PANCE Prep- MSK/Rheum Flashcards
1
Q
Most common type of shoulder dislocation and its MOI
A
anterior
-arm abducted, externally rotated
“Squared off shoulder”
2
Q
What is a Hill-Sachs lesion?
A
groove on humeral head (compression fracture from impact against glenoid)
(Hill- in the GROOVE)
3
Q
What is a Bankart lesion?
A
glenoid inferior rim fracture
BACK on glenoid rim
4
Q
How do you Dx and Tx an anterior shoulder dislocation?
A
DX: axillary and Y view xray: humeral head inferior/anterior to glenoid fossa
TX: reduction w/ pinprick* sensation over deltoid to r/o axillary nerve injury**
5
Q
What muscles make up the rotator cuff
A
SITS
- Supraspinatus—- tear to this is MC
- Infraspinatus
- Teres minor
- Subscapularis
6
Q
Describe PE findings for rotator cuff tear
A
- passive ROM> active ROM
- empty can tests- supraspinatus strength
Impingement tests:
- empty can tests- supraspinatus strength
- Hawkins: anterior pain w/ internal rotation of humerus while shoulder/elbow at 90degrees
- Drop arm test
- Neer Test: arm fully pronated w/ thumb down and pain w/ forward flexion
- suprasinpatus test: pain w/ abduction against resistance
7
Q
Describe Type 1, 2, and 3 shoulder separations
A
Type 1: ligamental sprain- nl CXR
Type 2: AC ligament ruptured, CC ligament sprained- slightly widening CXR
Type 3: AC and CC ligaments ruptured- significant widening on CXR
8
Q
TX of shoulder separation
A
brief sling immobilization, ice, pain control and ortho f/u
9
Q
What nerve injuries must be ruled out in proximal humerus/humeral head fx and humeral shaft fx
A
- proximal humerus/humeral head fx: brachial plexus or axillary nerve- check deltoid sensation
- humeral shaft fx: radial nerve injury- may cause wrist drop
10
Q
MC fractured bone in children, adolescents and newborns during birth
A
clavicle fx
**in children <2 suspect abuse
11
Q
adhesive capulitis is most common in who
A
40-60s w/ DM or hypothyroidism
**due to inflammation
12
Q
What is thoracic outlet syndrome?
A
idiopathic compression of brachial plexus (95%), subclavian vein (5%) or subclavian artery (1%)
13
Q
Clinical manifestations of thoracic outlet syndrome
A
- nerve compression: pain/paresthesia to forearm, arm or ULNAR SIDE of hand
- vascular compression: swelling/discoloration esp. w/ abduction of arm
- PE: + Adson: loss of radial pulse w/ head rotated to affected side
14
Q
complications of supracondylar humerus frcatures
A
- median nerve and brachial artery injury: Vokmann ischemic contracture- claw like deformity from ischemia w/ flexion/contracture of wrist
- radial nerve injury
15
Q
Presentation:
- MOI: FOOSH
- lateral (radial) elbow pain, inability to fully extend the elbow w/ a + fat pad sign on XR
A
radial head fx
16
Q
What is Kanavel’s signs?
A
FLEXor tenosynovitis (infection of the flexor tendon synovial sheath of the finger- MC w/ s. aureus)
- Finger held in flexion
- Length of tendon sheath is tender
- Enlarged finger (fusiform swelling of the finger)
- Xtension of the finger causes pain (pain w/ passive extension)**
17
Q
Presentation:
- MOI: direct blow to flexed elbow
- inability to extend the elbow
- complication: ulnar nerve dysfunction
A
olecranon fracture
18
Q
Presentation:
abrupt “goose egg” swelling (boggy, red elbow) w/ limited ROM w/ flexion
A
olecranon bursitis
19
Q
tx of olecranon bursitis
A
rest, NSAIDS, local steroid injection, avoid repetitive motions
20
Q
an Ulnar shaft fx is also called ___
A
nightstick fracture
21
Q
What is a Monteggia fracture
A
fx of proximal ulnar shaft fracture w/ an anterior radial head dislocation
22
Q
What is a Galeazzi fracture
A
fx of mid-distal radial shaft w/ dislocation of distal radioulnar joint
23
Q
what do Monteggia and Galeazzi fractures have in common?
A
BOTH UNSTABLE and need ORIF
Monteggia: fx of proximal ulnar shaft fracture w/ an anterior radial head dislocation
Galeazzi: fx of mid-distal radial shaft w/ dislocation of distal radioulnar joint
24
Q
radial nerve injury presents as ___
axillary nerve injury presents as __
peroneal nerve injury presents as ___
A
- wrist drop
- loss of pinprick sensation on deltoid
- foot drop
25
What is a nursemaid's elbow?
radial head subluxation
MOI: lifting/swinging/pulling a child 2-5y/o while the forearm is pronated and extended--> radial head wedges into the stretched annular ligament*
26
What is a Hutchinson fracture
aka Chauffeur's fracture
| -radial styloid fracture
27
What is the difference between tennis elbow and golfers elbow
Tennis elbow: LATERAL epicondylitis- inflammation of tendon insertion of extensor carpi radialis brevis (ECRB) muscle
**lateral elbow pain w/ wrist EXTENSION against resistance
Golfters elbow: MEDIAL epicondylitis- inflammation of pronator teres-flexor carpi radialis
**medial elbow pain w/ wrist FLEXION against resistance
28
Presentation:
- MOI: FOOSH w/ hyperextension
- presents w/ flexed elbow, marked olecranon prominence, and inability to extend elbow
Elbow dislocation (posterior MC)
29
TX and complications of elbow dislocation
1. EMERGENT reduction
2. posterior splint
Complications: brachial artery and median/ulnar/radial nerve injury
30
What is cubital tunnel syndrome and how do you dx
ulnar nerve compression at the cubital tunnel along the medial elbow (ulnar neuropathy)
PE:
+ Tinel's sign at elbow
+ Froment's sign (holds paper and compensates w/ flexion of thumb IP joint- pinching effect)
31
DX and TX of a scaphoid fracture
"aka navicular fracture"
DX: snuffbox tenderness
TX: tx as fracture bc increase incidence of avascular necrosis--> nonunion
*thumb spica
32
What is a Colles fracture
distal radius fx w/ DORSAL/posterior angulation (wrist fx)
| MOI: FOOSH w/ wrist EXTENSION
33
tx of colles fracture
sugar tong splint or volar forearm splint
34
What is a Smith fracture
reverse colles fracture- distal radius fx w/ VENTRAL/anterior angulation
(MOI: FOOSH with wrist FLEXION)
35
- Lunate doesn't articulate w/ both the capitate OR radius= ____
* "piece of pie sign" of AP and "spilled teacup sign" on lateral view
-Lunate doesn't articulate with capitate but still articulates with radius
- Lunate dislocation (EMERGENT consult needed)
| - Perilunate dislocation
36
What is complex regional pain syndrome?
autonomic dysfunction following bone or soft tissue injuries - MC affects UE
37
Presentation:
1. Pain out of proportion to injury following bone or soft tissue injuries
2. waxy or pale skin, brittle nails, loss of hiar
3. joint atrophy and contractures
complex regional pain syndrome
38
Management of CRPS
NSAIDS, PT, TCA
| ***Vitamin C prophylaxis after fractures may reduce the incidence of CRPS
39
What are the following finger injuries:
1. Mallet (Baseball) finger:
2. Boutonneire deformity:
3. Swan Neck deformity:
1. finger flexed at DIP joint and UNABLE to extend at DIP
2. Finger FLEXED at PIP joint and hyperextended at DIP
3. finger hyperEXTENDED at PIP and flexed at DIP
40
avulsion of extensor tendon w/ sudden blow to tip of extended finger w/ forced flexion
mallet finger
41
What is Gamekeeper's thumb
aka skier's thumb
- sprain or tear of the ulnar collateral ligament of the thumb--> instability of the MCP joint
* thumb far away from other digits esp. w/ valgus stress pulling thumb away from hand--- forced hyperabduction injury
Skiers thumb: ACUTE
Gamekeepers: CHRONIC hyperabduction injury
42
TX of Gamekeepers/Skiers thumb
Thumb spica and referral to hand surgeon
43
What is a boxer's fracture and how do you tx
fx of the neck of 5th metacarpal
tx: ulnar gutter splint and always check for bite wounds and tx w/ augmentin if present
44
What is a Bennett's and Rolando's Fracture
Bennett's: intraarticular fx through base of 1st MCP
Rolando's: Comminuted Bennett's fracture
45
Describe Salter-Harris Fractures
"SALTR"
Type 1: "Same" isolated growth plate fx
Type 2: "Above" metaphysis fx + growth plate fx (MC)
Type 3: "Lower" epiphysis fx + growth plate fx
Type 4: "Through" metaphysis fx, growth plate fx, and epiphysis fx
Type 5: "Rammed" growth plate compression injury
46
What is deQuervain tenosynovitis
stenosing tenosynovitis of the abductor pollicus longus (APL) and extensor pollicus brevus (EPB)
47
DX and TX of deQuervain tenosynovitis
PE: + Finkelstein test: pain w/ ulnar deviation or thumb extension
TX: thumb spica splint x 3 weeks
48
Presentation of carpal tunnel syndrome
*MEDIAN nerve entrapement/compression at carpal tunnel (common w/ DM)
1. Paresthesia and pain of palmer 1st 3 and 1/2 of 4th digits especially AT NIGHT
2. Thenar muscle wasting
49
DX and TX of carpal tunnel syndrome
DX: + Tinels sign: percussion of median nerve produces symptoms
+ phalens sign: flexion of both wrists for 30-60 sec reproduces pain
TX: VOLAR splint and NSAIDS
50
how do you differentiate carpal tunnel syndrome and pronator syndrome
*both median nerve compression
CTS: compression at carpal tunnel so pain in wrist/hands and worst at night
Pronator syndrome: compression in prox. forearm so pain in prox. forearm and NOT worse at night
51
Presentation:
hip pain w/ leg shortened, INTERNALLY rotated and adducted w/ hip/knee slightly flexed
VS
hip pain w/ leg shortened, EXTERNALLY rotated, and abducted
hip dislocation (posterior MC)
hip fracture
52
Presentation:
- MC in children 4-10y/o
- loss of abduction and internal rotation
- PAINLESS LIMING x weeks (worsen w/ continued activity esp. at the end of the day)
Legg-Calve-Perthes disease
53
what is Legg-Calve-Perthes disease
idiopathic avascular osteonecrosis of the femoral head in children due to ISCHEMIA of the FEMORAL epiphysis
54
DX and TX of Legg-Calve-Perthes disease
DX:
Hip XR: increased density of the femoral head, widening of the cartilage space, CRESCENT SIGN
TX: observation bc it is self-limiting w/ revascularization w/in 2 yrs, ortho, NWB
55
Presentation:
- MC 7-16y/o during growth spurt
- hip, thigh, or knee pain w/ limp
- external rotation of affected leg
Slipped capital femoral epiphysis
56
what is slipped capital femoral epiphysis and what how do you tx
femoral head epiphysis slips posterior and inferior at growth plate
TX: NWB--> ORIF
57
What is a Greenstick fracture and a Torus (Buckle) fracture
Greenstick: incomplete fx w/ cortical disruption and periosteal tearing on the convex side of fx "BOWING"
Torus/Buckle: incomplete fx w/ "WRINKLING" or "BUMP" of metaphyseal-diaphyseal junction
58
What knee injury is associated with the following MOI:
1. Valgus stress w/ rotation
2. Varus stress
3. Noncontact- pivoting jurying, deceleration, hyperextension and internal rotation
4. squatting, twisting, or trauma w/ femur rotation of the tibia
1. MCL
2. LCL
3. ACL
4. Meniscal tear
59
PE of ACL tear
1. pop and welling-- hemarthrosis
2. knee buckling and inability to weight bare
3. + Lachmans (most sensititve)
4. + anterior drawer test
5. +/- Segond fracture: avulsion of the lateral tibial condyle w/ varus stress to the knee
60
Segond fracture is pathognomonic for what injury
ACL tear
61
PE of meniscal tears
1. locking, popping, giving way
2. effusion after activities
3. + McMurrays sign
4. joint line tenderness
5. Apley test
62
Best way to dx patellar fracture
Sunrise view on xray
63
Patella baja = ___
| Patella alta = ___
baja= quadriceps tendon rupture: palpable defect ABOVE knee
alta= patellar tendon rupture: palpable defect BELOW knee
64
complications and tx of knee (tibial-femoral) dislocation
complications:
1. popliteal artery injury in 1/3rd of patients--> NEED arteriography
2. peroneal or tibial nerve injury
TX: immediate ortho consult
65
A positive apprehension sign (pt exhibits anxiety/forcefully contracts the quad when the examiner pushes laterally on patella) usually means ___
patellar dislocation (usually lateral dislocation)
or patellofemoral syndrome (chondromalacia)
66
What is Osgood-schlatter and how does it present?
-osteochondritis of the patellar tendon at tibial tuberosity from overuse or small avulsions (due to quad contraction on the patellar tendon insertion into the tibia)
- MC in 10-15y/o w/ chronic knee pain during growth spurts
- activity related knee pain/swelling
- PROMINENT and TENDERNESS TO ANTERIOR TIBIAL TUBERCLE
67
What is a baker's cyst and how do you tx
synovial fluid effusion (ex. from meniscal tear) that is displaced w/ cyst formation
tx: conservatitve: ice, assisted weight bearing, NSAIDS
68
What is patellofemoral syndrome
aka Chondomalacia
- idiopathic softening/fissuring of patellar articular cartilage
* MC in runner
-ANTERIOR knee pain "behind" or around the patella worsened w/ knee hyperflexion, prolonged sitting, jumping or climbing
69
MC cause of knee pain in runners
iliotibial band syndrome (usually lateral knee pain during onset of running then resolves)
70
+ Ober test: pain or resistance to adduction of the leg parallel to the table in neutral position
+ lateral condyle tenderness
ITB sydnrome (iliotibial band)
71
85% of ankle sprains involve what ligaments?
collateral (Anterior talofibular MC, calcaneofibular)
72
What ligament is the main stabilizer during inversion and eversion
inversion: anterior talofibular ligament (ATFL)
eversion: deltoid ligament
73
What are the Ottawa Rules for imaging?
Ankle:
1. pain along lateral malleolus
2. pain along medial malleolus
3. inability to walk >4 steps at the time of injury and in ER
Foot:
1. Navicular (midfoot) pain
2. 5th metatarsal pain
3. inability to walk >4 steps at the time of injury and in ER
74
Presents:
1. sudden heel pain after push-off movement, pop, sudden sharp calf pain
2. + Thompson Test
achilles tendon rupture
Thompson test: weak, absent plantar flexion w/ gastrocnemius is squeezed
75
There is an increased risk for achilles tendon rupture with ___ use
fluoroquinolone
76
What is a Maisonneueve Fracture
spiral proximal fibular fracture (due to rupture of the distal talofibular syndesmosis and interosseus membrane) as a result of a distal medial malleolar fracture and/or deltoid ligament rupture
*get prox. xray view to r/o
77
xray: Clear space: btwn tib and fib and deltoid lig. tenderness
Maisonneueve Fracture
78
Presentation:
- heel pain, tenderness to plantar/medial foot, worse w/ dorsiflexion of toes,
- pain worse after period of rest (ex. 1st few steps in morning)
- pain decreases throughout day
Plantar fasciitis
79
Presentation:
-pain/numbness at the medial malleolus, heel and sole
-pain worsens at night and with dorisflexion
+ tinel sign
Tarsal Tunnel syndrome (posterior tibial nerve compression from overuse, restriction or edema)
**Mimics plantar fasciitis pain but PF decreased throughout the day and TT pain increases throughout the day)
80
What is a bunion
Hallux valgus deformity of the bursa over 1st metatarsal
81
What is a hammer toe
deformity of PIP joint: flexion of PIP joint and hypertension of MTP and DIP join
82
What is Charcot's joint
aka diabetic foot
-joint damage and destruction as a result of peripheral neuropathy
*Obliteration of joint space on xray
83
What is a Morton's neuroma and how d you tx
degeneration/proliferation of the plantar digital nerve (MC at 3rd metatarsal head)
* walking on a marble
* *Positive Squeeze test
TX: wide shoes, glucocorticoid injection, surgery
84
What is a Jone's Fracture and how do you tx
transverse fracture through the diaphysis of 5th metatarsal
tx: NWB x 6-8 weeks then f/u xrya-- complicated by nonunion/malunion
85
What is a pseudojones fracture and how do you tx
transverse AVULSION tx at base (tuberosity) of 5th metatarsal
tx: walking cast x 2-3 weeks
86
What is a Lisfranc injury
disruption btwn the articulation of the medial cuneiform and the base of the 2nd metatarsal
Lisfranc joint: bases of 1st 3 metatarsal heads and their respective cuneiforms
tx: ORIF
87
What is this finding called and what does it mean?
| fracture at the base of the 2nd metatarsal
Fleck sign
| *pathognomonic for disruption of tarsometarsal ligaments in lisfranc injuries
88
Lateral shift of the second metatarsal or widening btwn metatarsals with weight baring x-rays
Lisfranc fracture/dislocation
89
Sciatica pain distribution is in what dermatome pattern
L5-S1: back pain radiating to the thigh/buttock, lower leg
90
How do Dx herniated disc (nucleus pulposus)
+ straight leg test
+ crossover test
+/- stretch, reflex and sensation deficits
91
Where is the herniated disc most likely?
- ANTERIOR thigh pain
- Sensory loss to the medial ankle
- Weak ankle dorsiflexion
- loss of knee jerk
- Weak knee extension
L4
92
Where is the herniated disc most likely?
- POSTERIOR leg/calf, gluteus pain
- Plantar surface of foot
- Weakness of plantar flexion
- Walking on toes more difficult than walking on heels
- LOSS of ANKLE jerk
S1
93
Where is the herniated disc most likely?
- LATERAL thigh/leg, hip, groin paresthesia and pain
- Dorsum of the foot: esp. btwn 1st and 2nd toes
- Weakness of big toe extension
- walking on heels more difficult than walking on toes
- normal reflexes +/- loss of ankle jerk
L5
94
Findings of Cauda Equina syndrome
1. new onset of urinary retention
2. new onset of bowel incontinence
3. Saddle anesthesia
4. Uni/bilateral leg radiation
5. decreased anal sphincter tone of rectal exam (no anal wink)
95
What is scoliosis and how do you tx
lateral curvature of spine >10degrees +/- associated w/ kyphosis or lordosis
dx: Adams forward bending test most sensitive
- Cobb's angel on AP/lateral films
96
Signs of Neurofibromatosis type I
1. Scoliosis
2. Cafe au lait spots
3. skin tags
4. Axillary freckles
97
What is:
Spondylolysis:
Spondylolithesis:
Spondylolysis: Pars interarticularis defect from either failure of fusion or stress fracture (often from repetitive hyperextension trauma)
**MC form of back pain in kids and adolescents
Spondylolithesis: forward slipping of a vertebrae on another
98
MC cause of osteomyelitis: ___
Salmonella osteomyelitis is pathognomonic for ____
S. aureus
Sickle cell disease
99
describe lab and xray findings of osteomyelitis
labs: increased WBCs, ESR, and CRP
Xray: periosteal reaction, lucent areas of cortical destruction, soft tissue swelling
*MRI is most sensitive test in early disease
**Bone aspiration is GOLD STANDARD
100
single swollen warm painful joint, decrease ROM, tender to palpation, fever
arthrocentesis: WBC >50,000 primarily PMNs,
septic arthritis
TX: Abx + arthrotomy w/ joint drainage
1. Gram + cocci: Nafcillin (vancomycin if MRSA suspected)
2. Gram - cocci or gonococcus: Ceftriazone
3. Gram - rods: Cefriazone + anti-pseudomonal aminoglycoside
101
- Pain out of proportion to injury
| - pain on passive stretching earliest indicator* tense extremitites
Compartment syndrome
Dx: increased intracompartmental pressure >30-45mmhg
TX: fasciotomy
(muscle/nerve ischemia and decreased perfusion)
102
MC bone malignancy
*it MC has METS to ___
Osteosarcoma
Lungs
*MC adolescents
103
XRAY: "hair on end" or "sun-ray/burst" appearance
osteosarcoma
TX: resection and chemo as adjuvant therapy
104
bone pain +/- palpable mass +/- fever MC on femur and pelvis
XRAY: lytic lesion, periosteal reaction "onion skin" appearance
Ewing Sarcoma
105
XRAY: Punctate or ring and arc appearance pattern of calcification
Chondrosarcoma (CA of the cartilage)
106
MC benign bone tumor
osteochondroma
| seen esp. ages 10-20y/o, MC In males
107
XRAY: pedunculated, grows away from growth plate and involves medullary tissue
osteochondroma
108
S/S of Paget Disease of the Bone (Osteitis Deformans)
1. MC asymptomatic or bone pain
2. high alkaline phosphates
3. warmth
4. Deafness if skull involvement
Labs:
1. increased alkaline phosphate
2. XRAY: blade of grass/flame shaped lucenecy (lytic phase), Coarsened trabeculae (sclerotic phase), cotton wool appearance (skull)
109
Tx of Paget Disease of the Bone (Osteitis Deformans)
1. Bisphosphonates (inhibits osteoclast activity- decreased bone resorption and turnover) or calcitonin
ex. Alendronate, Risedronate)
110
causes of drug induced SLE
procainamide, hydralazine, INH, quinidine
| + Anti-histone antibodies
111
1. joint pain, fever, malar butterfly rash
2. pericarditits, pleuritis
3. annular erythematous patches on face, annular
4. glomerulonephritits, retinitits, oral uclers, alopecia
SLE
112
How do you dx and tx SLE
DX:
1. + ANA (best initial but not specific)
2. + anti-ds DNA and anti-smith Ab (100% specific for SLE but not sensitive)
3. 4+ manifestations (malar rash, discoid rash, photosensitivity, oral painless ulcers, polyarthritis, serositis, proteinuria, seizure, anemia, luekopenia, thrombocytopenia, ANA, anti-ab)
TX:
1. Sun protection: sun screen, hydroxychloroquine (for lesions)
2. NSAIDS or acetaminophen for arthritis
113
Labs with Antiphospholipid Ab syndrome
1. + anticardiolipid Ab (associated w/ false + VDRL/RPR)
2. lupus anticoagulant
3. B2 glycoprotein I Ab. Women w/ APLS may have frequent miscarriages
114
```
Thickened skin (sclerodactyly)
Tight, shiny, thickened skin (localized or generalized)
```
Scleroderma (systemic sclerosis)
```
AKA CREST syndrome
C-calcinosis cutis
R-aynauds
E-esophageal motility disorder
S-Sclerodactyly
T- Telangiectasia
```
115
How do you dx and tx Sjogren's Syndrome
DX: ANA, esp antiSS-A and antiSS-B
2. + RF
3. Schirmer test (dry eyes)
TX: artificial tears, Pilocarpine (cholinergic)
116
How do you dx and treat fibromyalgia
1. diffuse pain in 11 out of 18 trigger points >3months* + widespread pain
2. moth eaten appearance of muscle biopsy
TX: exercise- TCA, SSRIs, pregabalin
117
pain/stiffness of the proximal joints (shoulder, hip, neck).
| - bilateral proximal joint aching/stiffness typically in the morning >30 min
Polymyalgia rheumatica
*CLOSELY related to giant cell arteritis
DX: clinical, increased ESR
TX: low dose corticosteroids
118
1. Heliotrope (blue-purple) upper eyelid discoloration
2. Gottron's papules: raised violaceous scaly eruptions on the knuckles
3. Photosensitive poikiloderma "shawl or V sign"
Dermatomyositis
119
risk factors for gout
1. purine-rich foods: alcohol, liver, seafood, yeast,
2. meds: thiazide, loop, ACEI, pyrazinamide, ethambutol, ASA ARBS, allopurinol (wait til flare goes down or away)
3. men
120
Compare and contrast the synovial fluid crystals and XRAY w/ gout and pseudogout
Gout: negatively birefringent; needle shaped
-monosodium urate
XRAY: mouse bite-punched out erosions
Pseudogout: weakly positive; rhomboid shaped
-Calcium pyrophosphate dihydrate
XRAY: chondrocalcinosis
121
Tx for Gout
1. Acute: NSAIDS, colchicine
| 2. Chronic: uric acid lowering agetns: allopurinol
122
TX for pseudogout
1. intraarticular steroids 1st line
2. NSAIDS, Colchines
chronic: NSAIDS
123
DX and TX of rhabdomyolysis
DX: labs: increased CPK >20,000, LDH and ALT
2. hyperkalemia
3. Hypocalcemia
4. UA dark urine that is + for heme but neg for blood
TX:
1. IV saline hydratation
2. Mannitol
3. bicarbonate to alkalinize the urine
124
What are Heberden nodes and Bouchards nodes
Herberden: DIP joints
Bouchards: PIP osteophytes
*w/ OA
125
Common clinical manifestations w/ RA
1. small joint morning stiffness, >60 min after initiating movement, improves later in day
2. Boggy joints
3. Boutonnieere deformity (flexion at PIP and hyperextend DIP)
4. Swan neck deformity (flexion at DIP, hyperextension at PIP)
5. Ulnar deviation
DX:
RF best initial test
126
RA + splenomegaly + decreased WBC/repeated infections = ____
RA + pneumoconiosis= ___
Felty's Syndrome
Caplan Syndrome
127
tx of RA
1. Prompt initiation of DMARDS (reduces permanent joint damage)- ex. Methotrexate***** (nonbiologic)
2. biologics
3. NSAIDs for pain, corticosteroids 2nd line
*all patients on DMARDs should have PPD to rule out TB before initiating therapy
128
```
HA
Scalp tenderness
jaw claudication
fever
visual changes
thickened temporal artery
```
Giant cell temporal arteritis
DX: Clinical DX!
- increased ESR CRP
- temporal artery biopsy (mononuclear lymphoycte infiltration, multinucleated giant cells, lamina cell degradation
TX: HD corticosteroids
129
s/s of Kawasakis
CRASH (4 of 5) and BURN
C-conjunctivitis- bilateral, nonexudative
R-rash, polymorphous
A-adenopathy, cerbical
S-strawberry tongue
H- hands and feet arthritis and swelling/peeling
and
BURN:
fever
130
tx of Kawasakis
1. IVIG + high dose ASA
| 2. corticosteroids if refractory
131
Describe what HSP is and its symptoms
IgA deposition in skin--> immune mediated leukocytoclastic vasculitis
*MC after URI sx
H-Hematuria
S-synovial arthritis
P-Palpable purpura MC on LE (not due to thrombocytopenia or coagulopathy)
A-abdominal pain
*HSP affects IgA*
132
How do you dx and tx HSP
DX: clinical dx
2. kidney biopsy: mesangial IgA deposits
3. normal coags
TX: supportive (self limited 1-6wks)
133
Clinical manifestations of Goodpasture's and how to treat
*IgG antibodies against type IV collagen of the alveoli and glomerular basement membrane of the kidney
GP= 1. glomerulonephritits (rapidly progressing) 2. Pulmonary hemorrhage (hemoptysis)
DX: biopsy
TX: Glucocortoicoids + cyclophosphamide
2. Plasmapheresis
134
-Chronic low back pain: morning stiffness w/ decreased ROM
- peripheral arthritis, sacrolitiitis*
-Increased ESR, + HLAB27,
XRAY: bamboo spine
Ankylosing sponlytitis
TX: NSAIDs, rest, PT,
135
1. arthritis: asymmetric inflammation
2. conjunctivitis/uveitis
3. Urethritis cervicitis
4. Keratoderma blennorrhagicum= hyperkeratotic lesions on palms/soles
+HLAB27
synovial fluid- bacterial culture negative (aspetic)
Reactive arthritis (Reiter's Syndrome)
Tx: NSAIDs
*MC post chlamydia infection
136
sausage digits
| XRAYS: pencil in cup deformity
Psoriatic arthritis
137
- Morning stiffness for at least 1 hour; gel phenomenon -->improves with activity
- Chronic, symmetric, systemic disease that primarily targets the synovium
- Small joints first – MCPs, PIPs, MTPs
rheumatoid arthritis
138
other joints involved in RA
1. C-spine: C1-C2 subluxation
2. Spine: compression fx
3. Shoulder: bursitis, tendon rupture
4. Elbow: bursitis, ulnar nerve entrapment (4th and 5th digit numbness)
139
risk factors for pseudogout
1. idiopathic
2. trauma
3. hemochromatosis
4. hyperparathyroidism (excess Ca2+)
140
goal uric acid level when managing gout
<6 or <5 if tophi is present
| *check uric acid level at baseline and 4-6 weeks after therapy, once <6 recheck annually or for compliance
141
how do you differentiate fibromyalgia vs chronic fatigue syndrome?
fibro: fatigue and sleep disturbance
- no PE findings despite pain
chronic fatigue: >6months and <50% reduction of normal activity
-short term memory loss, lymph nodes in axillae or neck, HA (actual PE findings)
142
when treating fibromyalgia its important to treat
1. Pain (NSAIDs, TCA, cymbalta, PT)
2. sleep
(trazodone, flexeril)
3. mood (SSRI, wellbutrin, cymbalta)
4. PT
*check TSH, fT4, CBC, CMP
143
What is the gold standard for drawing an ANA?
ANA by IFA (not direct ANA)
144
What disease do these profiles suggest?
1. ANA + anti-ds DNA
2. ANA + anti-RNP
3. ANA + anti-Smith (Sm)
4. ANA + anti-SSA (Ro)
5. ANA + anti-SSB (La)
6. ANA + anti-centromere (SCI-70)
1. ANA + anti-ds DNA= SLE, lupus nephritis
2. ANA + anti-RNP= mixed CT disease
3. ANA + anti-Smith (Sm)= SLE marker
4. ANA + anti-SSA (Ro) = Sjogrens, subacute cutaneous lupus, neonatal lupus
5. ANA + anti-SSB (La)= Sjogrens, SLE
6. ANA + anti-centromere (SCI-70)= scleroderma
145
SLE labs to monitor
```
CRP, ESR
CBC
UA
Serum creatinine w/ eGFR
anti-dsDNA
C3 and C4
```
146
SLE has increased risk for what cancer
non-hodgkin lymphoma (B cell association)
147
clinical features of APS (anti-phospholipid syndrome)
```
CLOT:
Clot
Livedo reticuarlis
Obstetrical complications/miscarriages
Thrombocytopenia
```
148
Enlarged, nontender firm parotid or submandibular glands
- dry eyes and mouth
- gritty or FB sensation in eye
Sjogren's syndrome
DX: schirmer test
TX: tx symptoms (eye drops, lozenges, vaginal lubricants)
2. systemic: pilocarpine, hydroxychloroquine
149
- sacroiliitis
- Insidious onset of back pain
- morning and nighttime stiffness that improves w/ activity
- globe loss of ROM in spine
ankylosing spondylitis
dx: crp, HLAB27
Xray: abnormal appearing SI joint/ bamboo spine
TX: PT, stop smoking, NSAIDs
- sulfasalazine and methotrexate for peripheral arthritis
- Anti-TNF therapy for axial arthritis
150
- Sausage digits
- enthesitis
- keratoderma blennorragica, circinate balanitits,
- sores of penis
reactive arthritis (reiters syndrome)
```
TX: Physical therapy
Intraarticular steroids
NSAIDs
Sulfasalazine, methotrexate (used less frequently)
Anti-TNF alpha agents
```
151
- generally polyarticular arthritis, affecting both small and large joints. tenosynovitis
- The fever pattern is distinctive, occurring daily or twice daily, usually in the afternoon or evening, often accompanied by Still’s rash (salmon-colored/pink migratory rash)
- iridocyclitis (anterior uveitis)
Juvenile idiopathic arthritis
DX: clinical, increased ESR, CRP
TX: NSAIDs and/or corticosteroids
*frequent eye exas todetect iridocyclitis
152
describe the joints affected with oligoarticular JIA and polyarticular
Oligoarticular: involves 4 or less joints, usually larger joints and often asymetrically
**increased blood flow to joints cause accelerated growth to affected limb causing leg length discrepancy
Polyarticular: involves 5 or more joints, usually small joints, usually symmetric
153
Type I oligoarticular JIA is associated with ___
Type II oligoarticular JIA is associated with ___
iridocyclitiis (anterior uveitis)
* slit lamp q 3 months if ANA+, q3months if 7y/o or less or q6 months if >7
Ankylosing spondylitis
154
When should you screen a child with oligo JIA for uveitis
- slit lamp q 3 months if ANA+,
- q3months if 7y/o or less
- q6 months if >7
155
tx of uveitis
topical steroids but in severe cases systemic meds are needed to tx eye inflammation
156
___ status is important with oligoarcticular JIA but __ status is important with polyarticular JIA
ANA
RF
157
RF+ polyarticular JIA is associated w/
rheumatoid nodules,
chronic arthritis
joint destruction
158
____ is inflammation at the insertion of tendons
Enthesitis
159
enthesitis-related arthropathies
ankylosing spondylitits
IBD associated arthritis
psoriatic arthritis
160
If joint aspiration occurs, joint fluid will have increased polymorphonuclear (PMN) cells and low glucose, in the setting of ___
JIA.
161
3-6y/o with an acute onset of difficulty walking/weight bearing, usually holding the affected leg rotated out. The children are well-appearing, but usually have a history of recent URI symptoms with/without fever
-limited internal rotation of the hip
Transient synovitis of the hip (aka reactive arthritis)
*Transient synovitis is only of the hip otherwise its considered reactive arthritis
TX: supportive (resolves on its on in 1-4weeks)
-Ibuprofen 40-50mg/kg divided TID
162
the most common joint in a child to develop into septic arthritis is
hip
163
describe a malar rash vs roscea
Malar: encompasses cheeks and nose, but spares nasolabial folds
Rosecea: involves nasolabial folds
