed if pain in the malleolar zone (anterior crook of the ankle) and 1 or more of the following:
  
  • tenderness over the lateral malleolus
  • tenderness over the medial malleolus
  • inability to bear wt for 4 steps both immediately postinjury and in the ED

Question 23

chronic low back pain

Answer 23

• Nerve root irritation: pain in back, radiates down leg
• musculoskeletal: localized area of tenderness
• sciatica: pain in distribution of sciatic nerve (buttcok, post thight, posterolateral aspect of leg around lat. malleolus to dorsum of foot and entire sole)
• sacroiliac jnt: unilateral low back and buttock pain, worse with standing in one position
• spinal stenosis: pain in elderly, increased with walking, relieved by leaning forward
• dx on all: XR of spine (nontraumatic)
  
  • Red flags: fever, wt loss, morning stiffness, hx of IV or steroid use, trauma, hx of cancer, saddle anesthesia, loss of anal sphincter tone, major motor wkness
  • CT: shows bony stenosis and lateral nerve root entrapment
  • MRI: identifies cord pathology, neral tumors, stenosis, herniated discs, infxns
• tx: short term relative rest w/ support under knees and neck, progressive ambulation as tolerated, fitness program (postural exercises - McKenzie exercises)
  
  • if no improvement x 6wk → bone scan, CT, MRI, or EMG

Question 24

bursitis

Answer 24

• inflam of bursa, caused by trauma or overuse
• common sites: subacromial, subdeltoid, trochanteric, ischial, iliopsoas, olecranon, prepatellar, suprapatellar
• sxs: pain, swelling, tnederness for weeks
• tx: prevent precipitating factors, rest, heat, time, NSAIDs steroid injctions only if no infxn, abx if unclear cause (aspirate)

Question 25

pes anserine bursitis

Answer 25

• pes anserine = gracilis, sartorius, and the semitendinosus, which meet at the medial tibia below the knee jnt and above MCL and medial fem condyle
• sxs: anterior medial knee pain (common in obese women with OA of knee, runners, various overuse syndromes), ant pain below jnt line, focal swelling over the bursa, increased TTP

Question 26

Prepatellar bursitis (housemaid’s knee, nun’s knee, carpet layer’s knee)

Answer 26

• pain anterior to patella, inflamed through repetitive kneeling on hard surfaces
• pain mild and restricted ROM from swelling
• presents as effusion over lower pole of patella, tender to palpation with bursal margins palpable

Question 27

olecranon bursitis

Answer 27

• caused by acute injury or repetitive trauma to olecranon bursa, less frequehntly caused by break in the skin, leading to septic cause (S. aureus)
• sxs: swelling over olecranon process (MC finding), mildly painful (acute) or painless (chronic), ROM preserved
• dx: no imaging indicated
• tx: avoid continued trauma to elbow and ace wrap for compression, NSAIDs and warm compresses, surg removal of bursa if nonresponsive to tx

Question 28

tendinitis and tenosynovitis

Answer 28

• common cause: overuse, arthritides
• commonly appears at: rotator cuff, supraspinatus, biceps, flexor carpi ulnaris, flexor carpi radialis, flexor digitorum, patella, hip adductor, achilles
• sxs: commonly occur together, pain w/ mvmt, swelling, impaired fn, may resolve over several weeks, but recurrence is common
• tx: rest, ice, stretching, NSAIDs, steroid injection and anesthesia alongside tendon (avoid intratendon injection dt rupture), excise scar tissue and necrotic debris

Question 29

subacromial or bicipital tendiitis

Answer 29

• produced by friction on the tendon of the long head of the biceps as it passes through bicipetal groove
• sxs: ant shoulder pain radiates down biceps into forearm, worse with overhead activity
• signs: limited abduction and external rotation, bicipital groove TTP
• dx; yergason supination sign + = pain with resisted supination of forearm with elbow at 90 degrees
• tx: young - repair surgically; older - surg not necessary if little to no pain

Question 30

achilles tendinitis

Answer 30

• pain attributed to inflammation and degeneration of Achiles tendon and attachment to calcaneus, common in runners and pts who suddenly increase their activity level or ppl who improperly stretch or train
• sxs: gradual onset during activity or after activity, pain on post calf, TTP over post calf above calcaneus (pain on passive dorsiflexion and resisted plantar flexion), ankle ROM and strength = normal
• dx: thompson test to rule out rupture
  
  • XR: soft-tissue shadow and calcifications along tendon and insertion
  • MRI: hypertrophy of Achilles tendon to rule out rupture
• tx: NSAIDs, PT for stretching and strength exercises; if left untreated, may progress to rupture of achilles