Orthopedics and Rheumatology Flashcards
Most common cause of hematogenous osteomyelitis spread in adults
Vertebral osteomyelitis
Initial treatment of choice for chronic osteomyelitis
Surgical debridement + cultures (not empiric treatment which is used in acute)
Most common bones affected by osteomyelitis in children
-Long bones of the LE
Most common organism in osteomyelitis
Staph aureus
Sickle cell disease and ostteomyelitis, puncture wound thru tennis shoe and osteomyelitis causative organisms
Salmonella, pseudomonas
When is pain usually worse in osteoarthritis patients? Is it usually symmetric or asymmetric?
The afternoon/evening, asymmetric
Bouchard and heberden nodes
PIP and DIP enlargement, respectively
Labs for diagnosis of rheumatoid arthritis (3)
- Rheumatoid factor (best initial)
- Anti CCP antibodies (most specific)
- ESR and CRP
All patients on biological DMARDS have to be tested for what condition?
PPD to rule out TB as it can reactivate TB
Developmental dysplasia of the hip tests
Barlow (dislocation) and ortolani (reduce) in <3 month old
>3 months galeazzi test
Most common type of hip dislocation, most common type of shoulder dislocation
Posterior, anterior
Hip fracture complication
Avascular necrosis in up to 13%, fractures of femoral head and neck associated with higher incidence of avascular necrosis
Painless limping worsened at end of day in childen 4-10 years think of ___. Painful hip groin thigh or knee pain limp in obese children 8-16 years think ____
legg calve perthes, slipped capital femoral epiphysis
Most common knee ligamental injury
ACL tear
Most sensitive test for ACL tear
Lachman test
Segond fracture definition
Avulsion of the lateral tibial condyle with varus stress to the knee, if present it is pathognomonic for a torn ACL
Most common mechanism of a PCL tear
Car dashboard collision
Peroneal nerve injury is manifested by
Foot drop
Inversion ankle sprain is often due to ___ while eversion is often due to ___
talofibular ligament, deltoid ligament
Ottowa ankle rules (5)
- Lateral malleolus pain
- Medial malleolus pain
- navicular pain
- 5th metatarsal pain
- Inability to walk >4 steps at a time
Maisonneuve fracture definition
Spiral fracture of proximal third of fibula associated with distal medial malleolar tibial fracture or rupture of the deep deltoid ligament thru transfer in the interosseous membrane, anyone with a distal ankle fracture should have proximal films to rule out this fracture
1st and 2nd most common bones affected by stress fracture
3rd metatarsal, tibia
Neuropathic (charcot) arthropathy definition
Joint damage and destruction as result of peripheral neuropathy from DM, PVD, or other diseases, can see joint or foot deformity, alteration of shape of foot, radiographs may show obliteration of joint space
Lab values useful in diagnosis of osteomyelitis, what is the initial imaging test, and what is most sensitive imaging test in early disease? What is the gold standard definitive diagnosis?
- WBC count, CRP***
- Radiographs
- MRI
- Bone aspiration
Interdigital (mortan’s) neuroma definition
Compressive neuropathy of the interdigital nerve often in women wearing tight fitting shoes, can cause lancinating or burning pain with weight bearing and some numbness or paresthesia, often worsened with reporducible pain with squeezing of foot
Jones fracture management
-Nonweight bearing in short leg cast for 6-8 weeks followed by repeat radiographs as often complicated by non-union or malunion, frequently requries ORIF or pinning
Pseudojones vs jones fracture
Pseudojones is more common and less serious and is a fracture thru the base of the 5th metatarsal compared to jones which is the diaphysis of 5th metatarsal and only requires a walking cast for 2-3 weeks to heal well
Most common type of salter harris fracture
type 2
Best outcome type of salter harris fracture, worst outcome type
Type 1, type 5
Above in the Salter harris classification means in the ____, while below means ___
long bone, in the epiphysis
Osteosarcoma definition
Most common primary bone malignancy in young adults, 90% occur in the metaphysis of long bones like distal femur or proximal tibia, most commonly mets to lungs, see bone pain that is worse at night, radiographs show hair on end or sunburst appearance or codman’s triangle, biopsy is definitive diagnosis
Chondrosarcoma definition
Cancer of cartilage, most commonly seen in adults 40-75 y/o, radiographs demonstrate punctate or ring and arc appearance calcification
Ewing sarcoma definition
Second most common primary bone malignancy in children and young adults, femur most common, bone pain and swelling accompanied by systemic symptoms, can see periosteal reaction or codman’s triangle as well
First line medical agents in patients not responsive to conservative lifestyle changes in fibromyalgia patients, what is another option?
- TCA’s like amitryptiline
- pregabalin
How does polymyalgia rheumatica present?
Pain and stiffness in proximal joints and muscles worse in the morning x2 weeks, may have difficulty combing hair and rising from a chair, will have normal muscle strength on exam**, closely associated with giant cell arteritis
Polymyalgia rheumatica treatment
Low dose corticosteroids
Most important initial test in rhabdomylosis symptoms (muscle pain or weakness or swelling + dark tea colored urine) and what other tests are done?
- EKG to look for signs of life threatening hyperkalemia
- Urine dipstick, creatinine kinase
Hyperkalemia treatment steps
-Calcium gluconate then insulin administered with D50 saline (glucose)
How does polymyositis present?
Progressive symmetric proximal to distal muscle weakness, decreased muscle strength on exam**
Polymyositis treatment
High dose glucocorticoids first line
Dermatomyositis presentation
Similar to polymyositis but also has gottron’s papules - raised scaly patches on dorsum of PIP and MCP joints, as well as heliotrope rash
Dermatomyositis treatment
High dose glucocorticoids first line
Screening test of choice for lupus (most sensitive), what is specific for SLE?
ANA, anti-double stranded DNA and anti Smith
How is mild lupus treated vs severe?
Mild is hydroxychloroquine with or without NSAIDS and maybe low dose corticosteroids, severe is high dose glucocorticoids or intermittent IV pulse methylprednisolone with other immunosuppressive agents
4 common drugs that cause drug induced lupus
Hydralazine
Procainamide
Isoniazid
Quinidine
Antiphospholipid syndrome definition
Idiopathic disorder with increased risk of arterial or venous thromboses (may see recurrent miscarriage)
Drug indicated for sjogren syndrome
Pilocarpine
Scleroderma (systemic sclerosis) is an autoimmune connective tissue disorder that leads to fibrosis of skin and internal organs, what is the classic syndrome associated with this?
CREST syndrome, calcinosis, raynauds, esophageal dysmotility, sclerodactyly, telangiectasias
Takayasu arteritis definition, how is it diagnosed, and what is first line treatment?
Chronic large vessel vasculitis affecting the aorta and its primary branches, manifests with constitutional symptoms and vessel ischemia like renal artery stenosis, lower extremity claudication, aneurysm rupture, diagnosed with angiography, treated with high dose corticosteroids
Kawasaki disease presentation, what is a complication of it?
Children often <5 years with fever x5 days (loooong fever) plus conjunctivits, rash, edema, adenopathy, strawberry tongue, etc.
If left untreated can cause coronary artery aneurysm
Kawasaki disease treatment
IV immunoglobulin + aspirin (yes, even in kids regardless of risk of reyes)
Polyarteritis nodosa definition and treatment
Systemic vasculitis of medium sized vessels, sees hypertension (especially in renal artery stenosis), renal or mesenteric angiography will show microaneurysms (beading), treated with glucocorticoids
Erythema nodosum
Inflammatory disorder characterized by tender nodules found symmetrically on the shins
Eosinophilic granulomatosis with polyangitis. Most common organ affected, triad of presentation, lab findings
Lungs, asthma + eosinophilia + chronic rhinosinusitis, P-ANCA positivity hallmark
Cyclophosphamide drug class
Immunosuppressant
Goodpasture’s disease 2 manifestations and treatment
- Glomerulonephritis, pulmonary hemoptysis
- Glucocorticoids plus cyclophosamide + plasmapheresis
What marker is positive in ank spondy?
HLA B27
Does ank spondy improve with activity? What are the radiographic findings associated with it?
YES, sacriliitis and bamboo spine
Ankylosing spondylitis treatment first ine
NSAIDs, exercise and physical therapy
Tumor marker AFP
Increased in hepatocellular carcinoma, decreased in down syndrome during gestatoin
Tumor marker CA-125
Ovarian cancer
Tumor marker CEA
Colorectal cancer
Arthrocentesis findings in gout
Negatively bifringent needle shaped crystals
What should be used for gout management in a patient with severe renal disease?
Glucocorticoids as nsaids are hard on kidney
Arthrocentesis findings in pseudogout
Positive bifringent rhomboid shaped calcium crystals
Best diagnostic test of osteoporosis
DEXA scan
Screening guidelines for osteoporosis
DEXA scan in 65 years or older or anyone with the risk
Most common level of a herniated disk
L5-S1
What level does the spinal cord terminate
L2
Causes of cauda equina syndrome
Lumbar disc herniation most common, spinal stenosis, trauma, tumors, epidural abscess, vertebral fractures
Diagnostic study of choice for cauda equina syndrome
MRI
Most sensitive finding of cauda equina syndrome
New onset urinary retention
Lumbar spinal stenosis is worsened with what?
Extension (relieved with flexion such as leaning forward)
Spinal epidural abscess, spinal cord compression diagnostic test of choice
MRI with gadolinium
Most sensitive physical exam finding for scoliosis, what is the confirmatory test?
Adams forward bend test, radiograph demonstrating cobb’s angle >10 degrees measured on ap and lateral film
When does scoliosis require treatment to stop progression such as bracing?
Cobb angle >25
Adson’s test
Loss of radial pulse with head rotated to affected side indicating thoracic outlet syndrome
Spondylolysis findings on radiograph
Scotty dog has a break in the neck
What are posterior glenohumeral shoulder dislocations associated with?
Trauma or seizures
Posterior fat pad sign
ALWAYS abnormal, concerning for supracondylar fracture in children or radial head fracture in adults
What nerve is injured in saturday night palsy which causes wrist drop due to weakened extensors in the forearm?
Radial nerve
Nightstick vs monteggia fracture
Night stick is just ulnar shaft without any other fracture wall monteggia aslo includes radial head dislocationa nd can cause radial nerve injury as sequellae
Galeazzi fracture definition
Mid distal radial shaft fracture with dislocation of distal radioulnar joint often from FOOSH, requires ORIF if unstable fracture, long arm or sugar tong splint temporarily
Splint for scaphoid (carpal navicular) fracture
Thumb spica, remember to re-image 2 weeks later if any anatomic snuffbox tenderness as may not show up initially but has high risk of nonunion
Colle’s and smith fracture treatment
Sugar tong splints
Complex regional pain syndrome definition
Autonomic dysfunction following bone or soft tissue injuries characterized by pain, hyperalgesia out of proportion, motor or trophic changes, edea, or vasomotor changes, clinical diagnosis, no other possible causes is diagnosis, nsaids are initial treatment, as well as physical therapy and and maybe TCA’s, vitamin C prophylaxis may reduce incidence of CRPS after fracture
How is mallet finger managed?
Splint of DIP joint (buddy tape?) for 6-8 weeks to see if heals, then if still not fixed surgical intervention
Gamekeeper’s thumb is a tear of what ligament? What is the management?
Ulnar collateral ligament of the thumb, treated with thumb spica splint and referral to hand surgeon because can affect pincer function otherwise
Boxer’s fracture initial management
Ulnar gutter splint
Management of carpal tunnel syndrome
Volar splint, nsaids, avoid repetitive wrist movement
Difference between carpal tunnel and pronator teres syndrome
Pronator terres syndrome is associated more with proximal forearm pain than wrist and hand pain and is not associated with pain at night, tenderness activated by pronation of the forearm is huge for pronator teres syndrome
