Orthopedics and Rheumatology Flashcards
What are the most common causes of low back pain?
Low back strain and prolapsed intervertebral disc
Differentiate the features of low back pain associated with a musculoskeletal cause, sciatica, SI joint problems, and spinal stenosis.
MSK: Point tenderness and localized to one region
Scia: Pain in buttock, posterior thigh, posterolateral aspect of leg to lateral malleolus.
SI: Unilateral low back and butt pain that worsens with standing
Sten: Pain in elderly worsened by walking and better when leaning forward.
T/F: X-ray is the best test to use on initial exam of a patient with complaint of low back pain.
False: X-ray typically not required if neuro exam is normal
What are the red flag S/S of low back pain?
fever, weight loss, morning stiffness, IVDU or steroid use Hx, trauma, CA, saddle anesthesia, loss of anal sphincter tone, motor weakness (req emergent x-ray)
What are the best uses of CT and MRI in the patient with low back pain?
CT: identifying bony stenosis and lateral nerve root entrapment
MRI: cord pathology, neural tumors, stenosis, herniated discs, and infections
What is the recommended treatment for uncomplicated low back pain?
Rest for 2 days with support under knees and neck
NSAIDs
Progressive walking to normal activities
Postural exercises/PT
Imaging if no improvement in 6 weeks
Surgery if conservative therapy fails (about 5%)
Define bursitis.
Inflammation of the thin walled sac lined with synovial tissue located in larger moveable joints.
Describe the common S/S and treatment for bursitis.
S/S: pain and swelling that may persist for weeks
Tx: Rest, brace/support, stretching, NSAIDs, steroid injection
Define and state common S/S associated with tendonitis.
Tendon inflammation most commonly s/p overuse and arthritis. S/S = pain with movement, swelling, impaired function, commonly recurrs.
What is the treatment for tendonitis?
Rest, ice, stretching, NSAIDs, steroid injection, surgery if conservative therapy fails.
Define and state common S/S associated with costochondritis.
Inflammation of rib cage cartilage. S/S: tender, radiating pain down limbs, C/P - often with inspiration
What are the risk factors for costochondritis?
Age > 40, high impact sports, manual labor, allergies, RA, ankylyosing spondylitis, reactive arthritis
What is used in diagnosis and treatment of costochondritis?
Dx: clinical –> imaging, ECG, serum labs to r/o other conditions
Tx: NSAIDs, lifestyle changes, rest, ice
Define and state the S/S of fibromyalgia.
Central pain disorder. S/S: non-articular MSK pain, fatigue, sleep disturbance, mood changes, cognitive disturbance, multiple trigger points, dysmenorrhea, IBS
How is fibromyalgia diagnosed and what other conditions should be ruled out?
Dx of exclusion –> r/o hypothyroid, Hep C, vitamin D deficiency
Describe the treatment of fibromyalgia.
SSRIs, SNRIs, TCAs may be helpful
Gabapentin to reduce pain and improve sleep
Exercise without overtraining
Treat associated psych disorders –> CBT, sleep assistance, stress reduction, mindfulness
T/F: NSAIDs are an essential part of treatment for pain associated with fibromyalgia.
False: NSAIDs have no benefit
What is the most common soft tissue tumor of the hand and what are they caused by?
Ganglion cyst –> arise from torn or degenerated joint capsule or tendon
What are the most common locations for a ganglion cyst and what is the most common cause?
Location: wrist and fingers
Cause: repetitive activity
What are the most common S/S associated with ganglion cyst?
Obvious swelling or joint pain with no obvious cause
Describe the treatment of ganglion cyst?
Observation, needle aspiration, surgery.
T/F: Ganglion cysts typically recur regardless of the treatment modality.
True
Define gout.
Altered purine metabolism and sodium urate crystal precipitate into synovial fluid.
T/F: Men are at much higher risk of gout than women.
True until menopause, then risk is equal.
What S/S are most commonly associated with gout?
podagra (attack at MTP of great toe), pain, swelling, redness, exquisite tenderness, tophi in chronic gout.
What are tophi?
Swollen, outgrowths at the joints under the skin
State diagnostic findings in gout.
Joint fluid: negatively birefringent rods
Serum uric acid > 8 –> common but not diagnostic
X-ray: small, punched out lesions
Describe treatment options for gout.
Lifestyle: elevation, rest, decrease purines in diet (meat, seafood, ETOH), weight loss, inc protein
NSAIDs –> indomethicin = drug of choice
Colchicine –> effective between attacks but bad GI AEs
Allopurinol –> DOC between attacks
What medications should be avoided by patients with gout?
ASA, thiazide diuretics
T/F: Allopurinol is used to reduce attacks of gout but is best to start when an attack is active.
False: never start allopurinol during acute attack
What is CPPD and what is the classic presentation?
Pseudogout –> usually older than 60 yoa, occurs in large joints in the lower extremities, S/S similar to gout but no tophi present.
State diagnostic findings in pseudogout.
Joint fluid: positive birefringent –> rhomboid shaped Ca pyrophosphad crystals
X-ray: fine, linear calcifications in cartilage
Describe treatment options for pseudogout.
NSAIDs for acute attacks (steroid injections an option)
Colchicine for prophylaxis (benefit controversial)
Define osteoarthritis.
Progressive loss of articular cartilage with reactive changes in bone.
T/F: Osteoarthritis is a clinical diagnosis in which imaging has no benefit.
False: 90% of osteoarthritis patients have evidence of disease on X-ray
Describe the S/S of osteoarthritis.
Dec ROM, joint crepitus, morning stiffness with pain that worsens throughout the day
What x-ray findings are indicative of osteoarthritis?
asymmetric joint narrowing, subcondral sclerosis, bony cysts, marginal osteophytes.
What are the treatment options for osteoarthritis?
DOC = APAP
Weight reduction, moderate exercise, NSAIDs, intra-articular steroids, braces, canes, joint replacement
Define osteoporosis.
Decrease in bone density s/p abnormal bone remodeling leading to increased risk of fracture.
Differentiate between type 1 and type 2 primary osteoporosis.
1: Post-menopausal (most prevalent) –> loss of estrogen or testosterone in men
2: senile –> occurs equally in men and women.
What bones are most commonly affected/fractured in primary osteoporosis?
1: Trabecular bone –> vertebrae, hip, distal radius
2: trabecular and cortical bone –> hip and pelvis
What conditions most commonly cause secondary osteoporosis?
Malignancy, steroid use, GI disease, hormone issues
What is the most beneficial method to evaluate patients for osteoporosis and when should it be used for screening?
DEXA scan –> Postmenopausal women < 65 yoa with one or more risk factor, Any woman > 65, women on HRT, osteopenia on x-ray, Fx with minimal trauma, patients with Hx of RA
Describe the normal and abnormal findings of a DEXA scan.
T-score > -1 = normal
T-score between -1 and -2.5 = osteopenia
T-score < -2.5 = osteoporosis
What are the management options for osteoporosis?
Prevention: weight bearing exercise, dec ETOH, ensure adequate Ca, Vitamin D, Phosphorus, smoke cessation
Bisphosphonate = DOC
HRT = risk for MI, breast cancer, blood clots
Describe plantar fasciitis and state which patients are most susceptible.
Micro-tears in the plantar fascia and the calcaneal origin. Most common in runners and overweight patients.
What S/S are most commonly associated with plantar fasciitis?
Pain with first few steps in the morning, heel pain at night, pain at calcaneal origin, inflexible achilles
What findings on imaging are most common in plantar fasciitis?
X-ray: normal
MRI: calcifications of plantar fascia
What treatment options are available for plantar fasciitis?
Conservative for first 6-12 months –> PT, stretching, heel pads, arch supports, massage with tennis ball
Steroid injections
Surgery only for extreme cases
What is the risk of steroid injections to treat plantar fasciitis?
Rupture of plantar fascia –> use with caution
What is another name for reactive arthritis and what is the classic triad of symptoms?
Reiter’s Syndrome –> “can’t see, can’t pee, can’t climb a tree” –> urethritis, oligoarthritis of large joints, uveitis.
Other than the classic triad, what are other clinical features of reactive arthritis?
Usually preceded by an STI, asymmetric arthritis usually involving large joints below the waist, mucocutaneous lesions.
What diagnostic findings are commonly present in reactive arthritis?
Most are HLA-B27 positive, synovial fluid culture is negative, evidence of permanent and progressive joint disease on x-ray.
What is the best management for reactive arthritis?
NSAIDs = mainstay of treatment, PT, Abx at time of infection can lower risk but do not alleviate symptoms after development.
Define rheumatoid arthritis.
Chronic inflammatory disease with synovitis affecting multiple joints and extra-articular manifestations.
T/F: Women are more likely than men to have rheumatoid arthritis.
True: women are three times more likely
What are the S/S of rheumatoid arthritis?
joint pain and deformity, muscle weakness, osteopenia, extra-articular changes in skin, lungs, kidneys, eyes, blood system, and heart.
What lab and imaging findings are used to diagnose rheumatoid arthritis?
ESR and CRP elevated (non-specific) RF positive in 80% of patients ACPA and anti-CCP positive in 95% of patients --> most specific test for RA Absence of ANA used to exclude SLE X-ray = juxta-articular demineralization
How is rheumatoid arthritis treated?
Refer to rheumatology
PT and OT
Pharmacology early –> NSAIDs and DMARDs, combo therapy with steroids and biologics (newer DMARDs)
Reconstructive surgery in severe cases
Define DMARDs and give some examples.
Disease Modifying Antirheumatic Drugs
Methotrexate (first line), sulfasalazine, hydroxychloriquine, leflunomide, azathioprine.
What is the most commonly affected ligament in an ankle sprain?
Anterior Talofibular
What is required to diagnose systemic lupus erythematosus?
At least four of the following: maloid rash, discoid rash, photosensitivity, oral ulcers, arthritis, serositis, renal disease, ANA, hematologic disorders, immunologic disorders (LE cell, anti-DNA, anti-SM), neuro disorders (seizures/psychosis) with no other cause
What medications may induce SLE?
Procainamide, hydralazine, isoniazid, methyldopa, quinidine, chlorpromazine
What serum labs are used to diagnose SLE?
ANA present 99% of the time but not specific to lupus
Presence of Anti-dsDNA is specific for lupus
Anti-Smith antibodies used to monitor disease progression.
